The characteristics and capabilities of the available open source health information technologies supporting healthcare: a scoping review protocol

Introduction Due to the many advantages of open source software (OSS), including reduced cost of licensing, more flexibility in terms of customisation and redistribution, better quality and no vendor lock-in, OSS in healthcare is increasingly gaining importance. Various open source health information technologies (OS-HITs) are continuously being designed and developed for different areas of healthcare to increase organisational efficiencies and quality of care at minimum costs. The objective of this scoping review is to identify the kinds of existing OS-HITs, their characteristics (e.g. functions) and capabilities (e.g. advantages/disadvantages) for various healthcare stakeholders (physicians and patients) and healthcare sectors (e.g. clinical, administrative). Methods We will conduct a scoping review to identify the range of available OS-HITs in international literature from 1980 to September 2018. Searches will be conducted in six major international databases, namely: Cumulative Index to Nursing and Allied Health Literature Plus, Excerpta Medica Database, Global Health, Library Information Science and Technology Abstracts, Medline and Web of Science to identify relevant published research. We will also search the Google search engine and Google Scholar for on-going and unpublished work and the grey literature. Searches will be peer-reviewed by two independent reviewers and will not be limited by methodology or language. Next, selected references will be tabulated for study characteristics by author affiliation, country of origin, the name of OS-HIT, healthcare area/sector, system requirements, stakeholders, complete solution and web link. Furthermore, functions, benefits/advantages, disadvantages and outcomes (e.g. usability) of OS-HITs will be extracted. Narrative and interpretative synthesis of data will be undertaken. Results We will report our findings in a peer-reviewed journal.


BACKGROUND
Source code of open source software (OSS) is publicly available for end-users who can examine, add, modify or distribute it, whereas source code of proprietary or 'closed source' software is only available to the person or vendor who developed it, 1 and users are solely dependent on the vendor for any modification. Due to the many benefits of OSS, such as low cost of licensing, flexibility (can be easily customised and redistributable), reliability (abundant support from peer developers), enhanced quality (patchwork for bugs) and no vendor lock-in, OSS in healthcare is increasingly being adopted worldwide. [2][3][4] Health care leaders are showing keen interest in open source health information technologies (OS-HITs) [an array of technologies (licensed software with its source code available and with the rights to modify, distribute and study) to save, exchange and analyse health information], such as electronic health/medical records (EHRs/EMRs) [e.g. United States' Veterans Health Information Systems and Technology Architecture (VistA) and Canada's OSCAR], district health information systems (DHIS) [e.g. DHIS2 (www.dhis2.org)] and Picture Archiving and Communication Systems (PACS), for example, Dicoogle 5 to avail themselves of the advantages of OSS. 2,6-8 For example, VistA, a free and OS EHR built and maintained by the United States Department of Public Health Services is considered to be the largest health information systems acquired globally. 9 It has been used extensively by the Indian Health Services, Mexican Government and many other healthcare facilities around the world. 2, 9 Moreover, National Health Service (NHS) England recently supported an initiative called Code4Health, which is an OS platform, a community and a learning tool, which aims to deliver safe and improved patient outcomes by enabling the use of OS digital technology and tools. 10-12 By using Code4Health, NHS England intends to create workable OS solutions, ensure to reuse and share all code created in the NHS through a library of assets, provide evidence of value of OSS to the health and social care community, achieve a self-sufficient eco-system of communities and provide equal opportunity for infrastructure services and OS commodities. 11 Another example is the study on the availability of OS-HITs commissioned by the Office of the National Coordinator for Health Information Technology under the terms of the Health Information Technology for Economic and Clinical Health (HITECH) Act. 13 This study focused on the availability of the OS EHRs for community clinics and safety-net providers (providers in the United States which offer access to healthcare to low-income people, including those who are uninsured and/or have limited or no access to healthcare); the comparison of total cost of OS EHR and the proprietary system; the ability of OS EHR to meet the needs of diverse populations (such as disabled, elderly and children); its interoperability with other disparate systems (such as claims processing systems and practice management system) and its conformity to the Meaningful Use requirements as per HITECH legislation. The authors concluded that OS EHRs can provide cost-effective and reliable solutions for safety-net providers, maintaining the same level of functionality required for Meaningful Use when compared with proprietary systems. Moreover, it can be customised efficiently by creating templates and modules to address and capture the various specific needs of the community. 13 In addition, the OS community and developers can offer substantial support to the community health centres as they continuously improve their products. 13 Finally, the deployment of OS EHRs may provide the most suitable solutions maintaining pace with the evolving requirements of Meaningful Use and changes in the health industry. 13 In a survey conducted by GatePoint Research, more than 100 healthcare executives affirmed that OSS, unlike propriety software, can be created with the collaboration of thousands of developers and people from the healthcare industry, such as clinicians who can use, improve and modify the OSS according to their needs. 2,14 According to a survey conducted by the World Health Organization, 2 OS-HIT is also gaining popularity in economically-developing countries due to the unaffordability of propriety systems and the fact that these often do not offer solutions for local health problems. OSS has strengthened the innovative capacity of HIT in many areas of healthcare in low-and middle-income countries. Biometric attendance monitoring of tuberculosis in India; mobile supply chain management tool for logistic management in Ghana and Tanzania; rapid short messaging service (SMS) to provide availability of essential medicines in Malawi and a telemedicine network in Congo, Egypt and Mali are a few examples of several OS-HITs used in developing countries. 15 Low cost or free OSS is beneficial for resource-constrained countries, however, countries with ageing population (over 65 years) such as Germany, Greece Italy, Japan and the UK are considering/planning lowering healthcare costs with better treatment options by adopting OS-HITs. [16][17][18] OS-HITs are also being used in fighting viral outbreaks such as Ebola. 19 The available commercial EHRs were not appropriate to use by clinicians in the Ebola outbreak but required a customisable software that could be used in the Red Zone (units to hold patients in isolation suspected with the Ebola disease 20 ) while wearing protective suits with minimal typing, high contrast colour schemes, large touch buttons for gloved hands and large fonts to see clearly within the protective masks. 19 Moreover, paper prescriptions and medical notes cannot be carried out to the treatment centre in the Red Zone as the virus can live on hard surfaces, which made it difficult for healthcare professionals to collect and manage information. 19 The OpenMRS community in collaboration with Save the Children and ThroughtWorks and partnership with Google Doctors Without Borders responded to the Ebola epidemic and provided data management and reporting solutions according to the needs of clinicians and staff. 19,21 Fortunately, this Ebola OS project, which can be easily customisable, can also become the groundwork for any subsequent solution required for another disease outbreak in future and could be deployed in days than in weeks. 19 These strengths, amongst others, have increasingly led the development and adoptability of OS-HITs. It is thus necessary for healthcare providers and managers to know the kinds of OS-HITs available for healthcare stakeholders (e.g. healthcare professionals, managers and patients) in various healthcare sectors to effectively select the most appropriate low-cost adaptable technology solutions based on their functions, advantages and usability; and their barriers and facilitators to the implementation or utilisation. A previous systematic review reviewed only the utilisation of OS EHRs globally from the year 1990-2012 using six scientific databases, namely, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), Library Information Science and Technology Abstracts (LISTA), Medline, Scopus and Web of Science. 22 Language selection of the selected papers was not given. The review found 13 OS EHRs (such as openEHR, OpenMRS and WorldVista) being utilised in 31 countries worldwide. We will employ a more comprehensive search strategy that may not only cover EHRs but may also include other OS-HITs, such as clinical decision support systems and PACS, to conduct a comprehensive systematic scoping review to identify and characterise all the OS-HITs available for several healthcare areas.

