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Adverse Event Reporting and EHRs: The MEDTECH Act’s Effects

Posted on December 18, 2014 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

Medical systems generate adverse event (AE) reports to improve service delivery and public safety.

As I described in my first blog post on Adverse Events, these reports are both a record of what went wrong and a rich source for improving workflow, process and policy. They can nail responsibility not only for bad acts, but also bad actors and can help distinguish between the two. The FDA gathers AE reports to look for important health related patterns, and if needed to trigger recalls, modifications and public alerts.

EHRs generate AEs, but the FDA doesn’t require reporting them. Reporting is only for medical devices defined by the FDA and EHRs aren’t. However, users sometimes report EHR related AEs. Now, there’s proposed legislation that would preclude EHRs as medical devices and stop any consideration of EHR reports.

MEDTECH Act’s Impact

EHRs are benign software systems that need minimal oversight. At least that’s what MEDTECH Act’s congressional sponsors, Senators Orrin Hatch (R- Utah) and Michael Bennett (D- Colorado) think. If they have their way – and much of the EHR industry hopes so – the FDA can forget regulating EHRs and tracking any EHR related AEs.

EHRs and Adverse Events

Currently, if you ask MAUD, the FDA’s device, adverse event tracking system about EHRs, you don’t get much, as you might expect. Up to October, MAUD has 320,000 AEs. Of these about 30 mention an EHR in passing. (There may be many more, but you can’t search for phrases such as “electronic health,” etc.) While the FDA hasn’t defined EHRs as a device, vendors are afraid it may. Their fear is based on this part of the FDA’s device definition standard:

[A]n instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including a component part, or accessory which is:

…[I]ntended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals…

I think this section clearly covers EHRs. They are intended for diagnostic, cure, mitigation, etc., of disease. Consistent public policy in general and a regard for protecting the public’s health, I think, augers for mandatory reporting of EHR caused AEs.

Why then aren’t EHRs devices that require AE reporting? In a word, politics. The FDA’s been under pressure from vendors who contend their products aren’t devices just software. They also don’t want their products subject to being criticized for failures, especially in instances where they have no control over the process. That may be understandable from a corporate point of view, but there are several reasons for rejecting that point of view. Consider what the FDA currently defines as a medical device.

Other Devices. The FDA captures AE reports on an incredible number of devices. A few examples:

  • Blood pressure computers
  • Crutches
  • Drug dose calculators
  • Ice bags
  • Lab gear – practically all
  • Robotic telemedicine devices, and many, many more.

ECRI on EHR Adverse Events

The respected patient safety NGO, the ECRI Institute, puts the issue squarely. Each year, it publishes its Top Ten Health Technology Hazards. Number one is inadequate alarm configuration policies and practices. Number two: “Incorrect or missing data in electronic health records and other health IT systems.” Its report says:

Many care decisions today are based on data in an electronic health record (EHR) or other IT-based system. When functioning well, these systems provide the information clinicians need for making appropriate treatment decisions. When faults or errors exist, however, incomplete, inaccurate, or out-of-date information can end up in a patient’s record, potentially leading to incorrect treatment decisions and patient harm. What makes this problem so troubling is that the integrity of the data in health IT (HIT) systems can be compromised in a number of ways, and once errors are introduced, they can be difficult to spot and correct. Examples of data integrity failures include the following:

  • Appearance of one patient’s data in another patient’s record (i.e., a patient/data mismatch)
  • Missing data or delayed data delivery (e.g., because of network limitations, configuration errors, or data entry delays)
  • Clock synchronization errors between different medical devices and systems
  • Default values being used by mistake, or fields being prepopulated with erroneous data
  • Inconsistencies in patient information when both paper and electronic records are used
  • Outdated information being copied and pasted into a new report Programs for reporting and reviewing HIT-related problems can help organizations identify and rectify breakdowns and failures.

ECRI spells out why AE reporting is so important for EHRs:

…[S]uch programs face some unique challenges. Chief among these is that the frontline caregivers and system users who report an event—as well as the staff who typically review the reports—may not understand the role that an HIT system played in an event…

The MEDTECH Act’s Effects

The move to curtail the FDA’s EHR jurisdiction is heating up. Senators Hatch and Bennett’s proposed act exempts EHRs from FDA jurisdiction by defining EHRs as passive data repositories.

Most industry chatter about the act has been its exempting EHRs and others from the ACA’s medical device tax. However, by removing FDA’s jurisdiction, it would also exempt EHRs from AE reports. Repealing a tax is always popular. Preventing AE reports may make vendors happy, but clinicians, patients and the public may not be as sanguine.

The act’s first two sections declare that any software whose main purpose is administrative or financial won’t come under device reporting.

Subsection (c) is the heart of the act, which exempts:

Electronic patient records created, stored, transferred, or reviewed by health care professionals or individuals working under supervision of such professionals that functionally represent a medical chart, including patient history records,

Subsection (d) says that software that conveys lab or other test results are exempt.

