Keywords

1 Introduction

In today’s dynamic digital era, startups and technological entities have been at the forefront of innovation and transformative change. Software Startups focus on crafting software tailored for various sectors, such as finance and education, providing everything from mobile applications to comprehensive enterprise platforms [20]. In the health-tech sector, health-tech startups are revolutionizing healthcare paradigms by leveraging cutting-edge technologies. They utilize different technologies in their product and service offerings to revolutionize healthcare and develop personalized health strategies [1]. However, while empowering patients, they face competition and inherent challenges, such as the need for more resources. A comparison between software startups and health-tech startups is shown in Fig. 1.

Fig. 1.
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A comparison between health-tech startups and software startups

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Central to this narrative is the rise and evolution of open-source software (OSS). From its early inception in the 1980s to its widespread adoption today, OSS has profoundly altered the product development landscape by promoting reusability, enabling free access to software source codes, encouraging collaborative contributions, and granting unparalleled freedom to its users [8]. Open-source software offers numerous benefits, including cost savings, enhanced security, and customization [10].

Health-tech products and services have gained importance because of their potential to enhance healthcare infrastructure. Integrating technology with healthcare solutions can improve care quality, foster innovative systems, and reduce costs [14]. In this domain, OSS can aid in areas such as electronic health record (EHR) systems and clinical decision support. Previous studies, such as that by Karopka et al. [11], have highlighted the advantages of OSS in healthcare, citing cost savings, flexibility, and improved interoperability. Syzdykova et al. [18] also emphasized the benefits of open-source EHR systems, emphasizing their role in enhancing patient care and achieving cost savings. Given the growing significance of healthcare, health tech startups can leverage OSS to meet healthcare demands.

Research Problem and Objective.

However, despite the importance of OSS and health-tech startups, we found very limited, if any, empirical research on OSS adoption in health-tech startups [11, 21]. For example, the authors in [20] discussed various topics on startups but failed to acknowledge OSS research in the startup context. Similarly, a recent literature review [21] lacked OSS research within health-tech startups. To address this gap in the literature, we carried out an empirical study of the benefits of adopting OSS for health-tech startups and the challenges they encounter during its adoption. To understand the topic, we conducted a background literature search on OSS and health-tech startups (Sect. 2). The study framed three research questions (RQs) to explore the issue, employed a qualitative approach, conducted semi-structured interviews with stakeholders in health-tech startups, and performed a thematic data analysis (Sect. 3). The findings shed light on the benefits of OSS in enhancing product development and the challenges faced during its adoption (Sect. 4). The study discussed the RQs, provided added value to the literature, offered recommendations for practitioners and suggestions for further research topics, and presented the conclusion (Sects. 5 and 6).

2 Background Literature

2.1 Health-Tech Startups

A startup is described as a “brand-new business with a cutting-edge technological and innovative business plan” [12]. Startup entities possess the capability for rapid growth and the potential to scale. Ehsan [6] provided a refined definition of startups, emphasizing innovation, growth potential, and risk embracement. A significant factor distinguishing startups from other firms is their focus on product innovation.

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Startups harness emerging technologies, such as artificial intelligence (AI), machine learning, and telemedicine, to devise novel solutions and transform conventional healthcare paradigms [17]. Research indicates that one of the primary strengths of health-tech entities is their ability to employ data analytics to craft tailored, data-informed health solutions [19]. Beaulieu et al. [1] highlighted the competitive landscape for these startups, noting that they not only compete with large established corporations but occasionally utilize the services provided by these industries.

2.2 Open-Source Software and Product Development

The origins of OSS can be traced back to the late 1990s, although the concept of free software had its roots in the 1980s. Perceptions of it have shifted over the decades, transitioning from a niche perspective to a mainstream approach accepted by individuals and firms. [8] As Karopka et al. [11] outlined, OSS empowers users with the freedom to utilize, modify, and disseminate software while granting access to its source codes. In today’s digital landscape, many examples of OSS, such as Android OS, Linux, and Apache, are widely adopted [11]. The current ubiquity of OSS means that several firms now design software by integrating OSS components. The OSS model is collaborative, with creators and users actively contributing to its evolution. However, licensing decisions remain the original developers’ preferences [10].

