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In a Top-Heavy EHR Market, Optimization Becomes the Focus

March 27, 2017
by Rajiv Leventhal
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Consolidation in the EHR market is forcing many vendors to exit the space. Now, the onus is on those remaining vendors to make sure their products streamline processes and improve the user experience

Last summer, a report from market researcher Kalorama Information revealed that Cerner, the Kansas City, Mo.-based electronic health record (EHR) vendor, thanks to its acquisition of Siemens Healthcare’s EHR business the year prior, holds the top spot in the EHR market, maintaining a slight lead over rival McKesson (Alpharetta, Ga.). In third place in the $27 billion EHR market is Epic (Verona, Wis.), followed by Allscripts (Chicago) in fourth place, the report noted.

In addition, within the EHR market, competitors are combining with a flurry of mergers and acquisitions among vendors. “Mergers and acquisitions are not new to the health IT market, but there seems to be an emerging strategy, which is attempting to reach a greater number of healthcare organizations, providers and patients through synergistic pairing,” the report’s authors wrote. As companies jump in and out of the market at a rapid pace, this creates concern for consumers who wonder if their vendor will be around after they purchase the product, according to the report. “At present, there are over 1,100 companies involved in the healthcare IT business in one aspect or another. This is not sustainable and so we are seeing consolidation activity,” Bruce Carlson, publisher of Kalorama Information, stated.

To this point, in an exclusive interview with Healthcare Informatics Managing Editor Rajiv Leventhal at HIMSS17 in Orlando, Allscripts CEO Paul Black noted that the consolidation that has taken place in the EHR market “is a natural evolution.” He added that if there is another stage of Meaningful Use, there won’t be anything close to 500 ONC (Office of the National Coordinator for Health IT)-certified EHRs. “I don’t know what the number [of certified EHRs] will be, but it will be greater than five and a lot less than [500],” Black said. “It’s a large industry and it’s becoming a more mature one, so there are haves and have nots in regards to the amount of money that one really has to spend on R&D to stay relevant and ahead of where the industry is going, and also to be a global player.”

Indeed, industry experts are quick to point out the speed at which consolidation in the EHR market is occurring, giving larger vendor companies the advantage, as they are financially stronger, while the smaller companies that are looking for funds to expand growth have become ripe for acquisition. “In the next three to five years, you will be talking about 20 or less [major EHR players],” predicts Mandy Long, chair of the Healthcare Information and Management Systems Society (HIMSS) EHR Association Clinician Experience Workgroup and vice president of product management at the Boca Raton, Fla.-based vendor Modernizing Medicine. Long additionally notes, “With the nature of the technology requirements that vendors have to meet in order to be successful and competitive, and thus make their client base successful, the bar being set is very high. You need to be architected to begin with and you need foresight to see where the industry is going. If you’re not easily set up to be interoperable, easily accurate, usable, and easy to update with rapid deployment, it will be challenging to stay competitive. We will see more vendors look at these requirements—as well as the ones needed for MACRA (the Medicare Access and CHIP Reauthorization Act of 2015)—and then exit the market,” she says.

To those paying close attention, it should not come as a surprise that the crowded field of EHR vendors is dwindling. Back in 2013, a Black Book Market Research report predicted that most vendors in this space will likely go out of business, merge or be acquired by 2017, according to the then-conducted survey of 880 EHR consultants, analysts, managers and support team members. Fast-forward to four years later, while there are still plenty of vendors offering an EHR product, it’s estimated that the top 10 EHR vendors account for about 90 percent of the hospital EHR market, based on 2015 Meaningful Use attestation data from the Centers for Medicare and Medicaid Services (CMS).


Mastering the EHR: How Optimization Services Foster Quality Documentation & Physician Satisfaction

We know the goal of the electronic health record (EHR) is to create an optimal work environment that allows providers to maintain a healthy work/life balance while efficiently capturing critical...

