Building the Free/Libre Open Source Health Care

(FLOSS-HC) Community: A Strategy for Pushing

Free/Libre Open Source in European Health Care

Thomas Karopka

IT Science Center Rügen gGmbH, Circus 14, 18581 Putbus, Germany

Abstract. Free/Libre Open Source Software (FLOSS) is both a process of

software development and a method of licensing. Although FLOSS plays a sig-

nificant role in several market areas, the impact in the health care arena is still

limited. This is mainly due to the special requirements and the different circum-

stances when compared to other market areas. However, FLOSS is thought to

be one of the most effective means to overcome the fragmentation in the health

care sector and provide a basis for more efficient, timely and cost effective

health care provision. In this position paper I will give a short overview of

FLOSS applications in the health care sector, I will briefly discuss the special

challenges and the identified barriers that need to be overcome to push FLOSS

in health care. I will then describe a possible strategy that may help in improv-

ing the situation for FLOSS in European health care.

1 Introduction

FLOSS is thought to be one of the driving forces in overcoming the fragmentation in

the health care market, which is one of the main efficiency barriers in the context of

ICT in health care. Other fields have already adopted the FLOSS business model to

some extend, e.g. Linux, MySQL, JBoss, Apache Tomcat or Mozilla Fire-

fox/Thunderbird are some popular examples of successful FLOSS applications. How-

ever, although quite successful in horizontal applications, i.e. that are useful in many

different industries, there is still limited success in vertical applications, i.e. applica-

tions that are specific to one single industry, such as the health care market. On the

other hand several governments are pushing open source in the public sector and the

European Commission’s initiative eEurope 2005 which builds on the Action Plan

(June 2000) sets the target “to promote the use of open source software in the public

sector and e-Government best practice through exchange of experiences across the

Union”. The European Union has set up the Open Source Observatory and Reposi-

tory for European public administrations (OSOR) (http://www.osor.eu) a site devoted

to the re-using, sharing and collaborative development of E-Government applications

for European public administrations. The site was official launched at the Open

Source World Conference in Malaga on October 20th 2008. So what about the health

care arena? In this paper I will give a non-comprehensive overview of FLOSS pro-

Karopka T. (2009).

Building the Free/Libre Open Source Health Care (FLOSS-HC) Community: A Strategy for Pushing Free/Libre Open Source in European Health Care.

In Proceedings of the 1st International Workshop on Open Source in European Health Care: The Time is Ripe, pages 3-7

DOI: 10.5220/0001828100030007

 SciTePress

jects in the health care sector, I will identify barriers for the adoption of FLOSS

strategies in health care and name challenges for the FLOSS community. The ideas

and theses in this paper where stimulated by discussions with various participants at

the EFMI special topic conference “Open Source in European Health Care” which

took place in September 2008 in London. My special thanks go to all participants of

this conference.

2 FLOSS Applications in Health Care

The “List of open source healthcare software” in Wikipedia [1] lists more than 120

different tools or projects in 19 categories. Some of the projects are apparently dead

or are not maintained for a long time. Other new initiatives like the “Open health

tools” project of the Eclipse foundation [2] or the newly founded Open eHealth

Foundation [3] are still missing. The largest category is the imaging/visualization

category with 39 applications followed by electronic health or medical records with

18 entries and medical practice management software with 12 entries.

If it comes to open source in healthcare often one of the most comprehensive and

most successful applications of FLOSS-HC, the VistA application [4], is mentioned.

This is an open source HIS application developed over several years by the federally

funded U.S. Veterans Administration. This software is further enhanced and adapted

for other healthcare systems under the WorldVista [5] project. As mentioned above,

hundreds of other tools have been developed with different levels of complexity and

maturity. To integrate this already huge amount of knowledge and person-years of

software development will be one of the top issues in the proposed strategy for Euro-

pean open source healthcare software.

