Bell Eapen

eHealth and Health Information System Consultant

10 points to consider before adopting open-source software in eHealth

Open-source software (hereafter OSS) is a phenomenon that has revolutionized the software industry. OSS is supported by voluntary programmers, who regularly dedicate their time and energy for the common good of all. The question that immediately comes to mind is how is it sustainable? Will they continue to contribute their social hours forever? Read the programmers perspective here. But does it make sense for healthcare organizations to accept their charity always? And, how do these organizations that adopt OSS improve the sustainability of these projects? These are some of the factors to consider:

artificial intelligence

Do you have enough funding?

OSS supporters are humanists with an emancipatory worldview. OSS is fundamentally not designed for an organization that can sustain a paid product. Firstly, there is the ethical problem of exploiting the OSS community. But more importantly, healthcare organizations with enough funding tend to spend more on the long-term maintenance and customization of OSS. Hence, OSS is generally designed to be an option when you have no other option.

Does the project have a regional focus?

OSS projects generally aim to solve global problems. So be careful when you hear Canadian OSS or Danish OSS. Regional OSS is mostly just cheaper local products masquerading as OSS for funding or for other reasons. They are unlikely to have the support of the global OSS community and is prone to burnout.

Is the OSS really OSS?

Any OSS worth its salt will be on GitHub. If you cannot find the project on GitHub, you should definitely ask why.

Is it really popular?

Some OSS that masquerade as OSS claim that they have a worldwide network of developers. The GitHub stars and forks would be a reasonable indicator of the popularity. Consider an OSS for your organization only if it has a thousand stars on the GitHub sky.

Are you looking for a specific workflow support?

Is your workflow generic enough to be supported by a global network of volunteers? Well, OHIP billing workflow may not be the right process to seek OSSM support.

Do you need customization?

If you need a lot of customizations to support your workflow, then OSS may not be the ideal solutions. OSS is ideally suited for situations where you can use it out of the box.

Do you have the time?

Remember that OSS is supported by voluntary programmers. So if you need a feature, you make a request and wait. If your organization is used to demanding, then OSS is not for you. OSS project is not owned by anyone, so their priorities may be different from yours.

Do you have internal expertise?

It is far easier to use an OSS if you have someone supporting the project in your organization. OSS community tends to respect one of their own more than an organization.

Supporting Open-Source Software?

It is crucial for organizations that depend on an OSS for your day to day operations to support the project. If the project becomes unsustainable, it affects the organization too. You can support the project in many ways such as donations, coding support and infrastructural support.

Do you know what OSS means and stands for?

Does the higher management know what OSS means and stands for? It is common in healthcare organizations to adopt OSS focusing on the free aspect.

“Free software” is a matter of liberty, not price. To understand the concept, you should think of “free” as in “free speech,” not as in “free beer”.

Personally, I think the first point is the most important. OSS is designed and intended for use in areas where a paid option is not viable. In other scenarios in healthcare, you are likely to spend more for an open-source product than you spend for a regular product.

Finally, a quick mention of some noteworthy OSS in healthcare. OpenMRS is an open-source EMR started with the mission to improve healthcare delivery in resource-constrained environments. DHIS2 is web-based open-source public health information system with awesome visualization features including GIS, charts and pivot tables.

Intelligent Federated Model of Health Information Exchange Clinical Viewers IFCV

I have blogged about federated search clinical viewers before. Essentially such viewers query source health information systems in real time and provide the user with a consolidated view. There is no data repository, ensuring data integrity and data privacy. Though the system can be slow because of the real-time search, there are many successful regional implementations of this type.

There is an obvious disadvantage for federated model of health information exchange viewers. Intelligence cannot be built into such viewers. Since there is no server side data storage, there is no scope for server side processing. The data comes together only in the rendered view. Some  mixed systems that have a data-repository provide some crude warning flags that are not-real time. But clinically useful alerts are beyond the capabilities of federated systems. So how do we build intelligent federated clinical viewers?

Intelligent Federated Clinical Viewer #IFCV

As HTML5 specifications mature, intelligence can be built into clinical viewers by client side processing and storage. Though local database storage implemented by Safari is too insecure at this stage for this purpose, it might become viable in the future. Some useful functionality can be built with the Session storage functionality that has been expanded to store up to 4MB of data depending on browser implementations. This is much more than the conventional cookie storage. The Sessions object persist only till the window is active and is reasonably secure. I have listed some typical use cases below.

A typical pharmacy module of a clinical viewer brings together all the medications the patient is on from all source hospitals. A client side script could identify drug interactions by analysing the view. This is beyond the local EHR system as disparate systems do not talk to each other.

If all the active drugs can be stored locally during the pharmacy module view, contraindications such as steroids in hyperglcemia can be alerted when the lab module is accessed. These intelligent alerts could be clinically invaluable.

The utopian dream of cross-communicating EHRs are still a long way in the future. Regional federated clinical viewers are going to rule the roost for some time. So intelligent federated clinical viewers may be worth a consideration. I don’t know whether this is already in the pipeline for vendors such as Mulesoft, Medseek or Mirth. If not, a link here (and a mail) will be highly appreciated when they do.

Twitter hashtag for this topic: #IFCV

Bring Your Own EMR (#BYOE)

The e-Health lessons from debacle is being debated widely. The idea of applying large scale IT initiatives in clinical domains has its own risks. As we relentlessly move towards a fully digital healthcare ecosystem, is it possible to hide some of its complexities from the clinicians?

Patient empowerment is the buzzword in eHealth now and clinicians are generally viewed with some skepticism. EHealth has learnt over the years (in the hard way) that the clinicians may be reluctant to relinquish their firm grip on clinical data. After all they generated the data and they are the custodians though they do not own it!

One of the approaches worth trying is to give the clinicians control and freedom over their end of things. In other words, separate enterprise EMR from the physician EMR. However the key to success in this scenario is interoperability.

Interoperability of EMRs are being actively explored by many research teams and organizations. However the emphasis is on better standardization. As interoperability emerges as a global paradigm, the standardization strategy that has failed for the last decade or so, still seems impractical?

Bring Your Own EMR

I am working on an interoperability solution that segregates physician EMR solutions logically and physically from Enterprise EMR solutions. I would like to call this Bring Your Own EMR (#BYOEpronounced as ‘bio’. The general framework is shown above. If you would like to join the #BYOE initiative or give feedback, shoot me an email!!

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