Can open source solutions be a great leveller for Indian Healthcare?

Soma Tah

Open platforms and protocols help innovators devise solutions that would otherwise require deep pockets. As India prepares to create electronic medical/health records (EMR/EHR) for each individual as part of the National Digital Health Mission (NDHM), fostering open source will encourage innovators to develop affordable HealthTech solutions.

Did you know that the obstetric forceps, used during childbirth to avoid maternal and newborn morbidity, were initiated in the 16th century but were kept a family secret for over 100 years by a family of midwives (the Chamberlens)? Various versions exist as to why they kept the forceps secret for so long. While one reason could be that using this sort of tool in childbirth was considered ‘meddlesome midwifery’ back then, it could also well be for knowing that they could earn a lot of money by being the people who could deliver a baby when no one else could. 

Imagine making a lifesaving tool inaccessible to the vast community of health practitioners for more than 100 years just for profits! Now, if you look at the ‘vendor-lock in’ strategy of the proprietary software vendors today, it is no better than the ‘obstetric forceps’ scenario. Experts say that the collaborative nature of the Open-source Software (OSS) or Free and Open-source Software (FOSS) development can potentially bring technology innovations into the healthcare space much more quickly than independent development. It can also bring down the cost of technology adoption in healthcare to a considerable extent, fast-track diagnostics and improve patient care. 

Indian Healthcare infrastructure consists of a large number of public and private hospitals. There are disparities in the cost of healthcare and the level of cutting-edge technology adoption in these hospitals. Now that India is preparing for the nationwide rollout of the National Digital Health Mission (NDHM), which will create electronic medical/health records (EMR/EHR) for each individual, open-source solutions can be a great leveller.  

Reasons OSS/FOSS-driven health systems are a better bet

Gurpreet Luthra, Tech Principal, Social Change Group, Thoughtworks India

“The most obvious benefit is financial i.e., no license fees, often no upgrade cost and a significantly reduced cost of ownership. With no vendor lock-ins, healthcare providers have the freedom to choose, decide and customize solutions to suit their contextual needs. All, without paying the ‘hefty’ fees to the ‘certified’ knowledge partners. OSS solutions will hold a trump card over proprietary solutions that claim inter-connectivity through tie-ups with partners. In our opinion, several fit-for-purpose OSS apps will ‘naturally’ take advantage of such inter-connectivity. And healthcare providers will not have to buy a ‘full stack’ because of possible compatibility issues,” said Angshuman Sarkar, Principal Consultant, Global Health Practice and Gurpreet Luthra, Tech Principal, Social Change Group, Thoughtworks India.  

While the aforementioned financial benefits are a rational approach to healthcare providers’ procurement strategy – OSS-driven health informatics systems are also a better bet for safer, high-quality peer-reviewed systems. “Unlike closed source, proprietary black boxes, OSS leverages the cumulative knowledge of the wider global community to bring innovation, accessibility and knowledge to the healthcare providers and patients. Also, when it comes to security and robustness, it is easier to perform an evaluation of an OSS for maturity of design and coding – than for proprietary software. With the latter, healthcare providers have to rely on contracts, promises and third-party certifications. The term ‘vaporware’ comes to mind, where many poorly engineered products hide behind fancy decks and good-looking UI/UX. With OSS, transparency builds trust,” they added.  

Additionally, OSS helps healthcare providers provide optimal solutions for low-resource environments, where the need for high-quality software is significant because of the disadvantages and limitations that a care provider might face. Bahmni, a FOSS EMR/EHR and hospital system, was conceptualized by Thoughtworks with the mission of providing comprehensive and quality solutions to low resource environments. Starting from a single NGO-run hospital in a Chhattisgarh village (which it was named after), Bahmni today is used in some of the most resource-constrained and trying environments of South Sudan, Afghanistan and even in resourceful cities across more than 50 countries.  

Gautam Rege, Co-founder & Director, Josh Software

“But the biggest example of the OSS advantage is the COVID-19 India tracker that was set up by the OSS community in 2020 - a completely volunteer-driven effort that is so beneficial to the general public and the healthcare industry at the same time! Ease of integration, interoperability of software, backend support, name it and you have it! The Aarogya Setu app by the Government of India operates on the same concept. Covid was just a wake-up call, we need to be better prepared and build more resilience. These have proven the potential of open source,” said Gautam Rege, Co-founder & Director, Josh Software. The Indian healthcare industry needs cost-efficient, fast and reliable solutions- something the OSS developer community certainly can work on, feels he.  

