The Importance of Using Open Source Technologies and Common Standards for Interoperability within eHealth: Perspectives from the Millennium Villages Project

Abstract

The purpose of this chapter is to illustrate the importance of using open source technologies and common standards for interoperability when implementing eHealth systems, and to illustrate this through case studies, where possible.
The sources used to inform this chapter draw from the implementation and evaluation of the eHealth Program in the context of the Millennium Villages Project (MVP).
As the eHealth Team was tasked to deploy an eHealth architecture, the Millennium Villages Global-Network (MVG-Net), across all 14 of the MVP sites in sub-Saharan Africa, the team not only recognized the need for standards and uniformity but also realized that context would be an important factor. Therefore, the team decided to utilize open source solutions.
The MVP implementation of MVG-Net provides a model for those looking to implement informatics solutions across disciplines and countries. Furthermore, there are valuable lessons learned that the eHealth community can benefit from.
By sharing lessons learned and developing an accessible, open source eHealth platform, we believe that we can more efficiently and rapidly achieve the health-related and collaborative Millennium Development Goals.

Full text

The importance of using open source technologies and common
standards for interoperability within eHealth: Perspectives from
the Millennium Villages Project
Andrew S. Kanter,
Director of Health Information Systems/Medical Informatics, Millennium Villages Project, Earth
Institute at Columbia University; Assistant Professor of Clinical Biomedical Informatics, College of
Physicians and Surgeons, Columbia University; Clinical Epidemiology, Mailman School of Public
Health, Columbia University; 622 W. 168th Street, VC5, New York, NY, USA 10032; Tel:
+1.212.305.4842
Rob Borland,
Development Coordinator, eHealth Program, Millennium Villages Project, Earth Institute at
Columbia University c/o The Millennium Villages Project, 475 Riverside Drive, Suite 401, New
York, NY, USA 10115; Tel: +263.712.347.911
Mourice Barasa,
Regional eHealth Specialist, Millennium Villages Project, Earth Institute at Columbia University, c/
o The Millennium Villages Project, 475 Riverside Drive, Suite 401, New York, NY, USA 10115;
Tel: +254.722.853.117
Casey Iiams-Hauser,
eHealth Solutions Coordinator, eHealth Program, Millennium Villages Project, Earth Institute at
Columbia University; MDG Centre West & Central Africa, BP 320, Hyppodrome Rue 287, Porte
341, Bamako, Mali; Tel: +223.20.219.133
Olivia Velez,
Postdoctoral Research Fellow, Department of Biomedical Informatics, College of Physicians and
Surgeons, Columbia University; 622 W. 168thStreet, VC5, New York, NY, USA 10032; Tel:
+1.646.685.7351
Nadi Nina Kaonga, and
Research and Evaluation Coordinator, eHealth Program, Millennium Villages Project, Earth
Institute at Columbia University; 475 Riverside Drive, Suite 401, New York, NY, USA 10115; Tel:
+1.603.969.4883
Matt Berg
Director of Emerging Applications, Modi Research Group, Columbia University; 134F SW Mudd,
MC: 4703, New York, NY, USA 10027; Tel: +1.212.854.3239
Andrew S. Kanter: Andrew.kanter@dbmi.columbia.edu; Rob Borland: rborland.mvp@gmail.com; Mourice Barasa:
barazam@gmail.com; Casey Iiams-Hauser: ciiamshauser@ei.columbia.edu; Olivia Velez: ov2111@columbia.edu; Nadi
Nina Kaonga: nnk2108@columbia.edu; Matt Berg: mlb2178@columbia.edu
Abstract
The purpose of this paper is to illustrate the importance of using open source technologies and
common standards for interoperability when implementing eHealth systems and illustrate this
through case studies, where possible. The sources used to inform this paper draw from the
Correspondence to: Andrew S. Kanter, Andrew.kanter@dbmi.columbia.edu.
NIH Public Access
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Published in final edited form as:
Adv Health Care Manag
. 2012 ; 12: 189–204.
