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AMIA Debate Highlights Tensions with EHR Vendors

November 18, 2014
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Audience agrees lack of collaboration between EHR vendors, academic medical centers stifles innovation

An American College of Medical Informatics debate held Nov. 18 at the AMIA Symposium in Washington, D.C., brought out some of the challenges academic informatics teams and commercial EHR vendors face in working together.

The four participants were asked to respond to the statement, “Resolved: The lack of interaction and collaboration between health IT vendors and academic clinical informatics units is stifling innovation and will continue to have a detrimental effect on the evolution of commercial products.”

Making the case that innovation is flourishing and that vendors are starting to open up their architectures were John Glaser, CEO of the Health Services Business Unit of Siemens Healthcare, and Jonathan Silverstein, vice president and Davis Family Chair of Informatics at NorthShore University HealthSystem in Illinois. Glaser pointed to the dramatic increase in venture capital flowing into health IT as an indication that rather than being stifled, innovation is flourishing. Many of the entrepreneurs come from an academic background, he said. Glaser also noted that the number of patents granted to the big EHR vendors has risen sharply in the last five years.

In rebuttal, Curtis Langlotz, M.D., a professor of radiology and biomedical informatics at Stanford University School of Medicine, said that most of that venture capital money is going to companies in the consumer space, not into startups that are likely to challenge the dominant EHR vendors. Given the size and scope of the leading EHR companies, it will be difficult for small players to compete. “There is not likely to be a Netflix that comes along and wipes out the dinosaurs,” he said, adding that the “calcified state” of the EHR market makes innovation difficult. Langlotz also said that in terms of a measure of innovation, he is more interested in the number of clicks it takes to get to patient information than in the number of patents the vendor has won.

Glaser responded by saying that although it is difficult for provider organizations to switch these systems, churn does occur. Providers do change vendors, and vendors want to be responsive. “The market is not locked up,” he said.

Silverstein argued that we are currently midstream in the evolution of EHRs. As they mature, there is a strong push for innovation and collaboration driven in part by new financing models. It is natural, he said,  that vendors are opening up to third-party applications with application programming interfaces (APIs).  He noted that vendors such as Epic and Cerner have made clear commitments to open architecture and FHIR.

Langlotz asked the audience members if they really thought vendors such as Epic have a clear commitment to open architecture, which drew a laugh from the crowd. “You can just answer that in your own head.” He added that innovations such as Smart on FHIR are very interesting. But the question is, as those apps get closer to the core business of EHR vendors, entering orders or doing documentation, are companies going to work with an app that threatens their core business? Or will they just develop the functionality themselves and put the small company out of business?

Langlotz said the radiology market has developed quite differently because there are stronger standards that users put in their requests for proposals. “Because of that effort, we get modular vendors. We have a healthy market for cloud-based image exchange, with startups competing against each other. That is a great model. We should take steps to encourage breaking apart these monolithic systems.”

Ross Koppel, an adjunct professor of sociology at the University of Pennsylvania, talked about the negative impact of EHR vendors protecting their proprietary information He cited as an example an FDA study on the role of CPOE screens in enhancing or reducing medication prescribing errors. The findings, he said, will not likely be shared because the vendors prohibit anyone from disseminating screen shots of their products. “We have an information void under the name of protection of IP,” he said.

In the Q&A session following the debate, Ted Shortliffe, M.D., Ph.D., a professor at both Columbia and Arizona State University, said he does not consider vendors getting academic medical centers to help them improve their products the type of synergy he is looking for. Like companies in the computer science space, cash-rich EHR vendors should do more to fund broad-based research, fellowships, and internships, especially as other funding sources for informatics are drying up.

Put to a vote of the audience following the debate, the resolution passed easily by a show of hands. But putting blame aside, both sides admitted that there needed to be more effort to collaborate between commercial system vendors and academic informatics groups.