JMIR MEDICAL INFORMATICS

Syzdykova et al

Review

Open-Source Electronic Health Record Systems for Low-Resource
Settings: Systematic Review
Assel Syzdykova1,2*, MSc; André Malta1*, MSc; Maria Zolfo3, PhD; Ermias Diro4, PhD; José Luis Oliveira1, PhD
1

University of Aveiro, Department of Electronics, Telecommunications and Informatics (DETI) / Institute of Electronics and Informatics Engineeringof Aveiro (IEETA), Aveiro, Portugal
2

BMD Software, Aveiro, Portugal

3

Institute of Tropical Medicine, Antwerp, Belgium

4

University of Gondar, Gondar, Ethiopia*

these authors contributed equally

Corresponding Author:
José Luis Oliveira, PhD
University of Aveiro
Department of Electronics, Telecommunications and Informatics (DETI) / Institute of Electronics and Informatics Engineeringof Aveiro (IEETA)
Campus Universitario de Santiago
Aveiro, 3810 193
Portugal
Phone: 351 234370523
Email: jlo@ua.pt

Abstract
Background: Despite the great impact of information and communication technologies on clinical practice and on the qualityof health services, this trend has been almost exclusive to developed countries, whereas countries with poor resources suffer frommany economic and social issues that have hindered the real benefits of electronic health (eHealth) tools. As a component of
eHealth systems, electronic health records (EHRs) play a fundamental role in patient management and effective medical careservices. Thus, the adoption of EHRs in regions with a lack of infrastructure, untrained staff, and ill-equipped health care providers
is an important task. However, the main barrier to adopting EHR software in low- and middle-income countries is the cost of its
purchase and maintenance, which highlights the open-source approach as a good solution for these underserved areas.
Objective: The aim of this study was to conduct a systematic review of open-source EHR systems based on the requirements
and limitations of low-resource settings.
Methods: First, we reviewed existing literature on the comparison of available open-source solutions. In close collaboration
with the University of Gondar Hospital, Ethiopia, we identified common limitations in poor resource environments and also themain requirements that EHRs should support. Then, we extensively evaluated the current open-source EHR solutions, discussing
their strengths and weaknesses, and their appropriateness to fulfill a predefined set of features relevant for low-resource settings.
Results: The evaluation methodology allowed assessment of several key aspects of available solutions that are as follows: (1)integrated applications, (2) configurable reports, (3) custom reports, (4) custom forms, (5) interoperability, (6) coding systems,(7) authentication methods, (8) patient portal, (9) access control model, (10) cryptographic features, (11) flexible data model,(12) offline support, (13) native client, (14) Web client,(15) other clients, (16) code-based language, (17) development activity,(18) modularity, (19) user interface, (20) community support, and (21) customization. The quality of each feature is discussed
for each of the evaluated solutions and a final comparison is presented.
Conclusions: There is a clear demand for open-source, reliable, and flexible EHR systems in low-resource settings. In thisstudy, we have evaluated and compared five open-source EHR systems following a multidimensional methodology that can
provide informed recommendations to other implementers, developers, and health care professionals. We hope that the resultsof this comparison can guide decision making when needing to adopt, install, and maintain an open-source EHR solution in
low-resource settings.
(JMIR Med Inform 2017;5(4):e44) doi: 10.2196/medinform.8131

http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 1
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Syzdykova et al

KEYWORDS
electronic health record; EHR; software; eHealth; open source

Introduction

health care, particularly in developing countries with minimal
financial resources.

Electronic Health Records

The major obstacles to OS EHR utilization in low-resource
settings were discussed by Fraser and Blaya [5] after theirexperience in developing countries. The authors shared lessons
they learned, highlighting key ideas such as the need for clinicalstaff involvement to provide qualitative data entry, the reuse ofvalidated EHR implementations, and planning of offline data
entry, which is particularly relevant because of an unstable
power supply and Internet connection.

The world has been moving toward global health and equity inaccessing health care services for many decades [1-3]. However,
the majority of low- and middle-income countries (LMICs) still
face challenges in providing comprehensive medical carecompared with the developed countries. Many factors influence
health care services in low-resource settings such as the lack offinancing, absence of health care policy, and limited technicaland human resources [4-9]. As a result, the adoption of eHealthin poorly resourced areas such as LMICs is a challenging task
because of their limitations and regional specificities. To bringpositive changes to public medical care in less developed
economies, the World Health Organization recommends the
adoption of electronic health (eHealth) solutions starting fromnational eHealth strategy [10] and electronic health records(EHRs) [11].
As information and communication technologies have rapidly
become involved in health care, particularly in patientmanagement, this has increased the efficiency and effectivenessof services provided by medical care facilities [12-14]. The
EHRs era began in the middle of the 1960s when health care
professionals changed the direction of patient management
toward digital format. EHR systems not only increase accuracy
and reduce mistakes through allergy alerts, access to laboratory
data, and immunization history but also improve organizationaland societal outcomes [13]. Moreover, the collected patients’
data can be used in research [15-19], giving an opportunity to
study diseases and extract knowledge from clinical data. Despite
the advantages of EHRs, the majority of developing countries
cannot afford expensive proprietary software from big vendors
and demand cost-effective solutions. Thus, the adoption of
open-source EHR (OS EHR) is a possible solution for LMICs.
Moreover, it is important to consider other accompanying
expenses such as power supply, Internet connection, staff
training, and system support.
One of the pioneers of OS EHR systems was the Veterans
Information Systems and Technology Architecture (VistA)
developed by the US Department of Veterans Affairs
implemented in the late 1970s [20]. The system is still
functioning and serves several million patients in US hospitals.
Almost four decades after the first OS EHR system wasintroduced in developed countries, it has reached the developingworld too [21].

eHealth in Low-Resource Settings
In several studies conducted on eHealth adoption in LMICs,
most were focused on EHR implementation [22-32]. Aminpour
et al [33] pointed out that open-source EHRs have been widelyused by resource-limited regions in all continents, particularly
in Sub-Saharan Africa and South America. The authors
concluded that HIS create opportunities to improve national

http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

In studying the success criteria of OS EHRs for resource-limited
settings, Fritz et al [24] concluded that a system’s functionality
and technical infrastructure play an essential role, whereas
financing is not a major aspect because of donors’ sponsorshipin developing countries. The authors also mentioned theimportance of organizational facets such as training availability,
project management, and staff involvement.
Other studies focused on the regional distribution of OS EHR
in developing countries, which included Africa [34-36], Latin
America [37], and Asia [38,39]. Several studies focused on
applying health record systems to concrete diseases such as
human immunodeficiency virus (HIV) [40,41], tuberculosis[42], and diabetes [43]. For instance, Manders et al reported on
their experience in the adaptation of an open-source healthrecord system in a hospital in Mozambique.
The study by Tilahun et al [44] in Ethiopia was based oninterviewing health care professionals in 5 hospitals. The
findings showed clinical staff’s dissatisfaction, for example,
with low service quality and entering data twice (both on paperand electronic medical records [EMR]). The authors suggest
focusing on training, user support, and providing enoughcomputers to increase the use of EMR systems by health care
professionals.

