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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.

If You Were an EHR, Which Would You Be?

Posted on August 6, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 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 was recently watching a video of Derek Hough, Dancer on Dancing with the Stars (and much more). In the interview Derek was asked which dance best fit various periods of his life. As an #HITNerd, I thought we could do something similar with EHR vendors. So…

If You Were an EHR, Which Would You Be? Are you…

Epic – Single minded, focused and dominating in their sphere. Closed to outside discussions, but very thoughtful and caring of those in your inner circle. A bulldog if someone comes after something you consider important. Built on an aging system that’s done well, but many question how much longer they can be successful on top of such an old platform.

Cerner – The second child who’s done really well for themselves, but wonders why the older brother gets all the attention. They’re successful, well educated, built on a strong foundation, open to improvement. They’ve recently taken on a little bit of baggage. They decided to marry someone who’s been divorced and has four children. We’re not sure how this new marriage is going to work out and how it’s going to impact the family structure.

MEDITECH – This is the middle child. Ahead of their time, but no one notices them anymore. They’re quiet and mostly stay to themselves in their corner. Sure, they’d like to be noticed and get more attention, but they don’t mind too much since they’ve been so successful.

Allscripts – Flashy. Exciting and unpredictable. They’re the one that wears the flashy green jacket to the party. They’ve worked on so many things in their life that it’s hard to really place who they are and what they do. They’ve seen a lot of success, but don’t make us predict what they’ll do next. They seem to have a clear vision of where there going (albeit different than it was 2-3 years ago), but that could change so you have to stay on your toes.

athenahealth – Despite some ADD tendencies, they’ve largely stayed the course on what they want to do and what they want to become. They’re always interesting to be around, because they’re never shy to say what they think or feel about anything. While not as successful as some other people, they still have a lot of potential that could blow up for good or bad. If nothing else, they’re the life of the party and always keep things interesting.

I could keep going, but that’s a good start using a few of the larger or more well known EHR vendors. Which one is most like you? Also, I really hope that many of you will join me in the comments and revise/improve upon what I’ve written or do something similar for another EHR vendor. Let’s have some fun and learn about people’s perceptions of these companies in the process.

Note: Cerner is an advertiser on this site.

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

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.

McKesson, Meditech Chosen As EHR Test Systems for Meaningful Use

Posted on January 23, 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.

Here’s an interesting situation which is just popped up on my radar screen.  CMS and the ONC have chosen the first two vendors to serve as designated test EHR systems, and they’ve gone with McKesson and Meditech.

These test vendors are there to help eligible providers meet the requirements of Meaningful Use Stage 2.  To meet MU Stage 2 requirements, providers must successfully conduct at least one exchange test with a CMS-designated test EMR. (The providers can also meet the requirements by performing one electronic exchange of a summary of care document with a recipient using a different EMR technology.)

What intrigued me about this is that CMS and ONC are starting out with only two vendors for use as test EMR providers.  Given the diversity in the marketplace, you’d think that CMS would want to have fuller stock of vendors lined up before it went forward announcing its plans.

If I were an eligible provider going this route, I’d want to have the choice of a wider range test EMRs. Given how little real interoperability there is between EMRs, I’d like to know that I had a fallback position if my original tests didn’t work out.  After all, nothing I’ve read here suggests that EPs won’t have a chance to try again if the initial testing doesn’t go through, and if I were a provider, it’d be good to know that I could take the shot with other test EMRs. But I could be wrong, and that could have an effect on whether vendors see this as a win.

Let’s see if other substantial EMR vendors take up the ONC’s call to serve as test EMR participants.  It will be interesting to see whether vendors see participation as a credibility-raiser or a chance to get pantsed publicly if interoperating with their systems is a pain.

EMR Vendors Want Meaningful Use Stage 3 Delay

Posted on January 29, 2013 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.

A group of EMR vendors have joined the chorus of industry organizations asking that Meaningful Use Stage 3 deadlines be moved up to a later date.  The vendors also want to see the nature of Stage 3 requirements changed to put a greater emphasis on interoperabilityInformation Week reports.