Subsection (e) exempts any software that makes recommendations for patient care.

There are several problems with this language. The first is that while it goes to lengths to say what is not a device, it is silent about what is. Where is the line drawn? If an EHR includes workflow, as all do, is it exempt because it also has a chart function? The bill doesn’t say

Subsection (d) on lab gear is also distressing. Currently, most lab gear are FDA devices. Now, if your blood chemistry report is fouled by the lab’s equipment ends up harming you, it’s reportable. Under MEDTECH, it may not be.

Then there’s the question of who’s going to decide what’s in and what’s out? Is it the FDA or ONC, or both? Who knows Most important, the bill’s negative approach fails to account for those AEs, as ECRI puts it when: “Default values being used by mistake, or fields being prepopulated with erroneous data.”

Contradictory Terms

The act has a fascinating proviso in subsection (c):

…[P]rovided that software designed for use in maintaining such patient records is validated prior to marketing, consistent with the standards for software validation relied upon by the Secretary in reviewing premarket submissions for devices.

This language refers to information that device manufacturers file with HHS prior to marketing. Oddly, it implies that EHRs are medical devices under the FDA’s strictest purview, though the rest of the act says they are not. Go figure.

What’s It Mean?

The loud applause for the MEDTECH act coming from the EHR industry, is due to its letting vendors off the medical device hook. I think the industry should be careful about what it’s wishing for. Without effective reporting, adverse events will still occur, but without corrective action. In that case, everything will seem to go swimmingly. Vendors will be happy. Congress can claim to being responsive. All will be well.

However, this legislative penny in the fuse box will prove that keeping the lights on, regardless of consequences, isn’t the best policy. When something goes terribly wrong, but isn’t reported then, patients will pay a heavy price. Don’t be surprised when some member of Congress demands to know why the FDA didn’t catch it.

Epic Tries To Open New Market By Offering Cloud Hosting

Posted on November 26, 2014 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

When you think of Epic, you hardly imagine a company which is running out of customers to exploit. But according to Frost & Sullivan’s connected health analyst, Shruthi Parakkal, Epic has reached the point where its target market is almost completely saturated.

Sure, Epic may have only (!) 15% to 20% market share in both hospital and ambulatory enterprise EMR sector, it can’t go much further operating as-is.  After all, there’s only so many large hospital systems and academic medical centers out there that can afford its extremely pricey product.

That’s almost certainly why Epic has just announced  that it was launching a cloud-based offering, after refusing to go there for quite some time.  If it makes a cloud offering available, note analysts like Parakkal, Epic suddenly becomes an option for smaller hospitals with less than 200 beds. Also, offering cloud services may also net Epic a few large hospitals that want to create a hybrid cloud model with some of its application infrastructure on site and some in the cloud.

But unlike in its core market, where Epic has enjoyed incredible success, it’s not a lock that the EMR giant will lead the pack just for showing up. For one thing, it’s late to the party, with cloud competitors including Cerner, Allscripts, MEDITECH, CPSI, and many more already well established in the smaller hospital space. Moreover, these are well-funded competitors, not tiny startups it can brush away with a flyswatter.

Another issue is price. While Epic’s cloud offering may be far less expensive than its on-site option, my guess is that it will be more expensive than other comparable offerings. (Of course, one could get into an argument over what “comparable” really means, but that’s another story.)

And then there’s the problem of trust. I’d hate to have to depend completely on a powerful company that generally gets what it wants to have access to such a mission-critical application. Trust is always an issue when relying on a SaaS-based vendor, of course, but it’s a particularly significant issue here.

Why? Realistically, the smaller hospitals that are likely to consider an Epic cloud product are just dots on the map to a company Epic’s size. Such hospitals don’t have much practical leverage if things don’t go their way.

And while I’m not suggesting that Epic would deliberately target smaller hospitals for indifferent service, giant institutions are likely to be its bread and butter for quite some time. It’s inevitable that when push comes to shove, Epic will have to prioritize companies that have spent hundreds of millions of dollars on its on-site product. Any vendor would.

All that being said, smaller hospitals are likely to overlook some of these problems if they can get their hands on such a popular EMR.  Also, as rockstar CIO John Halamka, MD of Beth Israel Deaconess Medical Center notes, Epic seems to be able to provide a product that gets clinicians to buy in. That alone will be worth the price of admission for many.

Certainly, vendors like MEDITECH and Cerner aren’t going to cede this market gracefully. But even as a Johnny-come-lately, I expect Epic’s cloud product do well in 2015.

Ten-year Vision from ONC for Health IT Brings in Data Gradually

Posted on August 25, 2014 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

This is the summer of reformulation for national U.S. health efforts. In June, the Office of the National Coordinator (ONC) released its 10-year vision for achieving interoperability. The S&I Framework, a cooperative body set up by ONC, recently announced work on the vision’s goals and set up a comment forum. A phone call by the Health IT Standards Committeem (HITSC) on August 20, 2014 also took up the vision statement.