Open-Source Solutions
In a recent comparison of OS EHR systems [45-47], the authors
used a multicriteria selection approach to compare and score
the tools. The authors examined 13 chosen systems andcompared 25 of their features.
One of the biggest open-source software (OSS) communities
in health care is the Open Medical Record System (OpenMRS)
led by Regenstrief Institute and Partners in Health; it focuseson the development of an electronic medical record solution to
be used in resource-constrained environments. Initially, thesystem was implemented in Kenya and then was rapidly adopted
by other health care organizations [35,48-58]. Starting from a
simple data model, currently, OpenMRS has become an EHR
platform with developers all over the world [59], contributing
to its Java-based service-oriented architecture [60].
Bahmni is an integrated clinical software, which combines threeopen-source platforms: (1) OpenMRS for patient records, (2)OpenELIS (OpenELIS Foundation) for laboratory management,and (3) OpenERP (Odoo SA) for hospitals’ accounting
JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 2
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS
operations. Bahmni was implemented by the ThoughtWorks
company in 2012. The main goal of the software is to provide
a universal solution for health care institutions. Bahmni has
been deployed mainly in low-resource settings such as India,
Bangladesh, and Nepal [61]. However, the number of
implementations is growing and spreading to other regions [62].
GNU Health (GNU Solidario) is another OS EHR system thatprovided hospitals with a wide range of functionalities forpatient management. The system was introduced in 2008 andhas been adopted in several developing countries such as
Paraguay, Kenya, the Philippines, and Bangladesh [63-66].
Open Source Clinical Application Resource (OSCAR) is a
nonproprietary EHR system, developed by McMaster
University, Canada. It is licensed under the GLv2, allowing
other programmers to reuse the system code by acknowledging
copyright and giving access to their modifications under thesame license agreement. Unlike many EHR tools, OSCAR has
been implemented mainly by doctors rather than developers.
However, it has become widespread among health care providers[67].
OpenVistA (Medsphere Systems Corporation) is another OS
EHR system based on the VistA software [55], one of the first
EHR systems implemented for American veterans. OpenVistA
allows multiple clinicians to simultaneously access various
patient data in real time. The system provides progress notes,
various templates, ordering and reporting tools, audit
capabilities, electronic signature, document management, anddata integration tools, among other features of OpenVistA.
FreeMED (FreeMED Software Foundation) is a modular
open-source system for medical data and was implemented
almost two decades ago in the United States. It also has anexternal billing subsystem called REMITT.
OpenClinic GA (Medical eXchange Solutions) is an open-source
system that includes EHR, laboratory management, andpharmacy management. It was implemented in 2006 in Belgium
and has been used in many countries worldwide. The system
has been used in several resource-limited settings, including
hospitals in Rwanda, Mali, and Burundi.
Overall, there are many open-source projects available for healthcare providers. However, we selected five OS EHR systems to
make detailed research of each and focus on the functionalities
provided, which are pointed out in the next section.

Methods
Identification of Key Features
In this section, we reviewed OS EHR systems discussing theirstrengths and weaknesses according to a set of predefinedparameters. The evaluation methodology was defined in close
collaboration with the University of Gondar Hospital, Ethiopia,
and it included two main aspects: (1) user requirements and (2)systems’ selection.
The selection of the most important features of these systems
was performed through interactive discussion sessions withexperienced physicians from Gondar and partners from the
http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

Syzdykova et al
EUROLEISH-NET research network, with great experience in
low-resource settings, both in Asia and in Africa. In this phase,the health care professionals’ help was crucial because of thespecificity of medical workflows and specialized vocabularies.
Moreover, we analyzed previous publications related to eHealthdevelopment in LMICs, where the authors also tackled thespecificity of the infrastructure and services. From this study,
we obtained the following set of features:
1.

Integrated applications referring to the type of subsystems
that are integrated in each solution
2. Configurable reports, general report templates may begenerated by an end user, without programming skills
3. Custom reports, specific report templates can be created bya user with basic programming skills
4. Custom forms allow making a form template to gather
patient data or other clinical information
5. Interoperability, ability to exchange data with otherapplications (it includes the support for standards such as
Health Level-7 [HL7], Fast Healthcare Interoperability
Resources [FHIR], and Digital Imaging andCommunications in Medicine [DICOM])
6. Coding systems, referring to the utilization of medical
terminology classification, such as SNOMED (Systematized
Nomenclature of Medicine) or International Classificationof Diseases (ICD)-10
7. Authentication methods enable users to access systems
without credentials by using the authentication fromthird-party application (eg, single sign-on, lightweight
directory access protocol [LDAP])
8. Patient portal can be accessed by patients to consult theirown records
9. Access control model, management of users’ access, roles,
and permissions
10. Cryptographic features refer to applying security techniques
to conceal patient data
11. Flexible data model can cope with various and dynamic
data characteristics
12. Offline support, still operating on the client side, when
disconnected from the server
13. Web client, the application can be accessed through acommon Web browser
14. Native client, has a client that runs natively on a specificdesktop platform (eg, in Windows or Linux)
15. Other clients refer to more than one client version to copewith hardware limitations
16. Code-based language, programming language used forsystem’s source code (eg, Java)
17. Development activity refers to how often the software is
updated and to the developers’ support
18. Software modularity refers to software engineering quality,
namely, how manageable the system is
19. User interface refers to the usability of the system and how
the user interface is perceived by end users
20. Community support includes discussion forum activities
and community contributions such as translation of userinterface to other languages
21. Customization, how easy modifications are without
rewriting the core code of a system to reach establishedrequirements
JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 3
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS
We ranked several features such as modularity, user interface,community support, and custom forms to show our evaluationof the EHR systems. The modularity rank, for instance,
highlights whether the platform architecture is well thought out
to simplify future modifications and additions from developers.
Community support is another important aspect of open-source
software that helps volunteer developers and IT teams to
improve and share their contributions.

Software Selection Process
The selection of open-source EHR software for this review was
based on a representative set of open-source EHR systems foundin the literature, as well as popular and active projects inopen-source repositories. The methodology, which is depicted
in Figure 1, included the following steps: (1) literature, (2) code
repositories, and (3) features filtering.
In the first step, we searched on PubMed for papers referring
to OS EHR software using the terms “open source” and “EMR
or EHR,” combined with the MeSH term “computer software.”We validated the content of the retrieved publications leading
to a total of 40 documents (D1=40). We also queried Google
Scholar using an advanced search composed by the term
“software” combined with the exact expression “open source”
and containing at least one of the terms “electronic medical

Syzdykova et al
record, electronic health record, EHR, and EMR.” From thereturned results (D2=12,500), we evaluated the top 100
documents to verify its relevance to our study. From thisassessment, we identified 30 potential solutions (P1=30).
In the second phase, a common Web search engine (Google)
was used, mainly for obtaining information about EHR
solutions, for example, project status and resources. For each,
we gathered the availability of public websites (24) and public
source code repositories (23), from which we ruled out the ones
outside the intersection of these (P2=20).
The last was the filtering step. First, we excluded the projects
with lower activity (code updates, discussion forums, casestudies, etc), which resulted in a more reduced set (P3=9). For
each of these solutions, we assessed their capability to fulfil thelimitations of a low-resource setting (eg, localization support
and cross-platform support), ending up with the following group(P4=5): GNU Health, OpenEMR, FreeMED, OpenMRS, andBahmni.
The selected systems were then installed and extensively
evaluated against the requirements previously discussed. In thefollowing sections, the characteristics of these five systems are
discussed and compared.