The group, the HIMSS EHR Association (EHRA), represents 40 vendors pulled together by HIMSS.  Members include both enterprise and physician-oriented vendors, including athenahealth, Cerner, Epic, eClinicalWorks, Emdeon, Meditech, McKesson, Siemens GE Healthcare IT and Practice Fusion.

In comments submitted to HHS, the vendors argue that MU Stage 3 requirements should not kick in until three years after a provider reaches Stage 2, and start no earlier than 2017. But their larger request, and more significant one, is that they’d like to see Meaningful Use Stage 3’s focus changed:

“The EHRA strongly recommends that Stage 3 focus primarily on encouraging and assisting providers to take advantage of the substantial capabilities established in Stage 1 and especially Stage 2, rather than adding new meaningful use requirements and product certification criteria. In particular, we believe that any meaningful use and functionality changes should focus primarily on interoperability and building on accelerated momentum and more extensive use of Stage 2 capabilities and clinical quality measurement.”

So, we’ve finally got vendors like walled-garden-player Epic finding a reason to fight for interoperability. It took being clubbed by the development requirements of Stage 3, which seems to have EHRA members worried, but it happened nonetheless.

While there’s obviously self-interest in vendors asking not to strain their resources on new development, they still have a point which deserves considering.  Does it really make sense to push the development curve as far as Stage 3 requires before providers have gotten the chance to leverage what they’ve got?  Maybe not.

Now, the question is whether the vendors will put their code where their mouth is. Will the highly proprietary approach taken by Epic and some of its peers become passe?

Study: Drug Problems Most Common EMR Safety Event

Posted on December 13, 2012 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 the phrase “EMR problems” comes to mind, most of us get a  mental image of hardware flaws, software bugs or integration problems. But according to a new study, the majority of EMR-related patient care problems stem from issues in how people interact with their system, specifically in documenting and administering medication.

In recent research, the Pennsylvania Patient Safety Authority queried the state’s patient safety reporting database to identify EMR-related events. After sifting out events that didn’t truly appear to be EMR-related, analysts were left with 3,099 patient safety issue reports. The events were then classified by the harm score assigned by the reporter.

As it turns out, the great majority of events (89%) resulted in no harm to the patient. Ten percent of events were reported as “unsafe conditions” but also resulted in no harm to the patient.  Fifteen events actually resulted in temporary harm to the patient:

* Six cases of entering wrong medication data
* Three cases of administering the wrong medication
* Two cases of ignoring a documented allergy
* Two cases of failure to enter lab tests
* Two cases of failure to document

The only event that resulted in significant harm stemmed from failure to properly document an allergy, analysts said:

Patient with documented allergy to penicillin received ampicillin and went into shock, possible [sic] due to anaphylaxis. Allergy written on some order sheets and “soft” coded into Meditech but never linked to pharmacy drug dictionary.

All told, medication errors were the most commonly reported event (81 percent), largely wrong-drug, dose, time patient or route errors (50 percent) or omitted dose (10 percent).

It’s worthy of note that according to the researchers, the narrative reports of EMR-related reports dug up from the Pennsylvania database differed meaningfully from reports found in FDA database MAUDE and Australia’s Advanced Incident Management System, which have different reporting requirements.

It seems that there’s a lot more work to be done in exposing the types of patient safety errors that may be unique to EMRs, but this looks like a good start.

Will Big EMR Vendors Use Healthcare Standards As A Weapon?

Posted on October 9, 2012 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.

Standards are a tricky thing. Some times, they bring a technical niche to its senses and promote innovation, and others, they’re well-intentioned academic efforts which gain no ground.  From what I’ve seen over the years, the difference between which standards gain acceptance and which end up in trash bin of history has more to do with politics than technical merit.

But what the EMR industry did neither? From the mind of my crafty colleague John, here’s a scenario to consider.  What if rather than going with an industry-wide standard for interoperability, the big EMR vendors agreed on a standard they’d share and more or less shut out the smaller players?

Yeah, I already hear you asking: “Wouldn’t that be an antitrust violation?”  While I am not and probably never will be a lawyer, my guess is if a bunch of big vendors deliberately, obviously shut the smaller players out, it would be. But standards are so slippery that I bet it’d be a while before anyone outside of our industry saw something funny going on.

