OpenEMR & OpenMRS

The Case for Open Source EMRs

Electronic medical record (EMR) systems are expensive. Commercial EMRs can cost thousands per provider per year, with additional fees for implementation, training, support, and upgrades. For small clinics, community health centers, and practices in resource-limited settings, these costs are prohibitive.

Open source EMRs offer an alternative. The software is free, the source code is available for modification, and there's no vendor lock-in. Organizations can customize, extend, and integrate without permission or licensing fees.

Two projects dominate the open source EMR space: OpenEMR and OpenMRS. While they share the "open" philosophy, they serve different markets and have distinct architectures. Understanding their differences helps you choose the right platform for your needs.

OpenEMR: The Established US-Focused EMR

Overview

OpenEMR has been around since 2001, making it one of the oldest open source EMR projects. It's designed primarily for the US healthcare market, with features aligned to American medical practices, billing requirements, and regulatory needs.

The platform is ONC-certified, meaning it meets federal requirements for meaningful use - a big deal for US practices that want to qualify for government incentive programs or avoid penalties.

Core Features

• Practice Management: Scheduling, patient registration, demographics
• Clinical Documentation: SOAP notes, problem lists, medication lists, allergy tracking
• e-Prescribing: Integrated with Surescripts and other e-prescribing networks
• Billing: Full medical billing, claims generation, payment tracking
• Patient Portal: Patients can view records, request appointments, message providers
• Reports: Clinical reports, financial reports, meaningful use reports
• Interoperability: HL7 interfaces, FHIR API, Direct messaging

Technical Architecture

OpenEMR is a traditional web application:

• Backend: PHP with a MySQL database
• Frontend: Mix of traditional server-rendered pages and modern JavaScript
• Deployment: Runs on Apache or Nginx web servers
• Platform: Linux, Windows, or macOS

The technology stack is mature and well-understood. Any web developer can work with it. Hosting requirements are modest - a small practice can run OpenEMR on a basic server or cloud instance.

Target Users

OpenEMR serves:

• Small to medium US medical practices
• Community health centers
• Free clinics
• Specialty practices (behavioral health, chiropractic, etc.)
• International clinics wanting a US-style EMR

It's particularly popular among practices that can't afford commercial EMRs but still need certification for meaningful use compliance.

Strengths

• ONC-certified: Meets US regulatory requirements
• Complete solution: Covers clinical and business needs
• Mature codebase: Two decades of development and refinement
• Active community: Forums, documentation, third-party support
• Easy deployment: Can be installed on standard web hosting
• Customizable: Open source, so you can modify as needed

Limitations

• US-centric: Not ideal for non-US healthcare systems
• User interface: Functional but not as modern as commercial EMRs
• Learning curve: Complex system with many features to learn
• Support model: Community support is free but not guaranteed; paid support available from third parties
• Customization requires technical skills: Making changes means diving into code

OpenMRS: The Global Health Platform

Overview

OpenMRS (Open Medical Record System) launched in 2004, designed specifically for resource-constrained environments. It originated in Africa to support HIV/AIDS care but has expanded globally to serve all types of clinical settings.

Unlike OpenEMR's focus on US practice management, OpenMRS emphasizes flexibility and adaptability. It's more of a platform than a complete EMR - you build your clinical workflows on top of it using modules.

Core Architecture

OpenMRS is built around several key concepts:

• Platform approach: Core system provides data model and APIs; functionality comes from modules
• Data model: Highly flexible, based on observations and concepts rather than fixed tables
• Modular design: Add features by installing modules (like apps on a phone)
• Multiple UIs: Different user interfaces for different users (clinicians, data entry clerks, etc.)

Technical Stack

• Backend: Java with Spring Framework
• Database: MySQL (PostgreSQL also supported)
• APIs: RESTful web services for all operations
• Frontend: Multiple options - legacy UI, reference application, custom UIs

The architecture is more enterprise-oriented than OpenEMR. Java developers will feel at home, but it's heavier and requires more resources.

Target Users

OpenMRS serves:

• NGOs and international health organizations
• Public health programs in developing countries
• Research institutions conducting clinical studies
• Specialty programs (HIV/AIDS, TB, maternal health)
• Any setting needing a highly customized EMR

It's particularly strong in low-resource settings where workflows differ dramatically from Western medicine and flexibility is paramount.

