Generally, when a healthcare organization chooses Free and Open Source Software (FOSS), they do so for financial reasons: No license fees, often no upgrade cost and a significantly low total cost of ownership. Moreover, as there are no vendor lock-ins, healthcare providers can build their solutions without paying the hefty fees to ‘certified’ knowledge partners. But that is just the first of the many benefits that FOSS can offer the rapidly evolving healthcare industry.
Transparency and trust
Today, healthcare is growing increasingly digital. Access to a patient’s medical history is becoming fundamental to healthcare delivery. Moreover, healthcare tech uses AI/ML for diagnosis, clinical algorithms for decision support, messaging/videos to share patients' personal information and more. So, healthcare must be conducted within an ethical (tech) ecosystem — one would not want another obstetric forceps scenario where a life-saving tool was inaccessible to the broader community for over 150 years.
Open source software ensures this. FOSS ensures transparency through peer reviews and independently testable environments. One can easily evaluate an open source software for design/code maturity, something that’s nearly impossible in proprietary software, where one has to rely on contracts, promises and third-party certifications.
Moreover, FOSS is also transparent about decision-making, product roadmap, competence, etc. The community will maintain a publicly visible defect tracker, have open discussions and be willing to democratically take the product in a direction that benefits the group’s core goals. This is very hard to find in proprietary tools that are hidden behind an impenetrable wall of intellectual property rights.
Ease of adoption and use
FOSS is often quicker to adopt or upgrade because the skills needed to build, support, upgrade, etc., are readily available. Even in cases where you need a specific domain or tech expertise, you are likely to find help on forums, documentation updates, software commits, or the partner community. This doesn’t mean that you don’t need to have or develop any internal capabilities at all, but that would be true of proprietary software too.
Community participation
Unlike closed source or proprietary black-box applications, FOSS leverages the cumulative knowledge of the broader global community to bring innovation, accessibility and knowledge to healthcare providers and patients. This is particularly hard in low-resource environments and traditional software vendors are known to skip solutions for such markets. FOSS, like Bahmni, the electronic medical/health records and hospital management system conceptualized by Thoughtworks, is being used in some of the most resource-constrained and complex environments (e.g Lesotho, DRC) worldwide, because of its ability to harness the community.
Security
Concerns in the healthcare industry exist around data security and privacy – Indian privacy laws are still not as widely adopted or as mature as The Health Insurance Portability and Accountability Act (HIPAA), The General Data Protection Regulation (GDPR) or The California Consumer Privacy Act (CCPA). Instead, there is reliance on consumer protection laws, telecommunications statutes, human rights provisions, and other measures to tackle data breaches and privacy violations.
To establish impenetrable security, we believe India needs healthcare-specific laws in line with the once proposed Digital Information Security in Healthcare Act (DISHA). Until such time, we believe that every open source product must make a full disclosure and be adequately validated by the healthcare community.
Interoperability
Today, much of health informatics software is being built at points of care or the edge of service delivery. So, we have limited options to avail services/products from, while patients and providers have to use apps hosted on ‘big’ portals. To address this, the Ayushman Bharat Digital Mission (ABDM) is establishing standards and protocols alongside an interoperable layer to provide patients, practitioners, payers and allied services with the desired user services. Such open market protocols will help innovators devise solutions that would otherwise require deep pockets.
When we speak of free and open source software, the ‘free’ part often takes over the conversation. But in sensitive fields like healthcare, FOSS can do a lot more. Apart from ensuring standardized protocols and interoperability, open source software solutions can leverage access and innovation beyond their capabilities. Fit-for-purpose open source apps will naturally take advantage of interconnectivity. And, healthcare providers will not have to buy a full stack of applications because of possible compatibility issues.
The promise of FOSS
We recommend that the National Health Authority and Ministry of Health actively support FOSS and its components that can be used as the starter blocks. This platform can then encourage innovators to build end-user applications and health service provider applications for the public health ecosystem.
In fact, more recently, Bahmni was added to the Digital Public Goods Alliance's DPG Registry. The DGP Alliance is a multi-stakeholder initiative endorsed by the United Nations Secretary-General, working to accelerate the attainment of the Sustainable Development Goals in low- and middle-income countries by facilitating the discovery, development, use of, and investment in digital public goods.
A glimpse: Digital Public Goods Registry displaying the number of open source resources by SDG
The Digital Public Goods Alliance (DPGA) and its registry promote digital public goods in order to create a more equitable world. To become a digital public good, projects are required to meet the DPG Standard ensuring they truly encapsulate open source principles.
Such practices will ensure clinics, hospitals and users who cannot afford expensive software will have a high-quality option available to them. This will level the playing field. Where there are gaps and emerging needs, startups will also feel encouraged to innovate and develop affordable tech options.
Building impactful long-term products for low-resource environments, in the healthcare space, requires expertise and thoughtful design. We shared our learnings in an XConf talk that drew from our 8 years of experience of building the open source Bahmni Hospital Management System.
The future of holistic digital health should be created by focussing on citizen welfare, privacy-by-design, early planning for scale, transparent and open governance, open code, achieving sustainability by developing the local ecosystem and focussing on interoperability through standardization. Our experience is; FOSS holds great promise in all of these regards.
A version of this blog was published in Economic Times.
Disclaimer: The statements and opinions expressed in this article are those of the author(s) and do not necessarily reflect the positions of Thoughtworks.
