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© 2021 Thoughtworks | Confidential
8 years of Open
Source Product
Development:
Lessons Learnt
© 2021 Thoughtworks | Confidential
About Us
2
Members of the Bahmni Product Development Team (and TW Global Health team)
A...
© 2021 Thoughtworks | Confidential 3
● One of the most popular FOSS
EMR/EHR/HIMS
● 50 countries, over 500
implementation...
4
https://www.bahmni.org/feature-list
5
BAHMNI - THE OUTREACH AND IMPACT
Jan Swasthya
Sahyog (JSS)
Bilaspur, India
MOH
LESOTHO
Population Served: 2 Mn+
Users Su...
Bahmni Implementations Across the World
6
7
EHR for low
resource
settings
Jan Swasthya Sahyog (JSS)
Bilaspur, Chhattisgarh
8
© 2021 Thoughtworks | Confidential
People in small places
do not have small
problems
9
2012  The first meeting of TW with...
10
Gudalur Adivasi
Hospital, Tamil Nadu
‣ 50 bed Hospital
‣ Infant mortality rate reduced to
300/thousand to 20/thousand.
‣ S...
Run by the tribals for
the tribals
12
https://ashwini.org/
© 2021 Thoughtworks | Confidential
endTB: Using Bahmni for Clinical Data Capture
‣ A Partnership among 3 organisations - M...
© 2021 Thoughtworks | Confidential
1. Country wide deployments - Bangladesh,
Lesotho, Nepal (preferred EMR.
2. Bahmni is ...
© 2021 Thoughtworks | Confidential
Architecture for Low Resource Environments?
1. Poor Electricity & Internet connectivity...
© 2021 Thoughtworks | Confidential 16
© 2021 Thoughtworks | Confidential
Deployment Options
• Laptop
• Desktop Computer
• In-premise Servers
• Private Data cent...
© 2021 Thoughtworks | Confidential
Large Footprint. Software Entropy.
1. Bahmni has over 1M LoC with 160K AngularJS.
2. De...
© 2021 Thoughtworks | Confidential
Security. Privacy. Patient Data.
Challenges
1. Less Technical Know-how on the ground.
2...
© 2021 Thoughtworks | Confidential
Product over Project Thinking
20
1. Easy to fund Projects, than a
Product Team.
2. Larg...
© 2021 Thoughtworks | Confidential
Early Years: Partnered with Grassroots Org
21
© 2021 Thoughtworks | Confidential 22
Team: Iterate, Discuss, Modify and Deploy on
Ground
© 2021 Thoughtworks | Confidential
Understand
Local Context
23
© 2021 Thoughtworks | Confidential 24
Long-term Sponsorship… from a caring &
competent organization
© 2021 Thoughtworks | Confidential
Experience in Global Health Informatics
25
© 2021 Thoughtworks | Confidential
Open Source
Technologies in Global
Health
26
Thoughtworks has been
instrumental in most...
© 2021 Thoughtworks | Confidential
Configurability
without coding
• Given the context of our target
segment, programmers a...
© 2021 Thoughtworks | Confidential
1. Country Wide Implementations
a. Country specific
distribution/packaging (NepalEHR,
e...
NDHM
Ecosystem Integration - Federated Architecture
- NDHM
© 2021 Thoughtworks | Confidential
Open Source
software isn’t successful
because of “software” --
it’s because of the
“eco...
© 2021 Thoughtworks | Confidential 31
© 2021 Thoughtworks | Confidential
1. Product thinking over Project
thinking.
2. Plan & Design for Software
Entropy over t...
© 2021 Thoughtworks | Confidential
Innovation?
33
“There are many criticisms of technology,
indicating that it can take aw...
© 2021 Thoughtworks | Confidential
Contribute to
Bahmni!
Google: “how to contribute to
Bahmni”
34
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Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 1 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 2 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 3 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 4 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 5 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 6 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 7 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 8 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 9 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 10 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 11 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 12 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 13 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 14 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 15 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 16 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 17 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 18 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 19 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 20 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 21 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 22 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 23 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 24 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 25 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 26 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 27 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 28 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 29 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 30 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 31 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 32 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 33 Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021 Slide 34
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Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021

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In this talk, at the Thoughtworks xConf 2021 - Angshuman & Gurpreet share the lessons learnt while building & deploying Bahmni, an open source hospital management system across resource constrained environments.

