Free/Libre Open Source Software in Health Care: A Review

Review Article Healthc Inform Res. 2014 January;20(1):11-22. http://dx.doi.org/10.4258/hir.2014.20.1.11 pISSN 2093-3681 • eISSN 2093-369X Free/Libre Open Source Software in Health Care: A Review Thomas Karopka, Dipl.-Ing.1,2,3, Holger Schmuhl, Dipl.-Inf.2,3,4, Hans Demski, Dipl.-Ing.3,4 1 BioCon Valley GmbH, Greifswald, Germany; 2International Medical Informatics Association Open Source Health Informatics Working Group, Geneva, Switzerland; 3European Federation Medical Informatics Libre/Free and Open Source Software in Health Informatics Working Group, Copenhagen, Denmark; 4 Laboratory for Medical Information Systems, Institute for Biological and Medical Imaging of the Helmholtz Zentrum Munchen, Neuherberg, Germany Objectives: To assess the current state of the art and the contribution of Free/Libre Open Source Sotware in health care (FLOSS-HC). Methods: he review is based on a narrative review of the scientiic literature as well as sources in the context of FLOSS-HC available through the Internet. All relevant available sources have been integrated into the MedFLOSS database and are freely available to the community. Results: he literature review reveals that publications about FLOSS-HC are scarce. he largest part of information about FLOSS-HC is available on dedicated websites and not in the academic literature. here are currently FLOSS alternatives available for nearly every specialty in health care. Maturity and quality varies considerably and there is little information available on the percentage of systems that are actually used in health care delivery. Conclusions: he global impact of FLOSS-HC is still very limited and no igures on the penetration and usage of FLOSS-HC are available. However, there has been a considerable growth in the last 5 to 10 years. While there where only few systems available a decade ago, in the meantime many systems got available (e.g., more than 300 in the MedFLOSS database). While FLOSS concepts play an important role in most IT related sectors (e.g., telecommunications, embedded devices) the healthcare industry is lagging behind this trend. Keywords: Sotware, Medical Informatics, Delivery of Health Care, Sustainable Development I. Introduction Today’s healthcare systems of most of the developed countries are challenged by an increase of age-related diseases due Submitted: December 21, 2013 Accepted: January 16, 2014 Corresponding Author Thomas Karopka, Dipl.-Ing. BioCon Valley GmbH, Walther-Rathenau-Str. 49a, 17489 Greifswald, Germany. Tel: +49-3834-515303, Fax: +49-3834-515102, E-mail: [email protected] This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ⓒ 2014 The Korean Society of Medical Informatics to demographic ageing as well as a rise of non-communicable diseases. At the same time many of the problems in low resource settings remain unsolved and new challenges arise. Information and communication technologies (ICTs) play a key role in the Internet area and have substantially transformed many domains. Although there is a broad consensus that eHealth plays a key role in modern healthcare delivery, the domain of health care is considerably lagging behind in terms of adoption of modern ICT tools and infrastructure. Free/Libre Open Source Software (FLOSS) has been successfully adopted across a wide range of diferent areas and has opened new ways of value creation. Today there are hundreds of examples of successful FLOSS projects and products ranging from Linux to Android, from Open/Libre Oice to MySQL, from the Apache Web Server to hundreds of embedded GNU/Linux kernels in different types of systems. Thomas Karopka et al Especially in times of inancial crisis and austerity the adoption of FLOSS principles opens interesting alternatives and options to tremendously lower total cost of ownership (TCO) and open the way for a continuous user-driven improvement process. In this paper the authors review the development of FLOSS in health care (FLOSS-HC) in the last decade and provide an overview of the state of the art in FLOSS-HC. This review considers free and open source sotware in the area of healthcare delivery and medical research and is based on the MedFLOSS database [1]. The domain of bioinformatics and computational biology is excluded from this review. his domain has a large number of FLOSS tools and projects and a very active and well organized global community with regular meetings. For example, the Bioinformatics Open Source Conference [2] is held yearly since the year 2000 and the Open Bioinformatics Foundation [3] a global non-proit, volunteer-run group is dedicated to promoting the practice and philosophy of Open Source sotware development and Open Science within the biological research