Spender et al. [16] delved into the determinants driving OSS adoption, emphasizing security, software quality, user experience, costs, effort, societal influences, and operational efficiency. Butler et al. [2] further pinpointed organizational strategies in OSS evaluation; larger entities often rely on structured frameworks or guidelines, whereas smaller outfits typically leverage collective decision-making steered by their leadership.

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For instance, Fitzgerald [7] observed that OSS initiatives generally exceed proprietary software in code quality and error minimization, an issue attributed to the extensive community of experts monitoring and refining the code. Nonetheless, OSS integration is full of challenges. Issues involving effective project oversight, intellectual property considerations, and security concerns demand attention [5]. Scacchi et al. [14] emphasized that adopting free OSS in crafting extensive software systems is gaining traction as a viable alternative strategy. This approach shows unique examples of project success, deviating from traditional software development practices, and introduces novel methodologies and paradigms in software creation [14].

2.3 Health-Tech Sector and Open-Source Software

The adoption of OSS within the healthcare sector is accelerating. The OSS development model has been influential because it grants the developer community access to freely available source codes, thus fostering collective contributions [11].

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However, Butler et al. [2] noted that organizations encounter challenges when integrating OSS components. They need help in crafting efficient operational procedures to evaluate OSS elements. This encompasses estimating the financial implications and risks of adoption, along with concerns about functional requirements and attaching to licensing terms. Given the rapid pace and expansive scale of software development in specific organizations, there is a persistent need to refine software evaluation techniques. While some firms rely on developer-driven strategies and unconventional approaches, others have established systematic protocols to evaluate OSS components, allowing for more detailed and layered assessments.

2.4 Health-Tech Startups, Open-Source Software, and the Research Gap

Based on our review and the available literature [11, 21], there is a need for empirical studies that specifically evaluate the use of OSS in health-tech startups. For instance, a paper by a software startup research network titled “Software Startups – A Research Agenda” [20] acknowledged the omission of OSS as a research topic, which is a limitation of their study. Additionally, a recent literature review of health-tech startups in healthcare service delivery [21] emphasized the transformative impact of technology on healthcare, highlighting quicker treatments, enhanced emergency care, and innovations, such as telemedicine and e-health. However, the review did not report and address the description of OSS research in the health-tech startup literature. Thus, current research regarding the application of OSS in health-tech startups is very limited and needs to be empirically investigated further. To address this research gap, we conducted an empirical investigation that guided health-tech startups on the advantages of OSS adoption.

3 Research Methodology

In our study, we focused on health-tech startups located in a Oulu city in Finland. Understanding the impact of using OSS in these startups is crucial. This study aims to determine the influence of open-source technological components on health-tech startups, and the challenges that these startups encounter when adopting OSS solutions. We have outlined the RQs in Table 1 to address this goal.

Table 1. Research Questions
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3.1 Research Approach

We adopted an empirical research approach using semi-structured interviews to delve into the experiences and viewpoints of interviewees concerning the adoption of OSS technology within health-tech startups. Qualitative research is useful for exploring complex scenarios, such as the incorporation of emerging technologies into organizational settings [4]. The startup's selection criteria depended on their use of OSS technology in product development. Interview participants from healthcare-related startups were selected based on their relevant expertise and background in the domain. We employed purposive and snowball sampling techniques to identify the case companies and select the interview participants. The aim was to identify OSS technology adoption among startups focusing on healthcare solutions. The interviewees included the startups’ chief executive officers, product managers, and key decision-makers familiar with integrating and utilizing open-source technology.

3.2 Data Collection

Semi-structured interviews served as the primary means of data collection. Interviews were used because of their adaptability, allowing for a tailored approach to collecting information and resulting in comprehensive and in-depth data [9]. To meet our research objectives, we designed a mix of open- and closed-ended questions to gather insights into the participants’ experiences and views on using open-source technology within health-tech startups. The set of interview questions was segmented into three sections. The initial section consisted of introductory questions, collecting information about the participants and their respective startups. The core segment of the interview revolved around questions related directly to our research aims. Finally, the concluding section comprised wrap-up questions. As the discussions progressed, some questions evolved naturally, such as how OSS was integrated into existing systems and its advantages.

