The Emergence of Openness in Open-Source Projects: The Case of OpenEhR

Contextual Barriers to Implementing Open-Source Electronic Health Record Systems for Low- and Lower-Middle-Income Countries: Scoping Review

BACKGROUND

Low- and lower-middle-income countries account for a higher percentage of global epidemics and chronic diseases. In most low- and lower-middle-income countries, there is limited access to health care. The implementation of open-source electronic health records (EHRs) can be understood as a powerful enabler for low- and lower-middle-income countries because it can transform the way health care technology is delivered. Open-source EHRs can enhance health care delivery in low- and lower-middle-income countries by improving the collection, management, and analysis of health data needed to inform health care delivery, policy, and planning. While open-source EHR systems are cost-effective and adaptable, they have not proliferated rapidly in low- and lower-middle-income countries. Implementation barriers slow adoption, with existing research focusing predominantly on technical issues preventing successful implementation.

OBJECTIVE

This interdisciplinary scoping review aims to provide an overview of contextual barriers affecting the adaptation and implementation of open-source EHR systems in low- and lower-middle-income countries and to identify areas for future research.

METHODS

We conducted a scoping literature review following a systematic methodological framework. A total of 7 databases were selected from 3 disciplines: medicine and health sciences, computing, and social sciences. The findings were reported in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. The Mixed Methods Appraisal Tool and the Critical Appraisal Skills Programme checklists were used to assess the quality of relevant studies. Data were collated and summarized, and results were reported qualitatively, adopting a narrative synthesis approach.

RESULTS

This review included 13 studies that examined open-source EHRs' adaptation and implementation in low- and lower-middle-income countries from 3 interrelated perspectives: socioenvironmental, technological, and organizational barriers. The studies identified key issues such as limited funding, sustainability, organizational and management challenges, infrastructure, data privacy and protection, and ownership. Data protection, confidentiality, ownership, and ethics emerged as important issues, often overshadowed by technical processes.

CONCLUSIONS

While open-source EHRs have the potential to enhance health care delivery in low- and lower-middle-income-country settings, implementation is fraught with difficulty. This scoping review shows that depending on the adopted perspective to implementation, different implementation barriers come into view. A dominant focus on technology distracts from socioenvironmental and organizational barriers impacting the proliferation of open-source EHRs. The role of local implementing organizations in addressing implementation barriers in low- and lower-middle-income countries remains unclear. A holistic understanding of implementers' experiences of implementation processes is needed. This could help characterize and solve implementation problems, including those related to ethics and the management of data protection. Nevertheless, this scoping review provides a meaningful contribution to the global health informatics discipline.

How do different stakeholder groups within an open source software project influence the project's development: a case study of OpenSimulator

Purpose

This research investigates how the value creation interests and activities of different stakeholder groups within one open source software (OSS) project influence the project's development over time.

Design/methodology/approach

The authors conducted a case study of OpenSimulator using textual and thematic analyses of the initial four years of OpenSimulator developer mailing list to identify each stakeholder group and guide our analysis of their interests and value creation activities over time.

Findings

The analysis revealed that while each stakeholder group was active within the OSS project's development, the different groups possessed complementary interests that enabled the project to evolve. In the formative period, entrepreneurs were interested in the software's strategic direction in the market, academics and SMEs in software functionality and large firms and hobbyists in software testing. Each group retained its primary interest in the maturing period with academics and SMEs separating into server- and client-side usability. The analysis shed light on how the different stakeholder groups overcame tensions amongst themselves and took specific actions to sustain the project.

Originality/value

The authors extend stakeholder theory by reconceptualizing the focal organization and its stakeholders for OSS projects. To date, OSS research has primarily focused on examining one project relative to its marketplace. Using stakeholder theory, we identified stakeholder groups within a single OSS project to demonstrate their distinct interests and how these interests influence their value creation activities over time. Collectively, these interests enable the project's long-term development.

Orchestrating open innovation through punctuated openness: A process model of open organizing for tackling wicked multi-stakeholder problems

Orchestrating open innovation initiatives characterized by frequent changes in stakeholders and activities can be a daunting task. As these initiatives need to adapt to the constantly changing requirements of the process, they can benefit from an open organizing approach that enables the direct participation of stakeholders, not only in the innovation process but also in its orchestration. Building on the constitutive view on open organizing, we argue that the interactions among various stakeholders can be orchestrated by an open organizing process complemented by elements of closure. However, determining when and how to deploy a closure to complement open organizing remains a practical and theoretical puzzle. We address this puzzle through a longitudinal field study of an award-winning open innovation initiative tackling the sustainability challenges of oceans. We show when and how temporary closures can catalyse the participation of diverse stakeholders across phases, while opening up the organizing process to participatory fine-tuning allows the orchestration to evolve with the changing requirements of the process. By emphasizing the temporal dimension of deploying closure in open organizing, we develop a process model explaining how punctuated openness—open organizing interrupted by moments of closure—can be used as an organizing principle.