The cover key lessons on sustainability, software entropy, designing tech4good systems, patient privacy and security, product thinking, etc.

The video recording for this talk can be accessed here: https://www.youtube.com/watch?v=HuqZvI0N9Po&list=PL8f-F_Zx8XA-kMENPeMMXT9KKo-x4F_NO&index=7

For more information on bahmni, please visit: https://bahmni.org

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Lessons learnt from 8 years of FOSS (Bahmni EMR) at Thoughtworks xConf 2021

  1. 1. © 2021 Thoughtworks | Confidential 8 years of Open Source Product Development: Lessons Learnt
  2. 2. © 2021 Thoughtworks | Confidential About Us 2 Members of the Bahmni Product Development Team (and TW Global Health team) Angshuman Sarkar ● Technical Principal ● 20 Years in Software & Global Health ● Architect (Bahmni, ProjectEKA ● NDHM Contributor, Digital/Public Health Policy habitue ● Open Source Evangelist ● Technical Principal ● 20 Years in Software Development ● Product Manager & Community Manager for Bahmni ● Passionate about Tech4Good ● Open Source Evangelist Gurpreet Luthra
  3. 3. © 2021 Thoughtworks | Confidential 3 ● One of the most popular FOSS EMR/EHR/HIMS ● 50 countries, over 500 implementations. 600 downloads a month ● Open Source, Open System, Open Community ● Preferred EHR/HIMS solution in many countries in Asia and Africa ● Strategic asset for Large Humanitarian Organizations ● Recognized as a Digital Public Good by DPGA & UNICEF in 2021 https://bahmni.org
  4. 4. 4 https://www.bahmni.org/feature-list
  5. 5. 5 BAHMNI - THE OUTREACH AND IMPACT Jan Swasthya Sahyog (JSS) Bilaspur, India MOH LESOTHO Population Served: 2 Mn+ Users Supported: 2000+ Patients Served: 500K+ Transactions: 1 Mn+ Population Served: 1 Mn+ Users Supported: 200+ Patients Served: 250K+ Transactions: 350K+ Population Served: 2Mn+ Users Supported: 500+ Patients Served: 10K+ Transactions: 400K+ Population Served: 2 Mn+ Users Supported: 2000+ Patients Served: 500K+ Transactions: 1 Mn+ 50+ Countries implementation Preferred EMR Solution - Asia, Africa Supporting 2Mn+ Patient Records Impacting 15Mn+ Population 500+ Sites Diverse implementations Highly Customised for Local flavour 20+ Accolades across Govt & NGOs MOH Bangladesh, Calcutta Kids, Partners in Health, JSS, Possible Sustainable Ecosystem BAHMNI Coalition Scaling Nationally across continents Featured in JIMR Study of EMR Featured in Digital Square Global Goods Product list Used as Clinical Research tool worldwide in TB, HIV etc. International Humanitarian Medical NGO
  6. 6. Bahmni Implementations Across the World 6
  7. 7. 7 EHR for low resource settings
  8. 8. Jan Swasthya Sahyog (JSS) Bilaspur, Chhattisgarh 8
  9. 9. © 2021 Thoughtworks | Confidential People in small places do not have small problems 9 2012  The first meeting of TW with JSS, Bilaspur
  10. 10. 10
  11. 11. Gudalur Adivasi Hospital, Tamil Nadu ‣ 50 bed Hospital ‣ Infant mortality rate reduced to 300/thousand to 20/thousand. ‣ Self reliant - Community collective, 75% of the tribal have dedicated to improvement of health 11
  12. 12. Run by the tribals for the tribals 12 https://ashwini.org/
  13. 13. © 2021 Thoughtworks | Confidential endTB: Using Bahmni for Clinical Data Capture ‣ A Partnership among 3 organisations - MSF, Partners in Health (PIH & Interactive Research & Development (IRD funded by UNITAID ‣ Operational over 25 countries ● http://endtb.org ● Dr. Cathy Hewison on Design, development, and deployment of the endTB electronic medical record ● Fighting Tuberculosis with Open-Source Tech OBJECTIVE ● To find shorter, less toxic and more effective treatments for ‘multidrug-resistant TB’ or MDRTB with two new drugs - Bedaquiline and Delamanid ● Aims to share findings with WHO and Governments for a much wider impact 13
