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Should You Use Open-Source Software Applications in Your Practice?
RAMIN KHORASANI, MD, MPH BITS AND BYTES
Should You Use Open-Source Software Applications in Your Practice? Luciano Prevedello, MD, MPH, Ramin Khorasani, MD, MPH Open-source software development has become popular with some segments of the health IT community, with the premise that end users, who best understand the problems to be solved and stand to gain from effective solutions, can drive innovation and collaborate on creating applications to improve clinical practice. In this column, we briefly review the general concepts of open-source applications to help you decide whether you can adopt them to improve your practice. WHAT IS OPEN SOURCE?
Open source, as a general term, refers to an end product that is made freely available by providing access to its design and implementation details. In IT, it means that the source code of a software application is freely available for distribution along with the program itself. Several licensing agreements exist; many of them protect the author’s copyrights while maintaining any derivative work free and open [1]. In this model, knowledgeable individuals who have access to the source code, have the ability to modify the original code to fulfill their specific needs, and contribute to the project by exposing their work to the entire open-source community. Some Web sites specialize in hosting open-source programs, keeping track of the many iterations of the software. With the right set of tools, individuals can contribute and collaborate more efficiently, significantly reducing the development cycle’s turnaround time. Because these applications are open to the community, a large set of users can continually test them as they become available. These hosting Web sites also
facilitate user feedback so that any bug or feature request can be tracked and readily exposed to developers. Not all open-source projects are funded, and benevolent contributors maintain many of them. Alternatively, the initial project may be funded, and as it matures or funding is eliminated, the code is exposed to the community for continued development. A few opensource projects receive permanent funding. Typically, the business model in this setting involves some sort of revenue stream either by providing training and support as a service or through the commercialization of different versions of the application. WHAT TYPES OF OPENSOURCE APPLICATIONS ARE AVAILABLE FOR MEDICAL IMAGING?
Open-source tools are available for many segments of the digital imaging chain. Radiology information systems with features including examination scheduling and results reporting are one example. Such features, along with paperless protocoling and work list generation, are available as open-source application through ClearCanvas (http:// www.clearcanvas.ca). PACS is composed of a Digital Imaging and Communications in Medicine (DICOM) server and a DICOM viewing station. DICOM servers are applications that manage each transaction of DICOM files (eg, from the modalities to the PACS storage). They represent a key component of the backend infrastructure of a medical imaging department. DCM4CHE (http://www.dcm4che.org) is an example of an open-source DICOM
© 2012 American College of Radiology 0091-2182/12/$36.00 ● http://dx.doi.org/10.1016/j.jacr.2012.06.033
server. A DICOM viewer, on the other hand, is the most familiar IT component of all radiology systems because it is the front-end interface between radiologists and DICOM images. Examples of open-source PACS and DICOM viewers applications include ClearCanvas and Osirix (http://www.osirix-viewer. com) [2]. Although several opensource speech recognition engines exist, they are not specifically tailored to the radiology domain. Other examples of open-source applications include DICOM Validation Tool Kit (http://dvtk.org), an application that assists in the development, testing, and servicing of medical interfaces such as DICOM and Health Level 7 [2]; Mirth (http://www.mirthcorp.com) a health care integration engine that allows users to transmit and receive Health Level 7 messages over a variety of end points; the RSNA Teaching File System (http://mircwiki.rsna. org), a teaching file application that can be integrated with PACS to collect interesting cases; Alert Notification of Critical Radiology Results (http://www.brighamandwomens. org/Research/labs/cebi/CCTR/), an application that automates the notification of critical test results and keeps track of their statuses to ensure closed-loop communication among providers; Pentaho (http:// community.pentaho.com), business intelligence software that helps one aggregate data from disparate databases and display them in summary tables or dashboards; and General Radiation Observation Kit (http:// www.brighamandwomens.org/ Research/labs/cebi/GROK/), an application that identifies dose reports (dose screens) within PACS, reads 751
752 Bits and Bytes
them, and extracts anatomy-specific radiation exposure information. Another application that is available in this category is Radiance (http:// radiancedose.com). Perl Automation for Radiopharmaceutical Selection and Extraction (http:// www.brighamandwomens.org/ Research/labs/cebi/PARSE/) focuses on extracting radiation information from nuclear medicine studies. WHAT ARE THE PROS AND CONS OF USING OPENSOURCE TOOLS IN YOUR PRACTICE?
