Open Source Electronic Health Records: Will They Support Clinical Data Needs of the Future? (Part 2 of 2)

The first part of this article provided a view of the current data needs in health care and asked whether open source electronic health records could solve those needs. I’ll pick up here with a look at how some open source products deal with the two main requirements I identified: interoperability and analytics.

Interoperability, in health care as in other areas of software, is supported better by open source products than by proprietary ones. The problem with interoperability is that it takes two to tango, and as long as standards remain in a fuzzy state, no one can promise in isolation to be interoperable.

The established standard for exchanging data is the C-CDA, but a careful examination of real-life C-CDA documents showed numerous incompatibilities, some left open by the ambiguous definition of the standard and others introduced by flawed implementations. Blue Button, invented by the Department of Veterans Affairs, is a simpler standard with much promise, but is also imperfectly specified.

Deanne Clark, vxVistA Program Manager at DSS, Inc., told me that VistA supports the C-CDA. The open source Mirth HIE software, which I have covered before, is used by vxVistA, OpenVista (the MedSphere VistA offering), and Tolven. Proprietary health exchange products are also used by many VistA customers.

Things may get better if vendors adopt an emerging HL7 standard called FHIR, as I suggested in an earlier article, which may also enable the incorporation of patient-generated data into EHRs. OpenMRS is one open source EHR that has started work on FHIR support.

Tolven illustrates how open source enables interoperability. According to lead developer Tom Jones, Tolven was always designed around care coordination, which is not the focus of proprietary EHRs. He sees no distinction between electronic health records and health information exchange (HIE), which most of the health IT field views as separate functions and products.

From its very start in 2006, Tolven was designed around helping to form a caring community. This proved useful four years later with the release of Meaningful Use requirements, which featured interoperability. APIs allow the easy development of third-party applications. Tovlen was also designed with the rights of the patient to control information flow in mind, although not all implementations respect this decision by putting data directly in the hands of the patient.

In addition to formats that other EHRs can recognize, data exchange is necessary for interoperability. One solution is an API such as FHIR. Another is a protocol for sending and receiving documents. Direct is the leading standard, and has been embraced by open source projects such as OpenEMR.

The second requirement I looked at, support for analytics, is best met by opening a platform to third parties. This assumes interoperability. To combine analytics from different organizations, a program must be able to access data through application programming interfaces (APIs). The open API is the natural complement of open source, handing power over data to outsiders who write programs accessing that data. (Normal access precautions can still be preserved through security keys.)

VistA appears to be the EHR with the most support for analytics, at least in the open source space. Edmund Billings, MD, CMO of MedSphere, pointed out that VistA’s internal interfaces (known as remote procedure calls, a slightly old-fashioned but common computer term for distributed programming) are totally exposed to other developers because the code is open source. VistA’s remote procedure calls are the basis for numerous current projects to create APIs for various languages. Some are RESTful, which supports the most popular current form of distributed programming, while others support older standards widely known as service-oriented architectures (SOA).

An example of the innovation provided by this software evolution is the mobile apps being built by Agilex on VistA. Seong K. Mun, President and CEO of OSEHRA, says that it now supports hundreds of mobile apps.

MedSphere builds commercial applications that plug into its version of Vista. These include multidisciplinary treatment planning tools, flow sheets, and mobile rounding tools so doctor can access information on the floor. MedSphere is also working with analytic groups to access both structured and unstructured information from the EHR.

DSS also adds value to VistA. Clark said that VistA’s native tools are useful for basic statistics, such as how many progress notes have not been signed in a timely fashion. An SQL interface has been in VistA for a long time, DSS’s enhancements include a graphical interface, a hook for Jaspersoft, which is an open source business intelligence tool, and a real-time search tool that spiders through text data throughout all elements of a patient’s chart and brings to the surface conditions that might otherwise be overlooked.

MedSphere and DSS also joined the historical OSEHRA effort to unify the code base across all VistA offerings, from both Veterans Affairs and commercial vendors. MedSphere has added major contributions to Fileman, a central part of VistA. DSS has contributed all its VistA changes to OSEHRA, including the search tool mentioned earlier.

OpenMRS contributor Suranga Kasthurirathne told me that an OpenMRS module exposes its data to DHIS 2, an open source analytics tool supporting visualizations and other powerful features.

I would suggest to the developers of open source health tools that they increase their emphasis on the information tools that industry observers predict are going to be central to healthcare. An open architecture can make it easy to solicit community contributions, and the advances made in these areas can be selling points along with the low cost and easy customizability of the software.

About the author

Andy Oram

Andy Oram

Andy Oram writes and edits documents about many aspects of computing, ranging in size from blog postings to full-length books. Topics cover a wide range of computer technologies: data science and machine learning, programming languages, Web performance, Internet of Things, databases, free and open source software, and more. My editorial output at O'Reilly Media included the first books ever published commercially in the United States on Linux, the 2001 title Peer-to-Peer (frequently cited in connection with those technologies), and the 2007 title Beautiful Code. He is a regular correspondent on health IT and health policy for He also contributes to other publications about policy issues related to the Internet and about trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business.