METHODS
A scoping review is a technique used to map the current literature in a field of interest, the key concepts underpinning a research area and the main sources and kinds of evidence available. 23,24 It was first defined by Mays et al. 24 noting that a scoping review aims to map rapidly the key concepts underpinning a research area and the main sources and types of evidence available. It has become an increasingly popular method for synthesising research evidence, 25,26 which can be of particular use when the topic is of complex and heterogeneous nature or has not been comprehensively studied. 24 There are different ways of conceptualising scoping reviews. 27 For example, according to Arksey and O'Malley, 23 a scoping study seeks to provide the broad coverage of the existing literature with varying degrees of depth to investigate the extent, range and nature of research activity; determine the value and potential cost of undertaking a full systematic review; summarise and disseminate research findings to the interested readers and identify research gaps in the existing literature. 23 Another purpose is 'literature mapping' to describe the literature and to synthesise findings from different types of studies; or 'conceptual mapping' to establish how a particular term is used by whom, for what purpose and in what literature 28,29 or 'policy mapping' to identify the relevant documents from government and professional agencies. 30 According to the National Institute for Health Research Service Delivery and Organisation Research and Development Programme, it is also useful for the elucidation of working definitions and conceptual boundaries of a particular topic area, conducted systematically, 28 but explicitly excluding quality appraisal (which is an integral component of a systematic review), to establish a frame of reference. 27 It can also be used as a preliminary step to a systematic review as it provides a rigorous and transparent approach for mapping areas of research. 23 The scoping review is registered with the Open Science Framework. It can be accessed at the following URL: https:// osf.io/rvfwm/ We will use a six-staged scoping review framework devel- The six stages are described as follows:

Stage 1: Identifying the research question
Research questions for scoping reviews should be broad so as to summarise the breadth of available evidence. 23 The Searches in the academic databases will not be limited to methodology (such as qualitative, quantitative, mixed methods and implementation studies) and language. References will be scanned from included studies to identify additional potentially eligible papers.
We will also search the Google search engine and Google Scholar [first 100 results being considered for each phrase/ term searched (see Appendix 2 for search terms)] for grey literature that may include websites and reports.

Stage 3: Study selection
After initial screening and deduplication of studies, two reviewers will independently check titles and abstracts against the inclusion/exclusion criteria as follows:

Inclusion criteria Participants and care settings
These will comprise various healthcare stakeholders, such as healthcare providers, carers, patients, facility managers and government/non-governmental authorities involved in using OS-HITs in different healthcare areas/sectors (such as clinical, administrative, surveillance and imaging) and diseases (such as diabetes, mental health and heart diseases).