Open-source software has several potential benefits. The reduced total cost of ownership, compared with existing commercial applications, is often discussed as a major benefit. However, the scope of the financial benefit depends entirely on your existing commercial contracts and whether you have the resources in your practice (either as hired employees or outsourced) to implement and maintain open-source tools. Another major advantage is the pace of innovation in the open-source community. You are likely to find opensource tools to address challenges in your practice where no current commercial solution is available. Also, when the source code is extensively peer reviewed, as in the case of several of the applications described above, the systems are typically secure and reliable. With open-source tools, institutions are not locked in to specific vendors, and there is greater control and flexibility over an application’s features. Despite these potential advantages, the use of open-source applications within the health care environment has been very limited so far for several reasons. A radiology practice, department, or institution
must have a reliable development team (which can potentially be outsourced) that can dedicate time to modify the code and customize the application to fulfill the practice’s specific needs. Some of the other cited reasons for limited adoption of open-source tools include a lack of “commercial-grade” support, executive teams with limited knowledge of the benefits of open-source applications, a lack of legal accountability (there is no legal bond between developers and users and no expectations or responsibilities between these two parties), functional gaps, and the lack of a clear roadmap [3]. HOW ARE OPEN-SOURCE APPLICATIONS TYPICALLY USED, AND WHAT TYPE OF RESOURCES DO YOU NEED TO TAKE FULL ADVANTAGE OF THESE TOOLS?
Open-source tools can be used as adjuncts to standard radiology processes (ie, DICOM toolkits) or as main components of the entire imaging chain (ie, PACS and radiology information systems). Typically, the scope and complexity of the implementation will dictate the resources needed for support. Because open-source applications are provided “as is,” preimplementation evaluation should assess the tool’s readiness or maturity for use in clinical practice and at large scale. Although the level of maturity of open-source software is typically relayed on the hosting Web sites, many of the issues related to specific sites can be found only when these tools are actually implemented. Therefore, having a knowledgeable team supporting the initial installation is important. Another aspect that needs to be thoroughly considered is the on-
going support many of our applications require in medical imaging. Mission-critical applications cannot have known points of failure, and prompt support from trained individuals is typically required. This can be achieved with local skills if available within the department or through support contracts with different vendors (including the one that developed the application itself). Although our traditional commercial vendors provide important tools to optimize our radiology practices, many gaps remain. Open-source tools may help you access applications to further improve your practice. Taking advantage of open-source tools, however, requires informed practice leadership and skilled IT resources not readily available in most radiology practices. Dedicating some effort to becoming familiar with available open-source tools to address some of your practice’s performance gaps can at the least help you better articulate needed functionality (or even pricing) to your preferred vendors. With some experience, knowledge, and dedicated resources, you may even try implementing one of these applications to extend the functionality of your existing commercial solutions. You may be pleasantly surprised by the results! REFERENCES 1. Ratib O, Rosset A, Heuberger J. Open source software and social networks: disruptive alternatives for medical imaging. Eur J Radiol 2011;78:259-65. 2. Nagy P. Open source in imaging informatics. J Digit Imaging 2007;20(suppl):1-10. 3. Murray PJ, Wright G, Karopka T, Betts H, Orel A. Open source and healthcare in Europe—time to put leading edge ideas into practice. Stud Health Technol Inform 2009; 150:963-7.
Luciano Prevedello, MD, MPH, and Ramin Khorasani, MD, PhD, are from the Center for Evidence-Based Imaging and the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. Ramin Khorasani, MD, MPH, Brigham and Women’s Hospital, Center for Evidence-Based Imaging and the Department of Radiology, 1620 Tremont Street, Boston, MA 02115; e-mail: [email protected].
