OpenEMR: Electronic Medical Records and Medical Practice Management Software

The EMR market is consolidating on two big vendors: Epic and Cerner. Depending on how you measure it (Hospitals on a system or Medical Records under management), either Cerner or Epic is #1 and the other is #2.

At this point, in the U.S., it is almost impossible for a newcomer to break into the market. There are many companies out there slowly losing market share to Epic or Cerner. Allscripts, Nextgen, McKesson/HBOC, GE, and others. Some are big, well-funded companies, others are more like startups with OK funding. Most of them are falling by the wayside, casualties to the bitter Epic/Cerner market war.

The HITECH act really exacerbated this point by accelerating spending on EMR's since 2008. Meaningful Use meant that a lot of homegrown systems had to be replaced, simply because hospitals couldn't keep up with the regulation and complaince. Likewise, smaller companies had to spend more money on compliance than adding features and also faded. Sure, there are plenty of Allscripts and HBOC customers out there, but their number is shrinking, not growing.

In a way it's a shame, because the two biggest vendors each have critical flaws. Cerner has a decent store in Oracle, but is hobbled by reliance on its own homegrown language for integration and middleware. The language is CCL and is like a cross between PL/SQL and TCL with HL7 Domain knowledge thrown in. Epic has an ancient store with Caché, which is really MUMPS with some OO and relational hooks tossed in. Cerner excels at customization, while Epic excels at disciplined project implementation. You can browbeat Cerner into giving you what you want, but you can implement Epic pretty much close to on time and close to budget with an impressive reliability.

Neither system really wants to interoperate with the other. It can be done, but it takes a months-long project with specialists writing HL7 interfaces to pass demographic, lab, and document data between each system. And this interoperability, once established, doesn't really help the patient. Docs can see orders entered in Cerner Powerchart displayed in Epic Hyperspace, but the patient doesn't necessarily get access to either the order or the result unless it goes to either system's portal.

Finally, you have to realize that you are dealing with a very powerful and conservative management culture. Many Silicon Valley startups with whizbang solutions have foundered when they run up against the entrenched incumbents. Well-funded companies with highly competent engineers have failed because they don't have the patience to spend a couple of decades building up a user base. Investors realize that they can get more bang for their buck elsewhere and leave the game. If you even want to make a dent, you have to be willing to spend at least 15 years and untold amounts of money just trying to take on the big guys. If you're going against a market with relatively short turnarounds, like a calendaring app or even a game console, you have a shot. If you're going against a market that is very conservative and waits at least a decade before reevaluating installed systems, you have a very tough row to hoe.

Ultimately, at least in the U.S., I think that implementing a new EMR is a sucker's game. You can spend millions and lose.

In New Zealand, the market is different at this point, but how long can they resist the network effects of the big vendors? Cerner and Epic are currently battling it out in Australia, and will exert pressure in NZ once that market is settled. I know for a fact that Cerner went after NZ in the late 90's but pulled back after it became clear that entrenched corruption in the NZ procurement system would determine the winner. I don't have names and places for you, but I was in Sydney at the time and remember the disappointment of the executive team when they realized that NZ at that point was not a genuinely open market.

You have mentioned in another post that you are concentrating just on records, and avoiding the extra complexity of the other systems in terms of patient management, practice management, supply management, etc… With all due respect, I think you are being naïve. A modern EMR system has to take into account the entire needs of the practice and how to manage it. When a health care practice is spending a buck, they want to get as much out of that dollar as possible. If vendor A is offering "just records", but vendor B is offering records plus practice management, they will go with vendor B. Every time.

In any case, I wish you the best of luck. I have a lot of experience in this sector and would be happy to share my knowledge with you.

EHR is not difficult. There's a lot to the required data model, but building a working system doesn't require mental gymnastics, just time and effort.

Selling isn't particularly challenging either. There is a tried and true model for selling to medical practices and hospitals that works. Customer acquisition is expensive and resource intensive, but it's doable with the right team and right investment for any product.

There is risk, but HIPAA is a lot more of a risk than a logical failure. With every HIPAA violation, there are fingers pointing in every direction, and that means that resources are required to respond to everything - even when it's painfully obvious the software isn't at fault.

I would say that the biggest challenge to creating a market for a new EHR product is that there are generations of people resistant to any real user interface changes. I'm not even talking about adding tabs or checkboxes. If an EHR product logically maps to one of the legacy powerhouses like EPIC, it makes sense to people. If it logically maps to health care instead - No dice. People are entrenched in a system that was designed by engineers for health care because that's all that was available for a generation. They've gone to classes to learn how to work in that environment, they've worked in it for years, and it works for them. A major shift of any sort means retraining doctors, nurses, call center operators... anyone and everyone up and down the food chain. Even in a small practice that's a lot of time and energy to invest. There is resistance every step of the way.