community. However, the situation in health informatics is quite diferent. In bioinformatics the tools are mainly used in research and not in healthcare delivery, i.e., researchers are programming for research and not for healthcare personnel and patients as end-users. In the following chapter an introduction to FLOSS in general is given since there are still many misconceptions and lack of knowledge about existing FLOSS concepts on the side of healthcare IT professionals. II. Open Source and Free Software he idea of freely sharing sotware and its underlying source code has been around since the early beginning of computing. Eventually the underlying principles got phrased in the mid-1980s by Richard Stallman. In an effort to write a free Unix alternative called GNU [4], he formulated the socalled Free Software Definition [5] in 1986. Any software conforming to this deinition must ofer the freedom of using, studying, sharing, and modifying that software to its users. Premise to these principles is the access to its source code. To support the free sotware movement and promote its ideas Richard Stallman founded the Free Sotware Foundation [6], a non-profit organization, in 1985. Adjacent to these efforts in 1998 the term Open Source was coined by Eric S. Raymond and Bruce Perens. Instead of sticking to the original notion of Free Sotware they wanted to have a clear wording for marketing purposes that is not easily mixed up with Freeware—a closed-source sotware that is given free of 12 www.e-hir.org charge but comes with considerable restrictions on its use. In the same year Raymond and Perens founded the Open Source Initiative [7], also a non-proit organization to circularize and promote their deinition of Open Source sotware. Although there have been quite some disagreements between both organizations and its adherers since then about who has the cleaner deinition and follows the more genuine and honest intentions, they both accept most software licenses in this ield to conform to their deinitions. In this paper the term Free/Libre and Open Source Sotware (FLOSS) is used in an attempt to embrace both communities. 1. Software Licenses Whilst authorship remains at any time with the originator of the sotware, re-use, modiication, and distribution of sotware and the access to its source code are regulated by the license under which it is released. Free software and open source licenses can primarily be assigned in one of three categories: permissive, weak and strong copylet. he main diference between these categories is if the sotware can be released under a diferent license than the original in case it is modiied and if it can be linked with other sotware that has a different license. Permissive software licenses permit both options. Popular examples are the Apache License [8], the BSD License [9] and the MIT License [10]. Weak copylet still permits linking to diferently licensed sotware but requires code changes to be released under the original software license. Popular examples are the Eclipse Public License [11], the Mozilla Public License [12] and the GNU Lesser General Public License [13]. Strong copyleft allows linking as well as releasing code changes only by sticking to the original license. Popular examples are the GNU General Public License [14] and the Affero General Public License (AGPL) [15]. he AGPL is in a way special as it additionally closes the so called “application service provider loophole”. The given requirements induced by the corresponding license normally must only be met in case the sotware is distributed. Nowadays, in the age of cloud computing, access to sotware’s functionalities are more and more ofered through Web interfaces according to the sotware as a service (SaaS) delivery model. As a consequence the users of such sotware services do not receive the actual software in source or binary form. Due to this providers of such service oferings are not enforced to meet the original license terms. To address this shortcoming the AGPL has been defined to especially include this use case and imply all license terms of the sotware as if it was distributed in source or binary form. Numerous guides are available that discuss the diferences, advantages and disadvantages of common Free Sotware and http://dx.doi.org/10.4258/hir.2014.20.1.11 Floss in Health Care: A Review Open Source licenses. A general in-depth essay has been written by Laurent [16] and is available as open book. Morin et al. [17] published a guide for the academic researcher. 