EMR Market Share

Editor’s Note: This is the first post on EMR and HIPAA by James Ritchie. James is a longtime journalist including the past eight years as a staff writer with the Cincinnati Business Courier.

Practice Fusion announced in June that it led the EMR industry in market-share gains.

Citing SK&A reports, the San Francisco-based firm boasted that it controlled 5.8 percent of the market as of May, up from 3.8 percent in July 2012. Beyond Practice Fusion, only Epic, AthenaHealth and Cerner showed gains.

In this data, which represents physician offices only, Allscripts was the market leader, with a 10.6 percent share. Not far behind were eClinicalWorks, with a 10.5 percent share, and Epic, with 10.3 percent. (The report that Practice Fusion links to is actually dated January 2013.)

But there’s more than one way to look at the EMR share picture.

Epic was the clear winner in a report by the Austin, Texas-based consultancy Software Advice on meaningful use attestations. Epic, based in Verona, Wis., accounted for 20.3 percent of attestations for a complete EHR in an ambulatory setting.

The firm’s competitors were nowhere close as of the March 2013 report. Allscripts was the system of choice for 11.6 percent of attestations by eligible professionals, and eClinicalWorks accounted for 8 percent. Next on the list were NextGen Healthcare, GE Healthcare and, with 2.7 percent share, Practice Fusion.

Software Advice claimed that the figures, based on Centers for Medicare and Medicaid Services data, might be the best around. They at least provide a standard in a market where vendors “use varied criteria to calculate their customer base,” according to the company.

Companies “might count number of users (which could include everyone from physicians to administrative staff), number of medical providers (which could include everyone from physicians to midwives) or number of practices,” Software Advice noted on its website.

Practice Fusion, founded in 2005, claimed in its press release to have doubled both its monthly active user base of medical professionals and its patient population between 2012 and 2013. The company claims to reach “a community of 150,000 medical professionals serving 65 million patients.”

The prospects for the free model that Practice Fusion uses are still up in the air. Doctors might question whether they want ads, unobtrusive as they are at the bottom of the screen, to compete for their attention when they’re entering patient data. Data, by the way, might prove to be the real revenue generator for Practice Fusion. In June the firm launched Insight, an analytics product offering a population-level view of diagnoses, prescribing patterns and other information. It’s a model worth watching. If Facebook and google can build businesses on data, maybe Practice Fusion can, too.

The SK&A figures show just how fragmented the outpatient EMR/EHR market is. The top 10 vendors accounted for only 64.8 percent of attestations, leaving about 35 percent of the market to the “other” category. By Software Advice’s count, 560 firms logged at least one meaningful use attestation.

Eager to steal share are firms like Irvine, Calif.-based Kareo Inc. It launched its own free, cloud-based EHR in February based on technology acquired from San Mateo, Calif.-based Epocrates Inc. The firm reported in June that 4,000 providers had signed on, with a third of them moving from another EHR.

Of course, ambulatory adoption is only part of the EMR story.

Epic is No. 1 among the nearly 3,000 hospitals that have received federal incentives for using complete electronic records systems, according to Modern Healthcare. The company holds a 19.6 percent share, followed by Computer Programs and Systems Inc. with 15.5 percent, Meditech with 14.1 percent and Cerner with 11 percent. The late-May report was based on numbers from CMS and the Office of the National Coordinator for Health Information Technology.

The inpatient market is far less fragmented than the outpatient space. The top 10 companies control 92 percent of share, according to the report.

No matter how you count share, the EMR space will continue to be hypercompetitive because of the dollars at stake. The market amounted to $20.7 billion in 2012, up 15 percent from 2011, according to the research firm Kalorama Information.

About the author

James Ritchie

James Ritchie

James Ritchie is a freelance writer with a focus on health care. His experience includes eight years as a staff writer with the Cincinnati Business Courier, part of the American City Business Journals network. Twitter @HCwriterJames.

8 Comments

  • James, I’d agree that there are multiple ways to measure the reach of an EHR. But I’d also point out that different EHRs are aimed at different audiences. For instance, a medical practice owned or affilliated with a major hospital probably should be using the same EHR as the hospital, or at least one that can be tightly integrated. But among independent practices, what gets picked will be highly influenced by the size and complexity (and financial standing) of the practice. A large practice, perhaps multi site, needs a large capacity system. But a small practice not in a high paying field might do best with an EHR such as Practice Fusion. Indeed, imagine a small GP practice using PF, linked to various small specialist practices in the are who are also using PF, easily sharing at least some patient data, all able to eprescribe to the same pharmacies. Inexpensive, and some sharing built right in. PF would have a huge advantage in this arena.

    IOTW, context is very important, and the market is segmented just the way medical care is. And market share ought to, IMHO, be looked at within market segments, not overall.

  • I agree. There’s a lot of nuance to consider. Your idea about the synergies they could get with a system like PF is interesting. I wonder if PF has gotten that kind of critical mass in any particular community? Where I live, the independent practices seem to have a wide variety of systems. The large hospital systems are acquiring many of the practices, though. In that case, they end up on Epic, as that’s what all of the large hospital groups are using.

  • The practices being bought out by hospitals seem to be mainly high value, large practices with expensive specialties whose doctors are already closely connected to the hospital. For instance, a local hospital near me will soon buy the practice that happens to include the hospital’s head of Oncology. BTW, they are not Epic, but some other systems on Long Island are.