Figure 1. Flowchart of the open source electronic health record selection process.

http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 4
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Results
GNU Health
GNU Health is an EHR software and health information system(HIS) developed by GNU Solidario, a nonprofit andnongovernmental organization for health and education
development. The main areas of GNU Health supports are (1)individual management, (2) patient management, (3) healthcenter management, and (4) information management.
Individual management refers to a person’s basic information,
genealogy, household, domiciliary infrastructure, and so on.
The GNU Health project emphasizes on the importance of socialand economic development, with a strong focus on relevant
factors such as level of education, occupation, living conditions,and family relations.
Patient management comprises the collection of different typesof data related to a patient’s health, for instance, lifestyleparameters such as diet and exercise, addictions, sexuality, or
safety. It also includes management of the patient’s health careregarding encounters and evaluations, medical procedures,
laboratory test requests or results, and so on.
Health center management mainly comprises enterprise resource
planning (ERP), for instance, financial and human resource
management, sales, invoicing and accounting, inventory, stock,and supply chain management. It also features a focus onpharmacy and laboratory management. The managed subject
can either be the institution as a whole or individual department.
Information management covers the tasks that combine data
produced on the platform. This includes building reports orpresenting demographics with configurable parameters, which
are useful for epidemiology studies or crossing different data,for instance.
The areas explained above generally involve teams fromdifferent fields of activity in which members generally only
work within their corresponding domain of information.
As the information stored by GNU Health is highly sensitive,
the platform is developed with a focus on data confidentiality
and integrity. It provides serialization, hashing, signing, andverification, which are commonly used in features that handle
or produce sensitive information such as reports, prescriptions,or laboratory tests. It allows doctors to digitally sign deathcertificates or users to verify the authenticity of reports compiledin other GNU Health systems. This is achieved via a bundledclient-side plug-in for pretty good privacy that uses GNU
Privacy Guard implementation.
Most of GNU Health’s functionality is provided by the official
add-on modules, which extend the core module. These are
separated into general domains or specialties, for example,
pediatrics, surgery, or genecology. Modules add newfunctionality to these domains by reusing models of given
entities and creating specification classes designed in othermodules. As this creates dependencies between modules, inorder for a target module to work, its parent modules need tohttp://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

Syzdykova et al
be installed as well. In GNU Health, the way to provide newfunctionality such as custom forms for collecting patient
information is through developing new modules. As this requires
programming knowledge, building and adding custom forms
becomes a difficult task for nondevelopers.
GNU Health user interface contains a global menu where
functionalities are presented in a tree-style structure (Figure 2).
The menu supports filtering by text, providing easier and quicker
ways to find the desired functionality. Several items can be
active at the same time, making use of tabs for arranging themultiple content panels. It is common for some features topresent a multitude of functionalities separated into their own
tabs, adding to navigation and display complexity.
GNU Health client does not provide offline support, that is,interactions made in the client while the server is disconnected
are lost. There is a workaround by deploying a GNU Healthserver on each client machine, synchronized in a centralized
mode with the main server. Replicating sensitive data in eachclient device would raise complexity, security, and privacy
issues and would also require different and more expensive
hardware than that needed for running just a GNU Health thinclient.

OpenEMR
OpenEMR is an EHR software, medical practice management
software (PMS), and ERP software mainly supported by OEMR
4, a nonprofit organization (NPO) whose goal is to ensure thatall people have access to high-quality medical care through its
software and services [68]. OpenEMR is licensed under GNU
general public license (GPL) and comes with a great amount offunctionality to cover a wide range of areas of an HIS in addition
to patient records and management, including support for billingand claims management, ERP, and information management.
The system is written in PHP, a scripting language that is widely
supported and has cross-platform runtimes. The use of Web
technologies makes the platform accessible through manydifferent devices, provided they have a compatible Web browser.
With respect to patient records, clinical observations can bemade through a variety of forms already provided. Observations
captured on a patient’s different visits can be presented later
through graphical charts or tables showing changes in values
over time. Free-text type notes can be attached to a patient’s
encounter and medical issues registered in a flexible system ofcoding, which supports Current Procedural Terminology (CPT),
Healthcare Common Procedure Coding System (HCPCS),ICD-9, ICD-10, and SNOMED Clinical Terms (SNOMED CT)
codes. In the prescription management area, doctors can registerprescriptions and their frequency, which can then be printed,
faxed, or sent electronically to a few supported third-party
platforms. This can be complemented with the pharmacy
dispensary module, which enables in-house drug dispensing
with support for inventory, integration with drug databases, andstock tracking. In patients’ history, medical procedures,
immunizations, and laboratory tests made can be registeredalong with results.

JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 5
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Syzdykova et al

Figure 2. User interface of GNU Health’s client application.

OpenEMR provides a robust calendar subsystem, which iscapable of handling different types of events, such asappointments, notifications, alerts, and automated report
generation. With this subsystem, it is possible, for example, toautomatically send an email reminder to a patient each time heneeds to take his medication, or automatically run reports ofweight assessment for children and adolescents each month.

such as past encounters and documents while browsing thepatient’s context or is used to show selected content in addition
to the first panel. This proves useful for showing related
information side by side but quickly builds up complexity inthe interface. Some functionality also opts to open a separate
frame inside the content panel, or even a new pop-up window
to display or gather information, again adding complexity.

OpenEMR provides a native portal aimed at use by patients andother registered users, supporting integration with other externalpatient portals. The reporting subsystem comes with anextensible profile of reports that cover many of the platform’s
different areas. Some of these are configurable, for instance,patient reports can include medical history, encounters, billing,
communications, or other patient-related information. Adding
custom reports to the OpenEMR platform is possible throughthe same method as the one used by the preloaded reports. These
are built with PHP programming for which a specific PHP
template for coding reports is provided. There is no alternative
method to create custom reports; consequently, programming
knowledge and other advanced computer skills are required forthe creation of new reports.

The OpenEMR project development is active, with an averageof two major releases per year. The project has a strong
community of users and backing companies, with many
OpenEMR modules developed by third parties and contributed
to OpenEMR, and these are now part of the project. The
documentation has extensive user and implementation guides
but falls short for developers.

For interoperability, OpenEMR supports the HL-7 standard,
which is used for exchanging patient data between othersystems, and the ANSI X12 Electronic Data Interchange
standard, mainly used in billing and invoicing in the ERP.
The OpenEMR platform can support more than 20 languages
and is compatible with Unicode Transformation Format(UTF)-8. The display language of the user interface is user
dependent, meaning that multiple users can use the platform
simultaneously in their desired languages.
User interaction with OpenEMR is via a Web interface (Figure3). The user interface arranges active content in a dual panel
mode. The first panel is always shown and is used to display
primary content of the active area or context. The second panel
either shows a given global functionality of the active context
http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

FreeMED
FreeMED is an EHR software and medical PMS by FreeMED
Software Foundation 7 and is licensed under GPL. FreeMED
has a modular architecture that is designed with functionality
and interface separation, which allows customization ordevelopment of modules without having to rewrite corecomponents of the system.
A patient record module contains personal and demographic
information. Preloaded templates are provided, which can beused for collecting clinical observations during patient visits.
Medical assistance is provided by the diagnosis family moduleand can be coded using CPT and ICD codes. It is possible toassign medication to a patient and manage a registry with them.
Patients can be arranged in groups that are assigned to doctors
or referenced in programs. There is an area for triage and call-ins
useful for registration secretaries, which can be complemented
by the appointment scheduling subsystem. Appointments canbe scheduled for either an individual or groups of patients, andthe interface has safeguards for double booking, presenting
warnings in case 2 patients get booked for the same provider at
the same time.
JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 6
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Syzdykova et al

Figure 3. User interface of the OpenEMR platform.