Interventions
Studies describing or elucidating the development, implementation and usage of OS applications/software end products (such as PACS, DHIS, EHRs and clinical decision support systems) in healthcare.

Exclusion criteria
We will exclude studies not falling in the healthcare domain; studies which have used OS technologies such as Hadoop to develop proprietary software or which describe OSS frameworks in healthcare instead of OS applications/software end products. Also, applications/software which are available for free (e.g. mobile apps) but do not provide access to their source codes will be excluded.

Stage 4: Charting the data
We will use customised forms to extract data from the eligible studies for this review. Two reviewers independently will tabulate the characteristics of OS-HITs by author affiliation and year of publication, country of origin, study design, the name of OS-HIT, intervention for a specific disease, intervention for the healthcare sector, system requirements (where available), complete solution and web link. Furthermore, functions, benefits/advantages (such as low maintenance cost, system/software reliability, real-time processing, processing speed, availability of tutorials and information system support), disadvantages (such as insecurity of data, incompatible with other system/software and unavailable system support) and outcomes (such as efficient workflow and optimised performance) of OS-HITs will be abstracted for analysis (see Appendix 3 for pilot data extraction forms).

Stage 5: Collating, summarising and reporting results
The results will be analysed descriptively and thematically 35 in terms of characteristics and capabilities (functions, benefits and outcomes) taking into consideration healthcare domains, study designs, technologies and/or interventions, contexts in which OS-HITs have been used, and will identify those actively under development. Results will be summarised in terms of different themes of OS-HITs available, in particular, healthcare domains.

Stage 6: Consultation
We will share the list of identified studies with experts to enquire about unpublished/on-going or published studies that we may have missed. Experts may also pinpoint the key developments of some OS-HITs that may not have been written up or are now out-dated.

DISCUSSION
The proposed scoping review will make several contributions to the HIT literature. First, it will provide healthcare stakeholders the corpus of available OS-HITs in different healthcare domains around the world, such as storing patient information in EHRs, collecting field data (such as malaria, tuberculosis, etc.) using mobile technology and providing remote healthcare through telemedicine. Second, the list of categorised OS-HITs [in terms of healthcare areas/sectors (clinical, administrative and/or finance), diseases (diabetes and malaria); characteristics; functions; advantages and outcomes] will be useful for healthcare managers and administrators to select from and implement the most appropriate OS-HIT that support their healthcare services. In addition, healthcare managers will be able to compare the available OS-HITs with their proprietary HITs, if any, running in their facilities. Third, this review will identify saturation of specific OS-HITs, such as EHRs and will identify needs and gaps for software developers to design OS-HITs for unsaturated areas of HIT. Fourth, this scoping review will help map the literature on OS-HITs and will catalyse subsequent more focused systematic reviews on specific OS-HIT in specific healthcare domains. For instance, one anticipated systematic review will be to assess the challenges and benefits of using OS PACS. Finally, this review will be valuable for policymakers involved in the planning, evaluation and procurement of HIT.

CONCLUSION
Results of this review will be published in a peer-reviewed journal. This scoping review will raise awareness of OS-HITs and benefit healthcare stakeholders to make informed judgements based on the characteristics and capabilities of OS-HITs when deploying or developing them in their healthcare facilities.  Describe the mechanism(s) that will be used to manage records and data throughout the review All references will be recorded in Endnote.

Selection process 11b
State the process that will be used for selecting studies (such as two independent reviewers) through each phase of the review (that is, screening, eligibility and inclusion in meta-analysis) Two independent reviewers will conduct searches using PRESS.

Data collection process 11c
Describe planned method of extracting data from reports (such as piloting forms, done independently, in duplicate), any processes for obtaining and confirming data from investigators Data will extracted into data extraction forms (see Appendix 3)

Data items 12
List and define all variables for which data will be sought (such as PICO items, funding sources), any pre-planned data assumptions and simplifications See data extraction forms in Appendix 3.

Outcomes and prioritisation 13
List and define all outcomes for which data will be sought, including prioritisation of main and additional outcomes, with rationale Characteristics and capabilities of OS-HITs available worldwide.

14
(NA) Describe anticipated methods for assessing risk of bias of individual studies, including whether this will be done at the outcome or study level, or both; state how this information will be used in data synthesis Data synthesis 15a (NA) Describe criteria under which study data will be quantitatively synthesised 15b (NA) If data are appropriate for quantitative synthesis, describe planned summary measures, methods of handling data and methods of combining data from studies, including any planned exploration of consistency (such as I 2 , Kendall's τ) 15c (NA) Describe any proposed additional analyses (such as sensitivity or subgroup analyses, meta-regression) 15d If quantitative synthesis is not appropriate, describe the type of summary planned. Narrative and interpretative analysis.
Meta-bias(es) 16 (NA) Specify any planned assessment of meta-bias(es) (such as publication bias across studies, selective reporting within studies)