Linux in Healthcare

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.

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.

Leading Applications

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 "i">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.

Future Growth

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.”

* "b">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.’”