Should You Use Open-Source Software Applications in Your Practice? Luciano Prevedello, MD, MPH, Ramin Khorasani, MD, MPH Open-source software development has become popular with some segments of the health IT community, with the premise that end users, who best understand the problems to be solved and stand to gain from effective solutions, can drive innovation and collaborate on creating applications to improve clinical practice. In this column, we briefly review the general concepts of open-source applications to help you decide whether you can adopt them to improve your practice. WHAT IS OPEN SOURCE?
Open source, as a general term, refers to an end product that is made freely available by providing access to its design and implementation details. In IT, it means that the source code of a software application is freely available for distribution along with the program itself. Several licensing agreements exist; many of them protect the author’s copyrights while maintaining any derivative work free and open [1]. In this model, knowledgeable individuals who have access to the source code, have the ability to modify the original code to fulfill their specific needs, and contribute to the project by exposing their work to the entire open-source community. Some Web sites specialize in hosting open-source programs, keeping track of the many iterations of the software. With the right set of tools, individuals can contribute and collaborate more efficiently, significantly reducing the development cycle’s turnaround time. Because these applications are open to the community, a large set of users can continually test them as they become available. These hosting Web sites also
facilitate user feedback so that any bug or feature request can be tracked and readily exposed to developers. Not all open-source projects are funded, and benevolent contributors maintain many of them. Alternatively, the initial project may be funded, and as it matures or funding is eliminated, the code is exposed to the community for continued development. A few opensource projects receive permanent funding. Typically, the business model in this setting involves some sort of revenue stream either by providing training and support as a service or through the commercialization of different versions of the application. WHAT TYPES OF OPENSOURCE APPLICATIONS ARE AVAILABLE FOR MEDICAL IMAGING?
Open-source tools are available for many segments of the digital imaging chain. Radiology information systems with features including examination scheduling and results reporting are one example. Such features, along with paperless protocoling and work list generation, are available as open-source application through ClearCanvas (http:// www.clearcanvas.ca). PACS is composed of a Digital Imaging and Communications in Medicine (DICOM) server and a DICOM viewing station. DICOM servers are applications that manage each transaction of DICOM files (eg, from the modalities to the PACS storage). They represent a key component of the backend infrastructure of a medical imaging department. DCM4CHE (http://www.dcm4che.org) is an example of an open-source DICOM
© 2012 American College of Radiology 0091-2182/12/$36.00 ● http://dx.doi.org/10.1016/j.jacr.2012.06.033
server. A DICOM viewer, on the other hand, is the most familiar IT component of all radiology systems because it is the front-end interface between radiologists and DICOM images. Examples of open-source PACS and DICOM viewers applications include ClearCanvas and Osirix (http://www.osirix-viewer. com) [2]. Although several opensource speech recognition engines exist, they are not specifically tailored to the radiology domain. Other examples of open-source applications include DICOM Validation Tool Kit (http://dvtk.org), an application that assists in the development, testing, and servicing of medical interfaces such as DICOM and Health Level 7 [2]; Mirth (http://www.mirthcorp.com) a health care integration engine that allows users to transmit and receive Health Level 7 messages over a variety of end points; the RSNA Teaching File System (http://mircwiki.rsna. org), a teaching file application that can be integrated with PACS to collect interesting cases; Alert Notification of Critical Radiology Results (http://www.brighamandwomens. org/Research/labs/cebi/CCTR/), an application that automates the notification of critical test results and keeps track of their statuses to ensure closed-loop communication among providers; Pentaho (http:// community.pentaho.com), business intelligence software that helps one aggregate data from disparate databases and display them in summary tables or dashboards; and General Radiation Observation Kit (http:// www.brighamandwomens.org/ Research/labs/cebi/GROK/), an application that identifies dose reports (dose screens) within PACS, reads 751
752 Bits and Bytes
them, and extracts anatomy-specific radiation exposure information. Another application that is available in this category is Radiance (http:// radiancedose.com). Perl Automation for Radiopharmaceutical Selection and Extraction (http:// www.brighamandwomens.org/ Research/labs/cebi/PARSE/) focuses on extracting radiation information from nuclear medicine studies. WHAT ARE THE PROS AND CONS OF USING OPENSOURCE TOOLS IN YOUR PRACTICE?