It’s no news to readers of this blog that interoperability is central to delivering better health care, both for individual patients who move from one facility to another and for institutions trying to accumulate the data that can reduce costs and improve treatment. But the state of data exchange among providers, as reported at these meetings, is pretty abysmal. Despite notable advances such as Blue Button and the Direct Project, only a minority of transitions are accompanied by electronic documents.

One can’t entirely blame the technology, because many providers report having data exchange available but using it on only a fraction of their patients. But an intensive study of representative documents generated by EHRs show that they make an uphill climb into a struggle for Everest. A Congressional request for ideas to improve health care has turned up similar complaints about inadequate databases and data exchange.

This is also a critical turning point for government efforts at health reform. The money appropriated by Congress for Meaningful Use is time-limited, and it’s hard to tell how the ONC and CMS can keep up their reform efforts without that considerable bribe to providers. (On the HITSC call, Beth Israel CIO John Halamka advised the callers to think about moving beyond Meaningful Use.) The ONC also has a new National Coordinator, who has announced a major reorganization and “streamlining” of its offices.

Read more..

Is the End of the Standalone EHR and PM Near?

Posted on July 25, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

News this week came out that simplifMD and Azalea Health were merging companies. It’s an interesting merger since Azalea Health has been strong on the PM side of things and an EHR that’s not yet MU 2 certified, while simplifyMD has been more focused on the EHR side of things. As one company they can put together their PM and EHR into one standalone system.

As Shahid Shah recently pointed out on his Healthcare IT Guy interview with Melissa McCormack from Software Advice, buyers are decidely more interested in an integrated PM and EHR. Here’s one of the questions and answers:

1. As EHR meaningful use requirements grow more involved, standalone billing or scheduling systems are becoming less viable. In fact, nearly 70 percent of the buyers we spoke with wanted integration between practice management and EHR. The trend of PM buyers looking for robust EHR integration grows more pronounced each year, and shows no signs of tapering off since EHR meaningful use requirements increasingly require physicians to utilize charting, billing and scheduling in tandem. Vendors who can offer seamless integration between these applications will have a clear advantage over those who cannot.

I find this question interesting, because the trend towards an integrated EHR and PM started when I first started blogging about EHR software about 9 years ago. Now there are only a few standalone EHR companies left. There are more standalone PM vendors left, but most of them see the writing on the wall and know that they won’t survive as just a PM. In fact, some of those PM companies have stopped developing their PM and are just at a stand still waiting for their last customers to leave. It’s been amazing to see how long some of these extremely small PM vendors have survived.

With that said, is the end of the separate EHR and PM near? I’d love to hear your thoughts.

I Want to Thank the Academy, Err, the Hospital CIO: EHR Hospital Market Share

Posted on July 7, 2014 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

We’re always interested in who’s up and who’s down. Whether it’s TV shows, Senate races, book sales or baseball stats, we want to know who’s up, who’s down and who’s going nowhere.

We’re big on trends, shares and who’s going where. The closer the race, the more avid the interest – My Nats would be sitting pretty if only the Braves weren’t so pesky. The EHR market place is no exception for interest, even if the numbers are a lot harder to follow than the National League East.

In my last foray into EMR market share, I looked at SK&A’s stats from their rolling survey of US medical practices.

Another company, Definitive Healthcare similarly tracks the hospital EHR marketplace. They’ve generously shared their findings with Healthcare Scene and I’ve used them here. Please note: Any errors, mistakes or other screw-ups with their numbers are mine alone. With that said, here’s what I’ve found.

How Many Divisions Does the Hospital Market Have?

Definitive divides the hospital market into several categories that can be daunting to follow. That’s not their making. It’s the nature of the market.

The major division that Definitive reports on is inpatient versus ambulatory systems. You might think that ambulatory systems are only for non hospital setting, but hospitals, of course, have many outpatients and use ambulatory EHR systems to serve them.

The Inpatient Marketplace

Among inpatient systems, EPIC leads with a 20 percent share shown in Tables I and II. The market is highly concentrated with EPIC, Cerner and Meditech commanding 54 percent. The remaining 46 percent scatters with no one breaking double digits.

Table I All Inpatient Hospitals EHR Vendor Market Shares

Table II All Inpatient EHR Shares

 The Ambulatory Hospital Marketplace

The picture for hospital ambulatory systems used is notably different. See Tables III and IV. While EPIC and Cerner vary slightly from their inpatient share, the other vendors shift all over the place. Allscripts barely registers 4 percent in inpatient, jumps to third place with 14 percent.

Siemens and HMS drop off the top ten being replaced by eClinicalWorks and NextGen. At 22 percent is the catchall, Other EHRs. This is up 8 percent from its inpatient 14 percent.

