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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.

EMR Market Share

Posted on October 6, 2010 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.

One of the most popular questions I get asked (although far behind the Which EMR is Best? question) is what’s the EMR market share look like. The problem is that there really isn’t any great data out there for EMR market share. Plus, the numbers that EMR vendors give out just clouds up the conversation completely.

Here’s an example from an article about Allscripts completed merger with Eclipsys:

“What this merger heralds is the coming together of the health care system,” says Tullman. In other words, Allscripts now provides service to about 180,000 physicians (roughly 30% of all U.S. physicians), more than 1500 American hospitals (about 50% of U.S. hospitals with 200 beds or more) and over 10,000 post acute care facilities (more than 75% of U.S. facilities).

These numbers just make me laugh. The wrong assumption that people make is that when they say they provide services to 180,000 physicians that they mean their providing EMR services. After all, Allscripts has something like 7 different EMR software products, right? Too bad that assumption would be way off base.

I think it’s pretty clear that the Allscripts product that’s most widely used is SureScripts (ePrescribing). Take out the SureScripts users and I wonder how many physicians really use Allscripts products. The number would be DRAMATICALLY lower.

Of course, we could have easily known this if we just looked at the “30% of all U.S. physicians” quote. There aren’t even that many physicians using an EMR (let alone an Allscripts EMR). I’m sure similar things could be said about the hospital numbers listed above.

Yes, these numbers are just the “spin” that is so prevalent in marketing and PR. That is their job after all. Hard to complain too much about them doing their job.

One thing is certain. Trying to figure out EMR market share is pretty much impossible. Plus, the ones that are the loudest aren’t always the ones with the most market share. Remember that.