    PF has a chance though to grab up lots of independents. But part of what they have to do is convince them that they will become more efficient by going to their EHR as opposed to paper; one doctor I know hates her hospital EHR so badly that she won’t use an EHR in her part time private practice. But other small practices, knowing they can share charts with other small practices and have an affordable EHR, would be good for PF to go after.

  • Thank you for purchasing and summarizing these reports. What they also don’t capture is the risk element of market distortions arising from EHR incentives payments. Clinicians and clinical organizations resisted uptake of these unregulated, unproven technologies until the market distortions (unfettered by safety or usability qualifications) were introduced to speed their uptake.

    I had a thought recently that, in a way, these market share reports are like reading pathology reports for cancer staging purposes; what proportion of the body is invaded by the cancer-like attributes of information systems that are:

    1. Not regulated (so, like cancer, have bizarre and irregular impact on patient care, patient care operations, and business operations’ risks.)
    2. Minimally “certified” against attributes that do not require fitness for direct patient care.
    3. Shielded from “treatment” ex: blocked from free market knowledge of defects or harms by contractual obligations to not report problems, defects, harms, etc., except to the vendor

    Nurses and a nurses’ professional organization are raising increasing concerns and taking public action to voice their concerns. At the same time, the entity charged with providing some oversight for EHR payments and utilities such as privacy/security inspections is having its budget cut.

    http://www.washingtonpost.com/politics/budget-cuts-force-scale-back-of-health-care-fraud-investigations/2013/07/25/888fee8e-f536-11e2-9434-60440856fadf_story.html

    It remains a fascinating exercise to ask why we are using taxpayer dollars to speed the uptake of patient care information systems in the absence of safety and privacy testing and free of evidence of utility. We all understand that the long term requires the effective and efficient use of information that computerization can provide, but that is the means, not the end. In the meantime, as so eloquently described by Dr. Robert Foote at Dartmouth Hitchcock Medical Center, EHR documentation systems, when improperly designed and implemented, are the adversary of clinical thinking. See “The Challenge to the Medical Record” in JAMA Internal Medicine, July 8, 2013, Vol. 173, No. 13m og, 1171.

    Meanwhile many, including me, labor in EHR Standards under the Standards Development Organization HL7 with the EHR System Functional Model Standard and the Records Management and Evidentiary Support Profile Standard. The former is slightly referenced in current US Policy on HIT but the latter has been entirely ignored. This is resulting in the implementation and use of EHR systems that will do things nobody in their right might would ever consider legitimate in a paper record (falsifying authorship, altering without evidence of alteration in record outputs, etc.)

    The health care industry will undoubtedly survive the damage wrought by the market growth of poorly designed, poorly implemented, poorly used HIT, but how many patients (and health care organizations) will suffer during our national experiment with these unregulated systems?

    My hope is that, as press reports and patient safety harms investigations (like the recent ECRI report) accumulate, this will lead conscientious clinical organizations to take a more patient-centric stance towards these systems. These are not “plug and play” systems. In the absence of meaningful expectations of safety and utility, the due diligence burden (and associated risks to patients and to the enterprise) is entirely on the clinician and the clinical organization.

    Best wishes and good luck to us all.

    RDGelzer, MD, MPH
    Advocates for Documentation Integrity and Compliance

  • Dr. Gelzer,

    Thank you for sharing your thoughts. After your point No. 1, I might never look at market share reports in the same way. At any rate, these are important issues to think about. The EMR market of today would certainly look different if the government had not taken up the issue.

    Best regards,
    James Ritchie

  • “It remains a fascinating exercise to ask why we are using taxpayer dollars to speed the uptake of patient care information systems in the absence of safety and privacy testing and free of evidence of utility.”

    The answer is “data”. The goal is a single payer system where the EMR systems all dump patient data to so the .gov can analyze it for costs and outcomes.

    An example of this would be;

    Analysis would show that a provider in the Miami is over testing for the same chief complaint and diag as a provider in Ft. Lauderdale. The single payer system would change the reimbursement for that provider in Miami because he is wasting money for the same treatment and outcomes as other providers in 15 miles north.

  • Corey,

    I don’t necessarily disagree that the government would like to do this. But don’t you think the systems are far from being standardized enough to make this realistic any time soon?

    When you look at what, say, hospitals have to do right now in order to get their data in shape and report it to the govt. for quality initiatives etc., it looks somewhat labor-intensive to me, far from a simple data dump. In Cincinnati, where I worked for quite a few years, all of the major hospital systems — five or six or so, depending on whom you choose to count — use the same vendor, Epic. But as far as I know, those Epics don’t talk to each other.

    I’m skeptical that the government’s right hand will know what its left is doing any time soon.

  • Corey,

    I disagree. I think the aim is to establish a nationwide care system with some degree of structured data and interop to manage the small % of patients that consume 80 to 90% of the Medicare/Medicaid resources that in turn have little to no personal resources.

    ObamaCare is just one piece of that puzzle also. The first move to a centralized Medicare/Medicaid for everyone.

    The “central planners” either don’t even realize what they are trying to do or dance around talking about it publicly.

    In any event not a bad idea.

    As I have posted though, most if not all of the admin and IT money has probably been largely wasted. We would have been much better off investing that money in basic bio-med research.

    Remember, “treat the cause, not the symptoms”?

    Let’s cure the really expensive, chronic stuff and then have an honest debate about the cost of heroic measures in the last 6 months of life.

    Why keep throwing money down the HIT rat hole that we all know won’t and can’t work as expected?

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