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implementation and evaluation of the eHealth Program in the context of the Millennium Villages
Project (MVP). As the eHealth Team was tasked to deploy an eHealth architecture, the
Millennium Villages Global-Network (MVG-Net), across all fourteen of the MVP sites in Sub-
Saharan Africa, the team recognized the need for standards and uniformity but also realized that
context would be an important factor. Therefore, the team decided to utilize open source solutions.
The MVP implementation of MVG-Net provides a model for those looking to implement
informatics solutions across disciplines and countries. Furthermore, there are valuable lessons
learned that the eHealth community can benefit from. By sharing lessons learned and developing
an accessible, open-source eHealth platform, we believe that we can more efficiently and rapidly
achieve the health-related and collaborative Millennium Development Goals (MDGs).
Keywords
eHealth; interoperability; open source; health information technology; standards; Sub-Saharan
Africa
Introduction
Background on the Millennium Villages Project
The Center for Global Health and Economic Development (CGHED) is a research unit at
the Earth Institute at Columbia University. CGHED develops and coordinates the Earth
Institute’s global health programs in low and middle-income countries, with an overall aim
to enable and support countries to achieve the Millennium Development Goals (MDGs).
CGHED houses the Millennium Villages Project (MVP) which is a community-led initiative
that seeks to serve as a model to help and empower rural African communities out of
extreme poverty and achieve the MDGs by 2015.
The MVP initiative is supported by a multi-disciplinary team of researchers at Columbia
University. The Columbia International eHealth Laboratory (CIEL) links the Department of
Biomedical Informatics at the College of Physicians and Surgeons, the Department of
Epidemiology at the Mailman School of Public Health and the CGHED at the Earth Institute
to help develop innovative electronic health (eHealth) solutions for use by MVP and others
around the world. MVP also involves partnerships with Millennium Promise (a Non-
Governmental Organization), the United Nations Office for Project Services (UNOPS) and
the United Nations Development Programme (UNDP) to support operations and
implementation of the program. The Millennium Villages constitute fourteen sites in ten
Sub-Saharan African countries with populations of between 5,000 to 85,000 people each in
Koraro, Ethiopia; Sauri, Kenya; Dertu, Kenya; Ruhiira, Uganda; Mayange, Rwanda; Mbola,
Tanzania; Mwandama, Malawi; Gumulira, Malawi; Potou, Senegal; Tiby, Mali; Toya, Mali;
Bonsaaso, Ghana; Pampaida, Nigeria; and Ikaram, Nigeria. MVP interventions are centered
on five sectors: agriculture, health, education, enterprise and infrastructure with a strong
focus on empowerment of women and girls.
The eHealth Program
To support increased access to health services and information and to improve the quality of
care, a broad range of information and communication technology (ICT) systems have been
designed, tested, deployed and evaluated as part of the Electronic Health (eHealth) Program
within MVP. Systems and initiatives that have been deployed include: 1) the Millennium
Villages Global-Network (MVG-Net)—which includes ChildCount+, ODK Clinic,
OpenMRS and other applications, 2) an upgrade of network connectivity in MVP sites
through a partnership with Ericsson, 3) provision of mobile handsets for all health workers
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in the fourteen MVP sites through a partnership with Sony Ericsson, 4) the provision of SIM
cards for health workers to create a closed user group and 5) the creation of a toll-free
emergency lines and toll-free SMS numbers for ChildCount+ and other RapidSMS-based
applications through partnerships with AirTel Bharti, MTN, and other mobile operators
(Kanter, Negin, et al., 2009; ChildCount+; Open Data Kit; OpenMRS).
To facilitate collaboration across the different countries, languages and governmental
systems, the MVP eHealth architecture has been built using a free/libre open source
software for health care (FLOSS-HC) platform and has focused on the use of open and
international standards, where possible. Open source is a description of both software and
the process for using and modifying the software (providing free access to source code and
allows for the sense of local “ownership” by developers and programs that use it (see Table
1)). The process of implementing MVG-Net across the MVP sites has highlighted numerous
lessons learnt that will be invaluable to health information technology as it relates to
implementation and the exchange of information across regions and nations (Kanter, Dick,
et al., 2009). Therefore, the purpose of this paper is to illustrate the importance of using
open source technologies and common standards for interoperability in the context of an
international eHealth project.
