So Many EHRs. So Expensive.

There are currently 386 software packages certified by an ONC approved certification body as ambulatory Complete EHRs, which means that the software should allow the user to fulfill all Meaningful Use requirements and possibly qualify the proud owner for all sorts of CMS incentives. There are 204 more software packages which are certified as ambulatory EHR Modules, and a proper combination of these packages could result in a Complete product, which if used appropriately could lead to the same fortuitous results.

There are 423 distinct manufacturers of ambulatory EHRs and EHR modules on the federal list. Most are software vendors, or wannabe software vendors, but a fair amount are facilities that developed an EHR for in-house use and had it certified. These are not really available for purchase. A very large number of listed vendors offer niche products for distinct specialties, such as optometry, oncology, behavioral health, etc. All that said, there is still an inordinate number of EHR “choices”, or so the story goes. By comparison, since we all love car analogies, there are 1,310 individual trims currently sold in the U.S., and around50 car manufacturers overall. If you ask an average citizen on the street to name their top 10 cars, chances are that you will get a Honda Accord, Toyota Camry, a Caddie, maybe a Ford truck, a Beemer, a Porsche and perhaps even a Beetle. You are not likely to hear anything about a Tesla or a Coda and rarely will anybody mention a Scion. Automotive modules are not widely sold for home assembly, so there is no parallel lesson there. One way or another, we manage to find our way when it comes to automobiles.

When it comes to EHRs, if you ask an average health care worker, including HIT experts, to create a top 10 EHR list, most will have trouble coming up with more than three or four, but generally speaking, you will end up with Allscripts, eClinicalWorks, Next Gen, maybe Epic, GE or Cerner, and sometimes Amazing Charts or e-MDs. Rarely, you may get the name of a newer or a more regional product and perhaps a specialty specific EHR as well. This doesn’t sound too daunting now, does it? At least no more daunting than shopping for a car. What about the Teslas, Codas, Fiskers or even Scions and Kias of the EHR world? Aren’t we missing out by not exploring every single innovator on that long list of hundreds of complete products and the collection of modular bits and pieces? Perhaps the next great thing, the diamond in the ruff, is already on the list….. Perhaps it will get added next week, or next month, or next year….

Perhaps, but I wouldn’t lose any sleep over it. Innovation is about more than using a web browser or an iPad to deliver the same old content, and those olden EHRs are teeming with innovation. The three committed partners for the cutting edge Surescripts-AAFP Physicians Direct collaborative platform are SOAPware, Amazing Charts and e-MDs, all on the “legacy” list. Cerner is positioning itself to replace Google Health in a very innovative consumer facing move. eClinicalWorks has a peer-to-peer communication system that has not been duplicated yet. Through the grapevine I hear that GE and e-MDs are both working feverishly on the next generation of EHRs. And the list goes on. In this day and age of massive regulatory demands, all EHR vendors must devote quite a bit of effort to compliance. Those with capacity for additional innovation are usually the well-established and well-capitalized companies, which are the same companies that amassed incredible expertise in health IT over the years. Speaking of the innovative Direct Project, it may be instructive for some to do a little homework on its originators (hint: it wasn’t two guys in a garage).

How about the widely advertised astronomic costs of these “legacy” EHRs? Why pay so much money for software when the new models are so much cheaper?Stories about doctors spending $250,000 in just the first year are not uncommon. Not sure what those doctors purchased, but whatever it was, they shouldn’t have bought it. eClinicalWorks, one of the top selling “old” EHRs, can be purchased for $250 per provider/per month. Can it get cheaper than that? Sure. Amazing Charts, another golden oldie, sells for less than $85 per provider/per month. The various ad-supported freebies notwithstanding, the next best thing would be for someone to pay the customer to use the software. Are there any new and bare bones EHRs on the federal list that sell for less? None that I know of. But maybe bare bones products are actually better, or simpler to use. Although “lees is more” is the new battle cry of health care, a little bit of complexity goes a long way. Guess who are the only recipients of the Surescripts White Coat Quality awards in ePrescribing (denoting commitment and achievements in the areas of safety and accuracy)? Two old eRx companies and two old EHRs – e-MDs and NextGen.

What about service? With the current flurry of EHR shoppers, largely driven by Meaningful Use incentives, those household name EHRs are flooded with new customers. The lines are long and customer service is spread thin. Should you go across the street and be treated like a king, since you probably are the only customer of one of those new bare bones vendors? If the lines are long at the Toyota dealer, should you go across town to the Kia dealer and pay the same amount of money that would get you a Camry for a minuscule Kia Soul?  It is also worth remembering that since the ultimate goal is exchange of information, when hospitals and various exchanges start building interfaces in earnest, the waiting lines will be reversed. Those using EHRs with the largest market presence will be first in the interoperability line.