FreeMED uses HL-7 for the exchange of medical data. This
support is obtained via integration with Mirth Connect, across-platform HL-7 interface engine.
FreeMED already comes with some configured reports, butadding new ones requires related technical skills and also
knowledge of the FreeMED data model. The reporting
subsystem is dependent on the Java library Jasper Reports forreport generation. There is a lack of documentation on how to
add custom forms to FreeMED. User interaction with theplatform is through a Web interface. After language selection
and user authentication, different functionalities are displayed
depending on the user’s access clearance. Access is controlledwith Access Control List (ACL), in the same way as described
previously for OpenEMR, also making use of the phpGACL
library.
The user interface has an always-present menu, which groups
functionalities in categories (Figure 4). The active functionality
is displayed on a content panel. Several items can be opened at
the same time, being grouped into tabs that keep its current statein the background without interrupting the user experience. The
content has a clean presentation, and while some more complex
features may show different functionalities grouped into theirown tabs, there is an option to choose the arrangement between
tabbed and flat presentation.
FreeMED is written mostly in PHP and Perl. Additionally, it
requires a Java runtime environment for the report subsystem
and JavaEE for REMITT, as they are written in Java. As all the

http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

technologies used in the software are cross-platform, FreeMED
can be run on different operating systems, ranging fromPOSIX-compatible such as Linux or BSD to Microsoft
Windows. The software is designed in a client-server application
model. The platform does not provide offline support, so if thecommunication is interrupted between the client and the server,
users need to wait for the reestablishment of the connection.
Akin to OpenEMR, access to the database is through the ADOdb
PHP library, which allows transparent usage of many different
database management systems (DBMS). Nevertheless, parts ofthe code base are not DBMS-agnostic, and thus, the project
recommends using MySQL.
FreeMED supports localization, and the project claims multiple
languages support in addition to English, including German,
French, and Polish. There is also an online public project tocontribute translations, which has already attained complete
localization in Portuguese and Russian [69]. FreeMED supports
multiple ISO character set formats and stores entry data withit, making it possible to maintain a demographic database in
one language and ISO set, independent of the localization that
displays.
The source code is available on a public repository website,which also provides a brief installation guide and a Virtual
Machine image of FreeMED for demo purposes. There are no
development guides, and the project lacks proper documentation
overall. There is also a FreeMED demo available online, butthere are no user guides on the official site or in the FreeMED
software itself.

JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 7
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Syzdykova et al

Figure 4. User interface of the FreeMED platform.

OpenMRS
OpenMRS is an EHR software led by two collaborative NPOs,
Regenstrief Institute and Partners in Health. One of the main
objectives of the project is to build a robust solution for healthcare with a special focus on resource-constrained environments.
OpenMRS is a highly modular platform, meaning that features
are external to the platform and added through add-on modules.
An application programming interface (API) plays a major rolein this by allowing access to OpenMRS platform functionality.
The platform core uses a centralized dictionary of concepts, acustomizable part of OpenMRS that strongly defines each
implementation. In the dictionary, concepts are metadata ofgiven entities, defined by name, data type, appropriate attributes,
and relationships to other concepts. These are used as models
to be instanced later in some user form or report. For example,
a value collected during a patient encounter is an instance of agiven concept that takes the form of an observation. As a model,
concepts work as the building blocks that describe forms, orders,clinical summaries, reports, and so on.
OpenMRS is officially released in two different distributions,
one which contains just the OpenMRS platform, and anothercalled the reference application, which packs selected modules
that extend and add features to the platform. The framework
standardizes modules and defines their interface presentation,communication, behavior, and security, enabling the creationof an OpenMRS application ecosystem. Through modules,
OpenMRS extends its features, providing appointment
scheduling and management, an event system for notifications,

http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderXa subsystem for allergy registration, representation of patient
observations through charts, and so on (Figure 5).
OpenMRS has a robust subsystem for the creation of custom
forms. Any form relies on a schema that defines the fields andconcepts it will use, which are supported by the concept
dictionary. Although custom forms can be created and theirform schema can be designed from within OpenMRS legacy
user interface, the methods for designing the forms are
independent of the platform.
A reporting subsystem allows three ways of building reports,that is, indicator reports, row-per-patient reports, or custom
reports. A report is built through associations with dataset
definitions that act as a key to values to include in the report.
The dataset can generally refer to person or patient properties
and similar attributes that contain only one recorded value stored
since its last entry, commonly used in row-per-person reports.
The combination of values from multiple observations is
possible and is used for building indicator reports. A report
definition can be programmed to filter (cohort) a defined set ofpatients for use as the input for report generation.
Access management follows a role-based access control(RBAC), which covers both the user interface and access to
OpenMRS API via REST services. Importing and exporting
metadata between platforms can be performed either manuallyor automatically, using the metadata sharing module. The
module is advanced enough to provide automaticsynchronization mechanisms, with support for record merging
and conflict resolution.
JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 8
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Syzdykova et al

Figure 5. OpenMRS’ modern user interface.

OpenMRS has native support for the HL-7 standard and can
export data directly to other applications. There is also support
for DICOM and radiology standards via a third-party module,in conjunction with dcm4chee, a medical imaging archive andmanager. Native support for FHIR is also present natively inthe platform from version 2.0.
Officially, the project provides an extensive wiki with featurescontent for developers, implementers, and end users. Two online
demos are provided, one of the reference application and anotherwith a demo for management of drug-resistant tuberculosis,
which can show the level of customization that OpenMRS
offers. Currently, more than 175 separate modules are available,
but their compatibility depends on the core version because ofchanges in the OpenMRS API.
OpenMRS has full UTF-8 support and some extra localizationsin addition to English, with the possibility to add more. The
project provides an online portal for collaborative translationof its user interface, reference application, and commonly used
third-party modules [57].

BahmniBahmni is a hospital system for low-resource settings developedby ThoughtWorks Global Health under an AGPL license.
Bahmni is built through separate OpenMRS modules, and its
user interface communicates with these using the OpenMRS
API via REST. The system incorporates most of the OpenMRS
platform functionality and extends it with support for picturearchiving and communication system (PACS), laboratory
information system (LIS), and ERP features. This is done via
integration with three separate applications: dcm4chee, which
provides the first; OpenELIS, which provides the second; andOpenERP (currently named Odoo), which provides the third.
In a registration process, information such as identity,
demographics, photograph, contacts, and other socioeconomic
details of a patient can be captured and associated with a person
via a newly generated patient identifier. Different types ofrelationships can be registered, including genealogical or
patient-provider relationships. When a patient registers with an
institution, there is a strong possibility that he already has
http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