Tonya Edwards, M.D., physician executive at consulting firm Impact Advisors, agrees that consolidation is the most significant trend happening in the EHR market today, noting that for large health systems, the options for enterprise solutions have gone down to three key vendors—Epic, Cerner, and Meditech (Westwood, Mass.), with a “smattering” of Allscripts. Both Long and Edwards feel that whichever vendor has the market lead at the moment—Cerner, Epic or another company—is not as important as the fact that there are just a few vendors that are dominating most of the space.

Tonya Edwards, M.D.

Edwards says she’s also seeing a trend of large enterprise vendors trying to get out to smaller and medium-sized organizations, many of which cannot afford the Epics and Cerners of the world. This is happening more frequently in physician practices and smaller provider organizations that can essentially purchase Epic’s Community Connect product, for instance, for a much cheaper cost via a “host” hospital locally that is already on Epic, explains James McHugh, Chicago-based managing director, revenue cycle business unit leader at consulting firm Navigant. This smaller organization can that way outsource the IT components of the EHR implementation to that host hospital, thus getting not only a cheaper cost than they would by purchasing it on their own, but also taking advantage of the transfer of clinical data and having everything on a single platform, McHugh says. “It is a trend we’re seeing quite a bit. And of course those two [provider] organizations might be competing, so they have firewalls to manage things. But the smaller systems are saying they want a Cadillac system even though they can’t afford it. So they will partner with a large system in the area to get on the Cadillac. We are seeing a lot of that on the physician side. They want to remain independent but they also want a really good EHR,” he says.

Long adds that in the acute care space, which she calls a “complex clinical environment,” there is the big technology barrier for some systems, regardless of if they are large or small. “So if these products were not architected to be able to peel apart their data to look at outcomes, and be able to play with other systems, the level of investment that will get them there will be very close to a rewrite. And that’s hard,” she says. For the smaller players specifically, Long notes that it may be a funding issue. “You may be architected in some way to get to that data, but the road from an investment standpoint may lock up your roadmap for years. So then it’s a question of being able to compete. If you can’t do more than regulatory requirements, how can you compete over the years with solutions who can do much more beyond that?”

Optimizing for the Future

Indeed, hospitals and health systems are also becoming increasingly focused on getting benefits from the EHR product, and therefore are deciding what’s in their best interest to prioritize for optimization. “Organizations are trying to get benefits out of the products they have spent so much money on. And they are trying to find resources to do that, since they have already spent all their money,” Edwards says, adding that optimization and seeing true ROIs are big works in progress. “I have not seen any organization that I can point to and say that this one is doing a superior job. Those that are doing a better job than others, though, are focusing on benefits and are putting a really good governance system in place that helps make them make good decisions that helps align with the organization’s strategic priorities as they continue to prepare for a value-based [healthcare system].”

McHugh, who previously was a founding partner of McKinnis Consulting Services, a revenue cycle firm that specialized in EHR implementations and optimization, and was recently acquired by Navigant in December 2015, adds to Edwards’ point, noting another piece to this trend that he’s seeing take place: that industry-wide, there have largely been poor reactions regarding EHR implementations. “We do know that ROIs on leading EHR products exist, but you don’t [hear much about them]. How quickly are these systems realizing it?”

McHugh adds that the top EHR vendors are now providing resources on the back end for their installs for remediation or even outsourcing of key revenue cycle functions. “So this is a signal that the industry is starting to accept poor implementations,” he says. “In a sense, this is offsetting poor implementation, and that’s pretty troubling. Rather than the vendors getting the original implementation right, they are being paid additional capital to fix the broken implementation. This presents conflict,” he says. 

James McHugh

As such, McHugh says this is further evidence that healthcare organizations need to develop and execute a holistic strategy prior to the implementation of technology instead of just getting the out-of-box solution in. He feels that organizations need to understand what the EHR vendors are doing and what their role in the conversion really is. “Is it managing IT, [making] an implementation plan, or managing more than that and looking at the metrics associated with it? Vendors talk a lot about selling the ROI during install, but they are not taking the time to ensure success of the install,” he says.