For a thorough analysis, each interview was audio-recorded and later transcribed. The participants’ consent was obtained for these recordings, and a summary of our findings was shared with them for their approval. Data were collected from six practitioners representing six different health-tech startups. All interviews were conducted via Microsoft Teams, with each interview lasting approximately 45 min. The participants had relevant experience in utilizing OSS in health tech startups. In Table 2, further details are available; for example, startups are denoted by “C” as ID. Furthermore, their business domain, such as Business-to-business (B2B) or Business-to-consumer (B2C), is highlighted. Similarly, their founding year and the number of the startup’s employees are mentioned. Finally, the Interviewee ID is denoted with “P” along with their role, and information on the startup's product or service description is stated.

Table 2. Overview of the Health-tech Startups’ Characteristics and the Interviewees’ Roles involved in the study
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3.3 Data Analysis

Thematic analysis was used to identify, examine, and establish recurring patterns within the data [3]. A systematic approach was taken with the interview transcripts to detect patterns, central themes, and essential insights. The data were organized and categorized using specific codes. Segments of text that represented similar ideas or notions were labeled with these codes. Upon further analysis of the coded data, common themes emerged. Each identified theme emphasized a principal aspect of the research, such as enhancing product development via OSS or the challenges faced when adopting OSS in health-tech startups (see Fig. 2 for code, sub theme, and themes that emerged after data analysis).

Fig. 2.
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Data analysis and thematic results

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3.4 Study validity discussion

To ensure the credibility and trustworthiness of our research findings, we used three assessment criteria. These were construct validity, which helped us to measure our study's objective accurately; external validity, which examined the applicability of our findings in real-world settings; and reliability, which aimed to ensure that our research methods and analysis were consistent and dependable. In the following section, we will discuss these three criteria in detail.

Construct Validity.

In this study, we developed interview questions aligned with the RQs to ensure construct validity. Additionally, data were gathered from six semi-structured interviews with individuals experienced in health-tech startups and product development. The potential for data inaccuracies because of the interviewer’s influence was reduced by conducting numerous interviews. As a result, this research mitigated some potential construct validity risks.

External Validity

This research discusses the utilization of OSS in health-tech startups. By incorporating interviews from various health-tech startups, the study minimizes potential biases that might have emerged if it were based on a single interview or company. The sample size was limited to six, and all the startups were based in Oulu, Finland. Therefore, results are confined in their generalizability.

Reliability

To ensure reliability, this empirical research provides a detailed explanation of the methodology, data collection, and analysis approach that was used to answer the research questions. However, it's important to note that different researchers may arrive at different outcomes, as the data obtained through semi-structured interviews can be influenced by various factors, including the context and the interviewee's level of knowledge at the time of the interview.

4 Result

We report the insights derived from the data analysis in this section, addressing the study’s objectives and answering the RQs.

4.1 Benefits of Adopting Open-Source Software for Health-Tech Startups

Time Efficiency:

A recurring theme among the participants was the time-saving advantage of OSS. P5 emphasized that without OSS, they would have had to “start from scratch,” which was a time-consuming endeavor. Similarly, P1 highlighted the “faster time to market” benefit, suggesting that their startup, C1, could swiftly introduce their products by leveraging pre-existing OSS. This approach allowed them to focus on innovating unique features rather than reinventing typical ones, which is a benefit particularly useful for health-tech startups with constrained resources.

Scalability:

P1 pointed out the scalability inherent in OSS. Scalability ensures software adaptability to fluctuating demands and allows for modifications to specific needs. This adaptability was confirmed by P4, who mentioned building proprietary software on top of OSS and showcasing the scalability potential of OSS.