Approach
The sources used to inform this paper draw from the implementation and evaluation of the
eHealth Program in the context of the MVP. In order to facilitate collaboration across the
different countries, languages, and governmental systems, an eHealth architecture was
developed—MVG-Net. MVP took advantage of a process based on an enterprise
architecture to show interrelationships between country-specific and more global
requirements for information systems and between architectures and solutions (as shown in
Figure 1). This was based on work by David Lubinski that describes how country-specific
requirements and existing solutions can inform a more generalizable architecture which can
then lead to common platforms and tools, which then lead to country-specific technology
solutions (Stansfield et al., 2008). Open source tools allowed us full control over the process
and permitted iterations on local requirements, creation of the general MVG-Net
architecture, and then local adaptation and country specific implementations.
Components of MVG-Net
MVG-Net (see Figure 2) has been deployed across all fourteen MVP sites. The architecture
is based on open source platforms. Open source platforms were preferred over proprietary
products due to cost and customization. Compared to proprietary products, open source
products require no license fees, can be tailored to fit the needs of the project, and have
support from the development community contributing to and using the particular product.
However, as with any technology—whether open source or proprietary—maintenance costs
still must be considered. The following are currently components of MVG-Net: Open
Medical Record System (OpenMRS), RapidSMS (ChildCount+) and Open Data Kit (ODK)
for Android™ (mClinic). We are also in the process of integrating two other open source
technologies: District Health Information System (DHIS2) and CommCare. MVG-Net takes
advantage of an open source database (MySQL), interface terminology, a centralized
concept dictionary (mapped to standard reference terminologies), and appropriate local
technology for data entry.
OpenMRS—OpenMRS is the core of MVG-Net. It is an open source, web-based electronic
medical record platform that functions as the local hub of health information collected from
different sources within the Millennium Villages. It has an easily extensible data model, and
can aggregate individual, person-level data collected from Community Health Workers
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(CHWs) as well as clinic-based personnel. In MVP, the platform has been used to automate
reports for the Millennium Villages Information System (MVIS) and various Ministries of
Health. Currently, OpenMRS has been deployed within each MVP site to serve as the
central database. It is also used to support facility-level data collection in several MVP sites
where users enter and access the information from desktop computers. There is a substantial
OpenMRS developer/implementer community that provides support via listserves, forums,
Internet relay chat (IRC) chat rooms and in-person annual meetings (Seebregts et al., 2009).
OpenMRS is has been downloaded in nearly 50 countries, is actively deployed around the
globe, and is part of national scale-up projects in Rwanda and elsewhere. (OpenMRS)
ChildCount+—ChildCount+ is an SMS-based mobile phone-based CHW point of care
support and data collection tool built on the RapidSMS platform (RapidSMS). It is aimed at
improving the health outcomes of pregnant women, newborns and children under 5 years of
age through ‘real-time’ data collection of household level data to trigger alerts, reminders
and health promotion messages via CHWs. The system also enables performance
monitoring for more effective supervision and management of community-based health. For
example, in Mayange, CHWs receive SMS notifications to conduct follow-up visits and to
remind women and children in their catchment area of upcoming clinic visits.
Open Data Kit—In the context of MVP, Open Data Kit (ODK) is currently being used for
collecting data on vital events (verbal autopsy) and immunization histories of children. ODK
is an open source Android™-based application that renders standard forms (Xforms) on
mobile devices such as smart phones and tablets. MVP uses ODK to collect data from
household interviews done in the collection of verbal autopsy information for each child and
maternal death occurring within an MVP site. This information is then used to inform
monthly or quarterly morbidity and morality reviews and resulting action of the health team
and community to address any pressing concerns (Ohemeng-Dapaah et. al, 2010).
Additionally, another ODK tool, mClinic, has been developed to provide a mobile interface
to link to OpenMRS. mClinic enables nurses, midwives and other facility-based staff to be
able to enter and access electronic patient information and receive clinical decision support
at the point-of-care. mClinic provides a mechanism for streamlining data collection for
monitoring and reporting and is being used in Tanzania to collect immunization information
for children under 2 years old.