Table III All Ambulatory Hospitals

Table IV All Amb Hospitals

Inpatient EHRs: Health Systems and Independent Hospitals

Definitive also breaks down inpatient hospitals by health system hospitals v independents. Almost a majority of health systems, 47 percent, choose EPIC and Cerner. See Tables V and VI. Indeed, the top four vendors, EPIC, Cerner, Meditech and McKesson astoundingly have a 74 percent share. The other vendors are at 7 percent or less.

Table V Inpatient Healthcare Systems Hospitals

Independent hospitals differ a bit from this pattern. Non major vendors have 12 percent and open source Vista has 5 percent, but otherwise the pattern is similar.

Table VI Inpatient Independent Hospitals

Inpatient Hospitals by Size: Under and Over 100 Beds

Hospitals with 100 plus beds, no surprise, favor EPIC, Cerner and Meditech. These three have a monopolistic 64 percent. See Table VII.

Table VII Inpatient Hospitals with =>100 Beds

Small, Inpatient Hospital Systems: A More Competitive Market

Small hospitals are a different story. The top five vendors are bunched around 14 percent each. See Table VIII. The mix of vendors is starkly different. Meditech and Cerner lead with EPIC third. However, Epic drops nine percent from the prior group to 14 percent in this.

In the prior tables, the top three vendors have a market majority. In this group, 65 percent of the market belongs to the third through tenth vendors. You can see the difference in competition in Tables VIII and IX.

Table VIII Inpatient Hospitals =>100 Beds

Table IX Inpatient Hospitals <100 Beds

Hospital Ambulatory EHR Systems by Bed Size

The ambulatory market for hospitals with 100 plus beds is similar to the inpatient market. EPIC, Cerner and Allscripts have a 53 percent share.

The remaining share is split among several vendors, with eClinicalWorks, and athenahealth making an appearance. Significantly, Other EHRs ranked second.

Smaller hospitals’ ambulatory systems, as with smaller inpatient hospitals, show a competitive market. The category Other EHRs actually leads with a 21 percent share. Tables X and XI show the difference between these two markets.

Table X Ambulatory Systems =>100 Beds Table XI Ambulatory Systems <100 Beds

Market Shares: What’s the Conclusion?

In this and previous posts, I’ve looked at EHR vendor market shares sliced up in several ways. I’ve used what I consider reliable, independent data sources from SK&A and Definitive Healthcare. I used their information because they are careful to include all practices in their surveys not just those that bother to reply.

I also used them for the simple reason that they were freely available to us. There are other sources, such as KLAS, that produce market surveys, but they charge about $2,500 for their analysis. Moreover, they keep all but the most general findings behind their paywall.

What then is the message from all these numbers? It’s this: there is a competitive market, but it’s only robust among small practices. Those with three or less practioners have the most competitive market with eClinicalWorks in the lead. Within major segments, EPIC, Cerner and Meditech dominate. The non hospital market is more mixed, but EPIC, Cerner, etc., share increases as practice size grows.

For these larger practices, it’s monopolistic competition. If you’re looking for an EHR and you have ten or more docs, you can find any number of vendors. It’s most likely you’ll end up choosing among just a few big guys.

This reminds me of when we shopped for kitchen cabinets and counter tops. We were impressed with some dramatic possibilities. The sales rep, who we got to know well, laughed:

“When folks start out they focus on the avant garde. Then they realize they’re choosing for several years. Suddenly they get more conventional.”

If you come by our place, you’ll see our oak cabinets and white tile counter top. I think it goes that way with hospital execs choosing EHRs. They may toy with something different, but in the end, they’ll go with what they know. After all, no one every got fired for buying EPIC. Well, almost no one.

Next: Attribution and Market Share

If you still haven’t got your fill of market numbers, I have one more topic to explore. I’m interested in knowing how market share relates to MU attestations. That is, does a high market share guarantee a high attestation rate? The next post in this series will look at that.

If you have questions on market share, please post a comment or write me at: carl@healthcarescene.com

A Look at the Nashville EHR Market

Posted on July 2, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I always love the discussions of the top healthcare markets in the US. When I hear this discussion, two cities that don’t likely get enough love and have a lot of healthcare companies are Nashville and Atlanta. Other people love to talk about Boston and San Diego is strong on the biotech side and has a growing mobile health side as well. Those are definitely some of the top cities for healthcare companies.

With this in mind, I was intrigued when Keith Cawley from Technology Advice emailed me some findings from a survey they did of the Nashville EHR market.