Utilization of Existing Components and Libraries:

Both P1 and P2 emphasized leveraging existing OSS components. By “using existing components instead of writing our code,” as P2 noted, health-tech startups can expedite their development processes. This view does not mean “reinventing the wheel” but capitalizing on the collective efforts of the OSS community. P4 and P5 provided insights into the diverse applications of OSS. For example, C4’s products are embedded in Linux and utilize various OSS libraries. By contrast, C5 focuses on virtual reality simulations, leveraging OSS components from the gaming industry, particularly Unity. These narratives highlight the versatility of OSS across various domains within health-tech startups.

Prominent Open-source Tools:

All interviewees highlighted the significance of OSS tools, with a recurrent emphasis on Linux, GIT, Angular, and Android Studio. For example, P1 said that Angular 2 +, Ionic, and Google Technologies underscore the growing trend of using open-source frameworks for mobile and web applications. Diving deeper, P3 elaborated on the multifaceted role of open-source tools, such as the pivotal role of GIT in version control in C3. Similarly, in C4, they used Yocto, a Linux-based tool, and Jenkins, a Java-based DevOps platform, to support the development of the diverse functionalities of their products. In C5, Unity further showcases the expansive open-source ecosystem available to startups, with its community being a valuable resource. By leveraging OSS tools, startups can optimize their development processes, support team collaboration, and properly allocate resources, thus achieving a more streamlined product development and delivery course.

In conclusion, the participants’ descriptions confirmed the pivotal role of OSS in within health-tech startups. The benefits, from time and cost efficiency to scalability, flexibility, and the ability to leverage existing solutions, empower health-tech startups to optimize resource allocation and accelerate development.

4.2 Ways in Which Open-Source Software Improve the Product Development

Most participants discussed the fast pace of product development because of support from the open-source community, as well as time savings because of proper version management of the product. They also mentioned cost reduction, which directly improved product development. Three principal subthemes were identified regarding the impact of OSS technology on product development: support from the open-source community, low development costs, and version management.

Open-Source Community:

The research participants frequently mentioned the support they received from the open-source community. P1 emphasized the vast resources available, including tutorials, which offer flexibility in using and modifying OSS. This view stresses the community’s role in aiding developers through valuable insights and resources. Comprising passionate software enthusiasts, the open-source community provides extensive help, often through experienced developers who share their expertise. P5 highlighted the community’s role in offering pre-existing tools, helping save time for developers. The respondents specifically mentioned Unity software’s open-source community, which aids game development, and how it played a pivotal role in the creation of C5’s product for evaluating attention deficit hyperactivity disorder symptoms through virtual reality simulation. The responses of P1 and P5 regarding the key role of the open-source community in enhancing product efficiency were consistent. The community promotes reusability and continuous development by providing a platform for knowledge sharing, collaboration, and innovation. Health-tech startups can leverage these resources to expedite their development processes, thus avoiding redundant efforts. The open-source community acts as a catalyst, pushing health-tech startups forward by providing them with resources and expertise.

Low Development Cost:

Most participants in the study emphasized the significant cost savings associated with OSS technology in the product development process. P1 highlighted the cost-effectiveness of OSS as a crucial advantage, especially for startups. Such software is often free or offered at a minimal cost, reducing the financial strain on developers. P2 stressed the absence of licensing costs when deploying OSS solutions, which is especially beneficial for health-tech startups aiming to keep their operational costs low. C3 and C6 were able to focus on saving by avoiding the purchase of expensive proprietary libraries, thus favoring open-source alternatives. The interviewees’ collective responses highlight the transformative impact of OSS on startups, particularly in terms of cost savings. The elimination of hefty licensing fees and the ability to customize software to one’s specific needs allow health-tech startups to allocate their resources more effectively. This results in financial savings and fosters innovation, scalability, and sustainable growth.

Efficient Code Management:

Code management is pivotal in software development; it facilitates collaboration, tracking of changes, and error prevention. The participants emphasized the significant role of OSS in version management, particularly the use of GIT. In C5, GIT is a core tool used for version management; its importance in tracking source code changes is highly valued. The tool aids in understanding the evolution of a product, ensuring regulatory compliance, and maintaining a clear change history. P3, with a programming background, also endorsed GIT, noting its ease of use when handling code and the recent switch of their start-up to this platform because of the positive feedback on it. Using an open-source tool for version management ensures reliability and stability during product development and saves time and effort.