Databases—OpenMRS is built on the open source MySQL database. This allows local
MVP staff (and other stakeholders) secure, but non-proprietary access to the data collected
by MVG-Net. The data can be reported on using any SQL-compliant toolkit. Non-
proprietary databases are important for allowing application owners flexibility to update
their data collection tools, or move the data whenever necessary.
Interface Terminology Mapped to Reference Terminologies—One major obstacle
to adoption of health information technology is the inability of users to locate and enter
information using internationally accepted clinical terminology (Kanter et al., 2007), given
their familiarity and use of locally accepted clinical terminology. To address this issue
within MVP, content has been translated from English into Kinyarwanda in Rwanda;
Swahili in Kenya and Tanzania; French in Mali, Senegal and Rwanda and Tigrinya in
Ethiopia. Additional localization is occurring on an ongoing basis. The data elements are
represented in the languages required at the interface using a multilingual standardized
interface terminology mapped to international medical reference standards. By this means
the data may be entered and viewed in multiple languages and it is translatable between
them. The reference standards (ICD-10, SNOMED CT, RxNORM, LOINC, CVX) allow
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MVP to report to international agencies, compare between MVP sites, as well as compare
with other organizations working in the same domains.
Centralized Concept Dictionary—Data collected across multiple different
organizations, countries and languages is rarely interpretable due to differences in design
and modeling of the information. OpenMRS ensures that data elements are semantically
understood by mapping most elements using a concept dictionary (OpenMRS Concept
Dictionary). In MVP, data compatibility is achieved via standardization and mapping at the
data element level. The concept dictionary is shared across all users and acts as a central
repository for the definitions of all the data collected. CIEL is responsible for maintaining
the dictionary that is currently used by over 32 different organizations in as many different
countries. The CIEL dictionary includes enhancements to ensure applicability in the context
of primary health care across Sub-Saharan Africa. Modifications can be made through the
development of site-specific subsets and requests made by the OpenMRS community for
new concepts to be added to the platform.
Local Technology for Data Entry—As described above, OpenMRS functions as a
central hub for person-level information within the MVP sites. MVP then takes advantage of
different data collection tools depending on the requirements of the users and the
infrastructure in the sites. Data entry is captured both at the point-of-care, through
ChildCount+ (standard cell phones using SMS), mClinic/ODK (smartphones using
Android™) and workstations using the web-based OpenMRS XForm interface, and
retrospectively by entering data collected on paper forms using the Microsoft Infopath™
application into OpenMRS.
Findings
As noted by Chan et al., “standards in data collection and reporting increase efficiency and
encourage collaboration within and between organizations” (Chan et al., 1999). The eHealth
Team recognized the need for standards and uniformity but also realized that context would
be an important factor. Therefore, the team decided to utilize open source solutions. This
next section will outline, in depth, the decisions and outcomes of setting up the open source
eHealth Architecture in MVP.
Making the Decision to Go Open Source
As described above, there are many reasons to favor open source over proprietary software
solutions. This includes cost, flexibility, ownership, and the benefit of a large passionate,
and involved developer and implementer community (Karopka et al., 2011). However, there
are tradeoffs that have to be taken into account:
•Resources
–Although FLOSS applications do not require licensing fees, they do often
require higher levels of developer support. Service and support may be
available for free for FLOSS applications from a volunteer community,
but organizations frequently must build in such support if they want to
ensure reliable availability of assistance. MVP has implemented a
structure which includes separate, development team and support staff.
The team of three developers responds to new development requests and
maintenance issues. The implementation and operation of MVG-Net is
supported by an eHealth Specialist in each country. The eHealth
Specialists do not develop any of the software but do help to localize and
ensure that the applications are in good working order. They also assist the
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MVP Health Team in acquiring the data and analyzing the results
generated by the tools.
•Innovation and Collaboration
–FLOSS promotes collaboration through the reuse of code that translates to
time and money savings for clients. The resultant culture of sharing and
proper attribution promotes open innovation. MVP partners with other
FLOSS organizations such as Dimagi in the US, Jembi Health Systems in
South Africa, Mindflow in Kenya and Baobab Health in Malawi.
•Transparency
–FLOSS applications are not developed as a “black box” meaning that
organizations can see and modify code as necessary to ensure that it serves
their purposes.
•Independence
–FLOSS avoids vendor lock-in, reducing the risk of negative unilateral
actions by the software provider.