Here are the most interesting findings:

  • Epic, the number one national electronic health record vendor, does not rank among the top five vendors in Nashville
  • Nashville healthcare providers are significantly more satisfied with their EHR programs than providers nationwide
  • 16 percent of providers in Nashville have already switched EHRs
  • Adoption rate among certain specialties is significantly higher than national averages
  • Cost appears to be the number one consideration for Nashville EHR buyers

This feels a bit like a slam on Epic, but I don’t think that Keith has a dog in that fight. I think the findings that Epic does well nationwide, but hasn’t done well in Nashville is quite interesting and worthy of further exploration.

They also put out the Nashville EHR market infographic below. Most interesting to me is the percentages and how the EHR market is still very diverse. Of course, the market can be broken down into smaller segments where we see more domination by certain vendors, but we’re still seeing a lot of EHR diversity in every region.

Nashville EHR Market Infographic.

EHR Product Market Shares Rankings: The Envelope Please!

Posted on May 27, 2014 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

In politics, it’s the horse race, that is, who’s in front and where’s the rest of the pack. We have our own EHR version, who’s got the biggest market share and where’s everyone else.

In politics, there’s no end of polling by candidates, parties, media and all stops in between. We aren’t so lucky. You can count the reliable EHR market share estimates on one hand and not need your thumb. Of those available, I’ve found SK&A’s to be the most comprehensive and reliable free option, though they do require a registration.

Leaders of the Pack

Table I shows the top 20 EHR vendors’ installed base for all US practitioners. Not surprisingly, Epic leads with about 11 percent. Table II shows the market’s concentration: the top seven have almost half the market.

Table I All practioners

The remaining 13 vendors have about a 20 percent market share. The remaining vendors, about 470 companies, have the remaining 30 percent. But don’t go away just yet. There’s more to the story.

Table II All Shares

Market Share by Practice Size

Market share by practice size refines the picture a bit more. For their analysis, SK&A divided practices into five classes shown in Table III. Each of these is examined in turn.

Table III Group Size

As you’ll see, the larger the number of practitioners in a class, the more concentrated the market becomes. However, the greatest number of practices is in the smaller classes. For example, SK&A reports that 80 percent of practices have 10 or less practitioners.

For example, both EPIC and eClinicalWorks have a ten percent market share. EPIC does this by having a large percent of practices with the highest number of practitioners.

 eClinicalWorks, on the other hand, achieves its share by selling to a many, smaller practices. As a result, you’ll see ECW’s market share drop as the numbers in a class increases, while EPIC’s share will go up.

Class 1 – 1 to 3 Practitioners

Table IV shows the top twenty vendors and again shows a heavy concentration in a few vendors. eClinicalWorks is the leading small practice EHR vendor with a 10 market share. The eight top vendors have half the market in this class.

Table IV 1 to 3 Practitioners

The other 12 top vendors have a 20 percent market share. The remaining 470 vendors split the remaining 30 percent.

Two EHR cloud vendors, Practice Fusion and athenahealth, have an 11 percent market share. While others offer hosted or private cloud products, these two are the sole cloud only solutions in the top 20.

This market segment shows less diversity than those before it. In this case, four vendors have almost half the market, Epic, Allscripts, eClinicalWorks and NextGen.

Class 2 – 4 to 10 Practitioners

The remaining 52 percent, Table V,  is spread among 16 vendors. Notably, athenahealth and Practice Fusion drop in this class to about 3 percent.

Table V 4 to 10 Practitioners

As the next classes show, the market tightens up considerably with a few vendors having greater and greater shares.After NextGen, the other 16 vendors have 30 percent of the market. This leaves all the remaining vendors with 23 percent of the market.

Class 3 – 11 to 25 Practitioners

In this class, Tables VI and VII, three vendors have a market majority: Epic, Allscripts and NextGen. The top seven vendors have over three-quarters of it. The concentration among is so great that three top 20 vendors, AdvancedMD, AmazingCharts and Office Ally are no shows.

Table VI 11 to 25 Practioners

Table VII 26 to 40 Practioner

Class 4 – 26 – 40 Practitioners

Table VIII shows the bunching of vendors in this practitioner class. Only about half of the major vendors had any significant share. All the remaining top 20 vendors lack any significant shares.

Table VIII 26 to 40 Practitioners

Epic’s dominance is even more pronounced in this final class as shown in Table IX. EPIC’s share 47.7 percent and GE has 11.9. Together, they have market share of about 70 percent.

Class 5 – 41 Practitioners and More

Epic’s dominance is even more pronounced in this final class as shown in Table IX. EPIC’s share 47.7 percent and GE has 11.9. Together, they have market share of about 70 percent.

Table IX 40 Plus Practioners

The remaining five vendors have a 20 percent market share: Allscripts, Cerner, NextGen, McKesson. The other 400 plus vendors divide the remaining 10 percent.

There are some interesting changes in this class’ shares, Table X, compared to the previous classes. Cerner drops from second place with 12.5 percent to fourth place with 9.2 percent.

Table X 40+ Practitioners

MEDICTECH all but disappears dropping from 4.7 percent to 0.9. On the other hand, EPIC, GE, Allscripts, NextGen and Greenway increased their shares.

