So Many EHRs and 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 around 50 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.