Open-source Electronic Health Record (EHR) systems have gained importance. The main aim of our research is to guide organizational choice by comparing the features, functionality, and user-facing system performance of the five most popular open-source EHR systems.
We performed qualitative content analysis with a directed approach on recently published literature (2012–2017) to develop an integrated set of criteria to compare the EHR systems. The functional criteria are an integration of the literature, meaningful use criteria, and the Institute of Medicine's functional requirements of EHR, whereas the user-facing system performance is based on the time required to perform basic tasks within the EHR system.
Based on the Alexa web ranking and Google Trends, the five most popular EHR systems at the time of our study were OSHERA VistA, GNU Health, the Open Medical Record System (OpenMRS), Open Electronic Medical Record (OpenEMR), and OpenEHR. We also found the trends in popularity of the EHR systems and the locations where they were more popular than others. OpenEMR met all the 32 functional criteria, OSHERA VistA met 28, OpenMRS met 12 fully and 11 partially, OpenEHR-based EHR met 10 fully and 3 partially, and GNU Health met the least with only 10 criteria fully and 2 partially.
Based on our functional criteria, OpenEMR is the most promising EHR system, closely followed by VistA. With regards to user-facing system performance, OpenMRS has superior performance in comparison to OpenEMR.
Open-source software (OSS) is computer software with a licensing provision that enables the users to modify, utilize, and distribute unmodified or modified versions [
One of the most significant benefits of OSS in the healthcare industry is that FOSS is easy to obtain as it can be downloaded easily from repositories. There are no restrictive licensing terms regarding distribution, derivative works, or modifications, and there are no software licensing fees. Open-source software is vendor neutral, which means that organizations or individuals do not suffer from vendor lock-in. Although there are numerous other benefits of cost savings and flexibility, opportunities to innovate while remaining independent from vendors is more applicable to healthcare [
Challenges of OSS in healthcare are organizational in nature, such as long-term support organization, funding and ownership for EHR certification, open-source business models, medical informatics and domain specific issues, functionality-based limitations, usability issues, challenges in resource-restricted environments, and challenges related human factors [
Relevant articles on open-source EHR systems were identified primarily using Scopus. We also used other databases, such as PubMed and IEEE Xplore, to ensure that we would not leave out any publications that are not indexed by Scopus. We searched publications from 2012 to 2017 to identify criteria to compare open-source EHR systems. Only English language articles were selected. The search terms were looked up in their titles and abstracts.
The next step was a detailed examination of papers and exclusion of irrelevant papers. We included articles that discussed ‘open-source electronic health record systems’ AND ‘comparison’ OR ‘adoption’ OR ‘utilization’ OR ‘analysis’ OR ‘application’.
A study conducted by Zaidan et al. [
Goldwater et al. [
Based on the results of the qualitative content analysis we selected meaningful use criteria and the eight-core functionalities from the IOM, finally totaling 32 criteria to compare the features and functionalities of various health FOSS. We adopted a set of performance criteria from the study conducted by de Abajo and Ballestero [
The study was conducted as follows. The open-source EHR systems were compared using a set of performance-measuring parameters by deploying the software on a local machine. Then they were compared in terms of meaningful use criteria and the IOM core functionalities.
The open-source EHR systems were selected in two steps. The top five EHR systems were selected based on their global website ranking and identification of the reach and popularity of open-source EHR systems over time. Alexa is a global ranking system that utilizes web traffic data to compile rankings. From the 15 listed open-source EHR systems (See
The evaluation in our study was carried out in two main phase, one by deploying the software and comparing the EHR systems using the standard set of criteria, and subsequently by comparing the performance parameters.
(i) Deploying each open-source EHR software: Documentation available on respective EHR system official websites were used for deployment. (ii) Establishing criteria to evaluate and compare: Based on the literature review summarized above, using qualitative content analysis, we developed an evaluation criterion extracted from the meaningful use criteria and eight-core functionalities listed by the IOM [
The selected parameters of user performance criteria include initial CPU use, startup time of the server, shutdown time of server, login time and CPU use, patient search time and CPU use, time for creating new patient and CPU use, time for change of patient and CPU use, average navigation time for the main menu and CPU use, logout time and CPU use. These performance criteria were implemented on a machine with a 64-bit Windows 10 operating system and 8 GB RAM.
The interoperability comparison focused on criteria based on meaningful use presented in
ZH Healthcare incorporated a mechanism to upload, process, display, and incorporate CCDA into OpenEMR. In OSEHRA VistA, this criterion is fulfilled by popHealth, which is an open-source quality measure reference implementation. In OpenEMR clinical information, the reconciliation criterion is fulfilled by the ZH Healthcare coordination module. OpenMRS stores all of a patient's details, visits, encounters, and observations.
