In addition, people (and patients) today are highly mobile. Insurers and healthcare organizations want to know that there are options for healthcare outside of the U.S. “Behind the scene” medical processes also cross national lines. For instance, a doctor or a radiologist can read an x-ray and dictate an analysis which is then transcribed at home by a transcriber on a PC, or in China or India.
The leading applications in healthcare that are based on Linux and Open Source are those that are typically hidden from view from all but IT. The applications are embedded systems in medical equipment like CT scanners and network applications, and in Web and print servers and DNS and proxy servers.
“The GE 64-slice CT scanner is the latest technology for imaging using CT,” said Jordan Rosen. “It can synchronize x-rays with your heartbeat and take detailed pictures between beats for clarity. These images are capturing so much detail that it’s getting to the point where you can see inside coronary vessels without using invasive procedures like catheterization. With this software, it is even possible to do 3D reconstruction of the heart. The entire software suite for this product is based on Linux and Open Source. All of the workstation viewers are Linux.”
The push for healthcare information sharing and an electronic medical record by 2014 also has organizations looking at Linux/Open Source, with its promise of standard interfaces that applications can easily integrate with.
“Linux and Open Source have great opportunities in the area of information sharing,” said Scott Handy. “Under President Bush, the electronic medical record (EMR) is being mandated to be a widespread reality by the year 2014. To this end, an Integrated Healthcare Infrastructure (IHI) standard has been defined. Here at IBM, we have built the first implementation of it, and we anticipate strong adoption by large healthcare organizations. If you are a small or medium sized healthcare organization, you need to partner with someone that can get you to the same set of standards.
We believe that we can deliver a more open version of IHI by using Open Source and Linux technology that is standards-based and scalable to the cost structure of smaller organizations. In this way, the entire healthcare information exchange can be facilitated.”
Handy explains that to attain a universal EMR, every vendor has to support the same set of interfaces. In 2005, IBM embarked on a mission to rewrite its proprietary interfaces to an Open Standards protocol, using Eclipse as a foundation. It implemented HIT as a research project, got hospitals to connect to it, and convinced business partners to adopt it.
“The options for vendors are to not use standards and to write the interfaces for the EMR themselves, which is expensive—or to use Open Source standards,” said Handy. “To the degree that everyone adopts the Open Source standards and uses the same code, we will have heightened interoperability and integration.”
Slower to move and yet still moving forward, are administrative and office applications that use Linux/Open Source. Since many healthcare personnel have extensive skills in Office applications, and since Linux/Open Source presently has weaknesses in areas like spreadsheet software, the main activity for Linux/Open Source on administrative applications has been in areas like portable kiosk stations for nurses and/or other administrative applications that do not require Microsoft Office.
“There are opportunities for sales on the server side, but the desktop area has been much slower to move into,” said Ce Ce Bowman, Industry Marketing Manager for Healthcare, Novell. “In general, IT is not receptive to having to manage two different operating system environments (Linux and Windows, or Linux and UNIX). ”
Jordan Rosen of Lille Corporation reported one mobile communications package for ambulances that Lille created that has been very successful. “Ambulances need effective mobile communications from their laptops, and we found that it was possible to develop a low cost Linux-Open Source solution by using elements of amateur radio technology and combining them with robust security, high reliability, low cost and scalability,” said Rosen. “This solved the problems of our customers, who were frustrated with antiquated systems and questionable systems stability—and who at the same time had to posture themselves for rapid growth.
“The architecture we sell is a thin-client Linux deployment that runs Citrix servers under Linux and provides end users with 80 percent of their needs through Linux-based software like Mozilla and Firefox. The clients can run native Linux applications, but they can also run Windows applications if that is what the user needs. It can scale from five to 10,000 desktops. With this kind of flexibility and the ability to use both Linux and Windows, organizations are well-positioned to respond to any business need with their software of choice.”
Barriers to entry
Linux/Open Source is moving forward, but there are still major “barriers to entry” in healthcare that must be overcome. These include concerns about security, constraints on change in IT, and a general lack of understanding about Linux/Open Source.
There are some perceptions that Linux is not secure. In reality, it is a more secure operating system than Windows. With Linux/Open Source, everyone can see the code before it is compiled, and verify that there are no “back doors.” Open Source can also incorporate data encryption, access, biometrics, and other special forms of security. Both Linux and Unix have an EAL+ 4 security rating.
Healthcare IT is also subject to system “change constraints” for reasons of cost, replacement pains and general inertia. “Like all technology transformations, there is always a group that says, ‘If it ain’t broke, don’t fix it,’” said Scott Handy. A complement to this problem is the dearth of vendor-supplied clinical applications using Linux.
