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Linux in healthcare is a tale of things seen and unseen. Linux/Open Source have enjoyed tremendous popularity in embedded systems and networks for major technologies used in healthcare that healthcare providers may not even be aware of. It has also experienced a steady adoption rate in healthcare applications. Nevertheless, the adoption rate of Linux/Open Source in healthcare lags that of other industries. Here’s why, and how that could change.

In 2006, Linux server sales are outpacing overall server sales by an 8:1 ratio, and Linux is outpacing Windows as an operating system in new sales at a rate of 5:1. This growth is occurring across all industry sectors, including healthcare, but healthcare presents a unique challenge. The criticality of patient care, coupled with intense regulation and limited IT budgets, delays adoptions of new technologies in healthcare.

“Many healthcare organizations have been using the same technologies for 20 or 30 years,” said Chris Bidleman, Director of Healthcare Solutions for the Americas for Novell. “In our healthcare trade show booth year after year, we had about the same volume of visitors. But after the healthcare information management initiatives (HIMS) last year, we noticed a significant increase in conversations around our trade booth at healthcare shows about Linux and Open Source. In fact, there was probably more volume in visitors and organizations at our healthcare trade booth last year than in all the previous years combined.”

Bidleman says that Novell has seen many hospitals asking about the Linux desktop, which has begun to open some eyes because it can save $50-$300 per desktop in licensing and management expenses. Nurses and other healthcare administrative staff who don’t typically use Microsoft’s Office products can just as easily work on Linux desktops, where navigation and other functions are straightforward, and learning curves are easy to manage.

“Overall, there is a large market opportunity for Linux in hospitals — but we see everyone moving toward information sharing and interoperability, which Linux/Open Source offers,” said Tom Wunderlich, Red Hat’s Product Management Director for Vertical Markets.

Red Hat, Novell, IBM and others acknowledge a lot of interest in Linux servers from the middle tier market of healthcare providers, who do not have the history of mainframe investments that large healthcare organizations have. “What’s unique about healthcare in 2006 is that, for the first time, small- and medium-sized organizations will spend more in cumulative dollars than large-scale organizations on IT,” said Scott Handy, Vice President of Worldwide Linux and Open Source, IBM-wide Infrastructure Initiative, IBM Systems and Technology Group. “Overall, the U.S. spends 1.7 trillion dollars on healthcare annually, so even a small percentage of revenue allocation to IT is a big number.”

Mature Linux platforms offer better performance, lower cost, and superior openness than Unix, a traditional mainstay in many smaller office and research laboratories. The importance of commercial Linux is also central to healthcare organizations. Nevertheless, there is still a lingering perception that Linux is for hobbyists and not for mission-critical applications.

The Chicken and the Egg

Commercial Linux is central to most healthcare buying decisions because healthcare providers want the assurance and the backing of strong vendors that will stand behind hardware and applications. They also want packaged applications that will fill the niches that they need to fill.

Here is the dilemma: There are still relatively few clinical systems and databases based on Linux and Open Source environments. Traditional healthcare software providers have proprietary solutions that they are slow to convert to a Linux platform — and the only thing that can change this is direct market pressure from the healthcare providers themselves.

Lille Corporation, a New York-based Novell reseller, decided to take an aggressive approach to Linux/Open Source. “In the early 1990s, we asked ourselves how we could deliver medical software to physicians throughout the U.S., and we began to look at different tools that we could use to produce the software,” said Jordan Rosen, Lille’s President. “We performed a comprehensive analysis of all of the tools and commercial libraries that could be used in software development, and we found a huge body of resources in Open Source. We also discovered that application prototyping with Open Source was superior to prototyping capabilities in other toolsets we had analyzed. Open Source applications offered outstanding functionality, and there was also the ability to get rapid support with such a well-established worldwide community of software developers.”

Rosen explained the value to product developers of tools that give you source code that you can modify and compile into your own products. “This made a tremendous difference to us in our speed to market,” said Rosen. “We found we could develop software and deliver it for use in our software as a service sales model. In doing this, we were able to provide our healthcare customers with a low-cost, managed, and secure solution. It was this turning point that convinced us to develop with Linux exclusively.”