4.3 Challenges in Adopting Open-Source Software

The challenges while adopting the OSS theme include frequent updates, OSS knowledge, and regulatory and security aspects.

Frequent Updates:

In health-tech startups, the rapid evolution of OSS presents significant challenges, as P3, P5, and P6 highlighted. They identified regular updates as a primary concern. While beneficial for software enhancement, these updates can disrupt development and validation processes. P3 emphasized the importance of understanding software to anticipate and manage these updates, noting that such changes can introduce complexities requiring time-consuming modifications. P6 elaborated on the challenges posed by updates, stressing that open-source frameworks often undergo annual revisions. This swift pace complicates the development process, sometimes necessitating a freeze to ensure consistency with the chosen framework version. Beyond development, P6 also highlighted the intricacies of application validation between updates. Ensuring that applications meet functionality, compliance, and performance standards becomes difficult, as each update might introduce changes that demand rigorous testing and verification. Adding to this challenge, P5 mentioned that the frequent updates inherent in open-source technologies result in the need to continuously validate them. Frequent changes can compromise the reliability and stability of applications, especially given the rapid pace of upgrades. While OSS offers numerous advantages, health-tech startups must navigate the inherent challenges that come with them. These include managing consistent updates, pausing development for stability, ensuring rigorous application validation, and enabling swift adaptation to updates. The participants highlighted the need for health-tech startups to be proactive and strategic when integrating OSS into their operations.

Open-Source Software Knowledge:

Open-source adoption in health-tech startups presents opportunities and challenges. A recurring theme among the participants was the steep learning curve associated with integrating OSS. P1 highlighted that unfamiliarity with OSS can slow down the development process. This view was supported by P4, who faced challenges in getting their team on board because of a lack of prior experience with open-source tools. Such challenges underscore the need for health-tech startups to invest in training and expertise in order to ensure seamless integration and effective collaboration. Another significant concern is the integration of open-source technologies with existing proprietary systems. As P1 pointed out, mismatches between the two can lead to technical issues, further delaying development. Health-tech startups must understand in depth the software they are integrating and invest in specialized expertise to navigate potential integration hurdles. Vulnerabilities in open-source components are another area of concern. P2 and P5 emphasized the importance of understanding the life cycles of open-source components and being aware of their vulnerabilities. Regular updates, while essential for security and functionality, can be challenging. As P3 noted, frequent updates, although beneficial, can strain resources and complicate the development process. These challenges have added significance for health-tech startups, in which patient data and system reliability are paramount. In essence, while OSS offers cost-effective and flexible solutions, health-tech startups must approach its adoption with caution, preparation, and a commitment to continuous learning.

Regulatory and Cybersecurity Imperatives:

Regulatory challenges are pivotal when integrating OSS, especially in sectors such as healthcare. Both P5 and P6 emphasized the significance of security and performance in this context. P5 stated that their startup, C5, constantly evaluated the impact of open-source technology on the safety and performance of solutions. The respondents highlighted the need to determine whether OSS technologies are integral to the system or merely serve as supplementary tools. This distinction is crucial in deciding compliance with regulatory standards. P6, on the other hand, highlighted the increasing importance of cybersecurity, especially with the proliferation of AI. As AI becomes more embedded in systems, the demand for robust security in OSS intensifies. The open accessibility of such software, while fostering innovation, can also introduce vulnerabilities. The insights from the participants underscored the dual-edged nature of OSS. While it offers flexibility and a vast pool of resources, it also demands rigorous scrutiny, especially in sectors governed by stringent regulations. The integration of AI amplifies security imperatives. It accelerates AI advancements but also necessitates heightened cybersecurity measures.

5 Discussion

In this section, we discuss the RQs, present their added value to the literature, provide recommendations to practitioners, and suggest further research avenues.

5.1 Answers to the Research Questions (RQs)

Open-source software has become an essential component for startups, offering a multitude of advantages that often surpass the difficulties associated with it. Our thorough analysis, based on extensive interviews and data, highlights the vital role of OSS in health-tech startups. While most startups use OSS in a similar manner, they vary in the tools they choose to implement. Table 3 provides a summary of our answers to the RQs.

