The Adoption of Open Source Software in Hospitals

1. The Adoption of Open Source Software in Hospitals Dr. Gilberto Munoz University of Maryland March 24, 2008

2. Agenda

3. The U.S. Health Care Industry Challenges • High costs • High 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 quality • Medical errors • Misdiagnosis • Inadequate treatment

4. Advantages of IT Use in Health Care

5. General Challenges to IT Adoption in Health Care

6. OSS – A Potential Solution to IT Challenges in Health Care • Open Source Software (OSS) • Source code available to its users • Users 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

7. OSS Pros & Cons in Health Care

8. Research Objectives 1. Understand the extent of OSS adoption in hospitals 2. Understand thefactors 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

9. Health Care & OSS Adoption Theory Facilitators (+) Inhibitors (-)

10. 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-purpose • Web servers, database servers, office suites, operating systems—Apache, MySQL, OpenOffice, and Linux, etc.

11. 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 adoption

12. 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 detailfrom respondents • Interview Objectives • Identify the factors facilitating or inhibiting OSS adoption by hospitals • Identify the inhibitors behind the non-adoption of OSS by hospitals

13. Results—Survey • Survey sent to260 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%

14. Adoption of OSS by Hospitals Non-adopters & adopters Characteristics of OSS adopters n=23 • 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) n=7 Q: Has your hospital adopted (i.e., acquired with plans to use) any open source software (OSS) application, product, or system?

15. Extent of OSS Adoption • Hospitals have adopted general-purpose products to a greater extent than domain-specific products *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

16. Results—Interviews Identification of Core Categories & Subcategories

17. 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

18. 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”

19. 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”

20. 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]…”

21. 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 results

22. Thank you!