–FLOSS offers freedom by allowing applications to be adapted and
modified locally.
•Localization/Customization
–FLOSS applications provide a significant advantage in flexibility when
customizing or localizing the software for use in the different settings. In
particular, many proprietary health care software solutions are designed
for resource-available environments and not for resource-limited ones.
–Localization also promotes and builds development capacity in the local
software industry. This capacity is critical for ongoing support and
customization which will be required over time. Since a greater proportion
of the resources stay in the country, the sustainability of local support is
also improved.
•Types of technologies, infrastructure
–The OpenMRS platform was chosen for MVP due to its extensible data
base design and central concept dictionary. This was a key factor in being
able to provide sufficient flexibility to address each country’s local data
collection requirements, while still being capable of maintaining the
database over time and retaining semantic interoperability of the data
elements.
–Mobile devices played a key role in overcoming the limitations of power
and computer connectivity in the field. Having several different mobile
solutions all linked into a central information system allowed MVP to take
advantage of different infrastructure and user contexts. These mobile
solutions include the use of basic/feature phones by CHWs during their
household visits and the use of smartphones for verbal autopsies and
point-of-care support in the clinics.
•Lessons learned
–Developing and deploying software solutions maintained by a single
organization is resource intensive and risky. Developing tools based on a
common platform developed by partnering organizations allows the
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sharing of development (and required resources) and reduces the reliance
on individual software engineers. The loss of a key developer in any
software project represents a large potential risk to the ongoing
sustainability of that system, especially if it is being maintained by a
single or small set of organizations. Working with partners in a
collaborative manner to create the underlying platform in which tools are
built helps greatly to reduce risk and costs.
Implementation and Evaluation
MVP implemented various components of MVG-Net in different sites during the pilot
phase. Rapid rollout to the whole MVP network put significant strain on the team and
prevented more rapid iteration of releases that would have increased acceptability of the
applications. MVP has focused on four sites for a mixed methods evaluation under the Open
Architectures, Standards and Information Systems for Healthcare in Africa project (OASIS
II), funded by the International Development Research Centre (IDRC) in Canada. OASIS II
specifically evaluates the impact of MVG-Net on qualitative and quantitative outcomes in
the Millennium Village sites. The results of OASIS II should be available by mid-2012
(OASIS II-IDRC).
•Lessons learned
–It is important to fine tune applications and solutions in a few sites then
implement, or implement in stepwise fashion.
–It is imperative to have adequate human resources (programmers, support
staff, etc.).
–It is not easy to set up a bridge between two information systems, and
interoperability as well as resources are required.
–Having development teams in multiple locations is very difficult. Do not
overly mix software development with implementation support.
–Cost-benefit analyses should be incorporated into evaluations. While
keeping track of expenses is useful, it does not fully capture the potential
costs or savings that result from implementation and use of eHealth tools
within a health system. Where possible, work should be done with an
health economist to incorporate such analyses into a monitoring and
evaluation framework for eHealth projects.
Practical Implications
When using an open source model there are many factors that must be taken into
consideration. This includes the types of applications used, how many organizations are
involved, and buy-in and capacity of stakeholders and end-users to adopt the tools for their
use.
With a large project like MVP, there will be many different applications used for multiple
purposes, both programmatic and organizational. There is not always an open source
application available for each use case, so the advantages and disadvantages of proprietary
versus open source must be considered when selecting the appropriate software for each
situation. In this case, an advantage for MVP is that it is a large multi-disciplinary project,
but under one organizational structure. Though MVP has partners in many areas, all
operational matters are unified so interoperability is easier to enforce than may be true in
other organizations/projects attempting similar initiatives. The MVP eHealth team consists
of several different project groups working in multiple countries under the larger heading of
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MVP. This means that using a common set of indicators and a centralized concept dictionary
required considerable communication and coordination between the project teams.
