A Patchwork Quilt of Unique EMR Software

We keep hearing about the Big National Data Bank for Healthcare Information. The thought is that you need a big data bank so everyone’s health information is available anywhere/anytime. This type of personal health information repository has many problems. First it is complex and expensive to set up and maintain. Second there are very significant and well-founded privacy concerns. And finally, this large, complex electronic structure may not be needed … it might even be counterproductive!

Is there another way to transport patient health data from one platform to another (so it can go from one EMR to another), so that healthcare providers, anywhere/anytime can provide fully informed care for individual patients which would be less expensive and higher in quality?

I think the answer is YES!

There are standard data exchange platforms currently being used which can help us all share “meaningful” personal health information. They are called the Continuity of Care Record (CCR), CCD and HL7. For more information on these platforms, I suggest you read Brian Klepper’s blog post. This blog gave me great insight into this connectivity issue.

In addition to obviating the need for a big data bank, these data exchange platforms make it possible for small, innovative EMR companies to compete and survive in the “EMR Jungle”. By allowing for diversity and encouraging innovation, we will end up with better EMR software. In addition, physicians will be able to pick EMRs that suit their practice style and can make them more efficient, productive and better doctors. I think we need a patchwork quilt of unique EMRs that are all well connected rather than a few big standard lemming EMRs that are totally connected by “big brother” or “big business”.

What are your thoughts on this topic?

About the author


Dr. Jeff


  • love the fact that you are not promoting one system over another. I like the concept of tailoring a program for the practice, instead of the other way around. The fear that I encountered, besides financial, were time related. How to spend maximum time with patients while participating in real time notation. Your blog is calming and written as one physician to another, not as a software developer. You can feel their “pain”.

  • I fundementally disagree. While I love competition and innovation and all things capitalism, the EHR market is NOT one where we need 300 different providers. EHR and PM systems are complex enough that they can be thought of as their own “operating systems,” (or platform, for which I foresee there will eventually be substantial 3rd party development, like current OSes and internet browsers, but this is a separate subject all together) if you will, where doctors browse (and create) medical information, just like browsers are now just as fundementally important to the way we browse the web as the operating system is to the way we browse our computer.

    The multitudes of EHR vendors out there represent the battle among hordes of OSes back 70’s and early 80’s, before Microsoft became the undisputed winner. I’m not advocating for one vendor to take 90% of the market, create broken software, and stop innovating, but there is a reason why only 3 major consumer OSes are available (and Linux barely counts with less than 1-2% marketshare).

    It is IMPOSSIBLE for each EMR vendor to coordinate with 300 other vendors to create true interoperability, even despite open standards like HL7. While HL7 is certainly a promising step forward for freedom of information and interoperability, it isn’t as simple as having each vendor conform to one standard. Software engineers from both parties have to sit down and talk for hours and then spend many more hours working before true interoperability can be achieved.

    I believe that all the biggest vendors will work on interoperability with one another knowing that they cant easily crush one another, leaving the smaller vendors helpless. This will recursively build upon itself until all the smaller ones fall off the radar.

    Having watched the software industry for many many years, I find it highly unlikely that there will be more than 5-7 ubiquitous EMR systems in 12-15 years.

  • Moreover, the current battle among smartphone OSes reiterates the idea that fact that in the software industry, there are never more than a handful of major players. Today, there are six major mobile OSes, and there are no major ones coming out in the foreseeable future (if ever). Even in 2009, which is a vastly different world than the OS battle of the 70’s and 80’s, there are only 6 mobile OSes: Symbian, Android, iPhone, Blackberry, Windows Mobile, WebOS. Say what you will about interoperability, but the software industry has consistently shown that there simply cannot be more than a handful of major platforms.

  • Kyle,
    I agree that there has to be some consolidation. A bunch of EMR companies are going to fail. Many of them will get acquired by other companies. Others will grow into powerhouses.

    However, there are over 36 medical specialties with unique EMR needs. Let’s not be surprised if each of those 36 medical specialties has 3 or so EMR companies that service them. That leaves about 100 EMR companies as opposed to the current list of 300 EMR. Certainly round numbers, but the number of specialties with specific needs is going to keep the number of EMR companies abnormally large.