Speaking further about optimization, McHugh says that everyone defines the word differently. EHR vendors will define it as fixing the out-of-box solution that they put in place and building out work queues that weren’t in place for the go-live. “But for us,” says McHugh, “that should have been done during implementation and worked out at that point. These are mature enough products where we shouldn’t have to push a lot of these things to post go-live.”

McHugh says that the reason so many organizations fail in their installs is because they do not take the operational needs and requirements into account, and they don’t prioritize the financial risks associated with the install early and often. “I tell our clients that the vendor is there to make sure you go live on time and within budget, because that’s what an IT install is about. But if you treat this as an IT install, it won’t go well. They will go live on time and within budget, but that doesn’t mean it’s successful,” he says. He adds that while the CIO takes on the IT part of the install, it’s the CFO’s job to make sure to minimize the financial impact on the organization. “Any EHR install is a disruption. They are very complex systems that are being put in place and they have to be customized, so this represents a huge disruption to the revenue cycle. Someone needs to manage that and mitigate the financial risk associated with the install,” he says.

In the end, it will undoubtedly be critical for vendors in the EHR market to make sure that their products are streamlining processes and improving the user experience. Many physician leaders still point to a study published last September in the Annals of Internal Medicine which found that during office hours, physicians spend nearly 50 percent of their time on EHR tasks and desk work, and outside office hours, they spend another one to two hours of personal time each night doing additional computer and other clerical work. This latest research has only added fuel to the argument that health IT can contribute to physician burnout. 

To this point, Edwards notes that the big-name vendors are doing lots of work to improve that user experience since products that were implemented three to five years ago or longer did not give great thought to usability aspects, and therefore have added a lot of unnecessary work for providers. Long agrees, adding that now that the physician community has experience with these products, they are more vocal around the importance of usability around technology. “There is a passion there. From a vendor perspective, I love that. I can engage with the physician community and end-user community, and understand what they need. This helps to drive better product at the end of the day,” she says.

Moving forward, the pressure will only ramp up as provider stakeholders will have to deal with the ongoing regulatory requirements related to health IT in addition to applying predictive analytics to anticipate outcomes—a necessary endeavor in healthcare’s future. As such, all of the sources interviewed for this story agree that the emphasis on optimization and getting a clear ROI will be greater than ever. Long concludes, “I hope that we as an industry are able to come together to get at the main goal—improve patient outcomes. The idea is to deliver high-quality care, enable the patient experience, and improve the patient-provider visit.”

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How BI Tools Are Helping Jefferson Health Battle the Opioid Crisis

September 21, 2018
by David Raths, Contributing Editor
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Helping clinical leaders identify prescribing patterns across the health system

Making health system changes to address the opioid crisis is challenging if you don’t have actionable data about prescribing patterns. With guidance from their chief medical officer, the business intelligence team at Jefferson Health in Philadelphia took advantage of the recent enterprise EHR implementation to create dashboards highlighting potential prescribing issues. Internal EHR development teams have already made changes to address the issues they found.

In a recent interview, Cara Martino, enterprise business intelligence manager at 14-hospital Jefferson Health, said that Jefferson was one of the first health systems to implement its Epic EHR and Qlik Sense at the same time. Many organizations that go live on Epic use Crystal Reporting, she said. “It was the combination of the two that allowed us to do this project,” she added. Before going live on Epic and using this new BI tool, Jefferson clinicians used a bunch of disparate systems for ambulatory, inpatient and emergency department physicians. “We weren’t able to aggregate the data,” she recalled.