health-related documents stored in other institutions, forexample, record scans, x-ray images, or other types. Bahmni
EHR supports storing these within the system and attachingthem to a patient’s profile. A patient’s profile is displayed
through a modular dashboard, where customizable widgets
display the most recent information from several different
categories of the patient’s medical records. These can be, forinstance, laboratory tests and results, programs enrolled in, or
last visit observations. From observations made in several
encounters, the history of changes can be presented.
Clinical services are centered around the patient’s profile. These
services become available in the consultation area of thedashboard after a patient is active in the system, that is, thepatient is in a given encounter with a provider. From here,
several types of services are provided: capturing observations,making laboratory or radiology orders, registering diagnosis
and medication, managing patient disposition, or taking
consultation notes (Figure 6).
With respect to clinical observations, Bahmni already provides
multiple forms by default. The form subsystem is very
customizable and can easily be extended with more forms. Thesecan be built by creating and changing specific concepts of thedictionary. The form’s layout and other parameters can be
defined in JSON and, if necessary, there is support for
integration with a server-side framework for advanced
customization of a form’s logic and other aspects. Current andpast diagnosis can be associated with a patient and registeredalong with attributes such as order, confidence, and status.
Diagnosis made can also be mapped to ICD-10 codes.
Regarding laboratory orders, Bahmni provides a panel of tests
divided in several categories. The laboratory subsystem is
flexible, making it possible to choose just the needed tests andcategories or arrange them all together. New laboratory tests
can be easily created and added just by using the concepts
dictionary.
Radiology orders containing patient and investigation details
can be requested within Bahmni EHR, which are sent to amodality via HL-7. The results are integrated with the patient
JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 9
(page number not for citation purposes)

JMIR MEDICAL INFORMATICS
profile even if they come as native unsupported formats, inwhich references to them are shown. For instance, results thatcome as DICOM images are archived in an accessible PACS
and referenced from the patient profile from which they can be
opened in compatible DICOM viewers.
Medication management includes registration of past and current
medication from a customizable drug registry, which has theroute, frequency, dosage, and instructions for each. There is adrug dispensing service, which is integrated with OpenERP andsupports in-house dispensing with segregation of stocks. Patient
disposition refers to a patient’s state usually set at the end of aprovider encounter.
OpenERP is used predominantly for sales and purchase
management, including inventory and accounting, and it isintegrated to some extent in Bahmni EHR. For instance,
registration fees or payment of drugs dispensed is registered in
OpenERP under patient billing and inventory.
The reporting area comes with many preloaded reports, which
can be run within a given period and exported to CSV, PDF,

Syzdykova et al
HTML, or Excel formats. Additionally, the platform provides
integration with Jasper Reports, giving support for custom,
flexible, and more varied reports.
The access control on Bahmni EHR is provided by the
OpenMRS platform. However, there are new access roles
associated with the new functionalities and services of Bahmni
EHR. Additionally, user access can now be set to use two-factor
authentication.
Bahmni EHR supports offline network alerts by displaying a
notification in the user interface when the connection is down.
This is helpful to avoid loss of filled-in data by submitting it
unknowingly when a connection to the server is down. True
offline support is also provided via a browser extension or amobile app, offering the possibility of filling in forms and otheruser interface functionalities without an active connection to
the server. The data produced with this functionality are saved
locally on the device and can be uploaded later. The community
is closely tied with the OpenMRS community as both comeunder the same forum and are very active.

Figure 6. Bahmni patient dashboard.

http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 10(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Syzdykova et al

Table 1. Matrix with several aspects of the evaluated electronic health records software. Some features were evaluated according to a ranking thatvaries between 1 (low) and 3 (high).
Feature or system

GNU Health

OpenEMR

FreeMED

OpenMRS

Bahmni1

EHRa, HISb

EHR, PMSc, ERPd

EHR, PMS

EHR

EHR, PMS, ERP, LISe,

Integrated applications

PACSf
2

Configurable reports

Yes

Yes

No

Yes

Yes

3

Custom reports

No

No

No

Yes

Yes

4

Custom forms

-

1

-

3

3

5

Interoperability

FHIRg, custom

HL7h

HL7, DICOMi

Coding systemsj6

ICD-10

HL7, DICOM, FHIRn

ICD-9/10,kl

SNOMED , CPT ,p

HL7, DICOM, FHIR

ICD-10, CPT, LOINC , CIEL/MVP , LOINC
ICD-10ATCo

CIEL/MVP, ICD-10,
SNOMEDHCPCSma7Authentication methods LDAPq

LDAP, ADr

-

-

-

8

Patient portal

No

Yes

No

No

No

9

Access control model

RBACs

ACLt

ACL

RBAC

RBAC

10

Cryptographic features

Sign, encrypt

Encrypt

-

-

-

11

Flexible data model

No

No

No

Yes

Yes

12

Offline support

Yes

No

No

No

Yes

13

Web client

Yes

Yes

Yes

Yes

Yes

14

Native client

Yes

No

No

No

No

15

Other clients

Yes

No

No

No

Yes

16

Code-based language

Python

PHP

PHP

Java

Java

17

Development activity

3

3

2

3

3

18

Software modularity

3

1

2

3

3

19

User interface

2

1

3

2

3

20

Community support

3

3

1

3

3

21

Customization

1

2

1

3

3

EHR: electronic health record.

b

HIS: health information system.

c

PMS: practice management software.

d

ERP: enterprise resource planning.

e

LIS: laboratory information system.

f

PACS: picture archiving and communication system.

g

FHIR: Fast Healthcare Interoperability Resources.

h

HL7: Health Level-7.

i

DICOM: Digital Imaging and Communications in Medicine.

j

ICD: International Classification of Diseases.

k

SNOMED: Systematized Nomenclature of Medicine.

l

CPT: Current Procedural Terminology.

m

HCPCS: Healthcare Common Procedure Coding System.

n

LOINC: Logical Observation Identifiers Names and Codes.

oATC: Anatomical Therapeutic Chemical.

pCIEL/MVP: Columbia International eHealth Laboratory/Millennium Villages Project concept dictionary.

q

LDAP: lightweight directory access protocol.

r

AD: Active Directory.

s

RBAC: role-based access control.

t

ACL: Access Control List.

http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 11(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Discussion
Systems' Comparison
The above assessment allowed us to undertake a systematic
review of five popular EHRs that can be used in low-resource
settings without being an economic burden. Due to constraints
in LMIC and according to the workflow of health careinstitutions, it is important to consider key operation
functionalities and the adaptability of each system. Table 1
summarizes these key aspects, presenting for each system thecharacteristics defined in our evaluation methodology.

Conclusions
Despite the wide adoption of EHR and eHealth solutions inmany developed countries, the scenario is quite unbalanced

Syzdykova et al
when compared with health digitalization in low-resource
settings. This work was performed in close collaboration with
the Hospital of Gondar, Ethiopia, with which the evaluation
methodology was defined. We conducted a local assessment of
the used solutions and identified a scenario that is very
dependent on IT solutions from nongovernmental organizations,which, despite their good will, led to partial and incompatible
solutions. There is a clear demand for open-source, reliable,
and flexible EHR systems in these health care facilities. Hence,the process of selecting a suitable solution that covers theirneeds is a central task. In this study, we have evaluated andcompared five open-source EHR systems following a
multidimensional methodology. We hope that the results of thiscomparison can guide decision making when needing to adopt,install, and maintain an open-source EHR solution in
low-resource settings.

Acknowledgments
This study has received funding from the European Union’s Horizon 2020 research and innovation program under the Marie
Sklodowska-Curie grant agreement No. 642609.

Conflicts of Interest
None declared.

References
1.
2.
3.
4.
5.
6.
7.

8.

9.
10.
11.
12.

13.

14.