This is available only in OpenEMR and OSEHRA VistA. In OpenEMR, this feature is available under the patient support tab in the user interface, and in OSEHRA VistA, this criterion is fulfilled by infobuttons. In OpenEMR (see
In OpenEMR, this has been supported by the ZH Healthcare (an EHR vendor) laboratory module. In OpenMRS and GNU Health, laboratory results are stored, but not in accordance with the HL7 implementation guide. In OSEHRA VistA, this criterion is fulfilled by the VistA laboratory module. Transmission of electronic laboratory tests is possible in all the selected systems. In openEHR, laboratory results can be transmitted to other EHR systems. In the case of VistA, this criterion is fulfilled by the VistA laboratory module.
In openEHR, this is supported by the ZH Healthcare care coordination module. OpenMRS exports according to the Clinical Document Architecture (CDA) standard, not the CCDA (a US-specific standard Consolidated CDA) standard. In VistA, data portability is fulfilled by a separate but related product called popHealth. OpenEMR supports capture, calculation, import, export, and electronic submission of clinical quality measures. OpenMRS, GNU Health, and OpenEHR calculate quality indicators only. In VistA, the CQM criterion is fulfilled by popHealth.
A comparison of the privacy- and security-focused meaningful use criteria are presented in
OpenEMR supports security measures, such as the authentication mechanism, access control, and authentication. In OpenEHR, this provided by Inidis, which is one of the OpenEHR partners. GNU Health has a central authentication system, and access control is fulfilled by security features in GNU Health. VistA has a strong access management architecture.
In OpenEMR, the automatic log-off feature was tested and confirmed by Jones et al. [
OpenEHR, OpenEMR, and VistA allow computerized provider order entry. In OpenEHR, clinical decision support is delivered through guideline definition language. GNU Health also uses the World Health Organization essential list of medicines. In VistA, decision support is supported by infobuttons.
Electronic communication between providers is available only in OpenEMR, OpenMRS, and OSEHRA VistA. In OpenEMR, patient-specific resources can be found under the patient support tab in the user interface. In VistA, patient-specific resources are supported by infobuttons. OpenEMR reports immunization information, syndromic surveillance, and cancer cases to public health agencies. Reporting of population health is done under the notifiable condition detector module.
In this study, we compared the selected systems using the integrated criteria that were developed. Although a few studies have compared the EHR systems [
In the context of health information technology, meaningful use is defined as the minimum US standard required for using EHR systems and for exchanging information between providers, between providers and insurance companies, and between providers and patients. While we acknowledge that other countries, particularly low- and middle-income countries [
Limitation: More than 15 open-source EHR systems are available, but because of time constraints, we compared only the five most popular EHR systems.
OpenEMR and OSEHRA VistA have all the eight-core functionalities, while other systems are lacking a few. Health information and data, result management, decision support, and administrative processes are the functionalities available in all the selected EHR systems.
Limitation: Because of the unavailability of web-based demo databases for GNU Health, VistA, and OpenEHR, we had to deploy locally based on publicly available configuration documentation. We acknowledge that some vendors might deploy these systems differently. Also, certain EHR systems are specially or purposefully built for epidemics or disaster situations [
The top two performing systems were OpenMRS and OpenEMR. The GNU Health, VistA, and OpenEHR-based systems were more complex and required many customizations before we could execute the user performance tasks. OpenMRS was found to be faster than OpenEMR. The CPU utilization is also higher with OpenEMR, as shown in
Limitation: The performance analysis was done on a single system, and this may differ from the performance of a system in a real-world setting. However, our goal was to test user performance on the most regular EHR tasks.
OpenEMR, OSEHRA VistA, OpenMRS, and GNU Health have good documentation. OSEHRA VistA has a very detailed package list including their descriptions and implementation guide.
Limitation: The documentation for OpenEHR is very poor, which forced us to rely on other web resources and articles to support the availability of features.
Investigating available open-source EHR systems is necessary, but few studies have compared the existing open-source EHR systems. These studies on available open-source EHR systems are not exhaustive, especially on security and interoperability. In this study, the top five globally ranked EHR systems were compared using integrated criteria that we developed. Based on our findings, in terms of functionality, OpenEMR is the most promising EHR system, closely followed by VistA. Other systems were found to be lacking in a US-specific functional requirement, but also in some security and interoperability requirements. Regarding performance on the most common user tasks, OpenMRS achieves superior performance in comparison to OpenEMR.
EHR: Electronic Health Record.
EMR: Electronic Medical Record, EHR: Electronic Health Record, MRS: Medical Record System.
EMR: Electronic Medical Record, EHR: Electronic Health Record, MRS: Medical Record System.
EMR: Electronic Medical Record, EHR: Electronic Health Record, MRS: Medical Record System.
EMR: Electronic Medical Record, MRS: Medical Record System.