What EHR Adoption Means to the Future of Interoperability

With a crowded EHR vendor market, there is now open space for ancillary technologies to connect the dots between disparate patient management and other technology and data sources.

Over the last ten years, the healthcare industry has undergone tremendous digital transformation spurred by federal efforts to eliminate paper-based clinical practices and reap the benefits of data analytics to support innovations in care delivery and payment reform. Providers moved quickly to complete EHR implementations and adopt a technology that is key to capturing clinical data with an eye on using the health IT standards within EHR systems to drive interoperability. 

But EHR technology is only one piece of the puzzle for resolving a system-wide lack of interoperability. And now that the EHR rush has subsided, providers are looking for opportunities to connect with new technologies (e.g., mHealth, telehealth, remote patient monitoring, wearables) solutions to bring ancillary systems and disparate data sources together to put actionable information in the hands of clinicians. The future of interoperability depends on the industry’s ability to manage their complex digital environments and allow data to lead to positive outcomes for individual patients and patient populations.

No technology is more indicative of and critical to this digital transformation than the electronic health record. EHR technology gives structure to clinical data and fuels analytics necessary for future quality improvement. According to Definitive Healthcare data on technology installs and contracted implementations at 7,411 US hospitals, the vast majority have settled on a choice of core EHR systems.

A decade ago, less than three-quarters of hospitals (73 percent) had adopted an EHR system. Five years later, the percentage of hospitals with EHR systems increased to 93 percent. Between 2014 and 2016, that percentage grew by three percentage points to 96 percent. And as of 2018, 98 percent of hospitals had an EHR system in place or planned to install one.

The impact of the EHR Incentive Programs (i.e., meaningful use) on adopting the technology is clear to see. Between 2009 and 2014 when the programs began disbursing financial rewards for EHR adoption, the industry saw a 20-percent growth in EHR implementations and use. As the programs started to wane between 2014 and 2016, gains in EHR adoption shrunk to 3 percent, and the past two years saw only a slight increase of 2 percent. The remaining holdouts are rural, critical access, and psychiatric hospitals.

Now that the dust has settled, it is clear which EHR companies and technologies will play a role in advancing healthcare interoperability. For both ambulatory and inpatients hospitals, the big three of Epic Systems, Cerner, and MEDITECH control the majority of the market.

Ambulatory EHR

• Epic Systems (35.0%)
• Cerner (26.2%)
• MEDITECH (11.1%)

Inpatient EHR

• Epic Systems Corporation (30.6%)
• Cerner Corporation (25.1%)
• MEDITECH (14.7%)

While a smaller number of EHR companies dominate the market, their EHR technology is likely one of many in a heterogeneous healthcare IT ecosystem that serves patients across specialties and sites of care. The 800 or more mergers and acquisitions in 2018 presented opportunities for healthcare organizations to take an enterprise-wide approach to EHR adoption. However, that approach likely introduced disruption as providers adopted the systems of the acquiring entity.

Definitive Healthcare data indicate that acute care hospitals have on average 1.64 ambulatory module vendors and 2.57 inpatient module vendors. Many IT leaders see value in maintaining multiple EHR systems to support their providers. In all likelihood, they are looking instead for solutions to make these systems interoperate within the organization as part of an overall push for health IT integration. So long as the systems in question are forms of certified EHR technology, the data they contain can be unlocked by leveraging the health IT standards that define clinical data structure.

The decrease in new EHR installs has proven a boon for ancillary system developers. Definitive Healthcare data shows a 1,287-percent increase in patient portal installs; 110-percent increase in computerized physician order entry system (CPOE) installs, and a 1,250-percent increase in clinical decision support (CDS) system installs.

Given its the enterprise nature of its technology, Epic Systems is the leading provider of patient portals (33.9%), CPOE (33.1%), and CDS (24.2%) followed its chief competitor Cerner (17.3%, 27.5%, and 24.16%), respectively.

However, other companies are beginning to gain traction in these areas as providers work to address health IT challenges unique to their organizations and staff.

One non-traditional player is Change Healthcare, whose CDS technology is used by nearly 15 percent of hospitals, only 2 percentage points behind Cerner and 5 percentage points ahead of MEDITECH. Close to one hundred companies are meeting the CDS needs of hospitals.

And while patient portals are generally included in leading hospital EHR systems, close to 60 companies are supplying products for sharing information with patients and their caregivers. While they lag considerably behind Epic Systems (33.9%) and Cerner (17.2%), the likes of Perficient (3.2%), Change Healthcare (2.9%), and InteliChart (2.2%) are gaining ground on MEDITECH (8.6%) and Allscripts (4.9%).

As healthcare organizations move from relatively unsophisticated patient portals to newer forms of engagement, they open the door for new companies and technologies to become part of their digital environments particularly for post-acute care, population health, and chronic disease management which require tailored approaches care for patients outside the hospital’s four walls.

While Epic Systems dominates the patient engagement/experience market for hospitals (45.5%), no other company commands more than a few percentage points. All told, more than 50 developers of patient engagement/experience technology now have a foothold.

While the data does not bear out a correlation between health IT adoption and quality, leading hospitals have invested considerable time and energy under the belief that technology and data are integral to the future of healthcare.

The diversity and multitude of health IT companies actively serving the data needs of hospitals will require healthcare leaders and stakeholders to develop a strategy for integrating these various forms of technology into a seamless experience for providers and patients. Savvy developers will use this knowledge of today’s EHR infrastructure to create solutions that work with existing systems.

EHR systems have helped providers successfully manage the patient record, but due to their narrow design are incapable of providing data-driven insight. As future models of care delivery will require providers to share data efficiently, hospital leaders will need to address the limitations of their existing health IT infrastructure.

The accelerated adoption of complementary systems is transforming EHR systems into more powerful tools for providers to focus on quality improvement, which both commercial and public payers are increasingly tying to reimbursement. As more and more tools become available at the point of care, they have the potential to lead to measurable outcomes that tilt in a positive direction.