2. Common Misunderstandings One popular advantage of FLOSS is that the sotware itself is available at no cost and is normally distributed as unrestricted download via the Internet. Many people infer from this fact that the underlying license terms prohibit any commercial exploitation and that there are no business models available to generate revenue based on FLOSS. Both points are not correct. he only diference to proprietary sotware and its underlying traditional business model is the absence of license costs. In the Open Source definition the stated clause “Free Redistribution” requires that the “license shall not require a royalty or other fee”. Any other sources of revenue, like for example service-based offerings, can be utilized to the same extent and without restrictions. To sum up, FLOSS is not the counterpart to commercial sotware. here are various business models available that offer convenient ways to generate revenue based on FLOSS [18]. Closely related is also another misconception in respect to costs. As the sotware itself can be obtained for free, it does not consequently mean that its use and TCO will be cheaper or at no costs. There are experiences that show that after using FLOSS for several years the TCO has been slightly cheaper or similar to proprietary sotware and that considerable savings could only be achieved by the absence of the license costs. Furthermore there are efects that are quite hard to be expressed in pure monetary terms like prevention of vendor lock-in. Another misinterpretation of FLOSS principles is related to the release and distribution of the resulting software. A common perception is that as soon as one modiies FLOSS or integrates it in a closed-source product, the resulting sotware and its source code have to be made publicly available to everyone via the Internet. But what actually is required varies strongly depending on the underlying license as described before. First of all this issue must only be addressed if the result is redistributed. For example source code that is licensed under a permissive FLOSS license can be modiied and/or integrated in closed-source sotware without the need to release the resulting product under similar terms. In contrast strong copylet FLOSS licenses would require a release under the same license and the provision of the resulting source code, but only to those who receive the sotware in binary form. Of course a public release on the Internet is highly appreciated by the community and is probably the easiest way to distribute the related source code. However, it Vol. 20 • No. 1 • January 2014 is not demanded by the underlying license terms. Sometimes FLOSS is falsely lumped together with freeware or shareware. Although the names itself may sound similar, freeware or shareware have nothing in common besides of that they may be gratis or can be shared. Both types are clear closed-source products that come with considerable restrictions on its use and may even contain advertising functionality or more serious threats on the privacy of its user. III. FLOSS in Health Care FLOSS-HC is different from FLOSS in other domains. The healthcare domain is very complex. Sotware solutions oten depend on regional and national regulations, inal products have to be certiied in most countries and health care providers require professional support services for available products. Many examples for successful FLOSS-HC projects are available today. There are several factors that are indispensable for the sustainability and the success of a product. Some of these factors are: 1) Existence of a developer and user community, 2) Reliable release cycle, 3) FLOSS governance, 4) Modular architecture, 5) Sotware documentation including handbook, and 6) Professional support services. Several scientiic papers have been published in the last decade about FLOSS-HC [19-42]. An overview of these articles is given in Table 1. Several researchers have carried out studies to find out reasons for adopting or not adopting FLOSS-HC. Pare et al. [43] have examined the main barriers to open source adoption by interviewing CIOs in Quebec’s health care organizations. he three most frequently cited barriers are according to their indings lack of internal IT resources and expertise, internal and external political pressure and lack of reliable information about open source products. Schmuhl et al. [44] have studied the view of health IT executives on the use of open source software in health care delivery in major hospitals in Germany and other European countries. Significant advantages have been seen in the absence of license costs and the opportunity to actively participate and collaborate on its development. Major disadvantages are lack of professional support and the lack of liability and accountability. The adoption of open source software benefits from executives’ dissatisfaction with proprietary vendors and their trust into the power of the community. Hindering factors are seen in the complex and