Open-source EHR: functionality, benefits
and limitations

Open-source EHR: functionality, benefits and limitations

January 5, 2023

Sergey Ivanov
by Sergey Ivanov, Head of Healthcare Center of Excellence

Healthcare software and electronic health records systems in particular tend to be quite expensive. To make matters worse, they are often not as efficient as the adopters had hoped. Cumbersome interface, poor interoperability, and limited practice-specific features are widely-known problems with EHRs that healthcare providers typically resolve with the help of an experienced EHR implementation team.

However, some hospitals choose a different path and opt for an open-source EHR solution instead of a proprietary one. While not all practitioners are aware of its benefits and value yet, this software has the potential to resolve most of the typical EHR issues.

Open-source EHR is software with a source code in the public domain and accessible to anyone. Contrary to proprietary EHR/EMR systems, there are no restrictions regarding open-source EHR’s code distribution, derivative works, or modifications, as long as they comply with the Open Source Initiative (OSI) criteria.

Widely known open-source EHR software

Target users
Solo practices Small and midsize organizations
Price
Free to download and use
ONC/HIPAA compliance
Depends on the solution
Security
As well-secured as proprietary software

Open-source vs other types of EHRs

Even though open-source, proprietary, and custom EHRs have the same purpose and similar features, they differ in various major aspects.

EHRs

Open-source

Proprietary out-of-the-box

Custom

Source code

EHRs

Open-source

Proprietary out-of-the-box

Custom

It’s possible to modify the source code to fit a particular organization’s needs

The solution’s source code cannot be altered

The system is developed from scratch and the source code can be changed

Features

EHRs

Open-source

Proprietary out-of-the-box

Custom

Basic features by default

Numerous pre-installed features

Features are based on a particular organization’s requirements

Price

EHRs

Open-source

Proprietary out-of-the-box

Custom

Free of charge

Upfront costs and regular license fees

Upfront costs may be greater than for out-of-the-box system or open-source solution

Interface

EHRs

Open-source

Proprietary out-of-the-box

Custom

Simple interface

More complex interface

Custom interface

Customer support

EHRs

Open-source

Proprietary out-of-the-box

Custom

Community forums are the major customer support source

Customer support is a part of implementation offer or a separate service

Customer support is a part of implementation or a standalone service.

Security

EHRs

Open-source

Proprietary out-of-the-box

Custom

Community is in charge of EHR’s security

Vendor is in charge of EHR’s security

Vendor is in charge of security

Compliance

EHRs

Open-source

Proprietary out-of-the-box

Custom

Compliance varies for every system

Compliance with major regulatory standards and ONC

Compliance with major regulatory standards, including HIPAA and ONC

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Essential features of open-source EHRs

Out-of-the-box features from most open-source EHR software can cover the basic needs of any healthcare organization.

Patient engagement capabilities

Billing management

Analytics and reporting

Prescription management

Appointments scheduling

Patient records management

Open- source EHR

Benefits of open-source EHR systems

While open-source software solutions (OSS) are appreciated for their affordability in the first place, they can bring many other advantages.

Cost-saving

Most open-source EMR software and EHR solutions are free software systems or at least significantly cheaper than popular licensed solutions, which can save a medical practice a significant portion of their budget.

The chart on the right shows that the most popular budget for EHR is roughly $500 per month for most healthcare organizations regardless of their size. However, $500 for a hospital with 100+ employees and a practice with only 5 staff members is a different sum. It’s no wonder that smaller and mid-sized practices prefer open-source solutions.

Scheme title: EHR budgets per provider, per month
Data source: softwareadvice.com — EMR Pricing Explained: Your Guide to Upfront, Recurring & Hidden Costs, February 25, 2021

High levels of customization

An open-source EHR lets healthcare professionals build a system with necessary features only. While it takes effort to customize the proprietary EHR because some functionality is built-in and cannot be altered, open-source EHR can be modified down to its basic features. As a result, a fully custom EHR can mitigate personnel burnout and reduce the time spent on administrative tasks.

Interoperability

Developers from open-source communities adhere to the particular standards of health data management and transfer, communication protocols, and documentation formats. This creates an excellent interoperable ecosystem, where EHR users successfully exchange patient data among open-source and proprietary systems. The transparency of the source code also enables simple and secure open-source EHR connection to other systems and third-party applications.

Strong security

A lot of medical practitioners dismiss open-source software, considering it poorly protected. In fact, the security of open-source EHR software is not inherently better or worse than proprietary solutions. What is more, the OSS community can be very vigilant, with enthusiastic users quick to report and fix any arising security problems. While proprietary systems need the EHR vendor’s team to solve problems in the new version, open-source EHRs can be improved and updated much quicker.

Risks and limitations of open-source EHRs

Despite their advantages, open-source EHRs come with their own drawbacks, so healthcare organizations should prepare for these potential challenges and have a solution on hand.