Key Features

• Patient Management: Registration, demographics, identifiers
• Encounter Forms: Customizable forms for clinical documentation
• Observations: Flexible data capture (vitals, lab results, symptoms)
• Order Entry: Medication orders, lab orders, procedures
• Reporting: Cohort building, data exports, custom reports
• Interoperability: HL7 support, FHIR modules, data exchange with other systems

Strengths

• Extreme flexibility: Adapt to any clinical workflow or data structure
• Global community: Implementations in dozens of countries, diverse perspectives
• Proven at scale: Used in national health systems managing millions of patients
• Research-friendly: Data model supports complex studies and analysis
• Active development: Large contributor base, regular releases

Limitations

• Complexity: Platform approach means more setup and configuration
• Not out-of-the-box: Requires significant customization for most use cases
• Resource intensive: Java stack needs more server resources than OpenEMR
• Steeper learning curve: Data model and architecture take time to understand
• Limited US billing: Not designed for American insurance billing workflows

OpenEMR vs OpenMRS: Direct Comparison

Aspect	OpenEMR	OpenMRS
Primary market	US private practices	Global health, NGOs, public health
Approach	Complete EMR out-of-the-box	Platform for building custom EMRs
Technology	PHP + MySQL	Java + MySQL
Ease of use	Moderate - many features to learn	Harder - requires configuration
Customization	Possible but requires code changes	Built for customization via modules
Billing	Full US medical billing	Basic or none (depends on modules)
Certification	ONC-certified for meaningful use	Not certified (not needed for target market)
Resource needs	Light - runs on basic servers	Heavier - needs more RAM and CPU
Setup time	Days to weeks	Weeks to months (for customization)
Best for	Small US practices needing full EMR	Custom implementations, global health programs

Which Should You Choose?

Choose OpenEMR if:

• You're a US-based medical practice
• You need ONC certification for meaningful use
• You want a complete solution with minimal customization
• Medical billing is a primary concern
• You have limited technical resources
• You want to get started quickly

Choose OpenMRS if:

• You're implementing in a non-US setting
• Your workflows don't match traditional Western medicine
• You need extreme flexibility and customization
• You're running a public health program or research study
• You have development resources to build custom modules
• You're managing a large-scale, multi-site deployment

Getting Started

OpenEMR

1. Try the demo: OpenEMR offers online demos at open-emr.org
2. Install locally: Download from the website, follow installation guide, or use Docker
3. Cloud option: AWS and other cloud marketplaces offer pre-configured instances
4. Join community: Forums and chat for questions
5. Consider professional help: Many consultants specialize in OpenEMR implementation

OpenMRS

1. Explore the platform: Visit openmrs.org for documentation and demos
2. Start with SDK: OpenMRS SDK simplifies development setup
3. Choose a distribution: Pre-configured packages for common use cases
4. Engage community: Active forums, developer calls, and conferences
5. Plan customization: Budget time for building/configuring modules

Support and Services

Both projects are free, but support ecosystems differ:

OpenEMR

• Community support: Free via forums and chat
• Commercial support: Many vendors offer paid support, hosting, and customization
• SaaS options: Some companies offer hosted OpenEMR (you pay monthly, they manage servers)

OpenMRS

• Community support: Free via forums, wiki, and IRC
• OpenMRS Inc: Non-profit that coordinates the project
• Implementation partners: Organizations that specialize in OpenMRS deployments
• Developer support: Large community of contributors for custom development

Total Cost of Ownership

"Free" doesn't mean no cost. Both systems require:

• Infrastructure: Servers (physical or cloud), backups, security
• Implementation: Configuration, customization, data migration
• Training: Getting staff comfortable with the system
• Maintenance: Updates, troubleshooting, user support
• Integration: Connecting to other systems (labs, billing, etc.)

Total cost of ownership over three years typically ranges from $10,000 to $50,000 for a small practice, depending on customization needs and whether you handle IT internally or hire help. Still significantly less than commercial EMRs, which can run $100,000+ for the same period.

The Future of Open Source EMRs

Both OpenEMR and OpenMRS continue to evolve. Recent trends:

• FHIR adoption: Both projects adding FHIR APIs for modern interoperability
• Mobile support: Apps and responsive designs for tablets and phones
• Cloud deployment: Easier hosting options for organizations without IT staff
• AI integration: Early experiments with clinical decision support and automation

As interoperability requirements grow and healthcare costs remain a challenge, open source EMRs will play an increasingly important role - particularly for small practices and global health settings.