Besides, the government is doing everything in its power to get EMR vendors to help providers achieve interoperability. Right now ONC is not getting much cooperation — in fact, I’d characterize the big vendors’ stance as ‘passive aggressive’ at best.  So if Epic, Cerner, Siemens, MEDITECH and their brethren found a way to make their products work together, they might get a gold star rather then an FTC/DoJ slap on the wrist.

Besides, it would be in the interests of the bigger firms to include a few smaller players in their interoperability effort, the ones in the big boys’ sweet spots, and then “oops,” the smaller companies would get acquired and the knowledge would stay home.

Right now, as far as I can tell, it’s Epic versus the rest of the world, and that rest of the EMR world is not minded to play nicely with anyone else either. But if John can imagine a big-EMR-company standards-based coup d’etat happening, rest assured they have as well.

John’s Comment: Since Anne mentions this as my idea, I thought I’d weight in a little bit on the subject. While it’s possible that the big EHR vendors could adopt a different standard and shut out the small EHR vendors, I don’t think that’s likely. Instead of adopting a different standard, I could see the large EHR vendors basically prioritizing the interfaces with the small EHR vendors into oblivion.

In fact, in many ways the big EHR vendors could use the standard as a shield for what they’re doing. They’ll say that they can interface with any EHR vendor because they’re using the widely adopted standard. However, it’s one thing to have the technical capability to exchange healthcare information and a very different thing to actually create the trust relationship between EHR vendors to make the data sharing possible.

Think about it from a large EHR vendor perspective. Why do they want to be bothered with interoperability with 600+ EHR vendors? That’s a lot of work and is something that could actually hurt their business more than it helps.

My hope is that I’m completely wrong with this, but I’ve already seen the large EHR vendors getting together to make data sharing possible. The question is whether they’re sincerely doing this out of a desire to connect as many health records as quickly as possible or whether it is good strategy. My gut feeling is that it’s probably both. It just works out that the first is better to say in public and the second is just a nice result of doing the first.

Hospital EMR Vendor Consolidating, But Physician EMR Market Still Dynamic

Posted on March 6, 2012 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.

If you don’t check out the HIMSS group on LinkedIn from time to time, you should. I always pick up something to think about when I visit, and this time was no exception.

A group of IT pros, most of whom seemed to have plenty of institutional memory of EMRs gone by, were talking about whether the current leaders of the EMR vendor pack would take over and most of the rest fall away.  The consensus, not surprisingly, was that hospital CEOs are herd animals, and that a few leaders are likely to take most of the market.

As things stand today, even EMRs that seem to be a better fit usually lose to the Epics, Cerners and Meditechs of the world, writes Richard Rauber, FHIMSS.

“Let’s say the preferred EMR has 10 clients similar to their facility, and the second choice has 75 clients in the same bed range with a high level of user satisfaction. Is the risk/reward ratio low enough to go with the smaller vendor? It today’s market it would be unlikely.”

If these posters are right, the hospital market is going to standardize on a dozen or so of the most successful vendors. Unfortunately, that’s likely to lead to some really nasty implementations, suggests Terry Montgomery, PMP: “I had such a project last year. They had to move the go live date three times and there were still bugs they had to fix.”

That being said, I think there will be a lot more dancing when it comes to the physician EMR market.  You’ve got breakout models like the no-cost Practice Fusion — and its bundle of VC cash to fuel the fire — iPad-based DrChrono, Free Mitochon PMS-EHR-HIE and a growing number of elegant, doctor-crafted implementations like SOAPware and Amazing Charts.

While the dynamic of hospital IT purchasing is to standardize on the big boys (the old “nobody gets fired for buying IBM” syndrome), physicians can’t afford to buy a system just because the practice across town thought it was cool. Not that such doesn’t happen, but it’s less likely.

I predict that doctors will have some great options to choose from when they hit HIMSS13 next year, systems integrated intelligently with revenue cycle needs but also cleanly designed and physician friendly.

The smaller EMR companies focused on doctors are just doing a better job of mirroring a doctor’s process, there no doubt in my mind. If only such logic would float upward to the billion-dollar boys behind the hospital giants.

Full Disclosure: Practice Fusion, Mitochon, SOAPware and Amazing Charts are advertisers on this blog.