Also, proprietary solutions often lead to disparate systems causing major interoperability issues. OSS helps to avoid many data interoperability issues that make it difficult to exchange health information between EHR and other health IT systems. “AI/ML technologies are at the forefront of healthcare innovations today and the AI/ML communities are thriving on OSS and open datasets. Along with many other areas, these are the upcoming domains where healthcare providers could gain massive benefits from being a part of the communities,” said Vikalp Sahni, CEO & Founder, Eka Care. “However, these are also the ideas where OSS and AI models built on top of open datasets bring in more nuanced challenges such as varied public policies and ethical concerns across nations in terms of data usage and models built on top of it,” cautioned he.  

Key concerns around embracing OSS/FOSS in Healthcare  

“While the nature of FOSS and the general challenges like licensing, lack of support, data privacy, security issues that come along with adopting FOSS in any industry, there are some aspects that are of more importance in healthcare,” said Ajit Narayanan, CTO, MFine. He explains them more in detail:  

Ajit Narayanan, CTO, MFine

Accuracy: Healthcare solutions using FOSS need to be extremely accurate. General-purpose software may not fit that bill and therefore providers need to be more careful about what software they pick for what use cases. This is particularly true in ML models or publicly available datasets used for training. 

Certification: The level of technology, reliability, support that a commercial vendor is able to provide, remains to be seen for OSS for very critical parts of the healthcare sector. This may hamper certification processes or slow them down. 

Licensing: Be very clear of what the licensing terms are for OSS. If this is not examined well, it can potentially lead to downstream costs. 

Security: Estimates that are close to 95 per cent of applications across industry sectors contain open source software and most of them are vulnerable. A security architecture/process is something providers need to have in place before the widespread adoption of OSS.  

Josh Software’s Gautam Rege has a different take on the matter. “The biggest misconception about open source is that it is not secure. The fact of the matter is that more than half of these security breaches happen due to human error, insecure practices during the installation and application of software products. If healthcare providers make it a thumb rule to understand the technology in and out before making the move, half the problem goes away. If you’re worried about fixing bugs

Angshuman Sarkar, Principal Consultant, Global Health Practice, Thoughtworks India

or error improvement rates, open source vulnerabilities can also be caught extremely quickly, thanks to the efforts driven by the OSS community,” said he.  

But looking beyond challenges, OSS adoption helps a great deal with continuous enhancement, easy integration, interoperability, standardization and most importantly saves you valuable time to digitization, said Narayanan. 

“Organizations should evaluate the FOSS’s partner ecosystem that has already adopted the software – are they active on forums, do they provide regular documentation updates, do they make regular commits to the software. This approach will help decide the nature of support needed and the access to said support. Companies might still have to invest in building ‘some’ internal capability to handle initial queries internally and quickly. But this is not very different from proprietary products like Databases, ERP packages, etc., where organizations either bring in employees with requisite skill sets or partner with IT organizations that provide the needed skills,” advised Thoughtworks’ Sarkar and Luthra.   

Will NDHM and OSS/FOSS foster affordable innovations in Healthcare?

Vikalp Sahni, CEO & Founder, Eka Care

NDHM holds a huge promise to transform India’s healthcare system. Adoption of OSS/FOSS opens up possibilities to build platforms and applications with best-in-class privacy policies and data sharing standards. “NDHM is being envisaged as an open digital ecosystem (ODE), a platform that breaks down data silos, enables information sharing with the patients’ consent and enables service innovation to deliver better healthcare to every Indian. The success of ODE depends to a large extent on its adoption by a large network of innovators, who build consumer-centric services on the platform. Open source enables governments to collaborate on a win-win basis with startups and tech talent while enabling sustained innovation,” said Eka Care’s Sahni. 

“NDHM is establishing standards and protocols alongside an interoperable layer – that ecosystem players can leverage to provide patients, practitioners, payers and allied services with the desired user services. Today, we have limited options to avail services/products - patients and providers have to use apps hosted on ‘big’ portals. However, the proposed Unified Health Interface (UHI) will allow the expansion of market reach where anyone can develop an End User Application (EUA) and Health Service Provider Application (HSPA) using the standardized UHI protocol. Such open market protocols will help innovators devise solutions that would otherwise require deep pockets. NHA/MoH should actively support FOSS/OSS and its components that can be used as the starter blocks, EUAs and HSPAs in the public health ecosystem. This will help ensure clinics, hospitals and users who cannot afford expensive software will still have a high-quality option available to them. We expect this to level the playing field. Where there are gaps and emerging needs, startups would be encouraged to innovate and develop affordable tech options,” said Sarkar and Luthra of Thoughtworks.    

“IIt is impossible to imagine a world without OSS or deliver the next level of innovation without OSS. MeitY is advocating extensive usage of OSS. OSS is likely to be a key component of GovTech 3.0 which plans to build an open, secure and inclusive digital ecosystem in India. NDHM is part of that puzzle,” said MFine’s Narayanan.