3 Challenges and Barriers for FLOSS-HC

The health care sector provides special challenges for FLOSS applications. While a

large part of traditional FLOSS applications is either in the professional IT sector

(server software, operating system software i.e. Linux) or in the traditional office

sector (OpenOffice, Firefox, Thunderbird) where the end users are used to IT applica-

tions, the situation in health care is different. Hospital Information Systems are very

complex systems often comprising hundreds of different small applications. Each

sector within the hospital often has its own standards and tools. This has led to a

fragmentation in the IT sector which hinders an effective information exchange be-

tween sectors or other health professionals that are part in the care process. The situa-

tion in the practice management sector is comparable. For example in Germany there

are more then 100 different providers of practice management systems. This leads to

a similar situation like in the HIS sector. Additionally the end users, the health pro-

fessionals, are often not trained sufficiently in the use of IT applications. Often they

feel uncomfortable with IT applications and perceive them as barriers instead of sup-

port for their work. These are challenges for IT in health care in general. For FLOSS

applications there are several additional barriers. Some of them are:

• Lack of professional support

• No road map (Sustainability?)

• IT administrators need someone to sue in case of failure

• Functional gaps

• Publish early – publish often not the right strategy in health care

• Health care needs mission critical applications

At the top of the agenda is the lack of professional support. It is absolutely necessary

for hospitals to get professional support if something is not working as expected.

Often changes have to be made to adapt the system to local specialties of the hospital.

Another point is the lack of a roadmap. Hospitals need to have sustainable solutions

and the possibility to plan the future extension of the system. FLOSS projects are

often driven by single persons or groups. If these persons loose interest in the project

or move to other fields, the product may not be supported further. This is absolutely

inacceptable in the health care market. Functional gaps need to be closed. If this can

not be done by the hospital IT group, the vendor should be able to provide this sup-

port. In the case of FLOSS it can not be expected that the community fulfils the re-

quests of the hospital because the developers usually work on features that they are

interested in or on a pre-specified work package. The usual strategy in FLOSS

projects is “publish early – publish often”. The community is part of the development

process. The test phase is done by the clients in the field. This is also not acceptable

in health care. Last but not least the security and reliability demands in health care are

extremely high. It is often not clear to the management in health care whether they

can trust the software in respect to these demands.

4 Success Factors for FLOSS

In this section I will look at the success factors for FLOSS applications. Probably the

most successful FLOSS application is the operating system LINUX. One of the rea-

sons for this success is the inventor of LINUX, Linus Torvald. He still coordinates

and integrates the Linux kernel together with input from the community. Other suc-

cessful FLOSS projects have different organizational structures. In the case of the

Apache project and the Eclipse Project a Foundation provides the professional frame

for managing and coordinating the development of the different applications and

products. Also from the sister field of bioinformatics we have learnt that successful

projects need either a professional structure or it depends on the leading role and the

support of an individual or a group, e.g. Ensembl [6] or BioPAX [7].

5 A Strategy for FLOSS in European Health Care

In the US FLOSS applications have already gained some success in the health care

market. This is mainly due to the professionalization of the sector. Companies like

ClearHealth Inc. [8], MedSphere [9], Akaza Research [10], WebReach Inc. [11] or

Tolven [12] have adopted the FLOSS business model. One advantage of the US mar-

ket is the size and the number of potential customers. It is far easier to reach the criti-

cal number of customers. In Europe this is more difficult due to the smaller countries,

the different health care systems and the language barrier. Several systems have been

developed in a European context (e.g. Care2x [13], O3 [14]) but the use is still li-

mited due to the aforementioned barriers to the market. Despite the differences in the

healthcare system and the language barrier, it is possible to work on the basis of

common standards and modules as several existing projects are trying to implement.

To push FLOSS HC application development in a European context I propose the

adoption of the following strategy:

1. FLOSS-HC inventory

(What is already there?)

In this first step an inventory should be carried out to provide an overview of

what is already there. To date several projects start inventing the wheel again.