One Student’s Perspective on Electronic Medical Records

Posted on December 7, 2011 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

I’ve had the good fortune in the past year or two to watch one of my daughters’ favorite babysitters blossom into a full-time nursing student at the University of West Georgia. Not only do my girls benefit from her great bedside manner, including an infinite amount of patience, but I get an occasional inside glimpse into the world of digital medical record keeping in the greater Atlanta area.

Her training at West Georgia has taken her to Children’s Healthcare of Atlanta – Egleston, Wellstar Cobb and Austell, Fayette Piedmont, Tanner Medical Center and Gentiva Healthfield Hospice. She graciously offered to share her rookie’s perspective on the electronic medical records – including SCM/Quest (Allscripts Sunrise Clinical EHR system) and Meditech – she has used at several of the facilities she has trained in.

How long have your healthcare training facilities had EMRs in place?
All except Gentiva Healthfield Hospice – in-home hospice care, for the most part, sticks with paper charting. If they were to make the switch to an EMR, they would have to have access to a central database from their personal computers/iPads/Blackberries, etc. All others have had some sort of electronic database for at least five years.

How intuitive did you find them to be in your first training sessions/rounds?
Once I had been trained in the first system I encountered, the rest seemed very user-friendly. They have been in use long enough now that they are efficient and fairly self-explanatory.

They all allow an employee to cluster patient care and spend enough time with the patient because the time stamp on documentation can be changed to the time that the intervention was completed. For example, I could complete a full assessment on a patient, bathe them and administer their medications without having to document in the computer every few minutes. I could just open their EMR after completing their care and add the correct time stamp on my documentation.

What were the easiest to use, and what were the most difficult?
Meditech was the most difficult to use, perhaps because I had limited access as a student. It was difficult to find complete admission notes and patient histories.

Speaking from a “rookie’s” perspective, what would you tell vendors of these systems to better their products?
Add a patient verification requirement before each documentation session, i.e. each set of vital signs, medications given, etc. (Something simple, like a box with the patient’s name and DOB and an “Ok” button)

Did your supervisors express any enthusiasm or dissatisfaction with any particular systems?
All expressed enthusiasm, but they also were concerned any time a system was to be updated with even minor changes. Fayette Piedmont uses one EMR system for Labor and Delivery, and a completely different system for the rest of the hospital. This means, for the staff, that a new baby’s records have to be re-entered into a new system once they are discharged from labor and delivery and admitted to the NICU or postpartum unit. It also means the pharmacy has difficulty accessing vital information when, for instance, they need to know a baby’s weight to send the appropriate dose of medication to the NICU.

How aware are you of post-implementation training that goes on with EMRs, based on the facilities you’ve trained at? Do your supervisors ever mention it?
Once an employee is hired, they usually must display proficiency with the charting system within a specified training period. When Fayette Piedmont updated SCM/Quest, they did not retrain each employee, but they did send out a packet with a detailed description of the changes. From what I have seen, the older nurses who may have preferred paper charting at one point do not seem to have any problems with the electronic charting.

Have you been made aware of any increase/decrease in positive clinical outcomes as a result of physicians/nurses using these systems? Any examples you feel comfortable sharing?
The major changes to these systems each time they are updated usually involve the addition of safeguards. For example, the newest version of SCM/Quest has the patient’s name, weight, room number and allergies on every page of the charting system, and in multiple locations on the page.

For the employees who pay attention, this has reduced many documentation errors. There is also an embedded link to drug guides in every electronic medication order with explicit instructions and safe dose ranges. For the employee who knows these features are there, they are a tremendous help, and they do serve to protect the patient. It is still possible to document in the wrong patient’s chart, without realizing it, in any system.

Needless to say, it will be interesting to see how her experience with EMRs changes as she continues her studies and then moves into the professional world of nursing, which will likely coincide with healthcare facilities continuing to move through the various stages of Meaningful Use.

Stay tuned for next week’s post, in which I’ll profile an EMR educator, and find out what other students are facing when it comes to EMR training. In the meantime, what sort of healthcare IT-related challenges will our new workforce face in the coming year? Please share your thoughts in the comments below.