continuously changing legal regulations relevant to health IT and the unpredictable evolvement and outcome of a community-based development approach. www.e-hir.org 13 Thomas Karopka et al Table 1. Free/Libre Open Source Software in health care reviews from 2003 to 2013 Author Year Title McDonald et al. [19] 2003 Open Source sotware in medical informatics: why, how and what Leong et al. [20] 2007 Free and open source enabling technologies for patient-centric, guideline-based clinical decision support: a survey Munoz-Cornejo [37] 2007 An empirical investigation into the adoption of open source sotware in hospitals Nagy [38] 2007 Open source in imaging informatics Yellowlees [33] 2008 Standards-based, open-source Electronic Health Record systems: a desirable future for the U.S. health industry Valdes [22] 2008 Free and open source sotware in healthcare 1.0 Murray et al. [21] 2009 Open source and healthcare in Europe: time to put leading edge ideas into practice Janamanchi et al. [23] 2009 he state and proile of open source sotware projects in health and medical informatics Pare et al. [43] 2009 Barriers to open source sotware adoption in Quebec’s health care organizations Bhandari and Snowdon [41] 2010 Adoption of open source sotware in healthcare Loiterman [24] 2010 Free as in freedom: open source sotware’s role in remaking healthcare in the twentyirst century Morrison et al. [36] 2010 Report on existing open-source Electronic Medical Records Atalag and van Hufel [25] 2010 Innovation and openness: Is there room for both Flores Zuniga et al. [34] 2010 Functionalities of free and open Electronic Health Record systems Karopka et al. [26] 2011 Towards open collaborative health informatics: the role of free/libre open source principles Reynolds and Wyatt [27] 2011 Open source, open standards, and health care information systems Webster [28] 2011 he rise of open-source Electronic Health Records Ratib et al. [39] 2011 Open Source sotware and social networks: disruptive alternatives for medical imaging Millard et al. [29] 2012 Open-source point-of-care Electronic Medical Records for use in resource-limited settings: systematic review and questionnaire surveys Maglogiannis [30] 2012 Towards the adoption of open source and open access Electronic Health Record systems Kobayashi [31] 2012 Open source sotware development on medical domain Sainz de Abajo and Ballestero [32] 2012 Overview of the most important open source software: analysis of the benefits of OpenMRS, OpenEMR, and VistA Vasudeva [42] 2012 Open source: an innovation paradigm Ingram and Arikan [35] 2013 he evolving role of open source sotware in medicine and health services Reynolds [40] 2013 Better value digital health: the medium, the market and the role of openness Vest and Stephens [45] 2013 The use and role of open source software applications in public and not-for-profit hospitals in the United States Goldwater et al. [46] 2013 he use of open source Electronic Health Records within the federal safety net Schmuhl et al. [44] 2013 Use of open source sotware in health care delivery: results of a qualitative ield study Vest and Stephens [45] have questioned CIOs of hospitals in the United States about the use and perception of open source sotware health information technology. heir central inding is that only general purpose applications are widely 14 www.e-hir.org used. Main advantage for adoption is seen in cost savings, disadvantages are primarily that available solutions did not sufficiently support the clinical workflows and that relying on these bared to much risk. Furthermore interviewees http://dx.doi.org/10.4258/hir.2014.20.1.11 Floss in Health Care: A Review stated to still rely heavily on vendor support. Goldwater et al. [46] have run a study on the use of open source Electronic Medical Records (EMR) within the United States Federal Safety Net. heir main results reveal that users value to be able to utilize a large community of developers and users to optimize the sotware to their needs and that the acquisition and implementation costs are lower compared to proprietary software. Factors restraining the dissemination and use of open source sotware are described to be the negative connotation associated with this type of software and the advanced technical skills that are required in-house to assure efectiveness of its application. 