Is Linux Ready for Prime Time?

Thinking about Linux? Who's not? Before jumping on the Linux bandwagon; however, CIOs need to answer a few key questions.

  • Has Linux demonstrated its security, reliability, scalability and availability for the proposed application?
  • Will necessary Linux-based software applications be available?
  • What is the true cost of Linux? That is, what other components will the hospital have to purchase to ensure comprehensive IT functionality?
  • Does the hospital have in-house Linux talent? If not, can it grow the talent or hire the necessary bodies to manage Linux applications?

Two or three years ago, Linux was a mere blip on the radar screen for hospital CIOs. Today, many believe that Linux will play a significant role in the enterprise. Indeed a number of hospitals have deployed Linux in the back office and data center. Healthcare IT dollars, however, are being increasingly allocated to clinical rather than financial solutions, and the IT requirements for mission-critical healthcare applications are tremendously different from those in the back office.

Patrick Boyle, business unit executive for IBM Healthcare, says, "For mission-critical applications, hospitals are still relying on multi-year proven operating systems. Many of our customers rely on IBM mainframe technology systems. And for most mission-critical IT applications, Unix is very much a tried-and-true operating system."

But Linux is emerging in the mission critical realm. Rik Primo, manager of Marketing and Strategic Relationships for Siemens Medical Solutions, counters, "Most medical imaging and IT vendors have Linux projects, and new PACS/RIS servers are increasingly on Linux."

So what do CIOs need to consider from the operating system perspective as they are looking at various diagnostic devices, information systems or applications? Boyle of IBM recommends that CIOs analyze a set of core requirements for software applications - scalability, security, availability and reliability and balance those against the institution's financial needs.


Scalability is straightforward. Linux has demonstrated that it can be effectively deployed from small single-user environments to huge networks. The operating system can run on very basic hardware, mobile hardware chipsets and powerful server-grade hardware.

Security will likely be an issue no matter which operating system is selected. Paul Chang, MD, director of Division of Radiology Informatics at the University of Pittsburgh School of Medicine and co-founder of Stentor, points out the unfortunate reality. "No system is ever 100 percent secure. There are security holes in Microsoft and in Linux as well. There will always have to be patches."

Whether or not Linux can meet other core operating systems requirements is debatable. Ken Jarvis, manager Hewlett Packard Healthcare Solutions and Alliances, says the key questions are:

  • Will Linux have the reliability, availability and dependability required to run a clinical information system?
  • Will the appropriate Linux software applications be available? Some vendors are moving some platforms to Linux, but they aren't taking the entire architecture to Linux.

According to Jarvis, the answer to the reliability question remains unknown. And on the applications front, independent software vendors aren't necessarily sharing information about which applications are being migrated to Linux, making it difficult to plan for some Linux applications.


There is a final factor that cannot be overlooked in the operating system picture - cost. Linux is touted as virtually free. Indeed some versions of the operating system are available online for free. More robust, commercial versions of the platform can be purchased at a relatively economical price. But there are costs associated with Linux. For complex healthcare applications that require web-application frameworks, relational databases and message queuing, Linux can be expensive. For example, a single web application running LAMP (Linux, Apache, mySQL and PHP) is essentially free, but LAMP-based server architecture is not scalable or supportable in healthcare. A true Linux web application server could entail purchasing the following components:

  • Linux from Red Hat (with support fees)
  • Database from Oracle ($9,000 per processor plus support fees)
  • J2EE Web Application Platform from BEA ($25,000 per server)

The other cost with any platform comes in the form of human resources. Vish Mulchand, director of server marketing for Hewlett-Packard, points out that when an organization calculates long-term costs - including staffing and training - of an operating system, the price of hardware and software pales in comparison.

If a hospital wants to deploy Linux in the data center or implement a Linux PACS server, it needs to analyze its IT skill set. Boyle says, "Hospitals should be able to leverage the latest technology without causing upheaval [among its IT staff]." If a hospital decides to tap into Linux, it needs a core group of Linux specialists. Can the hospital hire or grow Linux talent?

Hiring Linux talent may be a challenge in the short term as Linux expertise is not as readily available as Microsoft or Unix expertise, but in a few years, the Linux talent pool should be quite robust. Chang explains, "Linux experts are hard to find except at colleges and universities." Boyle adds, "Linux is so pervasive in the university environment that graduates coming out today may be more comfortable with Linux than Windows. In the future, there will be overwhelming Linux resources." Universities are not the only source of Linux talent. Linux has many core similarities with Unix when it comes to software development and maintenance. Boyle claims, "The translation of skills is rather straightforward. The typical Unix IT person will feel right at home with the Linux operating system."

Linux is here and is a force to be reckoned with. But effectively deploying a new operating system, particularly for mission-critical applications, is a serious undertaking. CIOs need to evaluate the knowns of the operating system, their in-house readiness and their IT partners' commitments in order to determine whether or not and where Linux is the right solution.

Is It All Relative?

The reality of operating systems for health industry CIOs is that it is not an either-or proposition. Paul Chang, MD, director of Division of Radiology Informatics at the University of Pittsburgh School of Medicine and co-founder of Stentor, notes, "From a development point of view, both Windows and Linux work and they inter-operate." Linux can support running multiple operating systems on one machine. This dual-booting feature offers the best of both worlds, enabling users to run both Windows and Linux applications. Similarly, VMWare and Virtual Server provide this capability on Windows.

Chang opines, "In the future, there will be a role for both platforms." Microsoft will likely remain the dominant solution on PACS workstations, tablets PCs, file and print servers and other desktop offerings. That other platform - Unix, with its exceptional scalability, is ideal for applications such as EMRs. Chang continues, "On the server side it's a fallacy to think you have to be one or the other. Linux and Microsoft do work well together. The enabling technology is web services." Web services, or XML, provide a common currency for the operating systems. The specific operating system becomes less important if applications and servers embrace XML, which allows everything to work together.

Patrick Boyle, business unit executive for IBM Healthcare, agrees. "When CIOs are making decisions about software applications, they should make sure they are working with an IT partner that adheres to open standards." With open standards, flexibility and cost-effectiveness increase dramatically. If the vendor embraces an open development strategy, the application will run on multiple operating systems and not tie the hospital to a single system, allowing the hospital to the tap into best of all worlds.