  • Kyle, great post and good points (you demonstrate why we (doctors) can’t leave this to the computer guys like you [no disrespect intended]). I believe that you are incorrect in a number of areas. We have a fundamental disagreement and I think you are wrong.

    First EMRs are not like operating system. They are like software applications. In fact, they ARE software applications. There are millions of software applications that currently run on the Microsoft platform (consumers have choice and variety). I agree that a few software applications will dominate because they are better than the others (more usable, more affordable, more efficient). We don’t have to limit the choices and the variety because market forces will select the best EMR systems. In fact, the more variety and the more choice, the better our free market system will work! This is a bottom up approach (innovators and small businesses compete), rather than a top down approach (where big government and big business decides what is best for us).

    We do have to worry about big companies, the big government and “misguided” computer guys telling us that our choices have to be limited because of bogus reasons (like connectivity and interoperability). We have to worry that analogies will be made which are “off the mark” to prove a point which is incorrect.

    Your assertion that “it is impossible” for 300 EMRs to communicate. This is also incorrect and false.

    Finally, IF the biggest vendors don’t produce software that is usable, affordable and efficient, then they will be in trouble (they will be outcompeted). Remember that the doctors will have the final say in what EMRs will thrive! The doctors are the “end users” and they are going to be making the purchase decisions. We need EMRs that are usable, affordable, efficient and help us do our jobs better (quality of care) with more satisfaction. That is the bottom line. We won’t accept any excuses (or bogus reasons) from the computer guys, the corporate executives or policicians.

  • John,

    You bring up a valid point about the medical specialties. The biggest EHR vendors won’t be able to develop all the templates necessary to adequately meet the demands of 36 specialties. However, they don’t necesarrily have to.

    Reiterating my thoughts about EHR software as a platform rather than a stand alone application, EHR software will eventually open up to support 3rd party development, just like OSes and web browsers. In the super connected internet world of 2009, it is nearly impossible to succeed without opening up. The growing open source movement (not that I’m saying open source EHRs will dominate, although they could) lends itself to content sharing and cooperation. The explosion of YouTube and dominance of the iPhone (which didn’t take off until it opened up to 3rd party software; now, all six mobile OS vendors are struggling to compete with the iPhone’s app store) are clear signs that to suceed, you have to open your platform to 3rd parties, not treat them like individual applications. Yes, EHR solutions are applications, but so are web browsers, and web browsers are arguably more a important part of of a modern computer than the OS itself, (especially with the advent of cloud based services like Google Docs, Amazon’s EC2 online storage/computing, etc).

    Once they open up their platforms, which will take some time (the EHR market is still in its infancy), vendors won’t have to produce all the EHR content for every specialty. They will be able to hire that out to others, and ultimately bring together an comprehensive EHR solution that covers all specialties. This will take years, no doubt, but will allow for complete EHR templates to be developed under one system for every specialty.

    As much as I’d like to believe that doctor’s voting with their dollars with determine the “winners” of the EHR vendor wars, it has often been shown that the best product does not come out on top, especially in the tech field. If that were the case, Microsoft wouldn’t be where it is now, betamax would have beaten VHS, iTunes wouldn’t be the default media player, etc. The big boys in the software industry will do their best to limit the competition, ultimately at the doctors’ expense. It is unfortunate that this is the case, but it should be something that doctor’s are prepared to embrace.

  • My own view is that competitive forces among insurers will drive the adoption of ‘one client, one record’. The initial force for this insurance based medical home will likely be the forthcoming insurance exchange providers. The record would stay with the exchange as long as insurance chosen was within it. There will not be one big data base in the cloud with everyone in it. Nor will their be a exchange system in which the completeness of information varies by region and treatment system. There will be competitive respositories for the medical home with an assurance that everything for coordination of care is present.

  • Kyle,
    I’m a big fan as I’m sure you are of open APIs in software. The iPhone being a great example and Twitter being another interesting example. What I’m not seeing is much movement in this are of development for EHR. I’ve seen some of this in the template creation, but not much beyond that. I’ll be interested to see an EHR vendor that understands and embraces this concept. Like you said, the open source EHR might be the ones to do this and have embraced this development model the most so far (although, with open source, it’s even more open than an API is).