Table 3. Summary of answers to the RQs
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5.2 Theoretical Contributions to the Literature

The findings of our study on incorporating OSS into the growth of healthcare startups align with earlier findings in various crucial aspects. A comparison with prior research reveals notable similarities and insights, which are discussed below.

Karopka et al. [11] and Santarsiero et al. [13], have identified an increasing trend in OSS adoption in healthcare. Our research confirms this, emphasizing the importance of OSS in fostering innovation, reducing costs, and adding value to the healthcare landscape within health-tech startups. Karopka et al. [11] highlighted the flexibility of OSS, granting users the freedom to access, distribute, and modify its content, especially its source codes. Our findings expand this by illustrating that health-tech startups derive substantial advantages from the transparent nature of OSS and its associated tools. Interestingly, our study introduces new perspectives, such as the role of OSS in product development and the tools that assist startups in managing code modifications.

Similarly, Shaikh et al. [15] and Butler et al. [2] pointed out the challenges of adopting OSS. Some of these are the same as those identified in our research. Both studies drew attention to difficulties, such as the pronounced initial learning phase, the unfamiliarity of OSS, navigation of constant updates, compliance with established protocols, and security concerns. Our findings underscore the need for health-tech startups to recognize the potential risks of OSS adoption and to conduct thorough evaluation and planning before its introduction. One particular challenge that has not been extensively covered in earlier works pertains to the depth of understanding required for OSS. This often necessitates health-tech startups investing in training on OSS, which demands time and resources.

5.3 Recommendations for Practitioners

Based on the results, we recommend that health-tech startups start adopting OSS to increase the efficiency of their products. They should consider using OSS tools, as these provide affordable options, scalability, flexibility, and time-saving benefits. Health-tech startups can use configurable software and existing infrastructure and make their development processes more efficient by utilizing these technologies.

Training and Education:

Health-tech startups should start investing in training and education about OSS for their team members because understanding the architecture, workflow, and paradigms of OSS is essential for successful implementation. Health-tech startups can reduce the learning curve associated with adopting open-source technologies by providing proper training and assistance.

Updates and Integration:

Health-tech startups should learn how often OSS updates itself and determine whether they want to integrate the updates into their systems. If OSS is updated rapidly, health-tech startups may encounter difficulties adapting their systems to the changes.

Risk Assessment:

Health-tech startups should also carefully consider and adhere to any regulatory obligations on using OSS and considering performance, safety rules, and security procedures. They should carry out a thorough risk analysis before deploying OSS. This entails knowledge about the vulnerabilities and difficulties linked to open-source technologies.

Community Engagement:

Health-tech startups should actively interact with the open-source community for advice and support. The enormous open-source community makes many resources, courses, forums, and professional opinions available. Health-tech startups may overcome obstacles, learn best practices, and accelerate their growth by utilizing the expertise and experiences of the community.

5.4 Study Limitations and Future Research

The study focused on health-tech startups, yielding a limited sample size of just six startups. This small size affects the broader applicability of the results, although they align with previous research. While the findings offer essential insights, they capture only some aspects of startups’ open-source adoption. The potential effects on creativity, teamwork, and competitive advantage require further exploration. In future studies, health-tech startups’ experiences with using proprietary solutions could provide a more profound understanding of the unique advantages and challenges of OSS. Additionally, an in-depth look into the security measures employed by health-tech startups when using OSS would be beneficial.

6 Conclusion

Health-tech startups have increasingly embraced OSS for its cost and time efficiency, scalability, and customization. Notable OSS tools are revolutionizing the development processes and code management of startups. However, startups also face challenges despite the numerous advantages of OSS, such as understanding OSS dynamics, managing frequent updates, adhering to regulations, and ensuring cybersecurity. Previous studies corroborate these findings, emphasizing the role of OSS in fostering innovation and cost savings. Health-tech startups are advised to invest in training, understand update cycles, assess risks, and engage with the OSS community to maximize the OSS benefits they obtain.