Source and Other Boring Details

The net has many EHR market share analyses, however SK&A’s stands out for several reasons. Most importantly is the active way they gather their statistics. They call every medical practice in the US every six months. This includes all hospitals, private or affiliated practices and urgent care clinics, etc. This approach means that few practices are left out and the answers gathered are on the same basis.

This differs substantially from studies that hang a question out and scoop in whatever they get. They don’t give all practices an equal chance to answer. They are flawed compared to those that actively contact practices or based on statistical samples.

Many other studies base their estimates on ONC’s MU attestations. In fact, most market studies I’ve seen cite ONC. The problem with ONC’s count is that it only includes those in the MU program. Those who don’t, perhaps 40 percent, are left out.

SK&A is not the only company that uses an active approach to determining market share. However, it is the only one I know of that actively surveys the market using that approach and publishes the results free. This is unusual.

I also want thank them for briefing me on their methodology. They did this with only the barest of descriptions of what I was up to.

Future Posts – Hospital and MU v Market Share

There are two other, related topics I’ll cover in future posts.

Hospital Practices

The first is a look at hospital based EHRs. Definitive Healthcare, similar to SK&A, actively surveys the in-patient market by calling practices. They have generously furnished their analysis to healthcarescene.com. Where SK&A breaks down its findings by class size, Dimension looks at hospitals by factors such as:

  • Bed size
  • Independent v affiliated hospitals, and
  • In-patient v ambulatory systems used in hospitals.

MU EHRs v Market Share

The last issue I want to look at is how the vendor rankings in MU’s attestations actually compare to those in this analysis. A preliminary look shows many differences.

EHR Post Acquisition, 2014 Certified, ICD-10 and the Amazing Charts Future with John Squire, President and COO

Posted on April 30, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I had the chance to sit down and interview John Squire, President and COO of Amazing Charts. I was interested to learn about the transition Amazing Charts has experienced after being purchased by Pri-Med and the departure of Amazing Charts Founder, Jonathan Bertman. Plus, I wanted to learn why Amazing Charts wasn’t yet 2014 Certified and their plans to make it a reality. We also talk about the value of meaningful use and the ICD-10 delay. Then, we wrap up with a look at where Amazing Charts is headed in the future.

Check out EHR videos for all of my EHR and Healthcare IT interview videos and be sure to subscribe to the Healthcare Scene youtube channel.

EHR Is Not Disruptive…And Never Will Be

Posted on April 28, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Ben Wanamaker and Devin Bean have an outstanding blog post on the Disruptive Innovation blog (Clayton Christensen Institute for those following at home) called Why EHRs are not (yet) disruptive. If you care about the EHR market, you should go and give it a slow thorough read. Well worth pondering what they’re saying. For those who don’t want to read the whole article, here’s a small excerpt:

The reason EHRs are not “roiling the health care landscape” with disruption is not that the technology is bad—rather it’s the business model in which they are being implemented. While there is some evidence that EHRs can help increase clinical quality, the technology is by and large being crammed into sustaining business models and used as an expensive sustaining innovation to replace paper records with complex electronic systems. Implementing new technology to sustain the way you already make money almost always keeps costs high and prevents true disruption. Indeed, the history of innovation is littered with companies that had a potentially disruptive technology such as EHRs within their grasp but failed to commercialize it successfully because they did not couple it with a disruptive business model.

Plus, this powerful quote:

EHRs have little reason to use the new electronic system differently from the old paper system, and so EHRs often neither decrease cost nor increase quality. They’re just next year’s more expensive model of paper-based patient records.

As I read this I thought, EHR weren’t meant to be and they won’t ever be disruptive. In fact, they cement in the status quo. I think we see this playing out more and more every day.

To be disruptive, we’ll need something to come from outside of EHR. It likely will have to buck the current reimbursement model. Payers and government really control the environment. As Steve Case said at SXSW V2V, government is the biggest customer of healthcare. That makes disruption difficult unless you go outside the current system.

The disruptive technology that comes will in many ways feel like an EHR, but it won’t be an EHR like we know it. My point is that technology will disrupt healthcare and many in the EHR world will see the disruptive technology and say that it looks very much like the EHR software of today. However, what they won’t realize is that it’s not the technology, but the business model that’s paired with the technology that’s so disruptive.

Has EHR Become a Bad Brand?

Posted on April 25, 2014 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

The other day, I had lunch at DC’s Soupergirl with the redoubtable Chuck Webster, workflow tool maven and evangelist. We talked a lot and discovered that both of us had a warm spot for the classic neighborhoods near Atlanta’s Piedmont Park. He as a transplant and I as a native.