In terms of external stakeholders, there is another set of factors to consider. Traditionally,
governments provide paper books/forms to be used by health care givers at the point of care
which are thereafter summarized to generate monthly reports to the relevant Ministry of
Health (MoH). There is limited implementation of eHealth Care platforms by governments
and very few have standards for setting up such platforms. Because of the absence of
standards, many projects have come up implementing health management information
systems (HMIS) in silos with limited consideration on interoperability. With limited HMIS
implementations in the countries with MVP sites, it means that there is limited technical
support at implementation sites. The use of FLOSS-HC with community support under the
MVG-net has leveraged on the community support to address technical issues that would
otherwise not be possible to solve.
Overall, the MVP implementations provide a model and valuable lessons learned for those
looking to implement informatics solutions across disciplines and countries due to the range
of topics covered and the geographical and situational diversity in which these solutions are
applied.
Social Implications
The MVP implementation of MVG-Net using FLOSS-HC applications and common
standards provides for widespread interoperability of health information systems within and
between countries, regardless of their technological and economic environments. This not
only reduces the cost of designing and implementation of the systems, but the ability to
share data and lessons learned between organizations and countries should allow for more
rapid, evidence-based decision-making and program planning. Sharing what works and what
does not work between countries and projects will allow us to be more efficient and more
rapidly reach the goals of achieving the MDGs by 2015.
Originality/Value of Paper
The process has highlighted numerous lessons learned that will be invaluable to health
information technology as it relates to implementation and the exchange of information
across regions and nations.
Acknowledgments
The authors wish to acknowledge the contributions of in each of the Millennium Villages Project sites. In
particular, we would like to thank the eHealth specialists, without whose support, MVG-Net would not have been
possible: In Ghana, Seth Ohemeng-Dapaah; in Nigeria, Innocent Olamiposi, in Tanzania, Killian Mahembe and
Athanas Alois; in Rwanda, Benjamin Rukundo and Teddy Kaberuka; in Kenya, Dickson U’kanga and in Uganda,
Emmanuel Toko and Henry Corrigan-Gibbs. This work has been funded by the generous support of the Rockefeller
Foundation, the International Development Research Centre and the Novartis Fund for Sustainable Development.
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Figure 1.
Enterprise architecture model (adapted from Stansfield et al. 2008)
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Figure 2.
Millennium Villages Global Network (MVG-Net)
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Table 1
The Open Source Definition (Open Source Initiative)
1. Free Redistribution
The license shall not restrict any party from selling or giving away the software as a component of an aggregate software distribution containing
programs from several different sources. The license shall not require a royalty or other fee for such sale.
2. Source Code
The program must include source code, and must allow distribution in source code as well as compiled form. Where some form of a product is
not distributed with source code, there must be a well-publicized means of obtaining the source code for no more than a reasonable reproduction
cost preferably, downloading via the Internet without charge. The source code must be the preferred form in which a programmer would modify
the program. Deliberately obfuscated source code is not allowed. Intermediate forms such as the output of a preprocessor or translator are not
allowed.
3. Derived Works
The license must allow modifications and derived works, and must allow them to be distributed under the same terms as the license of the
original software.
4. Integrity of The Author’s Source Code
The license may restrict source-code from being distributed in modified form only if the license allows the distribution of “patch files” with the
source code for the purpose of modifying the program at build time. The license must explicitly permit distribution of software built from
modified source code. The license may require derived works to carry a different name or version number from the original software.
5. No Discrimination Against Persons or Groups
The license must not discriminate against any person or group of persons.
6. No Discrimination Against Fields of Endeavor
The license must not restrict anyone from making use of the program in a specific field of endeavor. For example, it may not restrict the
program from being used in a business, or from being used for genetic research.
7. Distribution of License
The rights attached to the program must apply to all to whom the program is redistributed without the need for execution of an additional
license by those parties.
8. License Must Not Be Specific to a Product
The rights attached to the program must not depend on the program’s being part of a particular software distribution. If the program is extracted
from that distribution and used or distributed within the terms of the program’s license, all parties to whom the program is redistributed should
have the same rights as those that are granted in conjunction with the original software distribution.
9. License Must Not Restrict Other Software
The license must not place restrictions on other software that is distributed along with the licensed software. For example, the license must not
insist that all other programs distributed on the same medium must be open-source software.
10. License Must Be Technology-Neutral
No provision of the license may be predicated on any individual technology or style of interface.
Adv Health Care Manag
. Author manuscript; available in PMC 2013 July 05.