The Adoption of Open Source Software in Hospitals

Dr. Gilberto Munoz

University of Maryland

March 24, 2008

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Agenda

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The U.S. Health Care Industry Challenges

High costsHigh percentage of GDP & per capita

expenditure on health care Lack of financial resources Lack of regular sources of care Limited access to health care

15% uninsured

Unsatisfactory qualityMedical errors

MisdiagnosisInadequate treatment

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Advantages of IT Use in Health Care

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General Challenges to IT Adoption in Health Care

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OSS – A Potential Solution to IT Challenges in Health Care

Open Source Software (OSS)Source code available to its

usersUsers are free to use, inspect,

fix, modify, expand, compile and distribute it without charge

Software development method built on peer review, decentralization and frequent releases

Extensive and fast-growing number of users and software products

Technical innovation 6

OSS Pros & Cons in Health Care

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Research Objectives

1. Understand the extent of OSS adoption in hospitals

2. Understand the factors influencing or inhibiting OSS adoption

3. Provide hospitals IT managers and other health care organizations with an understanding of how external, technological and organizational factors affect the adoption process of OSS

4. Provide foundation for future work to investigate more determinants of OSS adoption in health care

5. Provide an empirical model for the adoption of OSS in hospitals based upon a grounded theory approach 8

Health Care & OSS Adoption Theory

Facilitators (+)

Inhibitors (-)

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Health Care Information Systems

Focus: Hospital software systems only

Two types of OSS products available for hospitals: Domain-specific

Electronic medical records (EMR) systems—VistA, OpenVistA, and Open EMR, etc.

General-purposeWeb servers, database

servers, office suites, operating systems—Apache, MySQL, OpenOffice, and Linux, etc.

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Methodology Choices—Survey

Survey Empirical method for data gathering from

a large number of geographically dispersed organizations or people (Babbie, 1998; Creswell, 1994; Fowler, 2002; Groves, 2004; Tashakkori & Teddlie, 1998)

One of the most popular empirical research methods in the IS domain

Survey Objectives Identify if there is any adoption of OSS in

the BWNV area hospitals Identify the characteristics of the

hospitals adopting or not adopting OSS Identify the types of OSS products and

the extent of their adoption11

Methodology Choices—Interviews

Interviews Quintessential qualitative method for

data collection (Miles & Huberman, 1994; Seaman, 1999; Strauss & Corbin, 1998; Yin, 2003)

Involve collecting non-numeric data from respondents

It allows to obtain data rich in description and detail from respondents

Interview Objectives Identify the factors facilitating or

inhibiting OSS adoption by hospitals Identify the inhibitors behind the non-

adoption of OSS by hospitals12

Results—Survey

Survey sent to 260 IT hospital managers across the BWNV selected from the HIMSS member’s database

Response Rate of Survey = (30/229*100) = 13.10%

Respondent profile: Director/Mgr of IS (26.7%), CIO/CTO/VP (20%), and project manager level (20%)

Type of hospital: Health care system hospitals (40%), followed by hospitals as a part of a multi-system network (36.67%)

IT budget—Half (50%) 2.1%-3.0% In-house IT personnel 90% More than five years of experience IT personnel

76.7% 13

Adoption of OSS by Hospitals

Hospital type Hospital as a part of a

multi-system network (42.86 %)

Type of IT personnel In-house (100%)

Years of experience IT personnel ≥10 (42.86%) 5-10 years (28.57%)

Hospital’s annual gross revenue ≥$501M (57%)

IT operating budget (annual) 2.1-3.0% (85.7)

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Q: Has your hospital adopted (i.e., acquired with plans to use) any open source software (OSS) application, product, or system?

Has your hospital adopted (i.e., acquired with plans to use) any open source…

Yes-AdoptionNo-Adoption

Per

cent

80

60

40

20

0

23.33%

76.67%

Has your hospital adopted (i.e., acquired with plans to use) any open source software (OSS) application, product, or system?

n=7

n=23

Characteristics of OSS adopters

Non-adopters & adopters

Extent of OSS Adoption Hospitals have adopted general-purpose products to a

greater extent than domain-specific products

15*MIRTH=cross-platform HL7 interface engine that enables bi-directional sending of HL7 messages between systems and applications over multiple transports*DCM4CHE=applications and utilities for healthcare IT. These applications have been developed in the Java programming language for performance and portability, supporting deployment on JDK 1.4 and up