More to this blog’s point, we discussed the state of EHRs and their numerous problems. Chuck wondered if EHR, per se, had become a bad brand? It’s a good question. Have we seen a once promising technology become, as has managed care, a discredited healthcare systems? It’s an easy case to make for a host of reasons, such as these:

Poor Usability. There are scads of EHRs in the marketplace, but few, if any, have a reputation as being user friendly. Whenever I first talk to an EHR user, I wait a few minutes while they vent about:

  • How they can’t put in or get out what they need to,
  • Their PCs being poorly located, inflexible or the wrong footprint,
  • Data that’s either missing, cut off or hard to find,
  • Logging in repeatedly,
  • Transcribing results from one system to put it in another,
  • Wading through piles of boilerplate, to get what they need etc., etc.
  • Having to cover PCs with sticky note workarounds.

As for patients, my friend Joe, a retired astrophysicist, is typical. He says when his doctor is on her EHR she doesn’t face him. She spends so much time keying, he feels like he’s talking to himself.

Now, it’s not completely fair to blame an EHR for how it’s implemented. The local systems folks get a lot of that blame. However, vendors really have failed to emphasize best practices for placing and using their systems.

Missing Workflows. EHRs, basically, are database systems with a dedicated front end for capturing and retrieving encounters and a back end for reporting. To carry out, their clinical role they have to be flexible enough to adapt to varying circumstances with a minimum of intervention.

For example, when you make an appointment for a colonoscopy, the system should schedule you and the doctor. It should then follow rules that automatically schedule the exam room, equipment, assign an anesthetist, and other necessary personnel, etc.

When you come in, it should bring up your history, give your doctor the right screens for your procedure, and have the correct post op material waiting. General business software workflow engines have done this sort of thing for years, but such functions elude many an EHR. EHRs without needed workflow abilities increase staff times and labor costs. They also mean users miss important opportunities and potential errors increase.

Data Sharing. Moving from paper to electronic records promised to end patient information isolation. Paper and faxed records can only be searched manually. However, with a structured electronic record, redundant entry would be reduced and information retrieval enhanced. Or so the argument went, but it hasn’t worked out that way.

While there are systems, such as the VA, Kaiser and various HIEs that fulfill much of the promise, it is still a potential rather than a reality for most of us. There are two basic reasons for this state of affairs: ONC’s mishandling of interchange requirements and one member of Congress’ misplaced suspicions.

ONC’s Role. ONC’s Meaningful Use program is meant to set basic EHR standards and promote data interchangeability.

When it comes to these goals, MU fell down from the start. MU1 could have been concise requiring an EHR to capture a patient’s demographics, vitals, chief complaint and meds.

Most importantly, MU could have made this information sharable by adopting one of HL7’s data exchange protocols. This would have given us a basic, national EHR system. Instead, MU focused on too many nice to have features, leaving data exchange way down the list.

ONC has tried to correct its data interchange a failing in MU2 to a degree, but it’s not there yet. Here’s what GAO, has to say about ONC’s efforts:

HHS, including CMS and ONC, developed and issued a strategy document in August 2013 that describes how it expects to advance electronic health information exchange. The strategy identifies principles intended to guide future actions to address the key challenges that providers and stakeholders have identified. However, the HHS strategy does not specify any such actions, how any actions should be prioritized, what milestones the actions need to achieve, or when these milestones need to be accomplished. GAO Report-14-242, March 24, 2014. Emphasis added.

Ron Paul. The other important obstacle to interchange came from Congress. When Congress passed HIPAA in 1996, it mandated that HHS develop a national, patient ID. However, in 1998 Ron Paul, (R-TX) deduced that since HHS wanted the ID system, it therefore wanted to put everyone’s medical records in a government database. He saw this as a threat to privacy. He got a rider added to HHS’s budget forbidding it to implement the ID system or even discuss one.

The ban’s remained in succeeding budgets. The rider has created a national medical data firewall for each of us, which hinders all of us. Paul’s gone from Congress, but Congress continues the ban. As Forbes’ Dan Munroe wrote about Paul’s ban:

The health data chaos we have today doesn’t allow for interoperability, portability or mobility. It’s why fax machines remain the ‘lingua franca” of U.S. healthcare. Every healthcare entity in the U.S. sees each patient, event and location as unique to them. For lack of a single identifier, there’s no easy or cost-effective way to coordinate patient care. Emphasis added.

While the lack of a patient ID is not EHRs fault, it noticeably reduces their ability to interchange information. State or other HIE’s are, in effect, workarounds for lack of a uniform ID. This situation adds to the perception of EHRs as unresponsive technology.

Onerous Agreements. As many an EHR buyer has found, vendors see EHRs as a sellers’ market. They use this to write onerous license agreements exempting their products from adhering to standards such as MU or from responsibility for costly errors or omissions.

These agreements not only limit liability, but often silence a buyer’s adverse comments. The effect is to cut buyers from any meaningful recourse. This shortsighted practice adds one more layer to the EHR industry’s image as unresponsive, self serving and defensive.

