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In the complex process of product development, the ongoing distribution of processes and globalization of markets force companies to implement means of cooperation between partners at remote sites and coordination of tasks. In this paper we describe a distributed software architecture which provides an integrated set of tools for a wide range of Rapid Product Development processes. The central component is an active knowledge base called ASN (Active Semantic Network) which is used as shared data repository and team process coordination and upon which the other components of the system operate. The scenarios described are coming from the car manufacturing area ranging from collaborative development of simulation prototypes using supercomputers to virtual reality analysis techniques.
At the time of the assessment, we uncovered 54 open source EHR projects, but only four of them had been successfully certified under the Office of the National Coordinator for Health Information Technology (ONC Health IT) Certification Program. In the majority of cases, the open source EHR software was downloaded by users in the United States (64.07%, 148,666/232,034), underscoring that there is a significant interest in EHR open source applications in the United States. A survey of EHR open source developers was conducted and a total of 103 developers responded to the online questionnaire. The majority of EHR F/OSS developers (65.3%, 66/101) are participating in F/OSS projects as part of a paid activity and only 25.7% (26/101) of EHR F/OSS developers are, or have been, health care providers in their careers. In addition, 45% (45/99) of developers do not work in the health care field.
The research presented in this study highlights some challenges that may be hindering the future of health care F/OSS. A minority of developers have been health care professionals, and only 55% (54/99) work in the health care field. This undoubtedly limits the ability of functional design of F/OSS EHR systems from being a competitive advantage over prevailing commercial EHR systems. Open source software seems to be a significant interest to many; however, given that only four F/OSS EHR systems are ONC-certified, this interest is unlikely to yield significant adoption of these systems in the United States. Although the Health Information Technology for Economic and Clinical Health (HITECH) act was responsible for a substantial infusion of capital into the EHR marketplace, the lack of a corporate entity in most F/OSS EHR projects translates to a marginal capacity to market the respective F/OSS system and to navigate certification. This likely has further disadvantaged F/OSS EHR adoption in the United States.
Despite these disadvantages, the F/OSS software has been growing in terms of the number of projects. The 8th Annual Future of Open Source Survey found that the number of F/OSS projects doubled between 2012  and 2014 .
We made an assumption that download frequency reflects the popularity of the software. This assumption is a commonly held belief in this research domain . We looked at the download number in the last 12-month period on SourceForge. Around 47 projects (87%, 47/54) in this study have information on downloads, a proxy for use of the software.
Programming language for each software system was examined and classified according to whether one or multiple were used. One open source study suggests that using one common programming language affects the success of the software project .
The setup of the system is not always obvious, and in some cases requires IT administration skills. The top 10 downloaded projects were analyzed, as these materials make the installation and usage of the system easier. The supporting materials included user guides, installation guides, and version demonstrations.
SourceForge provides important information about the software and gives the highest number of downloads for each EHR software system. The top 10 most downloaded projects were identified, in addition to the country that made the greatest number of downloads, to see if the adoption rate affects the number of downloads.
A survey was conducted in 2014 using the commercial survey tool SurveyGizmo (Boulder, CO). The survey consisted of 20 questions and took approximately 5 minutes to complete (Multimedia Appendix 1). The target audience included anyone who self-identified as a developer of health care F/OSS. Our questionnaire was modeled after a similar survey developed to compare proprietary and open source software in 2003 .
The OpenEMR project had the highest number of downloads (63,418 in a 12-month period) (Table 3). The data shows that the United States accounts for the majority of the downloads and constitutes 64.07% (148,666/232,034) of the total downloads of open source EHR projects on SourceForge. In total, 19% (10/54) of open source EHR systems have installation and user guides along with demonstration versions. The mean project age is 7 years with a range of 2 to 14 years.
In terms of project (spoken) language, a large number of projects were written in English (46%, 25/54), but surprisingly, 28% (15/54) were being developed in one or more languages besides English. It was found that 11% (6/54) of the projects did not specify a language (Table 4). Data shows that the number of downloads for projects with multiple spoken languages was very high (n=187,933); with a download rate three times the one-language projects (n=48,402). These numbers indicate a global interest in F/OSS EHR development and prove that the number of language translations is positively related to project success and popularity.
The survey results confirmed that many developers start developing F/OSS to give back to the community. Around 40% (39/97) considered it important or very important to give back to the community and 38% (37/96) considered the interaction with like-minded programmers to be important. A significant number of respondents were motivated to promote the mode of development and the ideal of freely modifiable software (47%, 47/99), while the remaining developers were motivated to provide alternatives to proprietary software (53%, 50/93). Some developers (27%, 25/97) began developing F/OSS software by modifying it to fit with their requirements or to fix the bugs in their existing software (32 %, 32/97), and 26% (25/96) of them were interested in learning how the program worked.
One of the unique findings in this research is that 74.2% (75/101) of health care F/OSS developers are not health care practitioners, and 45% (45/99) do not work in the health care field. Being a developer outside of the health care field can be a core problem for the development of usable clinical software with a high degree of functionality. This may serve to explain why open source EHRs have limited functionality today.
The availability of motivated developers and the need to continuously improve EHR systems will likely mean F/OSS EHR will continue to be part of the health care software landscape despite the many challenges these projects face today. Characterizing the challenges and benefits of adopting open source EHR will be important in understanding the value of these systems.
Many hospitals would benefit greatly from integrated software, rather than a disparate group of systems. However, the F/OSS option can be difficult to interface with commercial systems and may require personnel with multiple skill sets 
Although F/OSS software does not have licensing costs, effective implementation still requires skilled staff, time for installation, and time for learning the software. F/OSS EHR implementation cost can be as high as the proprietary software because of the add-ons, consultation costs, and need for assistance . An important aspect of the total cost of ownership of an EHR system is usability. Poor usability can directly impact the productivity of expensive health care providers and support personnel. The ability to freely modify F/OSS EHR systems and optimize them for local use likely translates into lower overall cost.
At an operational level, F/OSS software also presented reduced functions in decision support and knowledge management. Clinical reasoning, guidelines and protocols, quality assurance, and integrated care were rather limited or nonexistent in most applications . Developers lack medical knowledge as the majority of them are not health care practitioners, which may affect the efficacy of clinical decision support functionality.
One of the major shortcomings is the lack of liability and accountability in F/OSS. Our study did not address this issue. Few studies of F/OSS in health care have addressed the risks of using F/OSS. F/OSS EHR projects come without warranties regarding the development, release date, or fulfillment of functionality. F/OSS EHR systems do not have a commercial entity providing support and tend to rely on a volunteer community. This can be a significant risk for a software system that supports the core business of a hospital .
This study highlights a number of important aspects of F/OSS EHR. Open source software systems seem to be important to some health care organizations; however, only four F/OSS EHR systems are ONC-certified in the United States, which creates a barrier to broader use. Health care open source software also currently lacks directed corporate or governmental support for sustainability and growth of these software programs. We hope this research underlines the challenges that hinder the future of F/OSS and provides avenues for future research to study and improve adoption of F/OSS systems in the United States. 2b1af7f3a8