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Open-source software may be the key to an electronic health record system that even the smallest practice can afford.

Fam Pract Manag. 2003;10(6):65-69

Electronic medical record (EMR) systems, or electronic health record (EHR) systems as they’re also called (see “EMR or EHR?” below), are often prohibitively expensive for small practices. Add to that the challenges of implementing them and the distinct possibility that the software vendor could go out of business tomorrow and family physicians are left questioning whether adopting EHRs would be worth the risk. Given an affordable, reliable option, many say it would, according to a recent AAFP survey.1 That option may be open-source software, an approach to developing and licensing software that has quietly existed for more than 20 years.


Why are electronic medical record (EMR) systems now being referred to as electronic health record (EHR) systems? “There’s recently been a subtle shift in terminology,” says David Kibbe, MD, MBA, the AAFP’s director of health information technology. “EMR connotes a tool that’s for doctors only and something that replaces the paper record with a database. EHR connotes more of a connectivity tool that not only includes the patient and may even be used by the patient, but also provides a set of tools to improve work-flow efficiency and quality of care in doctors’ offices.”

According to Kibbe, an EHR should include a detailed clinical documentation function; prescription ordering and management capabilities; a secure messaging system; lab and test result reporting functions; evidence-based health guidelines; secure patient access to health records; a public health reporting and tracking system; mapping to clinical and standard code sets and the ability to interface with leading practice management software.

What is open source?

Open-source software has garnered fans in recent years for several reasons. Unlike traditional software, it isn’t proprietary and is therefore relatively inexpensive. It is generally distributed under a license that doesn’t include substantial fees to users. The source code is open, or shared, which enables many people to modify it and make it better. And, because the source code isn’t held by just one company or group of programmers, it also reduces the user’s risk of being saddled with unsupported software should a company go out of business. Also, in many cases, it is compatible with traditional software.

You may already be using open-source software without knowing it. If you bank online, buy books from or use Google for Web searches, you use open-source software. Examples of widely used open-source applications include the Linux operating system, Apache Web server software and Java language.

“In some ways, the open-source approach is similar to the peer-review process,” says David Kibbe, MD, MBA, director of information technology for the AAFP. “People share information and offer feedback to make improvements for the greater good. They even fix the bugs.” Kibbe is currently heading an AAFP project to develop an open-source EHR system for family practice (see “The AAFP open-source electronic health record system” on page 69). Kibbe doesn’t expect doctors who use open-source software to be “fiddling around” with source code. “Most won’t even worry about it,” he says. “Open source will benefit them anyway because it ends up being very reliable, constantly improving software that is very low-cost.”

Open source and EHRs

Until recently, little attention has been paid to designing EHRs for solo physicians or physicians in small group practices. “There is a huge demand from two- to five-physician practices who want an EHR because they know it will make their practice more efficient and their quality of care better,” Kibbe says, “but their needs have largely been ignored. They don’t have access to an information technology department like hospitals do, so a lot of the products currently available won’t work for them.”

The AAFP survey found that although 80 percent of members have investigated purchasing an EHR, less than 25 percent actually use one in their practices.1 Why? Cost was the biggest barrier, followed by concerns that the complexity of current products would decrease productivity and that vendors might go out of business. Kibbe says an open-source approach will address all of these concerns.

Open information exchange

According to Kibbe, developing open standards for connectivity is also central to the widespread adoption of EHRs. “We want EHR systems to be able to communicate with one another and with other information sources important to the family medicine work flow,” he says. “E-prescribing, lab results, vital signs and monitoring data are all examples of information that needs to find its way into the EHR inexpensively. Interface standards that are freely published and available to all software companies and information suppliers are key.

“In some ways, the current situation is similar to that which existed before railroad track gauges were standardized. It wasn’t until the late-1890s that the marketplace forced the various regional rail systems to agree on a uniform, consistent distance between the rails. Prior to that, people and goods had to stop, unload and reload at places where tracks of different sizes met. What we want to do with open source and open standards is to eliminate gauge breaks in the health information flows within the system.”


The AAFP is working with MedPlexus to offer members an affordable electronic health record (EHR) system by 2004. “Currently, our goal is to help members obtain an EHR for $150 per physician per month,” says David Kibbe, MD, MBA, the AAFP’s director of health information technology. “That’s many times less expensive than the proprietary commercial products currently available.”

The MedPlexus software will serve as the core architecture for the AAFP’s open-source EHR and will run on both desktop and hand-held computers and be compatible with a variety of operating systems. It will include an automated health care record as well as systems for order entry, medication and prescription management, clinical coding, tracking public health, and links to evidence-based diagnostic and therapeutic information.

Plans call for the EHR to be Internet-based. Users will need to have basic computer skills and Internet literacy. “The application will look like many Web-based systems, so people who are familiar with the Internet will feel very comfortable with it,” says Kibbe. “It should also be easier than most systems to implement.” The AAFP also plans to offer implementation support and training. For more information and updates on the EHR project, go to

A new solution

There aren’t any open-source EHR systems in widespread use and only a handful are actually being used in clinical settings. One is OSCAR (, developed by David Chan, MD, a family physician practicing in Canada. Another is ViSta used throughout the VA health system.

The lack of affordable EHR options is about to change, according to Kibbe. Vendors are starting to pay more attention to small practices and the integration of EHRs with practice management systems. “Not only will the AAFP have an offering in the upcoming year, but there will be a variety of more affordable EHR opportunities available in the near future,” he says. “Some of these will be open source and some will be proprietary. But they will increasingly share open standards such as XML, Java and the Internet to meet the demand for greater interoperability.”

The open-source approach is not a new idea, but according to Kibbe, it’s an idea whose time has come. It is one part of a solution that will enable health information to be transmitted and reported in a secure, standardized fashion. Ultimately this will not only improve patient safety and the quality of care, but it will also ease physicians’ work-flow burdens.

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Copyright © 2003 by the American Academy of Family Physicians.

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