Whither the Brand?

The question then is are things so bad that EHR needs rebranding? If so, how should this be done by calling EHRs something else, advocating for a different technology, or yet another alternative?

For some brands, a new name along with some smart PR will do. That’s how Coca Cola reversed its New Coke fiasco. EHRs have a tougher problem. EHRs are not a one vendor product. They are a program class. Reforming EHR’s brand will take more than effective PR. It will take pervasive technical and policy changes.

Change From Where?

Change in a major technical field, as in public policy, requires either overcoming or going around inertia, habit, and complacency. EHRs are no exception. Here are some ways change could happen.

External Events. The most likely source of change is a crisis that brings public pressure on both the industry and government. There is noting like a tragedy to grab public attention and move decision makers off the dime. I don’t want it to occur this way, but nothing like a tragedy makes events go into fast forward and move issues from obscure to inevitable. Given EHRs many patient safety problems, this is all too likely an outcome.

ONC Initiative. ONC could step in and help right matters. For example, as I have advocated, ONC could run NIST’s usability protocols for all systems seeking MU certification. It could then publish the test results giving users a needed, common benchmark. This, in turn, could be a major push to get vendors to regard usability, etc., as an important feature.

ONC is not inclined to do this. Instead, it asks vendors to pick one of several versions of user centric technology. As Bennett Lauber, Chief Experience officer of The Usability People recently told HIEWatch:

“Usability certification for meaningful use really isn’t a test the way the rest of the certification process is. (Testers) go out and observe users, and report back to the certifiers,” Lauber reports. “There seem to be different sets of evaluation criteria because ONC has not really defined usability yet….” Emphasis Added.

Recently appointed ONC Coordinator, Dr. Karen Desalvo, unlike her predecessors, has been frank about changing ONC’s course. She’s revamped her advisory committee structure and spoken about going beyond meaningful use to big data.Notably, she understands the need for and the problems of interoperability. However, she’s not offered any changes in standards. ONC is in the best position to implement real standards, but for both political reasons; it’s unlikely to do so.

To chill things politically, vendors only have to find a few Congressmen who’ll, for a well placed contribution, will send ONC vendor drafted letters threatening its appropriation, committee reviews, etc. It can happen otherwise, but as Damon Runyon has said, “The race is not always to the swift, nor the battle to the strong, but that’s the way to bet.”

User Revolt. The most notable user push back to the status quo has involved unilateral EHR vendor agreements.

As Katie Bo Williams of Healthcare Drive (edited by Hospital EMR and EHR’s Anne Zieger) has notably described, major lawsuits are costing some vendors dearly. The industry, however, has yet to set buyer agreement standards that could aid its and EHRs’ reputation.

These lawsuits might chastise vendors, but users will need to become bolder if they want change. EHR vendors have an association to protect their interests. So do hospitals, physicians, practice managers, etc. Users are the one group that’s not represented.

You may belong to this or that product’s user group, but there is no one group that looks after EHR user’s interest. If there were a well organized and led EHR user group that lobbied for better usability, workflow tools and universal data exchange etc., then these issues would become more visible. More importantly, users would be able to demand a place at the table when ONC, etc., makes policy.

Those interested in patient safety, too, are taking some new directions. Recently, ECRI convened the Partnership for Promoting Health IT Patient Safety to promote changes, within “a non punitive environment,” that is, in a collaborative setting among vendors, practioners, safety organizations, etc. While the group has not issued any reports, it offers two hopeful signs.

The group’s advisory panel includes experts, such as, MIT’s Dr. Nancy Leveson, who works in aeronautic and ballistic missile safety systems. The other factor is that the group has consciously sought to give vendors a place where they see the impact their products have on patient safety without the threat of litigation. Whether the group can bring this off and influence the market remains to be seen.

Technical Fix. It’s possible users may decide to fix EHR’s problems themselves. For example, the University of Pittsburgh Medical Center  (UPMC) uses a combination of EPIC, Cerner and its own clinical systems. It wanted to pull patient information into one, comprehensive, easily used profile. To do this, the Center developed a new, tablet front end that overcomes a variety of common EHR problems.

Once a major actor, such as Pitt, shows there is a market, others will explore it. You’ll know it’s a real trend, when a major vendor buys a front end start up and brands it as its own.

Natural Turnover. Finally, John recently raised the question of EHRs’ future in What Software Will Replace EHR? He thinks that change will come organically as more technically robust software pushes out the old.

Slowly replacing current EHRs with new tools is the most likely path. However, a slow path may be the worst outcome. Slow turnover would give us a mixture of even more incompatible systems. This would make the XP installed base problem look simple.

The EHR brand reminds me of a politician with both high positives and negatives. It may be liked by many, however, it also has a lot of baggage. As with a candidate in that position, something will have to change those negatives or it will find itself just an also ran.