Although this might be desirable to some extend, it is more effective to try to

work together and reuse modules as often as possible. A very valuable re-

sources to achieve this is the Wikipedia list of open source software in health-

care [1].

2. FLOSS HC Communication platform and software repository

(Where can I find FLOSS HC applications and information about FLOSS-

HC?)

The effort from the first package should result in a communication platform

backed up by a database which contains links to the resources assembled in

the first package. The platform should provide means for communication like

a wiki and/or a forum for discussion about the projects and the road map. The

forum should be moderated. Otherwise it is not possible to work towards a

common aim.

3. FLOSS HC use case database

(What is really needed? What is the impact of the proposed package? How

realistic are the chances of success?)

The database of already existing software and projects should be comple-

mented by a database of use cases where the necessities from the field are

stored in form of use cases. These use cases and may be workflows should

describe the use cases from the health professional point of view. This is

probably one of the most important but also most difficult parts to achieve.

4. FLOSS HC knowledge base

(Description of modules and their capabilities)

A sheer database of FLOSS software is not sufficient. With technologies like

the Web Services Description Language (WSDL) or an ontology about

FLOSS-HC applications it is possible to describe the capabilities of the soft-

ware and issue complex queries for searches in the knowledge base. A good

example from the bioinformatics realm is the TAVERNA tool [15] which

may be used to build workflows based on the orchestration of services from

over 1.000 registered service applications.

To successfully apply the strategy outlined above it is necessary to have some kind of

professional corporate body. Probably the most appropriate would be the foundation

of a European Center for FLOSS in European Health Care. This non-for-profit public

corporate body should provide monetary support and also the manpower in form of a

steering team that is responsible for guiding the community process and if possible

also organizational work. The concentration on the European level does not exclude

projects and initiatives from non-European states but mainly provides a means for

European funding and a thematic focus on issues that are relevant in a European con-

text. Having said this it is clear, that the initiative is open for all interested people and

that it should not be an effort to reinvent the wheel. There should be an exchange

with already existing similar efforts. Finally the communication platform should use

Web 2.0 technologies to provide the best possible means for communication and

interaction for all stakeholders.

6 Conclusions

FLOSS has become a viable alternative to proprietary software development in sever-

al business areas. However, in the health care IT sector open source is still rare. To

improve the situation and chances for FOLSS in health care, a coordinated action of

all stakeholders in FLOSS-HC is needed. To make FLOSS a viable alternative to

proprietary software in the health care arena, several barriers need to be overcome.

The proposed strategy may be one way to accomplish this aim.

Acknowledgements

The author likes to thank the organizers of the EFMI special topic conference “Open

source in European health care” as well as all participants for an inspiring conference

which provided the basic inspiration for this position paper.

References

1. Wikipedia list of open source healthcare software. http://en.wikipedia.org/wiki/

List_of_open_source_healthcare_software. 2008

2. Open Health Tools. http://www.openhealthtools.org/. 2008

3. Open eHealth Foundation. http://www.openehealth.wikispaces.net/. 2008

4. VistA CPRS Demo Site. http://www1.va.gov/cprsdemo/. 2008

5. WorldVista. http://worldvista.org/. 2008

6. Ensembl. http://www.ensembl.org. 2008

7. BioPAX. http://www.biopax.org/. 2008

8. ClearHealth Inc. http://www.clear-health.com. 2008

9. MedSphere. http://www.medsphere.com/. 2008

10. Akaza Research. http://www.akazaresearch.com. 2008

11. WebReach Inc. http://www.webreachinc.com/. 2008

12. Tolven. http://www.tolven.org/. 2008

13. care2x. http://www.care2x.org/. 2008

14. Open Three (O3) Consortium. http://gnbts9.units.it. 2008

15. Oinn T, Greenwood M, Addis M et al. Taverna: lessons in creating a workflow environ-

ment for the life sciences: Research Articles. Concurr Comput: Pract Exper 2006;

18(10):1067-100.