Results—Interviews

Core Categories Subcategories

1. Hospital IT human resources IT personnel In-house software development Medical informaticians

2. Hospital regulatory landscape

Patient-privacy protection and privacy legislation Lack of liability/accountability provided by OSS

3. Hospital software vendors Software vendor providers of OSS Satisfaction level with software vendors New software business models

4. Hospital organizational factors

Hospital organizational culture Hospital organizational structure

5. Hospital technological factors

Perceived lack of quality Perceived lack of security

6. International development of OSS

Labor cost and qualified programmers Type of health care systems

Identification of Core Categories & Subcategories

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Results—Interviews Lack of in-house development

The rule rather than the exception Dependency on software vendors for all IT operations and software needs

Lack of sufficient and skilled IT personnel IT staff personnel are exclusively devoted to the on-site support of IT systems

provided by vendors

Lack of medical informaticians Amalgamation of medicine and IT expertise

Perceived lack of general quality of OSS products “I think that the majority of the OSS are probably of inferior quality because

they are just gifts that any research lab puts together and hands out from a couple graduate students”

Hospital IT managers perceive that software provided by hospital software vendors have better quality in general

Perceived lack of OSS security “It is not the fact that the OSS won't be able to provide the functionality that we

need in the hospital. The major concern is going to be how secure OSS is…”

Lack of liability provided by OSS “The factor that caused us not to adopt OSS is the support and accountability

that comes with writing a check to a commercial software vendor”

Satisfaction level with software vendors 17

Results—Interviews

Hospital Software Vendors (HSV) HSV Play a pivotal role in the adoption of OSS in hospitals HSV Key facilitators for the adoption of both general-purpose and

domain-specific OSS products Current adoption of OSS by hospitals is a software vendor-driven

initiative put forward by offering and supporting OSS as a software option for hospitals

“We don’t have a conscious decision to adopt OSS because our hospital outsources a lot of our technical knowledge to vendors, so the adoption of OSS is coming through the vendor’s decisions for the most part”

“Hospitals are so dependent on vendors of hospital IT products that we are not in the position to kind of ‘buck the rules’ and go alone for the adoption of OSS”

“I am very happy using OSS because, for me, the best of two worlds is when vendors support an OSS solution. I am willing to pay for OSS, because I feel I have professional quality and control over the software” 18

Results—Interviews

Hospital IT budget IT budget with 3% or less have a propensity to adopt

OSS Hospital organizational culture

“Very conservative industry” when it concerns the willingness and support of IT management to adopt any new technology

Hospital organizational structure “The organizational design of the hospital has a major

influence on the adoption of software within the hospital, I don't want to use the word power structure, but it is almost the political landscape of the organization that influences the way we adopt any technology”

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Results—Interviews

Patient-privacy protection and privacy legislation OSS is perceived as posing a threat to patient’s privacy and

confidentiality as well as to HIPAA compliance mandates (domain-specific OSS products)

“A big factor why hospitals turn out not to adopt [OSS] is because of HIPAA regulations and PHI (Protected Health Information) telling you that you have to take the proper measures to be able to secure that information. If you are purchasing a clinical information system, then you have more assurance with a reputable vendor than getting [the clinical information system] from a Web site and then installing it into your organization”

Type of health care system Predominantly social and collective setup in their health care

systems “The adoption of OSS has been happening more in other parts of world like European

countries because of how their healthcare systems are setup. [Europe] is more a socially based system, whereas our health care system in United States is a provider care-based system where you have more private care management involved”

International development of OSS Europe and Latin America “Actually, VistA [Veterans Health Information Systems and Technology Architecture] is

much more deployed in foreign countries than in here [US]…” 20

Implications & Recommendations for Practice

Implications Cost-benefit factors are not an important issue for IT managers

when deciding to adopt OSS Quality, security and liability are important factors for IT

managers

Recommendations Include quality, security and liability in the business case for

OSS Involve all the stakeholders within the hospital in the adoption

decision-making (physicians, nurses, and other clinical personnel are the key stakeholders to address in the adoption process)

Assess the receptivity to the idea and philosophy of OSS Start adopting OSS with a small pilot project Collect data and metrics from the pilot project and

communicate the results21

Thank you!

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