Jefferson departments had tried to look at opioid prescribing previously, but “they were trying to manually abstract opioid data from the system, compile it in Excel, and try to see trending across the continuum of care, but they really weren’t able to do that very well,” Martino said. “Once we went live with Epic, we were able to standardize the work flow of entering the opioid order and prescription, and Qlik Sense allowed us to look at it from that enterprise view and to slice and dice the data a bunch of different ways.”

In response to the opioid epidemic in the Philadelphia area, Jefferson has created an opioid task force. In January 2018, Edmund Pribitkin, M.D., Jefferson’s chief medical officer, came to the BI team because he saw they didn’t really have good data to share. “We were bringing physicians and pharmacists together in a room to think through what we can change to address the opioid crisis,” Martino said, “but they didn't’ have baseline data to understand where we are going wrong.”

Pribitkin asked the BI team to develop a high-level dashboard with five key metrics to share at the clinical chair department level: 


Mastering the EHR: How Optimization Services Foster Quality Documentation & Physician Satisfaction

We know the goal of the electronic health record (EHR) is to create an optimal work environment that allows providers to maintain a healthy work/life balance while efficiently capturing critical...

• Prescriptions by provider and service;

• Number of orders with over 100 pills;

• Prescriptions written for more than 7 days, 5 days and 3 days;

• Patients with two or more opioid prescriptions within 30 days; and

• Morphine-equivalent daily doses over 50.

The metric around patients with two or more prescriptions within 30 days had been difficult to see when data was being entered in a lot of different ordering systems, but is much easier now because everyone is ordering through Epic.

Within a month, the BI team had a prototype created. In the dashboard, you can pick a patient with the most scripts, and below it populates the different providers who are prescribing for them. “Sometimes you pick someone on the higher end and only one person is prescribing to them. Usually it is a chronic pain clinician, and it is probably appropriate,” Martino said. “But then you pick someone who has six different providers providing them opiates. They may have no idea about each other. Now we get to have that conversation about what we can do in the EHR to notify them at the time of ordering that the patient already has something prescribed. Also, our quality department can notify these six providers via e-mail. They might ask whether we should refer this patient to a chronic pain physician. If they really need this much pain medication, are we treating them the right way?”

Showing clinical leaders a trending graph such as prescription orders of 7 days or more can have an impact on ordering trends and EHR recommendations. Martino, who is a nurse herself, described an example of how her team worked with clinician informaticists who build EHR workflow tools to make some key changes.

They saw in the data that there were examples of doctors were prescribing six opioids to the same patient within two minutes. On further examination, they found that clinicians were entering orders incorrectly and quickly canceling them. But the e-prescription interface with the pharmacy system wasn’t necessarily canceling the incorrect orders, and the patients could have six prescriptions waiting for them at the pharmacy.

“Our first step was to get a message out to providers to let them know if you are prescribing and sending to an outside pharmacy, you need to pick up the phone and talk to the pharmacy about a change in an order and make sure they know which is the correct one,” Martino said. They also worked on the pharmacy interface to generate those canceled order messages, so that if something is ordered and then canceled within 30 seconds, it alerts the pharmacy not to prepare it.

The BI team saw another EHR change that they thought might make a big difference in prescribing patterns. In the EHR quick buttons, duration of the prescription defaulted to 10 days. The quick button on order days had choices of 7, 10, 15 or 30. “We knew those were too high,” she said. “We wanted 3, 5 or 7.”

They worked with an emergency department doctor who was also an informaticist to pilot that change in the ED. “In the first month, we saw a drop from 32 scripts over 7 days to just two,” Martino said. The following month they saw a reduction of more than 65 percent in prescriptions of more than 7 days. “The best part is no one complained or said they were looking for the 10 button and it wasn’t there,” she added. Now that change is being rolled out enterprise-wide.