Last, but not least, what if tomorrow the perfect EHR is invented and you are stuck with the product you bought today? Here is where the car analogy stops working. If they invent a car that runs on water from the garden hose, chances are that you can trade your Toyota Camry in, lose a lot of value, but rather easily drive out in your brand new bubbly water car. Switching EHRs is hard. It’s not impossible, but it is expensive and fraught with peril. Since I can assure you that none of the EHRs currently on the federal list are the holy grail of EHRs, and there is none of those on the horizon either, you will take this risk on, no matter what you buy today. You need to decide if your odds are better with an established, “old” company that may charge you quite a bit of money to migrate data out of their EHR, or if you prefer to deal with a company that just vanishes into thin air one evening and the only thing left is a disconnected phone and perhaps a colorful website loaded with flash banners telling you how much money you can get in incentives from Uncle Sam. Of course, you don’t have to buy anything. You can just stand on your front porch, holding your garden hose, waiting for an impending miracle. And miracles do happen…..

Full Disclosure: I have no financial interest in the products mentioned in this article, or any other EHR software.

Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.

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15 replies »

  1. Thanks Dr Mike

    This really follows the car analogy Margalit started (brilliant!) initially.

    Apparently there are several models of data selling as well as different models of free. Some vendors package up data and sell it externally and others sell access to the data but don’t allow data to actually “leave” the system. I believe Practice Fusion is the former but am not sure about the Mitochon Systems, DrChrono, or others.

    Billing-subsidized takes % of billing…….5%-7% just from water-cooler chats…so I could be off by a few %……that can add up

  2. You’re not wrong. They sell the data. Ads are just a distraction in more ways than one. They also have some integrated billing solutions, not sure if that is a profit to them or not. But still, the price is right, and I am overall quite satisfied with Practice Fusion.

  3. I had some experience with GPO type purchasing, but honestly, the discounts are not that stellar. Better than nothing, but still only a few percentage points.

    I am on the fence regarding the freebies. I don’t know if the Google style ads are patient (diagnosis) specific or not, and even if they are not, there is something rubbing me the wrong way with pharma ads in the workflow. Now, if they limit the ads to non clinical stuff, It may make me feel better.
    Also, I am not sure I completely understand the business model. I don’t think you can support the entire operation with just ads. There must be a secondary source of revenue. I sincerely hope I’m wrong.

  4. Margalit

    Not to mis-lead but this is simple a GPO. Joint-purchasing arrangements exist at the REC level (pre-negotiated prices) and other organizations (http://www.cmanet.org/membership/membership-benefits/group-buying-discounts/cma-hit-list) but discounts favor large purchase commitments…..100’s of licenses at once vs the solo practioner buying one license…….back to the car analogy……most solo docs are very weary of buying the big brand new hummer

    I think the free/ad-supported model might work well since pharma/device marketing spend dwarf the relatively short-lived ARRA program. What will small practices do after 2016? Since pharma marketing ads are FDA regulated and would be in the form of a banner ad, the healthcare system would save money and be green at the same time:)

    Thoughts on the freebies (Practice Fusion, Mitochon Systems etc?)

  5. Lehr,
    I am interested in hearing more about your concept of joint purchasing solutions. Is this something you’ve seen occurring? If so, what was the arrangement?

  6. Best of the best,

    As BobbyG originally commented: “……the REC trenches are finding areas within major certified EHR products where they simply don’t work as advertised…..”

    I call it “……lost in the EHR Superbowl marketing frenzy” http://bit.ly/pZMdFm and concur that additional usability efforts will just add additional marketing noise and slow EHR adoption amongst smaller practices (1-2 MDs)

    So do joint purchasing arrangements or lower-cost solutions make sense?
    Where do the free or nearly-free EHR solutions fit?

    Ad-sponsored: Practice Fusion, Mitochon Sytems

    Nearly free:
    Billing-subsidized: AthenaHealth, MedIT Resources

    Other off-the-radar solutions?

  7. I don’t think they are actually regulating anything just yet, but they (FDA), have been trying to figure out the form such regulation may take, if and when it becomes the law. Seems the “if” portion is diminishing in importance….