1. Information Sources about FLOSS in Health Care on the Web A decade ago information and knowledge about FLOSSHC was only available through news groups and limited to a small group of experts. One of the irst initiatives to spread the news about the topic of FLOSS-HC was the news portal LinuxMedNews [47] developed by Ignacio Valdes. LinuxMedNews was founded in 2000 and since then nearly 2,000 articles have been published. he main objective of the site is to serve as a platform for medical FLOSS news. LinuxMed- News cover news about FLOSS Electronic Health Records (EHR), medical billing, EMR and practice management systems. Another source of information is Open Health News (OHNews) [48] which is a combination of news, information, and resource portal on all things related to ‘Open Health’— i.e., open source, open access, open data, open architecture, open standards, and open communities in healthcare. OHNews grew out of VistA News, a paper based industry newsletter. In 2010 a team was formed to create the online website which was launched in early 2011. Since then the site had more than 7 million hits and more than 135,000 unique users (data from website October 2013). In 2010 this portal did not yet exist and information was dispersed over the internet. The open information portal Medloss.org was created in 2010 out of the need to have a central repository of relevant FLOSS projects for the healthcare sector [26]. he main idea was to ofer a structured description, related links and additional information resources on a per project base. Originally this data could only be retrieved by utilizing a search engine, browsing relevant hits for more information or by mining a typical source code repository like sourforge.net or github.com. Medfloss.org Table 2. Resources for Free/Libre Open Source Software (FLOSS) on the Web Name Type URL Region served OpenHealthNews News/resource http://www.openhealthnews.com/ World COSI Open Health Web-portal http://sites.google.com/site/cosihealthit/ World MedFLOSS Web-portal http://www.medloss.org World FOSS-for-Health Web-portal http://www.foss-for-health.org/portal/ World LinuxMedNews News http://linuxmednews.com/ World Wikipedia List of Open Source in HC Wiki http://en.wikipedia.org/wiki/List_of_open_source_ healthcare_sotware World OSEHRA Foundation http://www.osehra.org/ North America/World Open Health Tools Foundation http://www.openhealthtools.org US/World Open Source Health Informatics in the UK Blog http://www.oshi-uk.com/ UK Open Health Innovation Blog http://opensource.com/health World eHealth Open Source Web-portal http://www.ehealthopensource.org/ UK eHealth Open Source LinkedIn Group http://www.linkedin.com/groups/eHealth-OpenSource-3407265 World Open Source Software in Health Care LinkedIn Group http://www.linkedin.com/groups/Open-Source-Software-in-Health-1849332 World Fred Trotter Blog http://www.fredtrotter.com/ US/World COSI: Collaboration, Open Solutions & Innovation, FOSS: Free and Open Source Sotware, HC: health care, OSEHRA: Open Source Electronic Health Record Agent. Vol. 20 • No. 1 • January 2014 www.e-hir.org 15 Thomas Karopka et al now offers a one-stop shop for anyone interested in medical FLOSS. Listed projects are tagged in multiple categories that are specific to the healthcare domain like application type, supported enterprise function, supported interoperability standards as well as in common properties like license, programming language, and supported platform. his guarantees not only easy discovery but also comparability of relevant candidates. Each project entry is enriched with links to the project’s homepage and its download, documentation and support sections. Moreover companies that are ofering services and scientiic publications are included in the database of Medfloss.org and interlinked with the project they are referring to. In numbers currently about 300 projects, 235 publications, and 100 services providers are listed. hese are being viewed by about 3,350 unique visitors of Medloss. org per month. Foss-for-health.org [49] is a portal that is initiated by Open Source and Standards PCTA (PANACeA Common Thematic Activities) that aims to create awareness of FLOSS in eHealth, promote its use and build both capacity and support for those starting to adopt it. PANACeA is the PAN Asian Collaboration for Evidence-based eHealth Adoption and Application. Table 2 contains an overview of online information sources about FLOSS in health care. 2. Events and Meetings for FLOSS in Health Care One of the first European Events for FLOSS-HC was the Special Topic Conference of the European Federation for Medical Informatics (EFMI) in 2008 which was organized by the Libre/Free Open Source Working Group (LIFOSS WG) of EFMI. More than 80 people from more than 15 different countries met at the premises of the British Computer Society in London to exchange experience of using FLOSSHC. he topic of this conference was “Open Source in European Healthcare”. This event was the trigger for a series of workshops organized by EFMI LIFOSS WG and International Medical Informatics Association (IMIA) Open Source Health Informatics Working Group (OS WG) [21,26,50]. In 