Although there are some other requests from clinicians for data about opioid prescribing, Martino said the BI team’s current goal is to help more clinicians gain insights into the data that already exists. “It is really hard to go from an institution that was not data-rich and had disparate systems and manually collected data to one that has one EHR and a robust BI tool that allows us to slice data in a million different ways,” Martino said. “We are trying to get the clinicians comfortable with the tools. There is so much we can do, but we have to get the data to the right people and educate them about how we are pulling it out of the EHR. It is easy for this not be a priority for clinicians because they are so invested in taking care of their patients. It is our job as informaticists to go to their meetings and talk about changes we can make. It is also important for us to have clinicians on our team and to be able to offer that informaticist viewpoint.”



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Survey: Physicians Sour on Value-Based Care Metrics, EHRs

September 19, 2018
by Rajiv Leventhal, Managing Editor
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They new research has several key findings related to value-based care, health IT and burnout

More than 50 percent of U.S. physicians who receive value-based care compensation said they do not believe that the metrics the reimbursement is tied to improve the quality of care or reduce costs, according to a new survey.

The research comes from The Physicians Foundation, an organization seeking to advance the work of practicing physicians and helps them facilitate the delivery of healthcare to patients. The Foundation’s 2018 survey of U.S. physicians, administered by Merritt Hawkins and inclusive of responses from almost 9,000 physicians across the country, reveals the impact of several factors driving physicians to reassess their careers.

Specifically, the new survey underscores the overall impact of excessive regulatory/insurer requirements, loss of clinical autonomy and challenges with electronic health record (EHR) design/interoperability on physician attitudes toward their medical practice environment and overall dissatisfaction—all of which have led to professional burnout.

The research revealed several key findings, including that value-based compensation is directly connected to the overall dissatisfaction problem, which is tied to metrics such as EHR use, cost controls and readmission rates, etc. Forty-seven percent (compared to 43 percent in the 2016 survey) of physicians have their compensation tied to quality/value, but when physicians were asked if they believe that value-based payments are likely to improve quality of care and reduce costs, 57 percent either disagreed or strongly disagreed that this is the case, while only 18 percent either agreed or strongly agreed that it is.

As one responding physician put it: “We are no longer in the business of healthcare delivery, we are in the business of ‘measures’ delivery.” More than 13 percent of physicians are not sure if they are paid on value.

What’s more, the research found that 88 percent of physicians have reported that some, many or all of their patients are affected by social determinants. Conditions such as poverty, unemployment, lack of education, and addictions all pose a serious impediment to their health, well-being and eventual health outcomes. Only one percent of physicians reported that none of their patients had such conditions.

Additional notable findings from the research included:

  • 18.5 percent of physicians now practice some form of telemedicine
  • 80 percent of physicians report being at full capacity or being overextended
  • 40 percent of physicians plan to either retire in the next one to three years or cut back on hours—up from 36 percent in 2016
  • 32 percent of physicians do not see Medicaid patients or limit the number they see, while 22 percent of physicians do not see Medicare patients or limit the number they see
  • 46 percent of physicians indicate relations between physicians and hospitals are somewhat or mostly negative

Coupled altogether, 78 percent of physicians said they have experienced burnout in their medical practices, according to the survey’s findings. And the results show that one of the chief culprits contributing to physician burnout is indeed the frustration physicians feel with the inefficiency of EHRs.

“The perceptions of thousands of physicians in The Physicians Foundation’s latest survey reflect front-line observations of our healthcare system and its impact on all of us, and it’s sobering,” Gary Price, M.D., president of the Foundation, said in a statement. “Their responses provide important insights into many critical issues. The career plans and practice pattern trends revealed in this survey—some of which are a result of burnoutwill likely have a significant effect on our physician workforce, and ultimately, everyone’s access to care.”

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Brigham Health’s 3-Pronged Approach to Reducing EHR’s Contribution to Burnout

September 18, 2018
by David Raths, Contributing Editor
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Focus is on individualized training, reducing unnecessary clicks, voice recognition tools

Research studies have found that “burnout” is nearly twice as prevalent among physicians as among people in other professions.  Physician surveys have found that 30 to 60 percent report symptoms of burnout, which can threaten patient safety and physician health. With EHR documentation ranked high among aspects of their work physicians are dissatisfied with, Brigham Health in Boston has taken a three-pronged approach to reducing the pain.