Who.int. 1978 Sep 12. Declaration of Alma-Ata URL: http://www.who.int/publications/almaata_declaration_en.pdf [accessed2017-11-03] [WebCite Cache ID 6ugtPfy0M]
UN.: United Nations; 2010. News on millennium development goals URL: http://www.un.org/millenniumgoals/ [accessed2017-11-01] [WebCite Cache ID 6ueDSb4Rc]
Sustainabledevelopment.un.: Citeseer Sustainable development goals URL: https://sustainabledevelopment.un.org/?menu=1300 [accessed 2017-11-01] [WebCite Cache ID 6ueDfhmcc]
Akhlaq A, Sheikh A, Pagliari C. Barriers and facilitators to health information exchange in low- and middle-income country
settings: a systematic review protocol. J Innov Health Inform 2015 Mar 27;22(2):284-292. [doi: 10.14236/jhi.v22i2.98]
Fraser HS, Blaya J. Implementing medical information systems in developing countries, what works and what doesn't.
AMIA Annu Symp Proc 2010;2010:232-236.
Chen W, Akay M. Developing EMRs in developing countries. IEEE Trans Inf Technol Biomed 2011 Jan;15(1):62-65. [doi:10.1109/TITB.2010.2091509]
Oluoch T, Santas X, Kwaro D, Were M, Biondich P, Bailey C, et al. The effect of electronic medical record-based clinicaldecision support on HIV care in resource-constrained settings: a systematic review. Int J Med Inform 2012
Oct;81(10):e83-e92. [doi: 10.1016/j.ijmedinf.2012.07.010] [Medline: 22921485]
Luna D, Almerares A, Mayan 3rd JC, González Bernaldo de Quirós F, Otero C. Health informatics in developing countries:
going beyond pilot practices to sustainable implementations: a review of the current challenges. Healthc Inform Res 2014
Jan;20(1):3-10 [FREE Full text] [doi: 10.4258/hir.2014.20.1.3] [Medline: 24627813]
Luna D, Otero C, Marcelo A. Health informatics in developing countries: systematic review of reviews. Contribution of
the IMIA Working Group Health Informatics for Development. Yearb Med Inform 2013;8:28-33. [Medline: 23974545]
World Health Organization, International Telecommunication Union. Who.int. 2012. National eHealth strategy toolkit
URL: http://www.who.int/ehealth/publications/overview.pdf [accessed 2017-11-03] [WebCite Cache ID 6uguBN7pY]
World Health Organization. Wpro.who.int/. 2006. Electronic health records: manual for developing countries URL: http://www.wpro.who.int/publications/docs/EHRmanual.pdf [accessed 2017-11-03] [WebCite Cache ID 6uguIzmXd]
Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, et al. Systematic review: impact of health information
technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006 May 11;144(10):742-752. [doi:10.7326/0003-4819-144-10-200605160-00125]
Alsaffar M, Yellowlees P, Odor A, Hogarth M. The state of open source electronic health record projects: a software
anthropology study. JMIR Med Inform 2017 Feb 24;5(1):e6 [FREE Full text] [doi: 10.2196/medinform.5783] [Medline:
28235750]
Reynolds CJ, Wyatt JC. Open source, open standards, and health care information systems. J Med Internet Res 2011
Feb;13(1):e24 [FREE Full text] [doi: 10.2196/jmir.1521] [Medline: 21447469]

http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 12(page number not for citation purposes)

JMIR MEDICAL INFORMATICS
15.
16.

17.
18.
19.
20.
21.
22.

23.

24.
25.
26.

27.

28.
29.

30.

31.
32.

33.
34.

35.
36.
37.

Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy
2011;4:47-55 [FREE Full text] [doi: 10.2147/RMHP.S12985] [Medline: 22312227]
Häyrinen K, Saranto K, Nykänen P. Definition, structure, content, use and impacts of electronic health records: a reviewof the research literature. Int J Med Inform 2008 May;77(5):291-304. [doi: 10.1016/j.ijmedinf.2007.09.001] [Medline:
17951106]
Lobach DF, Detmer DE. Research challenges for electronic health records. Am J Prev Med 2007 May;32(5 Suppl):S104-S111.
[doi: 10.1016/j.amepre.2007.01.018] [Medline: 17466814]
Jensen PB, Jensen LJ, Brunak S. Mining electronic health records: towards better research applications and clinical care.
Nat Rev Genet 2012 May 2;13(6):395-405. [doi: 10.1038/nrg3208] [Medline: 22549152]
Coorevits P, Sundgren M, Klein GO, Bahr A, Claerhout B, Daniel C, et al. Electronic health records: new opportunities
for clinical research. J Intern Med 2013 Dec;274(6):547-560. [doi: 10.1111/joim.12119] [Medline: 23952476]
McDonald CJ, Schadow G, Barnes M, Dexter PR, Overhage JM, Mamlin BW, et al. Open source software in medical
informatics—why, how and what. Int J Med Inform 2003 Mar;69(2-3):175-184. [doi: 10.1016/S1386-5056(02)00104-1]
Fraser H, Biondich P, Moodley D, Choi S, Mamlin B, Szolovits P. Implementing electronic medical record systems indeveloping countries. J Innov Health Inform 2005 Jun;13(2):83-95. [doi: 10.14236/jhi.v13i2.585]
Jawhari B, Ludwick D, Keenan L, Zakus D, Hayward R. Benefits and challenges of EMR implementations in low resource
settings: a state-of-the-art review. BMC Med Inform Decis Mak 2016 Sep 6;16:116 [FREE Full text] [doi:10.1186/s12911-016-0354-8] [Medline: 27600269]
Jawhari B, Keenan L, Zakus D, Ludwick D, Isaac A, Saleh A, et al. Barriers and facilitators to electronic medical record(EMR) use in an urban slum. Int J Med Inform 2016 Oct;94:246-254 [FREE Full text] [doi: 10.1016/j.ijmedinf.2016.07.015][Medline: 27573333]
Fritz F, Tilahun B, Dugas M. Success criteria for electronic medical record implementations in low-resource settings: asystematic review. J Am Med Inform Assoc 2015 Mar;22(2):479-488. [doi: 10.1093/jamia/ocu038] [Medline: 25769683]
Blaya JA, Fraser HS, Holt B. E-health technologies show promise in developing countries. Health Aff (Millwood) 2010
Feb;29(2):244-251 [FREE Full text] [doi: 10.1377/hlthaff.2009.0894] [Medline: 20348068]
Piette JD, Lun KC, Moura Jr LA, Fraser HS, Mechael PN, Powell J, et al. Impacts of e-health on the outcomes of care inlow- and middle-income countries: where do we go from here? Bull World Health Organ 2012 May 1;90(5):365-372 [FREEFull text] [doi: 10.2471/BLT.11.099069] [Medline: 22589570]
Millard PS, Bru J, Berger CA. Open-source point-of-care electronic medical records for use in resource-limited settings:
systematic review and questionnaire surveys. Br Med J Open 2012 Jul;2(4):e000690 [FREE Full text] [doi:10.1136/bmjopen-2011-000690] [Medline: 22763661]
Kalogriopoulos NA, Baran J, Nimunkar AJ, Webster JG. Electronic medical record systems for developing countries:
review. Conf Proc IEEE Eng Med Biol Soc 2009;2009:1730-1733. [doi: 10.1109/IEMBS.2009.5333561]
Clifford GD, Blaya JA, Hall-Clifford R, Fraser HS. Medical information systems: a foundation for healthcare technologies
in developing countries. Biomed Eng Online 2008 Jun 11;7:18 [FREE Full text] [doi: 10.1186/1475-925X-7-18] [Medline:
18547411]
Sood SP, Nwabueze SN, Mbarika VW, Prakash N, Chatterjee S, Ray P, et al. Electronic medical records: a review comparing
the challenges in developed and developing countries. : IEEE; 2008 Presented at: Proceedings of the 41st Annual HawaiiInternational Conference on System Sciences (HICSS 2008); January 7-10, 2008; Waikoloa, HI, USA. [doi:10.1109/HICSS.2008.141]
Williams F, Boren SA. The role of electronic medical record in care delivery in developing countries. Int J Inf Manage
2008 Dec;28(6):503-507. [doi: 10.1016/j.ijinfomgt.2008.01.016]
Tilahun B, Fritz F. Modeling antecedents of electronic medical record system implementation success in low-resource
setting hospitals. BMC Med Inform Decis Mak 2015 Aug 1;15:61 [FREE Full text] [doi: 10.1186/s12911-015-0192-0][Medline: 26231051]
Aminpour F, Sadoughi F, Ahamdi M. Utilization of open source electronic health record around the world: a systematic
review. J Res Med Sci 2014 Jan;19(1):57-64. [Medline: 24672566]
Dillon DG, Pirie F, Rice S, Pomilla C, Sandhu MS, Motala AA, African Partnership for Chronic Disease Research (APCDR).
Open-source electronic data capture system offered increased accuracy and cost-effectiveness compared with paper methods
in Africa. J Clin Epidemiol 2014 Dec;67(12):1358-1363 [FREE Full text] [doi: 10.1016/j.jclinepi.2014.06.012] [Medline:
25135245]
Akanbi MO, Ocheke AN, Agaba PA, Daniyam CA, Agaba EI, Okeke EN, et al. Use of electronic health records in
sub-Saharan Africa: progress and challenges. J Med Trop 2012;14(1):1-6. [Medline: 25243111]
Mostert-Phipps N, Pottas D, Korpela M. Improving continuity of care through the use of electronic records: a South African
perspective. S Afr Fam Pract 2012;54(4):326-331. [doi: 10.1080/20786204.2012.10874244]
Fernández A, Oviedo E. 20.iadb. 2011. e-Health in Latin America and the Caribbean: progress and challenges URL: http://www20.iadb.org/intal/catalogo/PE/2011/08957.pdf [accessed 2017-11-03] [WebCite Cache ID 6ugvXXS0P]