I'm just a patient, but I see the advantage to paper.

1. Once it's on your digital record--it's vunerable to hackers, or staff sending a patient's information off without their consent--with a tired swipe, or send key.

2. Once a doctor knows you have been on a potentially addictive drug, or had a problem in the past with addiction, or theses days; self medication, good luck trying to get relief from future pain.(pain=physical, and emotional.) About a year ago I went to a hospital with a case of shingles that looked twice as bad as those commercials on t.v. The staff looked at my record, and I could tell they were concerned about something. Yes--I'm on a low dose of a benzodiazepine. They didn't even bring up pain medication. I didn't even ask, but the pain was bad. Here's a script for 3 10mgs of predisone. I walked out of the emergency room with a prognosis of Anxiety on that stapled care instructions. I was so misserable, I didn't care. They mixed up my record with the guy next to my bed.

3. A compassionate/caring doctor will sometimes write things on paper they wouldn't on a electronic document. In the ninties, my long retired family doctor asked me if I tested positive for the AID's virus, he would put the results in sub-script writing only he would know. He was protecting me from being denied insurance.

4. I thought electronic medical records would be available for patients online. I don't know if patients can access them, nor care anymore. I'm so tired of the system, I just don't care much anymore.

The combination of OpenEMR being open source, open community, volunteer driven, physician driven and getting significant use in the real world makes it a perfect vehicle to glean really useful insights into EMR use and I highly recommend looking into it in your research endeavors. For example, in subjects such as EMR system development and the effects of regulation.

A really nice and innovative example on EMR system development is the development of the Eye module released in OpenEMR's most recent version 5.0. A practicing ophthalmologist, Dr. Ray Magauran, decided to develop a ophthalmology module in OpenEMR with the goal of actually improving efficiency over paper (as a physician, I would confidently say I have never used an EMR that is faster than paper). What this physician/developer did was simply amazing and the details of this eye module(including the makings of it) can be found here: http://www.open-emr.org/wiki/index.php/Eye_Exam

What I think is innovative here is that this was designed, built, tested, and used by a practicing physician on the front lines.

Then on the flip side can also learn about the dichotomy of fulfilling regulations versus developing an innovative and efficient EMR system, which OpenEMR provides a ring side seat too since the road to complete meaningful use certification was done the open source way(ie. in full public view).

Oh man, this is so insanely true, allow me to just contextualize this for you with a POV from the States.

I'm not in medicine (oh thank Christ) but I come from a family where I couldn't ignore the the industry if I wanted to. (Literally every male for 3 generations on both sides have worked directly in either medicine in a university capacity after their PhD, actively practice(d) medicine, or more commonly done both.) My mother's an RN, and my sister's a BS/LPN who's one of those "do gooders" who jumps around (on her third graduate degree now) working usually neuro AC or OR full-time concurrently. So I've heard it from the board-level to the overworked resident side to the 'thank god that fellowship is over' and the 'just got off a double and had three GSRs and a handfull of standard MeOHs', from the the early EHR adopters (interestingly enough, B&W/Partners in Boston) side, the pen-and-paper side, to the 'in between'. The 'in between' is the worst for every one, at every level, bar none, unless you're the one on the steaks-and-strippers sales side.

The limbo period is where absolutely everyone is frazzled because things don't work the way they used to. That's fine for us since we design the damn things, if the scheduling API changes we can just use ...anything really... to make that new JSON invocation or XML-RPC call and Bob's your uncle. But everyone can't be expected to "just pop the hood change the carburetor's flow by 3cfm"; they just want their damned car's engine to turn over so they can use the vehicle. So everyone else is fighting new apps and new workflows while still having to make sure that you're still maintaining an SLA of literally 24/7 operational functionality in certain departments with maybe 3 hours a quarter of scheduled yellow-time for upgrades on 3AMs of the first Sunday each month.

