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KLAS Research: Small Hospitals’ Buying Decisions Impacting EMR Market Share

May 25, 2018
by Heather Landi
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A new KLAS Research report tracks shifts in electronic medical record (EMR) vendor market share among acute care hospitals, and finds that smaller hospitals are seeking technology solutions that meet their needs and limited budgets, and these contracts are making a mark on the EMR market.

In 2017, 216 acute care hospitals contracted for a new EMR, with 1–200 bed hospitals accounting for the vast majority (80 percent) of these decisions. The KLAS report notes that these smaller hospitals are hungry for new technology but often resource poor. “Over half that signed a new contract in 2017 chose a less expensive or less resource-intensive platform—namely, athenahealth, Meditech, and the community deployment models from Cerner and Epic,” the report states.

The report investigates hospital EMR market share and shifts that impacted buying energy in 2017. To determine EMR market share, KLAS Research analyzed the vendors in use at 5,278 acute care hospitals in the U.S. with 200 or fewer beds.

Epic and Cerner continue to maintain the largest EMR market share among small hospitals, with 26.7 percent market share and 24.8 percent, respectively. Meditech had 17 percent of the small hospital EMR market in 2017, followed by CPSI (10.3 percent), Allscripts (7.2 percent), Medhost (4 percent) and athenahealth (2 percent).

In 2017, Cerner saw the most acute care hospital wins out of all vendors, while Epic had fewer wins but sustained no losses, giving Epic the highest net market share growth, according to KLAS. Cerner lost 25 hospitals, 15 due to customer standardization. Epic’s strong integration and consistent development are major reasons that their market share remains more stable and that they are chosen by larger health systems and hospitals, KLAS researchers wrote. What’s more, Cerner’s and Epic’s alternative deployment models for smaller hospitals both saw significant wins. Overall, Cerner gained 29 acute hospitals and Epic gained 46 hospitals.

Athenahealth also saw a significant number of acute care hospital wins in 2017, gaining 28 hospitals. KLAS notes that the vendor is capitalizing on smaller hospitals’ hunger for new technology. “athenahealth’s inpatient solution continued to gain traction, garnering more contract wins among small hospitals than any other solution. The cloud-based platform is particularly attractive to the smallest hospitals, who require minimal IT footprints and up-front costs,” the report states.

Indeed, athenahealth’s 2017 wins occurred solely among hospitals with under 50 beds, the report notes. “Questions regarding the solution’s maturity are a concern for some—in 2017, 13 contracted customers backed out before going live, returning to previous vendors, primarily CPSI,” KLAS researchers wrote.

Meditech’s new cloud-based technology (Expanse) also generated buying energy among smaller hospitals, as the vendor saw its first market share increase in three years. According to KLAS, the Expanse platform has been in development for many years, with ambulatory integration and enhanced usability as key goals, and it has created increased migration activity among Meditech’s legacy customers—58 percent of those who made a go-forward decision in 2017 chose Expanse, while 42 percent went with other vendors.

“Historically, Meditech’s systems have not generated significant consideration outside of the existing Meditech base, but Expanse is changing that. Some community hospitals (1–200 beds) using other vendors’ legacy solutions chose in 2017 to switch to Expanse,” the report states.

Last August, Allscripts acquired McKesson’s Enterprise Information Solutions for a reported $185 million, a portfolio that includes Paragon (EHR); STAR and HealthQuest (revenue cycle solutions); Lab Analytics and Blood Bank; and OneContent (content management solutions). With that deal, Allscripts nearly doubled their acute care EMR customer base with the acquisition of McKesson’s Paragon and Horizon EMRs. However, KLAS notes that both solutions have been losing customers for years, and 2017 was no different.

“It should be noted that many Horizon and Paragon customers who left in 2017 had already made decisions to switch to other vendors prior to being acquired by Allscripts. These losses are no surprise given Horizon’s sunset status and McKesson’s consistent underdevelopment of Paragon, most significantly their inability to deliver an integrated ambulatory solution,” KLAS researchers wrote.

More notable, KLAS says, are the losses sustained by Sunrise Clinical Manager (SCM), Allscripts’ go-forward solution for larger organizations. SCM’s market share had been relatively stable for a number of years, but in 2017, two large multihospital organizations switched their SCM hospitals to Epic, looking to simplify their IT infrastructure and consolidate to an integrated solution.