2010 the first FLOSS track at Med-e-Tel [51], the flagship conference of the International Society for Telemedicine and eHealth (ISfTeH) [51] took place followed by tracks in 2011 [53] and 2012 [54]. In 2013 Med-e-Tel featured an “Open Source Village” to give FLOSS initiatives and projects the opportunity to demonstrate their work. In 2010 O’Reilly decided to integrate a track on healthcare in the O’Reilly Open Source Convention (OSCON) [55], probably the most important FLOSS event in North America. On the website Andy Oram explains why a healthcare track was integrated: “We believe that advances 16 www.e-hir.org in APIs, giving data to patients, open source software, and interactive mobile devices will free healthcare IT. We don’t know precisely which technologies will win out or how the whole thing will it together—so we want to use OSCON to help figure that out.” [56]. The healthcare track took place at OSCON 2010 [55], OSCON 2011 [57] and OSCON 2012 [58] but was discontinued in 2013. However, other events take over the role. In 2012 the irst Open Source Electronic Health Record Agent (OSEHRA) Open Source Summit took place and a second edition followed in 2013 [59]. 3. Working Groups and Other Initiatives In 2002 the IMIA OS WG [60] was founded with the ambition to promote FLOSS among the IMIA community and beyond. he IMIA OS WG aims to: disseminate knowledge about the beneits and prospects of FLOSS-HC among IMIA members and outside of IMIA; provide a neutral collaboration platform for all stakeholders in healthcare in respect to FLOSS; foster collaborations between FLOSS-HC projects; and lower the perceived barriers to the adoption of FLOSSHC. he Working Group closely collaborates with other Working Groups and initiatives with similar objectives among them the EFMI LIFOSS WG [61] and the Collaborative Care Team Open Source Working Group of the ISfTeH. Moreover, the American Medical Informatics Association has a working group for open source in healthcare as well [62]. Several Linux distributions have created dedicated projects to assemble medical related FLOSS packages and supply them as a module integrated in their software collections. he most well known are DebianMed [63], OpenSUSE Med [64], and Fedora Medical [65]. In the following paragraph we list some best practice examples from the MedFLOSS database. IV. Best Practice Examples One of the best known examples is the Veterans Health Administration VistA sotware that grew out of the Department of Veterans Affairs (VA) in the United States. The development began in the late 70s and early 80s and is now considered one of the most complex and useful systems covering the needs of a whole hospital. In an article in Health Afairs the potential value of the VA’s health IT investments is estimated at $3.09 billion in cumulative beneits net of investment costs [66]. he early pioneers later formed a group called the hardhats and the history of the VistA sotware can be found on their website [67]. Starting as a bottom-up initiative this has now transformed into an oicial organisation http://dx.doi.org/10.4258/hir.2014.20.1.11 Floss in Health Care: A Review created by the VA, the OSEHRA [59] as well as several ofsprings like WorldVistA [68] and OpenVista [32,69]. Other useful sources about the history and milestones in FLOSSHC can be found in Peter Groen’s COSI blog [70]. WorldVistA aims to adapt and extend the VA models and the values and principles on which they are based beyond the United States Federal government. “Drawing on experience with medical software going back four decades, the United States Department of Veterans Afairs originally designed VISTA’s 1) sotware structure, 2) support, 3) sotware lifecycle, 4) community organization, 5) expertise lifecycle, 6) management, and 7) economic relationships to make these things possible. Only a system based on these principles can fulfill the promise of using computers to improve health for everyone, everywhere. WorldVistA intends to realize that dream.” [68]. An example of WorldVistA’s activities is the Hakeem Project. he Hakeem Program was launched 2009 and aims to computerize all of the public hospitals and clinics in Jordan (50 hospitals as well as up to 800 clinics). It is the irst national eHealth project in Jordan. Hakeem is based on WorldVistA and is adapted to the needs and requirements of the Jordan health system including translation into Arabic. he customization is done by Electronic Health Solutions (EHS), a non-proit company based in Jordan. In the UK there exists an initiative to adopt VistA for the UK National Health Service (NHS) called NHS VistA [71]. “As a group of clinicians, IT professionals, NHS managers and patients, we think the NHS needs a high quality, clinically-led, EHR