Limitation

What you can do

Limited set of out-of-the-box features

Limitation

What you can do

Most open-source EHR software offers only a basic set of features from the get-go, which virtually eliminates the difference between EHR and EMR software. These might be sufficient for some general practices, especially smaller ones, but others find themselves in a need of additional functionality sooner or later. Even if additional modules are easy to install, it takes time, effort, and requires another round of adjustment from IT personnel.
Be realistic when planning an EHR implementation and write down all the features you might find necessary now or in the nearest future. After that, you can go for an open-source system that meets the majority of criteria.
Lack of 24/7 support

Limitation

What you can do

While an open-source community is welcoming and helpful and can provide you with lots of useful resources and tips, it can’t compare to dedicated customer support a commercial EHR vendor offers. Open-source EHR users can’t reach out to a support team and get the issue fixed right away by a professional, which can prove to be a serious setback in a medical setting.
You can hire a specialist to support your open-source EHR system, which is still cheaper than purchasing an EHR vendor’s support in some cases. Another option is to delegate this responsibility to a member of your staff, if you happen to employ a person with OSS experience, an IT expert, or simply a clinician willing to put time and effort into fixing arising issues.
A limited number of properly compliant systems

Limitation

What you can do

Open-source EHRs may not have the necessary compliance mechanisms developed for countries that don’t have the equivalent of HIPAA or GDPR regulations. Another reason for non-compliance is that the community can’t keep the software up to date with the changes in regulations.
Research the system you want to implement and make sure it complies with the regulations necessary in your particular region. Your choices might be limited, but by adopting a compliant system you will ensure your patients’ information is protected and avoid penalties from the regulatory authorities.

Open-source EHR target companies

Due to their advantages and limitations, open-source EHRs are suited for some companies more than others.

Companies with tech-savvy staff

If your clinicians are fluent enough with open-source software, implementing an open-source EHR is a logical step. Specialists familiar with open-source systems can help with its implementation and employee training, making the adoption smooth.

Practices with limited funds

Many small, local or developing country-based organizations just don’t have the money for proprietary EHR and don’t want to install their free versions because of the ads, hidden costs, or models of monetization that charge patients instead of the practice. If you are willing to put effort into adapting to open-source software to cut costs, open-source EHR is a good call.

Organization with unconventional workflows

There are cases when proprietary EHRs just don’t cut it in terms of personalization and functionality. Companies that want to fully customize a system to their clinical workflow might prefer open-source products, as they are much easier to personalize than proprietary systems.

Open-source EHR customers

That said, you don’t have to match any of the above criteria if you want to implement an open-source system. There are many more reasons to opt for it: the need for enhanced transparency of patient data handling and clinical workflows, the belief that healthcare software should remain free for everyone, or the wish to support the OSS movement.

Notable examples of open-source EHR adopters

Still, not only small and middle-sized practices choose open-source software. Huge international organizations also opt for open-source solutions when they want every aspect of their operation to be fully transparent to the public and get an EHR fully customizable to their needs.

The state of North Carolina saves millions of dollars thanks to VistA

A large mental health in-patient facility operated by the state of North Carolina has implemented a VistA-based free and open-source software stack for electronic records. With the facility funded by taxes, a decision was made to implement a free and open-source solution, which saved North Carolina taxpayers millions of dollars. Here’s K.S. Bhaskar, the president of database company YottaDB that implemented VistA in this case, talking about this and other healthcare organizations that have chosen VistA-based EHR software.

Open-source EHR improves profit margins for community health centers

An Independent Physician Association (IPA) in Texas consists of 520 physician practices, most of which don’t have EHRs. The main listed reason for practices’ refusal to implement such a software is the high cost of the proprietary systems. However, member physicians can lose as much as 15% of the revenue paid for health services due to late or inaccurate reporting of a patient’s medical condition. This puts practitioners in a dire need for quick and paperless patient records exchange. By implementing OpenEMR, the Association solved the problem of inadequate reporting, helping physicians gain their deserved incentive bonuses and improve their care quality through teamwork enabled by practice management capabilities.

Best open-source EHR solutions

Although there are dozens of open-source EHR systems on the market, only a selected few can compare in popularity with large proprietary platforms like Epic or Meditech. We’ll describe them and a couple of other more widely-used open-source EHR solutions in detail.