  14. 14. © 2021 Thoughtworks | Confidential 1. Country wide deployments - Bangladesh, Lesotho, Nepal (preferred EMR. 2. Bahmni is under evaluation in Bihar. 3. Used in: a. Hospitals NGOs, Private, Govt, etc. b. Clinical Research c. Primary and Tertiary care - e.g. re-countructive Surgery d. Programs  HIV, TB, Burns ANC / Mother-Child Care, etc. e. Oncology (in-roadmap) f. Integration with NDHM (going live-soon) Now Bahmni has been used in... 14
  15. 15. © 2021 Thoughtworks | Confidential Architecture for Low Resource Environments? 1. Poor Electricity & Internet connectivity. 2. Outdated hardware, routers, network, etc. 3. Extreme climatic conditions. 4. More patients. Less users/doctors. Overloaded system. 5. Less-Technical capability or exposure. 6. Inability to pay. 7. Lots of Data. No security. No backups. No privacy. 8. Cheap Android phones. Or Feature phones. 9. Malware, Viruses, Lack of Security Consciousness. 10. In-premise / Laptop deployments. 15 The Lake Clinic, Cambodia
  16. 16. © 2021 Thoughtworks | Confidential 16
  17. 17. © 2021 Thoughtworks | Confidential Deployment Options • Laptop • Desktop Computer • In-premise Servers • Private Data center • Cloud Providers 17 • Direct Installation Ansible) • Vagrant • Docker Containers • AMI Images
  18. 18. © 2021 Thoughtworks | Confidential Large Footprint. Software Entropy. 1. Bahmni has over 1M LoC with 160K AngularJS. 2. Development started in 2013 8 years). ○ Puppet → Ansible. ○ Vagrant → Docker. ○ Mingle → JIRA. ○ AngularJS -> React. ○ CentOS -> Rocky Linux?  Docker? ○ OpenMRS  2016 version. Odoo v10. etc. 3. Plan for upgrading / retiring. 4. Abstractions & Loose Coupling. Choices that continue to bug us: 1. Frontend codebase in Single repo - compromised modularity and SoC. 2. Over reliance on framework (didn’t leverage POJO enough). 3. Modular dynamic loaded components were de-emphasized - with single SPA; struggle to allow customization or pluggability. 4. Created our own design system; turned out to be costly and assimilation of contribution inline with overall product design.
  19. 19. © 2021 Thoughtworks | Confidential Security. Privacy. Patient Data. Challenges 1. Less Technical Know-how on the ground. 2. Unpatched Networks / Routers / Systems. 3. Malware Attacks. 4. No Trust Boundaries. Shared Wifi. 5. Patient Discrimination (HIV, Albino, Homophobia, Ethinic, Sexual Violence, etc). 6. Shared Passwords 7. Vulnerable Libraries in the wild. 8. Default Usernames/passwords. 9. No appreciation or understanding of Privacy rights. 10. Digital Data - easy to lose, steal, replicate! 11. Very few orgs have awareness of Operationalising Digital Security / Safety protocols. 1. SMS based OTP 2. Fine-Grained Authorisation Model 3. Audit Log - Even for VIEW of records 4. Installer sets up firewall and other security features. 5. Documentation & scripts on Server Security / Hardening. 6. LetsEncrypt based certificates. 7. Threat Modelling & Trust Boundaries 8. …. A lot more to be done!
  20. 20. © 2021 Thoughtworks | Confidential Product over Project Thinking 20 1. Easy to fund Projects, than a Product Team. 2. Large Surface Area makes for Local Optimisation of Decisions over Global Optimisations Tactical > Strategic) 3. Fragmented Features - work for only specific use-cases. 4. No holistic vision / strategy. 5. Large Tech Debt, re-inventing the wheel. 6. Products: More sustainable for OSS / Tech4good situations. 7. Core Product - as a platform. Plugin architecture for custom extensions by community.