Open-source software has several potential benefits. The reduced total cost of ownership, compared with existing commercial applications, is often discussed as a major benefit. However, the scope of the financial benefit depends entirely on your existing commercial contracts and whether you have the resources in your practice (either as hired employees or outsourced) to implement and maintain open-source tools. Another major advantage is the pace of innovation in the open-source community. You are likely to find opensource tools to address challenges in your practice where no current commercial solution is available. Also, when the source code is extensively peer reviewed, as in the case of several of the applications described above, the systems are typically secure and reliable. With open-source tools, institutions are not locked in to specific vendors, and there is greater control and flexibility over an application’s features. Despite these potential advantages, the use of open-source applications within the health care environment has been very limited so far for several reasons. A radiology practice, department, or institution
must have a reliable development team (which can potentially be outsourced) that can dedicate time to modify the code and customize the application to fulfill the practice’s specific needs. Some of the other cited reasons for limited adoption of open-source tools include a lack of “commercial-grade” support, executive teams with limited knowledge of the benefits of open-source applications, a lack of legal accountability (there is no legal bond between developers and users and no expectations or responsibilities between these two parties), functional gaps, and the lack of a clear roadmap [3]. HOW ARE OPEN-SOURCE APPLICATIONS TYPICALLY USED, AND WHAT TYPE OF RESOURCES DO YOU NEED TO TAKE FULL ADVANTAGE OF THESE TOOLS?
Open-source tools can be used as adjuncts to standard radiology processes (ie, DICOM toolkits) or as main components of the entire imaging chain (ie, PACS and radiology information systems). Typically, the scope and complexity of the implementation will dictate the resources needed for support. Because open-source applications are provided “as is,” preimplementation evaluation should assess the tool’s readiness or maturity for use in clinical practice and at large scale. Although the level of maturity of open-source software is typically relayed on the hosting Web sites, many of the issues related to specific sites can be found only when these tools are actually implemented. Therefore, having a knowledgeable team supporting the initial installation is important. Another aspect that needs to be thoroughly considered is the on-
going support many of our applications require in medical imaging. Mission-critical applications cannot have known points of failure, and prompt support from trained individuals is typically required. This can be achieved with local skills if available within the department or through support contracts with different vendors (including the one that developed the application itself). Although our traditional commercial vendors provide important tools to optimize our radiology practices, many gaps remain. Open-source tools may help you access applications to further improve your practice. Taking advantage of open-source tools, however, requires informed practice leadership and skilled IT resources not readily available in most radiology practices. Dedicating some effort to becoming familiar with available open-source tools to address some of your practice’s performance gaps can at the least help you better articulate needed functionality (or even pricing) to your preferred vendors. With some experience, knowledge, and dedicated resources, you may even try implementing one of these applications to extend the functionality of your existing commercial solutions. You may be pleasantly surprised by the results! REFERENCES 1. Ratib O, Rosset A, Heuberger J. Open source software and social networks: disruptive alternatives for medical imaging. Eur J Radiol 2011;78:259-65. 2. Nagy P. Open source in imaging informatics. J Digit Imaging 2007;20(suppl):1-10. 3. Murray PJ, Wright G, Karopka T, Betts H, Orel A. Open source and healthcare in Europe—time to put leading edge ideas into practice. Stud Health Technol Inform 2009; 150:963-7.
Luciano Prevedello, MD, MPH, and Ramin Khorasani, MD, PhD, are from the Center for Evidence-Based Imaging and the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. Ramin Khorasani, MD, MPH, Brigham and Women’s Hospital, Center for Evidence-Based Imaging and the Department of Radiology, 1620 Tremont Street, Boston, MA 02115; e-mail: [email protected].