Looking at other EMR vendors and market share, the report notes that organizations using CPSI (Healthland and Evident), Medhost, Cerner Soarian, and Meditech’s Magic, C/S, or 6.x solutions make up over one-third of all hospital contracts in the United States. Many of these traditional small-hospital platforms are seeing high rates of replacement as provider organizations consolidate and as customers switch to more attractive deployment models, the report found.

“CPSI Evident sustained the highest losses of any platform in 2017, with customers turning to other vendors in search of things like innovative technology, responsive support, and consistent upgrades. CPSI’s Healthland customers are in a similar situation,” KLAS researchers wrote.

Smaller hospitals have expressed initial interest in eClinicalWorks’ cloud-based inpatient solution (10i); to date, very few contracts have been signed.


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Study: Many U.S. Hospitals won’t Reach HIMSS Stage 7 Until 2035

August 14, 2018
by Rajiv Leventhal
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Unless the healthcare IT ecosystem experiences major policy changes or leaps in technological capabilities, many hospitals will not reach Stage 7 of HIMSS Analytics’ Electronic Medical Record Adoption Model (EMRAM) until 2035, according to new research.

The study, published in the August edition of the Journal of Medical Internet Research, analyzed Healthcare Information and Management Systems Society (HIMSS) Analytics’ EMRAM data from 2006 to 2014.

HIMSS Analytics is the research arm of the Healthcare Information and Management Systems Society (HIMSS). HIMSS Analytics developed the EMRAM in 2005 as a methodology for evaluating the progress and impact of electronic medical records on health systems around the world. Tracking their progress in completing eight stages (0-7), hospitals can review the implementation and utilization of information and technology applications culminating with Stage 7, which represents an advanced electronic patient record environment. Other Stage 7 requirements include: leveraging an external HIE (health information exchange); use of a data warehouse; and having robust data analytics functions.

The researchers of this study noted that the meaningful use (MU) program has promoted electronic health record (EHR) adoption among U.S. hospitals. And while studies have shown that EHR adoption has been slower than desired in certain types of hospitals; generally, the overall adoption rate has increased among hospitals.

However, the researchers continued, these studies have neither evaluated the adoption of advanced functionalities of electronic health records (beyond meaningful use,) nor forecasted EHR maturation over an extended period in a holistic fashion. “Additional research is needed to prospectively assess U.S. hospitals’ electronic health record technology adoption and advancement patterns,” the researchers stated.

The HIMSS EMRAM data set was used to track historic uptakes of various EHR functionalities considered critical to improving healthcare quality and efficiency in hospitals. A technology diffusion model was then used to predict the technological diffusion rates for repeated EHR adoptions where upgrades undergo rapid technological improvements. The forecast used EMRAM data from 2006 to 2014 to estimate adoption levels to the year 2035.

In 2014, more than 5,400 hospitals completed HIMSS’ annual EMRAM survey (86 percent of total U.S. hospitals). Back in 2006, the majority of the U.S. hospitals were in EMRAM Stages 0, 1, and 2. But by 2014, most hospitals had achieved Stages 3, 4, and 5, the study noted.

The researchers found that in 2006, the first year of observation, peaks of Stages 0 and 1 were shown as EHR adoption precedes HIMSS’ EMRAM. By 2007, Stage 2 reached its peak. Stage 3 reached its full height by 2011, while Stage 4 peaked by 2014. This forecast indicates that Stage 5 should peak by 2019 and Stage 6 by 2026, according to the data revealed in the study.

The researchers noted, “Although this forecast extends to the year 2035, no peak was readily observed for Stage 7. Overall, most hospitals will achieve Stages 5, 6, or 7 of EMRAM by 2020; however, a considerable number of hospitals will not achieve Stage 7 by 2035.” They concluded, “These results indicate that U.S. hospitals are decades away from fully implementing sophisticated decision support applications and interoperability functionalities in electronic health records as defined by EMRAM’s Stage 7.”

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HHS OIG Fines eClinicalWorks $132,500 For Violating Corporate Integrity Agreement

August 1, 2018
by Heather Landi
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The Health and Human Services (HHS) Office of Inspector General (OIG) fined electronic health record (EHR) vendor eClinicalWorks $132,500 for failing to report patient safety issues to the regulatory body as reportable events in a timely manner.

