Open Source EHRs Set to Grow; Government backing gives open source a boost.

(Editor's note: For more on open source software, read the June 2009 print cover story titled "Open Sesame.")

On the surface, open source technology seems questionable—software engineers finagling with code and cobbling together a system that constantly evolves from countless minds. In reality, open source is a viable option for HIT, and its ability to retool and reshape rapidly may prove beneficial as new technologies and health care innovations emerge.

"The trajectory of open source is dramatic," said Tom Jones, MD, chief medical officer, Tolven, who works with open source systems. "It's doing nothing but increase."

With Washington abuzz, open source is on the rise. But certification issues may prove to be a glass ceiling over its upward climb.

Federal Attention

Open source options for health care started gaining ground in government last September, when Rep. Pete Stark promoted its low-cost approach to EHRs in a proposed bill. The Health-e Information Technology Act of 2008 called for standards and deadlines for widespread EHR adoption and noted the potential open source technology has to help small and rural hospitals get on board.

Open source popped up again on Feb. 17, with the signing of the American Recovery and Reinvestment Act (ARRA), which echoed many of Rep. Stark's suggestions. While it doesn't champion open source as the solution, ARRA does call for an investigation into open source options for HIT. The deadline for study results is slated for Oct. 1, 2010.

The most recent gust of federal support hails from West Virginia; Sen. John D. Rockefeller IV proposed legislation in April that promotes open source technology as a way to help providers—especially small and rural organizations—launch EHRs that meet government requirements. The Health Information Technology Public Utility Act calls for a new grant program to fund open source implementations and continued conversations among open source suppliers. The legislation now awaits debate.

Interest isn't just on paper, either. Dr. Jones cited a report last year that found more than half of federally funded IT projects in the U.S. use open source components. Though not fully open source, those projects recognize the value of community-based development, Dr. Jones said.

"I think it's a broader move and a very wise line of thinking at the federal level to support open-source projects," said Rick Jung, chief operating officer, Medsphere Systems Corp., noting that the Nationwide Health Information Network, a government pilot for health information exchange, was recently open sourced. It's proof the industry is at a "tipping point," according to Jung.

Getting Certified

As open source gains popularity, it'll have to contend with certification issues. By its nature, the community-based technology is constantly evolving, which makes it difficult to certify by today's standards. The Certification Commission for Healthcare Information Technology (CCHIT) is currently the main certifying body for EHRs, but its criteria do not accommodate the open source approach, critics say.

"Once you get certified, because the [open source] product is evolving so quickly, that evolution has to, under the current methodology, become re-certified. And that's a $50,000 endeavor today," explained Mike Doyle, CEO, Medsphere.

Those who have been certified admit it's an arduous task. While it's worth the effort to earn certification that lasts several years, the application process is too daunting to complete for each open source innovation.

CCHIT has also been criticized for focusing too much on functionality—"bells and whistles," Doyle said—and not enough on usability and patient safety. "Just like the Good Housekeeping 'Seal of Approval,' there are basic things that need to be in an EHR, but a better way of looking at the efficacy of that EHR is clinical outcomes," Doyle explained.

Open source proponents are hoping recent government interest in EHRs will yield new certification criteria. The stimulus plan established an HIT Standards Committee to define certification requirements for EHRs, but it has yet to define "certified." CCHIT has offered its criteria for consideration, but open source advocates want standards to be more welcoming to innovation. "We absolutely believe there needs to be some level of certification, but it just needs to be flexible enough to enhance community contributions," Jung said.

In response to ARRA, CCHIT is re-examining its certification criteria to be more accessible to different EHR models. The commission announced its 2009-2010 requirements last month, but is waiting for feedback from the HIT Standards Committee before accepting applications, according to a press release. On June 16, CCHIT hosted a Web conference that addressed the open source community's concerns about certification standards. Stakeholders were invited to ask questions and share comments during the "Town Call."

Regardless of who or what the new certifying body turns out to be, Jung said it's important that standards address quality of care. "You've got to certify that it does what you need it to do and you're having the right outcomes," he explained. "And that's where we'd like to see this go."

Cheryl McEvoy is an editorial assistant with ADVANCE.