“We keep an eye on the ecosystem of healthcare system integrators and technology suppliers,” said Red Hat’s Tom Wunderlich. “We ask ourselves, ‘How can we be sure that they are integrated into Linux hardware and Open Source software?’ We certify partners in both the hardware and software areas. The goal is that all systems that run on Windows or Unix can run in Linux also. When the end customers are demanding high performance, low cost solutions, it is incumbent on suppliers to provide them.”
Healthcare executives are still exploring and learning about Linux and Open Source. In many organizations, the knowledge of the Linux/Open Source value proposition still resides with the technicians, and not with the decision-makers.
Most industry observers feel that healthcare’s uptake of Linux can dramatically increase, pending advancements in several key areas:
Change. As IT asset cycles run their course and servers and clients are up for replacement, some of those replacements will be based on Linux. Microsoft’s new Vista operating system might also be a contributor, since Vista is a dramatic departure from Windows and is likely to cause retraining of office personnel on Microsoft applications. If extensive re-training is necessary, it might be enough to make healthcare organizations consider a migration to Open Source office applications, which are less expensive to license and more akin to what people are already used to with Windows.
Connectivity and Integration. Linux/Open Source is already enjoying considerable success in healthcare network infrastructures and embedded systems in medical equipment. Meanwhile, the push for an electronic medical record (EMR) makes Linux/Open Source a logical choice for information sharing. In the future, using multiple core processors will enable organizations to handle multiple information services such as real-time video, scans, correspondence and other network applications.
Partnering for Delivery of Critical End Applications. Healthcare end applications using Linux/Open Source remain in short supply, but “critical mass” vendors like IBM, Red Hat and Novell are starting to tip the scales to where both healthcare providers and application suppliers are engaged in Linux/Open Source projects with important deliverables.
“There is a big opportunity for healthcare organizations to participate in Open Source projects,” said Red Hat’s Tom Wunderlich. “If you get involved in Open Source and take the time to understand the benefits in licensing costs, choice, flexibility, standardized development, collaboration, and time to market, you will see the benefits first hand.”
IBM uses a research lab and invites healthcare companies and vendors to test applications. Novell sponsors pilot programs for desktops. “Pilots like this will help vendors like Dell, which has a Linux desktop solution,” said Novell’s Bidleman. “It is a huge step forward just to introduce this desktop technology to healthcare organizations.”
Partnering assures healthcare that the applications it adopts will be supported by credible vendors. It also provides a “spawning ground” for large healthcare organizations to adopt applications—which in turn encourages smaller organizations to do the same. Growing adoption will inspire software providers to deliver Linux/Open Source versions of their products.
“More and more Open Source applications are being adopted by the market, and at some point using Open Source will be considered “normal” in healthcare,” said IBM’s Scott Handy. “The commercial Open Source vendor space is taking off, which will help with credibility and support issues. There is also the OHF bridge, which allows you to write an application or connection that simply “plugs in” to the bridge, even if the application resides on a legacy system.”
Virtualization. Virtualization — the ability to consolidate physical servers by placing logical “instances” of these servers on a single hardware platform — is a very hot trend in healthcare and other industries. “Virtualization provides cost savings and redundancy. You save on hardware, staffing, and administration when you can run multiple instances of an operating system on a single machine,” said Tom Wunderlich. Virtualization is also an easy cost savings justification that can be used with upper management.
Virtualization with Linux/Open Source can be done on network servers or even on traditional mainframe platforms. For example, multiple instances of Linux/Open Source can be run on an IBM Z Series mainframe — a point not lost on large-scale healthcare organizations. “The mainframe is still being used as a data and transaction repository hub on networks,” said Scott Handy. “We’re seeing people connect mainframes into open platforms with the mainframe hub as a backend.”
A Prescription for Sucess
A critical mass of Linux applications for healthcare providers is perhaps two years out, but Linux is already available in network infrastructure and several niche areas, and is poised to grow at a slightly greater rate than the overall market.
Organizations that can craft strategies for Linux/Open Source will be ahead in the game—as will companies that move forward with server consolidations and virtualization, which is greatly facilitated by Linux/Open Source. Organizations should be sure to partner with a reputable vendor that can provide extensive support. Initial deployments should be conducted in non-critical “pilots” before large-scale release.
“Linux won’t be putting Microsoft out of business,” said Forrester’s Michael Gould, “But it has crossed the chasm to where it is no longer considered ‘risky.’”