Open-source health information technology: A case study of electronic medical records

Validation of adult asthma case definitions for primary care sentinel surveillance

BACKGROUND

Most asthma diagnoses and patient care take place in primary care settings. Electronic medical records (EMRs) offer an opportunity to utilize technology to improve asthma diagnosis and care. The purpose of this study was to create and validate separate case definitions for suspected and confirmed asthma in primary care EMRs, to enable surveillance, benchmarking, and quality improvement in primary care settings. The objective of this study was to develop a case definition for suspected and confirmed asthma for use in a primary care sentinel surveillance system.

METHODS

A single chart abstractor conducted a manual audit of 776 randomly selected patient charts from an academic primary care practice EMR in Kingston, Ontario. Following the single chart abstractor classification, a consensus on chart classification as "not asthma", "suspected asthma", or "confirmed asthma" was achieved between the abstractor, a family physician, and a respirologist using Canadian Thoracic Society (CTS) criteria. Case definition algorithms based on billing codes, clinical data elements and medications were applied to the site's Canadian Primary Care Sentinel Surveillance Network (CPCSSN) data for the same charts and compared to abstractor classifications to determine each algorithm's measurement properties.

RESULTS

The prevalence of suspected and confirmed asthma were 7.3% (n = 54) and 2.4% (n = 18), respectively. None of the proposed case definitions could differentiate between suspected and confirmed asthma. One algorithm consisting of billing, clinical, and medication elements had the highest Youden's Index for either suspected or confirmed asthma. The algorithm had a sensitivity of 81%, a specificity of 96%, positive predictive value of 71%, negative predictive value of 98%, and a Youden's Index of 0.77 for combined suspected or confirmed asthma cases.

CONCLUSION

An EMR case definition for suspected or confirmed adult asthma has been validated for use in CPCSSN. Implementation of this case definition will enable the development of a surveillance electronic tool (eTool) for adult asthma that can foster quality improvement.

Economic Efficiency of an Open-Source National Medical Lab Software in Canada

Although the Canada federal government has invested over $3.1 billion developing health information technology (HIT), all 10 provinces still have their own separate HIT systems, which are non-interoperable, expensive, and inconsistent. After first reviewing how these systems operate, this paper analyzes the costs and savings of integrating the common billing, lab results, and diagnostic imaging (BLD) functions of these separate systems using free and open-source software and proposes a system for this, HermesAPI. Currently, 8 provincial governments representing over 95% of Canada's population allow private companies to create their own electronic medical records (EMR) system and integrate with provincial BLD systems. This study found the cost to develop and maintain HermesAPI would be between CAD$610,000 to CAD$740,000, but would prevent CAD$120,000 per company per province in development costs for a total savings of $6.4 million. HermesAPI would lower barriers to entry for the HIT industry to increase competition, improve the quality of HIT products, and ultimately patient care. The proposed open-source approach of the HermesAPI is one option towards building a more interoperable, less expensive, and more consistent HIT system for Canada.

LesionMap: A Method and Tool for the Semantic Annotation of Dermatological Lesions for Documentation and Machine Learning

Diagnosis and follow-up of patients in dermatology rely on visual cues. Documentation of skin lesions in dermatology is time-consuming and inaccurate. Digital photography is resource-intensive, difficult to standardize, and has privacy concerns. We propose a simple method—LesionMap—and an electronic health software tool—LesionMapper—for semantically annotating dermatological lesions on a body wireframe. We discuss how the type, distribution, and progression of lesions can be represented in a standardized way. The tool is an open-source JavaScript package that can be integrated into web-based electronic medical records. We believe that LesionMapper will facilitate documentation in dermatology that can be used for machine learning in a privacy-preserving manner.

Entrepreneurial actions and the legitimation of free/open source software services

Free/open source software users were previously responsible for managing the challenges associated with their software themselves. Recently, a new generation of entrepreneurs seized this emerging market opportunity by positioning themselves as service providers for free/open source software users. Conceptualizing such providers as “institutional entrepreneurs,” we find that due to the nature of the free/open source software context, they exhibit a different set of legitimation actions compared with similar efforts in other contexts. Based on our empirical analysis of free/open source software service providers and drawing on prior theory, we identify two entrepreneurial actions aimed at gaining legitimacy specific to the free/open source software context, namely, product-based theorization actions and evangelization actions. We also demonstrate that institutional entrepreneurship is shaped by the nature of free/open source software products and the openness values at the core of the free/open source software movement. Our work hence underscores the importance of the context of institutional entrepreneurship.

Open-Source Electronic Health Record Systems for Low-Resource Settings: Systematic Review

Background

Despite the great impact of information and communication technologies on clinical practice and on the quality of health services, this trend has been almost exclusive to developed countries, whereas countries with poor resources suffer from many economic and social issues that have hindered the real benefits of electronic health (eHealth) tools. As a component of eHealth systems, electronic health records (EHRs) play a fundamental role in patient management and effective medical care services. Thus, the adoption of EHRs in regions with a lack of infrastructure, untrained staff, and ill-equipped health care providers is an important task. However, the main barrier to adopting EHR software in low- and middle-income countries is the cost of its purchase and maintenance, which highlights the open-source approach as a good solution for these underserved areas.

Objective

The aim of this study was to conduct a systematic review of open-source EHR systems based on the requirements and limitations of low-resource settings.

Methods

First, we reviewed existing literature on the comparison of available open-source solutions. In close collaboration with the University of Gondar Hospital, Ethiopia, we identified common limitations in poor resource environments and also the main requirements that EHRs should support. Then, we extensively evaluated the current open-source EHR solutions, discussing their strengths and weaknesses, and their appropriateness to fulfill a predefined set of features relevant for low-resource settings.

Results

The evaluation methodology allowed assessment of several key aspects of available solutions that are as follows: (1) integrated applications, (2) configurable reports, (3) custom reports, (4) custom forms, (5) interoperability, (6) coding systems, (7) authentication methods, (8) patient portal, (9) access control model, (10) cryptographic features, (11) flexible data model, (12) offline support, (13) native client, (14) Web client,(15) other clients, (16) code-based language, (17) development activity, (18) modularity, (19) user interface, (20) community support, and (21) customization. The quality of each feature is discussed for each of the evaluated solutions and a final comparison is presented.

Conclusions

There is a clear demand for open-source, reliable, and flexible EHR systems in low-resource settings. In this study, we have evaluated and compared five open-source EHR systems following a multidimensional methodology that can provide informed recommendations to other implementers, developers, and health care professionals. We hope that the results of this comparison can guide decision making when needing to adopt, install, and maintain an open-source EHR solution in low-resource settings.