Lille’s story is not unusual. Many commercial developers of medical software on the Windows platform actively use Open Source for underlying capabilities like security, compression, and Web services, and because Open Source works on so many different computing platforms. These vendors recognize the value of Open Source as a way to leverage and get products to market without reinventing the wheel. Better yet, the use of Open Source is entirely transparent to customers using Windows as their desktop operating system.

Rosen notes that the original MUMPS (now known as “M”) operating system first developed at Massachusetts General Hospital was used to write virtually every type of medical application for the VA hospitals. M is public domain software that can be taken by any vendor and adapted for commercial use and sale. Many healthcare software companies that are looking at Linux/Open Source versions of their products are building products around the framework and the code repository already offered by M, to keep costs down and speed time to market. At the same time, these software companies are hearing more from their healthcare customers about the new applications that they would like to see that can interoperate with both Linux and Windows.

Drivers of Linux/Open Source Adoption

Analysts and industry practitioners have differing opinions of the drivers that are now behind healthcare’s migration into Linux and Open Source, but there are seven major drivers that most agree on:

  • Cost Savings and Reductions. Linux and Open Source saves money: commodity servers outfitted with Linux are cheaper than specialized or proprietary hardware. Open Source reduces licensing fees. And the perception is that Linux and Open Source lower IT administrative costs.

    “The biggest driver for healthcare organizations is reduced costs,” said Bidleman. “More money per capita is spent on healthcare in the United States than in any other country. At the same time, U.S. healthcare has one of the lowest IT expenditure rates, at about 2-5 percent of revenues. Compare this to healthcare organizations in other countries that have an IT expenditure rate that is 5-10 percent of revenues.”

    Linux and Open Source also promises to ease system integration. Without much integration, current hospital applications introduce tremendous waste and cost on a daily basis. For example, if a patient switches hospitals, the institutions often have to fax documents back and forth and re-key data. Integration drives these costs down since data is only entered once, and then routed to wherever it is needed.

  • Better Patient Service. Today’s healthcare environment is extremely competitive, and hospitals, clinics, and other institutions are enhancing patient service to differentiate. “Patient service is a very competitive factor for healthcare organizations,” said IBM’s Scott Handy. “When the patient doesn’t have to re-supply information, x-rays, and so on, there is less frustration. Integrated information systems can deliver this.”

    There is an even more important reason for systems to integrate. In the U.S., it is estimated that 150,000 deaths occur each year because of avoidable medical errors. An electronic patient record and other system integration can preclude many such accidents.

  • Improved Information Sharing. HIMS and other healthcare initiatives, along with the mandate for an electronic medical record by 2014, are driving healthcare organizations of all sizes to do whatever they can to enhance information sharing. As part of the effort, they are exerting pressures on their hardware and software providers to help.

    “The key is adopting standards in these areas: shipments of documents, scanning of documents, content such as x-rays and scans, and data queries,” said Scott Handy. “If we can get a full-blown adoption of this by vendors, large, small and medium sized healthcare organizations will all have the support levels from their vendors that they need and we can provide an “on ramp” with affordable solutions for virtually any organization.”

  • Satisfactory Vendor Support and the Right Solutions. Healthcare providers want to see credible vendors with strong applications and support organizations backing Linux/Open Source. This is the “chicken and the egg” dilemma described earlier, because while vendors wait for customers to justify Linux/Open Source ports or investments, customers wait for deliverables.
  • Vendor Independence. Fenced in by proprietary vendors and forced to pay the high costs of technology licenses and support, healthcare organizations see Linux and Open Source as a way to assert independence. “Even if organizations are using a major brand of Linux, they know that they can easily move to other Linux distributions,” said Michael Goulde, healthcare analyst for Forrester, Inc.
  • Adoption by Large Healthcare Providers. Goulde also believes that many healthcare organizations are smaller clinics that look for dollar savings but also proven applications. “The Linux market is moving slower because many of these organizations or companies are reluctant to move forward until the market does,” said Goulde. “They want to see larger organizations making investments in Linux and Open Source, and they want to see vendors more aggressive in providing Linux and Open Source applications.”
  • Requirements of the Global Healthcare Environment. A key driver for hardware and software vendors is the global environment. China is an enormous market opportunity for these companies, but they have to be able to offer Linux solutions to compete there. Europe is also largely Linux-based.

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