http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

Syzdykova et al

JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 13(page number not for citation purposes)

JMIR MEDICAL INFORMATICS
38.

39.
40.

41.

42.

43.

44.

45.
46.

47.
48.

49.

50.

51.

52.

53.

54.

55.

56.
57.
58.

Scholl J, Syed-Abdul S, Ahmed LA. A case study of an EMR system at a large hospital in India: challenges and strategies
for successful adoption. J Biomed Inform 2011 Dec;44(6):958-967 [FREE Full text] [doi: 10.1016/j.jbi.2011.07.008][Medline: 21846508]
Aminpour F, Sadoughi F, Ahmadi M. Towards the application of open source software in developing national electronic
health record-narrative review article. Iran J Public Health 2013 Dec;42(12):1333-1339.
Manders EJ, José E, Solis M, Burlison J, Nhampossa JL, Moon T. Implementing OpenMRS for patient monitoring in an
HIV/AIDS care and treatment program in rural Mozambique. Stud Health Technol Inform 2010;160(Pt 1):411-415. [doi:10.3233/978-1-60750-588-4-411] [Medline: 20841719]
Puttkammer N, Zeliadt S, Balan JG, Baseman J, Destiné R, Domerçant JW, et al. Development of an electronic medical
record based alert for risk of HIV treatment failure in a low-resource setting. PLoS One 2014 Nov 12;9(11):e112261 [FREEFull text] [doi: 10.1371/journal.pone.0112261] [Medline: 25390044]
Fraser HS, Thomas D, Tomaylla J, Garcia N, Lecca L, Murray M, et al. Adaptation of a web-based, open source electronic
medical record system platform to support a large study of tuberculosis epidemiology. BMC Med Inform Decis Mak 2012
Nov 7;12:125 [FREE Full text] [doi: 10.1186/1472-6947-12-125] [Medline: 23131180]
Ali MK, Shah S, Tandon N. Review of electronic decision-support tools for diabetes care: a viable option for low- andmiddle-income countries? J Diabetes Sci Technol 2011 May 1;5(3):553-570 [FREE Full text] [doi:10.1177/193229681100500310] [Medline: 21722571]
Tilahun B, Fritz F. Comprehensive evaluation of electronic medical record system use and user satisfaction at five
low-resource setting hospitals in Ethiopia. JMIR Med Inform 2015 May 25;3(2):e22 [FREE Full text] [doi:10.2196/medinform.4106] [Medline: 26007237]
Kiah ML, Haiqi A, Zaidan BB, Zaidan AA. Open source EMR software: profiling, insights and hands-on analysis. Comput
Methods Programs Biomed 2014 Nov;117(2):360-382. [doi: 10.1016/j.cmpb.2014.07.002] [Medline: 25070757]
Zaidan AA, Zaidan BB, Al-Haiqi A, Kiah ML, Hussain M, Abdulnabi M. Evaluation and selection of open-source EMR
software packages based on integrated AHP and TOPSIS. J Biomed Inform 2015 Feb;53:390-404 [FREE Full text] [doi:10.1016/j.jbi.2014.11.012] [Medline: 25483886]
Zaidan AA, Zaidan BB, Hussain M, Haiqi A, Mat Kiah ML, Abdulnabi M. Multi-criteria analysis for OS-EMR software
selection problem: a comparative study. Decis Support Syst 2015 Oct;78:15-27. [doi: 10.1016/j.dss.2015.07.002]
Mamlin BW, Biondich PG, Wolfe BA, Fraser H, Jazayeri D, Allen C, et al. Cooking up an open source EMR for developing
countries: OpenMRS - a recipe for successful collaboration. AMIA Annu Symp Proc 2006;2006:529-533. [Medline:
17238397]
Mohammed-Rajput NA, Smith DC, Mamlin B, Biondich P, Doebbeling BN, Open MRS Collaborative Investigators.
OpenMRS, a global medical records system collaborative: factors influencing successful implementation. AMIA Annu
Symp Proc 2011;2011:960-968. [Medline: 22195155]
Tierney WM, Achieng M, Baker E, Bell A, Biondich P, Braitstein P, Tanzania-Uganda Openmrs Consortium. Experience
implementing electronic health records in three East African countries. Stud Health Technol Inform 2010;160(Pt 1):371-375.
[doi: 10.3233/978-1-60750-588-4-371]
Catalani C, Green E, Owiti P, Keny A, Diero L, Yeung A, et al. A clinical decision support system for integrating tuberculosisand HIV care in Kenya: a human-centered design approach. PLoS One 2014 Aug 29;9(8):e103205 [FREE Full text] [doi:10.1371/journal.pone.0103205] [Medline: 25170939]
Anokwa Y, Ribeka N, Parikh T, Borriello G, Were MC. Design of a phone-based clinical decision support system forresource-limited settings. 2012 Presented at: Proceedings of the Fifth International Conference on Information andCommunication Technologies and Development, ICTD '12; March 12-15, 2012; Atlanta, Georgia, USA p. 13-24.
Kasthurirathne SN, Mamlin B, Kumara H, Grieve G, Biondich P. Enabling better interoperability for healthcare: lessons
in developing a standards based application programing interface for electronic medical record systems. J Med Syst 2015
Nov;39(11):182. [doi: 10.1007/s10916-015-0356-6] [Medline: 26446013]
Haskew J, Rø G, Saito K, Turner K, Odhiambo G, Wamae A, et al. Implementation of a cloud-based electronic medical
record for maternal and child health in rural Kenya. Int J Med Inform 2015 May;84(5):349-354. [doi:10.1016/j.ijmedinf.2015.01.005] [Medline: 25670229]
Allen C, Jazayeri D, Miranda J, Biondich PG, Mamlin BW, Wolfe BA, et al. Experience in implementing the OpenMRS
medical record system to support HIV treatment in Rwanda. Stud Health Technol Inform 2007;129(Pt 1):382-386. [Medline:
17911744]
Seebregts CJ, Mamlin BW, Biondich PG, Fraser HS, Wolfe BA, Jazayeri D, et al. Human factors for capacity building:lessons learned from the OpenMRS implementers network. Yearb Med Inform 2010:13-20. [Medline: 20938564]
Thompson A, Castle E, Lubeck P, Makarfi PS. Experience implementing OpenMRS to support maternal and reproductive
health in Northern Nigeria. Stud Health Technol Inform 2010:332-336. [doi: 10.3233/978-1-60750-588-4-332]
Wolfe BA, Mamlin BW, Biondich PG, Fraser HS, Jazayeri D, Allen C, et al. The OpenMRS system: collaborating toward
an open source EMR for developing countries. AMIA Annu Symp Proc 2006;2006:1146. [Medline: 17238765]