    You’re right that the best EMR isn’t going to win out. My fear is that marketing dollars is what is going to win out in the EMR market.

  • Kyle,

    I think you have a fundamental misunderstanding of what an EMR is. It is a tool doctors use to take care of their patients (it is a medical record which is electronic (on a computer rather than being on paper). You can add stuff to an EMR, but you can’t change its basic nature. It IS an application NOT a platform! You build it (the EMR) on a platform and the platform can be open or closed and you can build other applications to work with the EMR. The EMR is an application. Peroid. End of story.

    Kyle, what is your background? I am a doctor. Internal Medicine. What is your expertise and how do you think you know so much about EMRs, etc?

    Also your analogies to YouTube and the iPhone are off the mark. EMRs are used by individual physicians for individual patients and the information can be shared, it is not a public forum or platform that large populations use for basic communication. It is not illustrative to compare EMRs to the iPhone or YouTube unless I am missing your point.

    I would love to debate you on this topic on this blog. Maybe Dr. Jeff or John can set something up so we can flesh this out. One of us is way off base or we are having a terrible miscommunication!

    I fear that many of our EMR System designers (like you) have basic misconceptions about the EMR (and about patient care) and that is why we are having such trouble getting EMRs that are usable.

  • I am a founder of the company which created StreamlineMD, a hosted EMR service for smaller practices. (Full disclosure – StreamlineMD was later sold and I am no longer associated with it).

    It was evident from our beginning in 2005 that customizing the EMR for the particular needs of a given practice would be paramount to widespread success. Even within a speciality like Pain Mgt, we created several variations of templates to cover the particular procedures and methods used. Even beyond that, Doctors had specific preferences as to note style and language. Our service included accommodation of these realities (at least within the limitations of our software).

    As such, the best EMRs are both Applications and Platforms. The application part is clear, however, a major design difference between products is their ability to be customized for particular situations and clients. That makes a well designed EMR a platform as well as an application.

    In line with this platform perspective, multiple specialties can use a single EMR if the clinical content is also designed properly. I think that there will always be many specialty specific EMRs around because they have the best chance to get the clinical focus correctly and EMRs are inherently sticky products. No one wants to change once implemented.

    It is an enourmous amount of difficult work to develop all specialties for one EMR. Nextgen in particular has done what some call a credible job of that.

    However, as also pointed out, the larger companies, including Nextgen are notorious for very low practical usability scores. As software companies, they show little appreciation for complex, time sensitive operational environment found in medical offices.

    Although I would anticipate consolodation in the industry, I think there will be a wide range of vendors for the product. The ubiquity of Billing software certainly has not reduced the number of vendors there. The vendor list will simply have different names over time as the good ones grow or consolodate and the lesser ones disappear.

  • Dear Forum,

    CCR, CCD(CDA compatible CCR), C32 further restricted version of
    CCD are continuing to delay the acceptance of a single standard
    for the exchange of JUST demographic data. I am currently working on a standard for Patient Identifying Information that
    could be a single standard that only applies to ID confirmation.

  • I have been heavily involved the upgrade and set-up of of multiple EMR’s. I’ve found that they all have glitch’s. It almost seems where one lacks another has value. For example, E-clinical works has canned and inaccurate reporting. If that is what we depend on in a physician productivity based organization, I see issue. It is pretty reliable, once set up on getting the job done, but most certainly lacks in various modalities. GreenWay has a less proprietary reporting feature, but is so expensive, cumbersome and detail oriented to maintain, that there is a large probability you will spend more funds than you will ever make on Meaningful Use incentive. Athena Health is also reliable, but this is an outsourced agency handling your billing, you have no access to master files, and limited control of the set-up structure of your EMR.

  • Great comment Rachel. I’m glad to have someone with your experience participating in this community. Please share more of your knowledge so we can all learn.

    I think you’re true. I’ve often said that you’re not making the choice of the perfect EMR. Instead, you’re making the choice for the EMR issues that you are most willing to put up with. Not to mention the EMR benefits that said EMR will provide you that outweigh those issues.

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