Hospitals face a grimacing task in the move to EHRs. In addition to workflow adjustments and IT upgrades, there's the trouble of financing the system. Hailed as "free" software, open source systems provide an alternative to more expensive proprietary technology. But what's the real price of looking beyond traditional vendor options? ADVANCE adds it up.

Defining "Free"

Open source software is "free" in the sense it can be downloaded at no cost. The source code is posted on a public Web site, so any hospital, practice or interested party with enough IT knowledge can access the software and use it without paying the traditional licensing fee.

"The basic model is that open source software itself is accessible to everybody," said Mike Ginsburg, marketing manager, DSS, a software supplier that recently open sourced its vxVistA system.

Tom Jones, MD, chief medical officer, Tolven, helped build applications for health information exchange using open source technology and now offers them for public use. He said the open source approach lets providers test drive systems to see which ones fit. "It is being able to drive the car before they even talk to the dealer," Dr. Jones explained. "Everybody's saving time and money."

So what's the catch? Open source must be tailored to meet a provider's specific needs, but most hospitals and physician offices don't have the time, staff or skills to customize the technology. Open source partners, therefore, offer to configure the system and provide ongoing support and maintenance-for a fee.

"Think of it as a tool. The tool itself happens to be free, but the work, knowledge and transformation it enables is how Medsphere earns its living," said Rick Jung, chief operating officer, Medsphere Systems Corp. The company developed OpenVista, an open sourced version of the Department of Veterans Affairs' (VA) EHR system, VistA.

Medsphere follows a subscription-based business model. Providers can download OpenVista and its applications free of charge. If they need help configuring the system, they can sign up for a 5-year contract that includes implementation, training, support, maintenance and what the company calls "clinical transformation."

"We focus on helping the practitioners make sure they not only get maintenance and support for the system, but use it to drive the practice in the right direction," Jung explained.

Even with the subscription fee, open source is cheaper than traditional proprietary systems. According to Jung, a large teaching facility paid $90 million for a traditional EHR system. The West Virginia Department of Health and Human Services, however, spent only $9 million for a 5-year contract with Medsphere to cover eight hospitals.

While DSS also offers support and maintenance contracts to providers looking for IT help, the company doesn't require anyone to sign up in order to download the software.

"People can make the determination themselves of whether they want to support [the software] themselves, hire a third party to support it or hire us to support it," Ginsburg said. "We don't have any strings attached."

A Community of Innovation

Open source isn't just about keeping a cap on the coffer; it's about constantly improving care. One of the driving principles of open source is fostering a community of users that exchange best uses. Once users download the software and alter it to their needs, they are encouraged to share any tweaks with the community so other users can benefit from the developments.

Medsphere encourages anyone who downloads OpenVista to share templates, best practices or helpful tips with the larger community. Jung said the contributions have helped bring the EHR system to "a whole other level," and it's also attracted interest from notable health care organizations. "What we're finding is the likes of University of Pittsburgh Medical Center, Kaiser and others are actually downloading theses templates," he said.

As part of its no-strings policy, DSS doesn't require users to contribute to the vxVistA pool. In fact, users are allowed to alter the software and resell the customized applications for a profit, Ginsburg said. Like Medsphere's OpenVista, DSS' vxVistA is based on the VA's open sourced EHR, so DSS is simply upholding the free and open policy, he explained.

Open source developers are also extending a hand to proprietary suppliers and promoting community among vendors. "We're looking for all of the other people involved with either commercial software or open software, both, to join our community and help increase the quality of the system," said Joe Byers, vice president of sales and marketing, DSS.

Open source technology can integrate with applications from different systems, as long as the vendor agrees to participate. vxVistA, for example, has integrations with anesthesia, infectious disease tracking, and coding and compliance software, among others. Some proprietary vendors, however, prefer to keep their technology out of the open source realm, according to Byers.

Dr. Jones agreed that open source technology isn't intended to shut out proprietary systems, but to interact with them. At the same time, he cautioned against open source systems that are interwoven with proprietary applications, which can lead to licensing problems when the code is unlocked to the public. Instead, he advocates for systems that are built from the ground up using all open source components, so parts can be swapped in or out without any hang-ups.

Running the Risks

As users upload customizations, the constant pool of improvements makes quality assurance (QA) critical. Everyone is invited to contribute their tweaks and innovations, but some alterations aren't in the community's best interest. Open source projects headed by companies like Medsphere and DSS have QA built in, but some open source communities may not have such filters. When exploring open source options, it's best to pick one that has a defined governing body that monitors changes, Dr. Jones suggested.

Open source systems also run the risk of fizzling out. When forums go silent, the system stops evolving and users no longer reap the benefits of exchange. Promising open source projects have high Web activity and a buzzing forum, according to Dr. Jones.

A strong support team is also vital to keep up with system evolution. While vendor systems include support in contract agreements, some open source systems do not guarantee help.

"I used to call open source support the 'Blanche DuBois' model, where you always depend on the kindness of strangers," Ginsburg said. "I guess in non-critical situations that's fine, but in health care it's not."

Dr. Jones also noted the risk involved when support isn't part of the deal. "Somebody will say, sure you can use this, but don't bother us about how you use the code because we're too busy," he said.

What it ultimately comes down to, the experts said, is whether the system improves the delivery of care. Open source is less expensive than proprietary systems, but poor support and governance can send cost savings out the window. "The key focus is quality software," Ginsburg said. "Whether it's open source or proprietary, you've got to make sure the quality's there in terms of what it does and how it does it." n

Cheryl McEvoy is an editorial assistant with ADVANCE.