http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

Syzdykova et al

JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 14(page number not for citation purposes)

JMIR MEDICAL INFORMATICS
59.

60.
61.
62.
63.

64.
65.

66.

67.
68.
69.

Syzdykova et al

Seebregts CJ, Mamlin BW, Biondich PG, Fraser HS, Wolfe BA, Jazayeri D, OpenMRS Implementers Network. The
OpenMRS Implementers Network. Int J Med Inform 2009 Nov;78(11):711-720. [doi: 10.1016/j.ijmedinf.2008.09.005][Medline: 19157968]
Maglogiannis I. Towards the adoption of open source and open access electronic health record systems. J Healthc Eng
2012;3(1):141-161. [doi: 10.1260/2040-2295.3.1.141]
Bahmni. Implementations URL: https://www.bahmni.org/implementations [accessed 2017-11-01] [WebCite Cache ID
6ueGVeCW0]
Syzdykova A, Zolfo M, Malta A, Diro E, Oliveira JL. Customization of OpenMRS for leishmaniasis research and treatment
center in Ethiopia. J Int Soc Telemed eHealth 2017;5:e65 [FREE Full text]
Avelino JN, Hebron CT, Laranang AL, Paje PN, Bautista MM, Caro JD. Requirements gathering as an essential process
in customizing health information systems for small scale health care facilities. 2014 Presented at: 5th International
Conference on Information, Intelligence, Systems and Applications (IISA); July 7-9, 2014; Chania, Greece. [doi:10.1109/IISA.2014.6878729]
Karopka T, Schmuhl H, Demski H. Free/Libre open source software in health care: a review. Healthc Inform Res 2014
Jan;20(1):11-22 [FREE Full text] [doi: 10.4258/hir.2014.20.1.11] [Medline: 24627814]
Prodhan UK, Rahman MZ, Abid A, Bellah M. Development of a telemedicine model with low cost portable tool kit for
remote diagnosis of rural people in Bangladesh. 2016 Presented at: International Conference on Innovations in Science,
Engineering and Technology (ICISET); October 28-29, 2016; Dhaka, Bangladesh. [doi: 10.1109/ICISET.2016.7856513]
de la Torre I, Martinez B, Lopez-Coronado M. Analyzing open-source and commercial EHR solutions from an international
perspective. 2013 Presented at: 2013 IEEE 15th International Conference on e-Health Networking, Applications & Services(Healthcom); October 9-12, 2013; Lisbon, Portugal. [doi: 10.1109/HealthCom.2013.6720708]
Safadi H, Chan D, Dawes M, Roper M, Faraj S. Open-source health information technology: a case study of electronic
medical records. Health Policy Technol 2015 Mar;4(1):14-28. [doi: 10.1016/j.hlpt.2014.10.011]
ONC-Authorized Certification Body. Chpl.healthit. Certified health IT product list URL: https://chpl.healthit.gov/ [accessed2017-11-01] [WebCite Cache ID 6ueHJkBQ3]
FreeMED Software Foundation. Transifex. FreeMED open source EMR/PM system URL: https://www.transifex.com/
freemed/freemed/ [accessed 2017-11-01] [WebCite Cache ID 6ueHS7j7L]Abbreviations
ACL: Access Control List
ATC: Anatomical Therapeutic Chemical
API: application programming interface
CIEL/MVP: Columbia International eHealth Laboratory/Millennium Villages Project
CPT: Current Procedural Terminology
DBMS: database management systems
DICOM: Digital Imaging and Communications in Medicine
eHealth: electronic health
EHR: electronic health record
EMR: electronic medical record
ERP: enterprise resource planning
FHIR: Fast Healthcare Interoperability Resources
GPL: general public license
HCPCS: Healthcare Common Procedure Coding System
HIS: health information system
HIV: human immunodeficiency virus
HL7: Health Level-7
ICD: International Classification of Diseases
LIS: laboratory Information system
LDAP: lightweight directory access protocol
LMICs: low- and middle-income countries
LOINC: Logical Observation Identifiers Names and Codes
NPO: nonprofit organization
OpenMRS: open medical record system
OS EHR: open-source EHR
OSS: open-source software
OSCAR: open source clinical application resource
PMS: practice management software
RBAC: role-based access control
http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 15(page number not for citation purposes)

JMIR MEDICAL INFORMATICS

Syzdykova et al

SNOMED-CT: Systematized Nomenclature of Medicine-Clinical Terms
UTF: Unicode Transformation Format
VistA: Veterans and Information System &Technology Architecture

Edited by G Eysenbach; submitted 04.06.17; peer-reviewed by V Maojo, D Revere; comments to author 12.07.17; revised version
received 14.08.17; accepted 13.09.17; published 13.11.17
Please cite as:
Syzdykova A, Malta A, Zolfo M, Diro E, Oliveira JL
Open-Source Electronic Health Record Systems for Low-Resource Settings: Systematic Review
JMIR Med Inform 2017;5(4):e44
URL: http://medinform.jmir.org/2017/4/e44/
doi: 10.2196/medinform.8131
PMID: 29133283©Assel Syzdykova, André Malta, Maria Zolfo, Ermias Diro, José Luis Oliveira. Originally published in JMIR Medical Informatics(http://medinform.jmir.org), 13.11.2017. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work, first published in JMIR Medical Informatics, is properly cited. The complete
bibliographic information, a link to the original publication on http://medinform.jmir.org/, as well as this copyright and license
information must be included.

http://medinform.jmir.org/2017/4/e44/

XSL• FO
RenderX

JMIR Med Inform 2017 | vol. 5 | iss. 4 | e44 | p. 16(page number not for citation purposes)