According to the OIG website, eClinicalWorks paid the fine July 18. The EHR vendor is required to report these patient safety issues to OIG as part of its corporate integrity agreement (CIA) with the agency.

eClinicalWorks entered into a CIA back in May 2017 as part of a settlement with the U.S. Department of Justice to resolve a False Claims lawsuit. According to the DOJ’s case, the company allegedly violated federal law by misrepresenting the capabilities of its software and for allegedly paying kickbacks to certain customers in exchange for promoting its product, according to the U.S. Department of Justice. As part of that settlement, eClinicalWorks also paid a $155 million settlement over the allegations.

The five-year CIA requires, among other things, that the company retain an Independent Software Quality Oversight Organization to assess eClinicalWorks’ software quality control systems and provide written semi-annual reports to OIG documenting its reviews and recommendations. The company must provide prompt notice to its customers of any safety related issues and maintain on its customer portal a comprehensive list of such issues and any steps users should take to mitigate potential patient safety risks.

Further, the agreement also requires eClinicalWorks to allow customers to obtain updated versions of their software free of charge and to give customers the option to transfer their data to another EHR software provider, without penalties or service charges. The vendor must also retain an Independent Review Organization to review its arrangements with healthcare providers to ensure compliance with the Anti-Kickback Statute.


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Survey: Physicians Cite EHRs as Biggest Contributor to Burnout

July 31, 2018
by Heather Landi
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A recent survey on physician burnout and stress found that, perhaps unsurprisingly, physicians cited electronic health records (EHRs) as the top factor contributing to stress, followed by dealing with payers and pre-authorization and then regulatory compliance.

Reaction Data, a market research firm focused on the healthcare and life sciences industries, surveyed 254 physicians across the country in a wide variety of specialties about what factors contribute to physician burnout. Twenty-one percent of respondents cited EHRs, followed by payers/pre-authorization (19 percent), regulatory compliance (18 percent) and internal bureaucracy (17 percent). And, these factors all have a common theme: they are time consuming and prevent the physician from providing care for the patient.

Other burnout factors cited by respondents included work/life balance (11 percent) and malpractice risk (6 percent).

Patients, not surprisingly, were only mentioned by 2 percent as causing an undue burden. The survey report cites one orthopedic surgeon who commented, “Our current healthcare non-system needs to be radically changed. Way too expensive and chaotic. Profit must be eliminated.”

Across different specialties, EHRs were consistently cited as a top burnout factor, although, surgeons and physician leadership cited payers/pre-authorization as a bigger burden (22 percent and 24 percent, respectively) than EHRs (20 percent).

When asked how EHRs could be improved to reduce the burden, one-third of respondents (34 percent) cited improving user-friendliness. According to the survey report, one pediatrician suggested that EHR vendors “Create one by and for physicians, not administrators and technogeeks.”

Another respondent, an orthopedic surgeon, commented, “Develop a better and more user friendly EMR. It shouldn’t take 20 minutes to do something that dictation takes three minutes.”

Seventeen percent of respondents would like to see vendors add dictation and scribe features to EHRs, 13 percent would like to spend less time documenting in the system, and 9 percent suggested replacing or getting rid of EHRs. Other suggestions to reduce EHR stress included reducing clicks (7 percent), more physician input (7 percent), focus on patient outcomes (6 percent), improve interoperability (4 percent) and additional training (3 percent).

Overall, the survey results indicate that physicians want an easier system with dictation features that reduces the time required in the system. “They want more face to face time with the patient, rather than staring at a monitor and a keyboard,” the report authors noted.

“The nurses and medical assistants need to be able to put more of the data into the EHR, permitting the doctor to spend more time with the patient,” one gastroenterologist and survey respondent said.

The survey results also indicate that EHR stress appears to know no brand name loyalty. Of those who said EHRs are one of their main causes of stress, 39 percent are using Epic, 18 percent use Cerner, 11 percent use Allscripts and the remaining respondents use athenahealth, Meditech, NextGen, eClinicalWorks and GE.

One respondent, an emergency medicine physician, commented, “EHR seems to be predominantly a billing tool, secondarily a compliance tool. Start over and design EHR for patient care. Too many boxes to click, too many irrelevant alerts, soft or hard ‘stops’ (best practice alerts in Epic), create alert fatigue. Very little useful clinical decision support.”

Physicians also cite regulatory burdens as a contributing factor to burnout and stress. Thirty-seven percent of respondents would like to see fewer rules, 32 percent would like to see more simplification and 15 percent said more physician input was needed.

According to the report, one chief medical officer recommended shifting reporting to an automated system that retrieves data from the EMR rather than manual reporting. A CMIO added, “Get rid of what seems to be unnecessary regs that don’t contribute to patient care or quality of care.”


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