Brigham Health, which is the parent organization that includes Brigham and Women’s Hospital, Brigham and Women’s Faulkner Hospital and the Brigham and Women’s Physicians Organization, rolled out its implementation of Epic in 2015. In a Sept. 18 presentation that was part of the Harvard Clinical Informatics Lecture Series, Brigham Chief Information Officer Adam Landman, M.D., said the organization’s initial EHR physician training was eight hours of classroom training on where to find things in the EHR instead of focusing on workflows and how to use the EHR to support it.  “Our experience was not the best,” Landman admitted.  They followed up with tip sheets, a help desk and a swat team to do service calls, but providers only rated those interventions as somewhat helpful, so Brigham informaticists re-doubled their efforts to:

• Improve the EHR;

• Provide one-on-one training in the clinical setting; and

• Offer voice recognition software and training.


Mastering the EHR: How Optimization Services Foster Quality Documentation & Physician Satisfaction

We know the goal of the electronic health record (EHR) is to create an optimal work environment that allows providers to maintain a healthy work/life balance while efficiently capturing critical...

Landman said IT teams at Brigham feel a sense of urgency about reducing the burden of EHR documentation. “Burnout is an epidemic, and the EHR is a component of this,” he said, adding that the changes are not just a one-year cycle but must involve continual iterative improvements. “We need to be more aggressive about making changes,” he said.

He described some efforts to reduce notifications and remove clicks from the medication refill process. They also removed a hard stop when discontinuing a medication. Those three changes alone reduced the number of clicks per month by 950,000 across the health system.

They also worked to reduce clinical decision support alerts with very low acceptance rates by turning them off. Three alerts with very low acceptance rates were turned off. “If we thought they were important, we would fine tune them to increase the acceptance rate,” Landman stressed. “That is part of clinical decision support lifecycle management. But we will continue to iterate to reduce the number of unnecessary clicks.”

A year and a half ago, Brigham also created a one-to-one support program, in which an expert trainer would meet the physicians in their practice and help them with their work flow. A pilot project involved four specialties, including general surgery. Each session was 90 minutes to two hours long, and providers were offered one or more follow-up sessions, as well as optional training on speech recognition. After seeing some negative feedback on their initial classroom training, the one-to-one sessions were met with a very positive response. Almost 95 percent said it was valuable, and 95 percent said they thought their efficiency with the EHR would improve following the training. Based on that early success, the training effort is now being rolled out to much larger groups of physicians at Brigham and across the Partners HealthCare network.

In another attempt to improve documentation turnaround time, Brigham has made voice recognition tools and training available to physicians. They made two-hour training sessions mandatory for those interested in adoption, with additional personalization sessions also available. Informaticists partnered with departments to build department-specific order sets. (Brigham also started offering 15-minute e-learning sessions for residents.) More than 90 percent of surveyed physicians said the training met expectations, and 70 percent said they would be willing to have additional training, Landman said. Currently 5,000 physicians across Partners are trained to use voice recognition tools with the EHR.

Landman also cited a study that compared U.S. and international use of Epic that saw a huge disparity in length of documentation notes. The U.S.-based users’ notes were nearly four times longer on average than those of their international counterparts. Epic users overseas tend not to complain about the burden of documentation, he noted. This has to do with how the provider notes are used in billing, he said, adding that CMS is working on proposals to change billing requirements that may alleviate some of the documentation burden for physicians.

In closing, Landman urged informatics colleagues to think about working on EHR optimization research and studying the impact of policy and technology changes. “New technology tools can seem fun and exciting, but for physicians who see up to 100 patients per day, they can be quite overwhelming,” he said. “We don’t want physicians spending half their time doing administrative work.”






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