Let's start with getting paid, since everyone needs a paycheck, right? The new system dictates that all employees have to badge-in with new RFID's at certain points (entrances, exits, secure regions, etc). In theory, great idea. Part-time employees salary now gets automated plus now we can ensure better operational security (why is Dr Jane, 9AM-6PM, internal medicine, badging into the OR, 4 floors from her office 5 hours after her shift, where all the Demerol happens to be kept...?). Any non-salaried employees pay-check gets tied into the badge-in/out and literally 70% of the staffers forget to do this, since they never had to before and after lunch they're just walking back in as they normally would. Jon the Janitor pulls up his Bank of America statement and is wondering why last weeks check (bi-monthly, with one pay-cycle close period for adjustment/payout -- so some of these hours, remember, are from potentially 5 weeks ago) was for $90 instead of $2400. So he calls HR to get the money he worked for, and Oprah who's been a great HR employee tries to figure out where the 'alter' feature is and after 5 minutes of "bear with me, sorry, this is a new system...(awkward pause)..." they finally figure out how to make adjustments to the hours (turns out the a manager 2 levels up has to authorize the labor change, since it's past the adjustment business rule of +/- 10% of the hours). AP is slammed with a 40% increase of workload since all those checks have been sent out and we're already in to the second week of the new cost-accounting period. So everyone is frantically calling in 5 weeks after the quarter closed as to why last weeks check was for $90 instead of $3400. Having fun yet?

So Tim works the support-desk phones making sure Derm's scheduling is taken care of. He's spent 20 years making sure all those follow-ups are properly scheduled, all the new patients coming in have the proper primary referrals, etc. Not a glamorous job but he's good at it. Jane's in her 50s and been seeing Dr Eczema for 8 years. She's calling to schedule her yearly just to make sure that mole on her neck which was 2 of 5 on the ABCDE ("looks alright now, let's keep an eye on it though") hasn't developed into a malignant growth. He tries to pull up her file (there's about a 75 second delay there as he fumbles around with the new system's UI and "no no, that's not your subscriber ID, that's your patient ID, your member ID is 8 digits and begins with 40", he finally gets to the right modal menu, and has no idea to even see if her doctor has any availability on the Tuesdays mornings she's got some free-time to take off from work. (Before this, he's would have always just told Jane to "please hold.." and punched in the extension number for Dr Eczema's PA, Mr Clockwork to see if there's availability.) So now he's literally iterates through every possible drop-down, for every 15-minute interval Jane can take off work (9AM to 11:30AM, 10 slots), for the next 6 weeks (takes say 4min30sec per patient). It ends up taking him five minutes, but he gets really good over the course of 8 months at clicking buttons (clocks that down to just under 2 minutes, boom!) before a co-worker tells him there's an "Availability" modal hidden 3 sub-screens in that lets you access Dr Eczema's full calendar. (He was sick on that training session day.) Tim's ecstatic.

Don't get me started on the the custom iPads that the CIO thought "we gotta have, it's the new thing!" which no one uses since the GUI is obtuse and every room has a desktop which is far easier to take notes while talking to your patients. 6 months later, 2k iPads are gathering dust and everyone just uses an RDP session into the Win2k12 server since it's way way easier to take notes/make referrals/write scripts. Don't get me started on actual selection process, as board-level CIOs' wife happens to hold 200k shares of pre-IPO stock she scored 12 years ago that's worth a small fortune now. He conveniently omitted that fact, and rather than recusing from the selection committee was actively pushing for it. (True story.)

Now the CIO is evaluating 'hmm should we go to Cerner?' because we have 2k iPads sitting around doing nothing, some 60 year old absolutely-brilliant neurologist who's responsible for a ton of patient draw (as such, a lot of political clout) can't figure out how to use the damned thing. (An apt comparison would be "ever tried to help your grandparents use email during the hotmail-era?" for those of you who remember that sort of thing.) [Basically the equivalent of moving from SAP to Sage500/Dynamics/other-ERP which also happens; the Mayo Clinic transitioned from EPIC to another EHR while my uncle was there, all sorts of fun I heard!]

There are all sorts of issues on the logistics "who gets what money for what and when". E.g. you have changing insurance issues (i.e. OK, so this patient with this internal medical record saw Dr Foo in dept Bar, which we can internal cost accounted at $x, let's get this invoice for $y out to... (oh damnit, ok who is their health insurance company, let's ping the state's open exchange since this patient gave us their MassHealth ID number[or whatever appropriate exchange your state has if they opted to take the ACA federal funding] and see who their insurance provider is so we can bill this out). Single-payer would be a blessing in reducing complexity!

If you've ever wondered why some cities drop 12 million dollars on a new HR platform only to have it fail 18 months in, it's because information management is hard, regulatory reporting burdens are high, and transition costs (both the political stake the primary project manager who initiates the change-over, as well as the actual quantifiable monetary costs) are astronomical. ATC still uses software designed in the 70s where their web interface is literally screen-scraping IBM CISC software. It's horribly inefficent, but it's been battle-field tested.