Chart title: Popular open-source and proprietary EHR systems based on search trends

Data source: Google Trends

OpenEMR is the most popular open-source electronic health records and medical practice management solution according to their website, with more than 3000 downloads monthly. It is written in PHP, has detailed and exhaustive tech documentation, and a secure API which simplifies modification and integration. OpenEMR also has rich functionality for clinical decisions and competes with popular proprietary EHRs.
Compliance
OpenEMR is HIPAA-compliant, meets the criteria of the 2015 Edition CEHRT, and provides basic FHIR support for easy patient information exchange and integration with other healthcare systems
Remote access
OpenEMR is a web-based suite that supports remote access from PCs, laptops and mobile devices
Core features
Electronic medical records management with sophisticated input capabilities like voice recognition Patient profile forms that include demographics, a variety of health metrics, diagnosis and treatment information Data storage and transfer according to FHIR/CCDA Appointment scheduling for multiple facilities with alerts, notifications and instant messaging capabilities E-prescription module Billing management, claims management, and insurance tracking Reporting and analytics Patient portal

The source code of VistA gave a start to many derivative versions of it: OpenVistA, OSHERA VistA, etc., which aren’t all free. The solution is written in MUMPS, a language used specifically by healthcare software providers. Big players like Epic also use it, but the community of developers for this language is small, which makes it hard to find IT service providers or support teams.
Compliance
Most free versions are not ONC-certified. OSHERA VistA meets most Meaningful Use criteria but is not officially verified. The paid versions of the system are properly certified and compliant with GDPR and HIPAA
Remote access
Most free versions are on-premise only but can be connected within the intranet system VistAWeb, which allows hospitals with VistA EHR to seamlessly share medical records
Core features
Patient records management and extended profiling that includes demographics, health metrics, diagnosis and treatment info, and immunizations Appointment scheduling capabilities Module that supports e-prescribing Medical billing, claim and insurance management features (depending on the version) Patient engagement tools, including a messaging system, patient portal integrations or educational materials (depending on the version)

OpenEHR is not a ready-to-use system, but rather a blueprint and a set of tools that can be used to assemble a custom medical EHR with the help of an implementation team. OpenEHR includes an EHR base, serving as a foundation for EHR system building; an EHR server, which provides a secure REST API to store and query clinical data; and EtherCIS (Ethereal Clinical Information System), an open source platform compatible with the openEHR standard and designed to allow simple interactions with clients through RESTful API.
Open-source EHR customers
clinical processionals
hospitalEHR
regionalEHR
research analytics
domain knowledge
openEHR Vendors
platform systems
platform apps
openEHR International
clinical models
specifications
open source software

There are a variety of modules created by different developers based on Odoo’s open source code, which can serve as great building blocks for healthcare solutions. One such block is a hospital management system that also includes EHR functionality. The base module is inexpensive and doesn’t require much technical knowledge to install and use “as is”, so it is a great start for those who want to tap into open-source software. Yet, we suggest installing some premium features with the help of a dedicated implementation team to reap maximum benefits from this system and personalize it for your organization.

Image title: Odoo-based EHR module for HMS
Data source: apps.odoo.com

Odoo-based EHR module for HMS

Basic

Premium

Patient management features

Basic

Premium

Patient registration Patient details Patient registration card, barcode print Registration notifications Medical alerts

Patient photo capture Vaccination records Insurance management Patient portal access Medical personnel dashboards

Appointment and treatment management features

Basic

Premium

Treatment management Appointment management Tracking patient’s consultation and waiting times Automated follow-up scheduling

Online appointment booking Patient queue management Laboratory and diagnostics management Pharmacy management

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How to choose the right EHR solution?

The choice of an EHR solution is a difficult one because so much in the hospital will depend on it. Should you go for a more transparent, cheaper but harder-to-implement open-source EHR or choose a more costly and less personalized but ready-to-use commercial solution? Or, maybe, your ideal EHR should be customly developed? We recommend answering the following essential questions to make the best decision.

No
Do you have around $500 to pay for an EHR monthly?
Yes
No
Do you have tech-savvy staff, a dedicated IT-team, or a budget to hire a professional for EHR support?
Yes
Yes
Do you need a lot of customization?
No
Do you mind seeing a lot of ads every day or prefer charging users for the EHR?
Do you mind outdated interface design?
Do you need a dedicated support team?
Does your EHR have to be integrated with lots of other healthcare solutions?
Yes
Yes
Yes
Yes
No
No
No
No
Free
Open-source
Custom software
Out-of-the-box solution

However, for some practitioners the answers to the questions above are not straightforward.

In such cases, we advise you to consult a professional to help you choose the solution that meets your organization’s requirements.

Consider open-source EHR for your medical practice

Open-source software has the potential to revolutionize the healthcare industry by solving the old interoperability problem, making quality solutions more affordable for small and mid-sized practices, and delivering a satisfactory level of personalization even for niche fields of medicine. However, the community of enthusiasts providing technical support and delivering new versions of open-source EHRs is too small for such systems to gain traction with the healthcare industry.

Implementing and using most open-source solutions often requires technical skills that regular practitioners often don’t have. Whether the OSS community will overcome this obstacle and become the new hope of the healthcare industry or not, only time can tell. Meanwhile, you can always turn to Itransition for an expert consultation, open-source EHR implementation, or integration services. With an extensive knowledge of the industry, our team will also support or upgrade your current open-source software to boost its performance and your care services.

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