that works across all health and social care settings. Realistically, VistA is the only afordable way for the NHS to achieve this goal.” [71]. Another impressive best practice example is the OSCAR system developed at the McMaster University in Canada. The system is now called OSCAREMR [72] and currently supports over 1.5 million patients across Canada by offering an extremely versatile, browser-based, EMR with high clinical functionality and advanced research capabilities. “OSCAR is deeply rooted in its user community as relected in its motto, ‘Connecting Care, Creating Community’. his community is a vital part of the OSCAR ecosystem, with members from academic and research institutions, community practices, hospitals, ambulatory and outreach programs, public health departments, other social service agencies, and the OSCAR Canada User Society.” [72]. CONNECT is an open source sotware and community that promotes IT interoperability in the United States healthcare system. CONNECT enables secure electronic health data exchange among healthcare providers, insurers, government agencies and consumer services [73]. Vol. 20 • No. 1 • January 2014 Open Health Tools [74] is a not for proit association that aims to assemble or develop a comprehensive harmonized tool suite to enable the deinition, development and deployment of interoperable EHRs. Several projects are supported that cover the life cycle of EHRs in the broadest sense including development of standards, architectures, documentation, and training. For example Open Health Tools provides client side implementations of several key IHE proiles. hese implementations were used successfully by over 35 systems in various IHE Connectathons in North America and Europe. The Japan Medical Association has developed a medical accounting/billing system (Online Receipt Computer Advanced [ORCA]) in 2000 which is now used by more than 10.000 medical providers. ORCA is based on Debian GNU/ Linux and Ubuntu and uses PostgreSQL as database system [75]. V. FLOSS in Low Resource Settings he FLOSS approach is of particular interest for low resource settings. Being available without licensing fees makes these products the only viable solution for many countries. Another important advantage of FLOSS systems is the adaptability to local needs. OpenMRS is probably the best known and widest deployed system. Based on a clinical database model developed at the Regenstrief Institute in the United States and funded by the Rockefeller Foundation and International Development Research Centre Canada, this project managed to set up a powerful user and developer community including small local companies providing support and customization services for OpenMRS [76-79]. GNU Health is a free health and hospital information system with a focus on low resource settings [80]. Development has started in 2008 under the name ‘Medical’. he system is based on a free and open enterprise resource planning program, Tryton [81] and follows the same modular approach like the underlying enterprise resource planning (ERP) sotware. A big advantage of this approach is that the sotware “inherits” all modules that are developed in the Tryton ERP community. Despite its short history GNU Health provides extensive functionality and has installations in several countries worldwide, among them Argentina, Jamaica, Paraguay, Kenya, Laos, Philippines, Bangladesh, and Malaysia. Recently the government of Jamaica chose GNU Health as a national health IT system. GNU Health is further developed by a global community of health IT experts, physicians, and other end-users coordinated by GNU Solidario [82], an NGO based in Spain. GNU Health achieved several awards www.e-hir.org 17 Thomas Karopka et al among them the Free Sotware Foundation award for projects of social beneit in 2011. The District Health Information System [83] is a highly flexible, open-source health management information system and data warehouse developed by the Health Information Systems Programme (HISP). “he Health Information Systems Programme has since 1994 expanded from a pilot project in three Cape Town health districts to a global SouthSouth-North network active in around 15 countries/states with over 200 million people in Africa and Asia.” [84]. he core development activities are managed and coordinated by the Department of Informatics at the University of Oslo, and supported by The Norwegian Research Council, The Norwegian Agency for Development Cooperation (NORAD), The University of Oslo, and The Norwegian Centre for International Cooperation in Education. he system supports the capture of data linked to any level in an organisational hierarchy, any data collection frequency, a high degree of customisation at both the input and output side. It