    Which is more reason for the various government usability efforts to chill out a bit http://bit.ly/pZMdFm

  8. Breaking news…


    “…Also, the FDA has begun regulating EHRs as medical devices because, according to the agency, health IT has advanced so far that the professional intermediary is no longer required or used. Thus, under the Federal Food, Drug and Cosmetic Act, health IT is characterized as a medical device. Per voluntary reports from patients, clinicians and user facilities, the FDA has cited data indicating 260 reports of health IT-related adverse events, including 44 reported injuries and six reported deaths, resulting in the agency issuing its final rule in February classifying “Medical Device Data Systems” as low Class 1 medical devices, requiring post-market surveillance.

    According to Roberts, the FDA has three possible options for regulations:
    • Focus on post-market safety;
    • Focus on quality manufacturing and post-market safety; or
    • Require pre-market approval.”

  9. That’s a very good point and off the top of my head what I see rising to the top is natural language and voice processing, as well as health information exchange. And this is the correct development of things, IMHO.

  10. Innovation can also be purchased. Positioning and consolidation are some of the keys to this “game”. If one looks at the merger and acquisition volume as well as multiples of the increasing HIT deals, one can see which functions are rising to the top…or will be dismantled by the purchaser. Providers were placing bets a year ago and to a lesser extent are doing that now. The car analogy is good for an extended outlook, which occurs with mature markets and competition.

  11. I bought my first and only import, Honda Accord, when it ceased being completely bare-bones. I kept it for a while and it was great, but I drive a Jeep now, and drove a Jeep before this one, and a Mercury before that……. and I am certain my next one will be from another Detroit company 🙂

    I do agree about connected care being the goal regardless of what you “drive” to get there. It won’t be long now either. EHRs were not designed to talk to each other, not so much because of EHR vendors’ preferences. They were designed that way because those who bought EHRs had business models that required no “talking” with other systems. Business models are now changing rapidly and the software vendors will oblige (are obliging). It’s really not that hard from a technology point of view.

  12. The car analogy is great. Many can still remember the days when we would only buy a Chrysler or Chevy and not the bare-bones imports. After slow changes in purchasing habits, Toyota and Honda dominate in volume and are entrenched car companies. Who knew?

    It has been only the recent past that US car companies have stemmed the tide and been competitive. New companies to our market like Hyundai/Kia have developed competitive products to Toyota/Honda/Ford and introduced innovative marketing campaigns to boot (remember the Assurance Program & Guaranteed Trade-in?).

    Prospective EHR buyers just need to reflect and decide to stick with “improved” legacy products or evaluate free (advertising) or close-to-free (% of billing) EHR products. Ok, so when did you buy your first import? What finally convinced you?

    We actually don’t need a miracle but just a vision for how things out to be and then “drive” in that direction…..how about connected care? systems that talk to each other? “reasonable cost?

  13. Thanks, Bobby.

    The one thing that those certifications cannot test in their current format, is software bugs. When the vendor knows in advance the handful of steps tested, and the vendor is free to supply its own data, making sure that the software performs as required for that particular test and that particular data set is easy, and it does not necessarily imply that the same software will work well for different steps and different data sets. Hence the problems you encounter in “real life”.

    Data migration can currently be performed at very little expense for standard demographics. With some more expense, you can get another small subset of codified elements, such as meds, immunizations, diagnoses and orders (CPTs) and whatever the vendor can export to CCD. Lab results are best obtained directly from the lab. If the practice has been using a national reference lab, you can usually get an historic dump of electronic results. Non codified elements could be also mapped although at great expense to the practice and it is probably not worth it. The rest should be available as PDF. And, yes, this is not much better than scanning paper in.

  14. Nice post. I am reminded of “The Paradox of Choice.”

    Of the ONC/CHPL “certified” systems, I would like to see the breakout of all those who applied versus those who passed (I won’t be holding my breath). If it turns out to be 100%, then it’s really just “Pay (a lot) to Play.”

    Moreover, we in the REC trenches are finding areas within major certified EHR products where they simply don’t work as advertised (e.g., as expressed in their MU upgrade training manuals).

    “I’m doin’ this with every patient encounter; why is my MU dashboard tell me I’m as yet failing this numerator/denominator measure?”


    And, “Service”? LOL.

    “Should you go across the street and be treated like a king, since you probably are the only customer of one of those new bare bones vendors?”

    And, precisely how are you going to migrate your practice data comprised of hundreds to thousands of one-to-one and one-to-many variables reposed in dozens of RDBMS tables, each with their own unique data dictionaries that make migratory data cross-mapping the stuff of ulcers?