  21. 21. © 2021 Thoughtworks | Confidential Early Years: Partnered with Grassroots Org 21
  22. 22. © 2021 Thoughtworks | Confidential 22 Team: Iterate, Discuss, Modify and Deploy on Ground
  23. 23. © 2021 Thoughtworks | Confidential Understand Local Context 23
  24. 24. © 2021 Thoughtworks | Confidential 24 Long-term Sponsorship… from a caring & competent organization
  25. 25. © 2021 Thoughtworks | Confidential Experience in Global Health Informatics 25
  26. 26. © 2021 Thoughtworks | Confidential Open Source Technologies in Global Health 26 Thoughtworks has been instrumental in most of the key products listed here.
  27. 27. © 2021 Thoughtworks | Confidential Configurability without coding • Given the context of our target segment, programmers are impossible to find. • Different hospitals and regions have different UI needs. • Cookie-cutter solutions won’t work 27
  28. 28. © 2021 Thoughtworks | Confidential 1. Country Wide Implementations a. Country specific distribution/packaging (NepalEHR, eHospital Kenya, etc). b. Local/Regional implementers. c. Interop: FHIR standard Adopt early) 2. Sustainable Business Model for Implementor Ecosystem a. Support / Upgrades b. Training c. Implementations d. Starter Kits / Add-ons 3. Core Product also needs a sustainable funding strategy a. Collaboration b. Partnerships Lessons in Sustainability 28
  29. 29. NDHM Ecosystem Integration - Federated Architecture - NDHM
  30. 30. © 2021 Thoughtworks | Confidential Open Source software isn’t successful because of “software” -- it’s because of the “ecosystem encompassing the software”. 30
  31. 31. © 2021 Thoughtworks | Confidential 31
  32. 32. © 2021 Thoughtworks | Confidential 1. Product thinking over Project thinking. 2. Plan & Design for Software Entropy over time. 3. Low Resource Environments can be more challenging than “Enterprise scale”. 4. Security & Privacy - competes with Good UX. 5. Choose aligned Customers at the start. Build collaboratively. 6. Tech4Good cannot sustain without Local Partners & ecosystem development. 7. Successful Open source needs a funding model & community. Lessons! 32
  33. 33. © 2021 Thoughtworks | Confidential Innovation? 33 “There are many criticisms of technology, indicating that it can take away the human element of health care. Bahmni has shown us how technology can help, and still remain very human”  Dr. Yogesh Jain “Successful projects are 99% perspiration, and 1% innovation”  Linus Torvalds, Exec Director, Linux Foundation “And Inspiration”  Gurpreet & Angshu, Thoughtworkers
  34. 34. © 2021 Thoughtworks | Confidential Contribute to Bahmni! Google: “how to contribute to Bahmni” 34

In this talk, at the Thoughtworks xConf 2021 - Angshuman & Gurpreet share the lessons learnt while building & deploying Bahmni, an open source hospital management system across resource constrained environments. The cover key lessons on sustainability, software entropy, designing tech4good systems, patient privacy and security, product thinking, etc. The video recording for this talk can be accessed here: https://www.youtube.com/watch?v=HuqZvI0N9Po&list=PL8f-F_Zx8XA-kMENPeMMXT9KKo-x4F_NO&index=7 For more information on bahmni, please visit: https://bahmni.org

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