has been translated into a number of languages. For India there is a dedicated network, HISPIndia [85], a not for profit NGO specializing since more than a decade in designing and implementing solutions in health informatics for the public health sector in Indian states, and also recently in Bangladesh and Sri Lanka. OpenClinic GA is a FLOSS software for management of hospital information lows. he program has been developed since 2006 by a Belgium company and put in the public domain in 2008. Currently more than 15 country specific localizations are available and more than 2 million patients are served by these installations ranging from small clinics to entire hospitals. he biggest user community is in Burundi, Rwanda, and Mali, and the program features a full billing system for Central African public and private health insurance systems. More details can be found on the wiki site of the project [86]. OpenHIE is a community of FLOSS health IT projects made up of many different organizations and individuals [87]. OpenHIE is comprised of six sub-communities covering the areas of Client Registry, Provider Registry, Facility Registry, Terminology Services, Shared Health Record, and Interoperability Layer. he main objective of the OpenHIE project is to use FLOSS components to build a health information exchange. VI. Conclusion FLOSS has gained much attraction in the recent decade. In healthcare it has always been used to some extend in re18 www.e-hir.org search and academic settings. However, FLOSS-HC delivery is much more demanding and most countries lack a FLOSS ecosystem, including, e.g., professional support services, that is essential for the sustainability of solutions. North America has the longest tradition in applying FLOSS-HC delivery. It is home of many mature, stable and widely disseminated FLOSS applications. Some of them are even used on a global scale. he deployment of FLOSS systems in healthcare delivery is comparatively low in Europe. Due to the fragmentation of healthcare, with a wide range of diferent systems run at national level, it is diicult to get a clear picture about FLOSS usage throughout the continent. here is also no organized FLOSS-HC community in Europe as such. However, on a national level the igures vary extensively. he UK has a long tradition of FLOSS-HC and very recently has made considerable progress and has without doubt the most active and vibrant FLOSS-HC community in Europe. In 2012 a series of “NHS Hack Days” [88,89] have been started each bringing together around “120 volunteer doctors, developers, designers and other ‘geeks who love the NHS’” [40] with the objective to improve currently available solutions or ind solutions for existing problems. Regarding low resource settings, there are a number of mature and stable systems. Several systems are deployed in different countries and even on diferent continents. However, compared with the proprietary systems the level of usage is still low. he objective of an open platform where diferent modules can be plugged in and where different applications can be assembled to form a highly adaptable and conigurable system has yet to be approached. he ‘global community’, if this exists at all, is still very fragmented. Open Standards, Open Science, Open Data, and FLOSS are the most promising way to create synergies and make healthcare more achievable on a global level. Besides the sharing of knowledge and resources, FLOSS is facilitating health information systems that are sustainable at a long-term, as not only the sotware but also the data that they contain are accessible and thus allow for migration processes. he past ive years have seen a tremendous growth in global initiatives and collaborative effort among different FLOSS projects. Several sites have been developed to function as a one-stop-shop for news and information around FLOSSHC (e.g., MedFLOSS, OpenHealthNews, COSI, OSEHRA). It is now time for governments, policy makers, regulators, NGOs, healthcare IT providers, and healthcare providers to create open ecosystems to foster innovation and remove barriers for cross-sectoral, collaborative team-based healthcare research and delivery. http://dx.doi.org/10.4258/hir.2014.20.1.11 Floss in Health Care: A Review Conlict of Interest No potential conflict of interest relevant to this article was reported. 11. Acknowledgments he authors would like to thank the FLOSS community, the enthusiastic project founders, the visionary pioneers as well as the anonymous sotware developers and coders dedicating their time and brains to provide the public with excellent tools and applications to make healthcare delivery more achievable and afordable for all. 12. 13. References 14. 1. 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