The trends in ambulatory electronic health record implementation are starting to mirror what's happening in hospitals - which makes sense, of course, since so many outpatient providers are being bought up by and tethered to hospitals nowadays.
"If you look at where the activity is in the hospitals, when an organization changes systems, they are going to Epic, Cerner and MEDITECH to the tune of 70 percent of the time - it's basically an oligopoly," says John Hoyt, executive vice president of HIMSS Analytics. "All three of those have offered for years - and Epic for more years - an ambulatory system."
Indeed, those three major players in the hospital space are nestled comfortably in the top five vendors implemented by outpatient clinics - sharing space with more traditional ambulatory vendors Allscripts and NextGen. Epic, as it is, is far and away the top dog, with 32 percent of those tethered clients. Cerner and MEDITECH sit with about 8.7 percent and 6.9 percent, respectively.
Granted, those numbers start to look different when examining smaller and, especially, untethered practices. But the move toward that EHR triumvirate points to one overarching wish for hospital-owned clinics, says Hoyt.
"It's a clear move that the market has caught on that you want, as much as you can pull it off, one common system in the ambulatory space and in the hospitals. It's a clear move that the industry is beginning to solidify around vendors who have one common clinical data architecture for ambulatory and inpatient."
HIMSS Analytics data "clearly shows a solid, consistent move toward vendors who offer acute care and ambulatory on the same clinical data architecture," he says. "And Allscripts does not do it. GE does not do it. McKesson does not do it."
It should be noted that not everyone thinks these particular systems are the right ones to move the industry forward. Many have carped that the Epics of the world are a) too expensive and b) too staid - old-fashioned code, first developed decades ago, not agile enough for a fast-changing landscape.
Expensive, many of these systems are indeed. "There's clearly going to be a problem of IT cost-per patient-day from some of these vendors," says Hoyt.
And those who argue that client-server is passe, and cloud is the wide-open and endlessly updatable future? What about, say, an athenahealth? Whither their client base?
"You will see in the data that their footprint is there, but they're not top three or four," says Hoyt. (Indeed, they're barely in the top 10, with just 1.6 percent of ambulatory clinics opting for their cloud-based approach.) "But their model is what the industry needs: software-as-a-service."
Some of the big three are straddling that line. "Cerner is doing that," for one, says Hoyt. They sell an ambulatory product for a fixed monthly price and it's run via a data center." With this approach they've gained many small practice clients.
"That's clearly the future, if we're going to continue to have one- or two- or three-doc practices," he says. "And we will. For another 40 years - or 30 years."
Still, for the time being, "Epic is very, very solid" when it comes to tethered practices. "They're 25-30 percent of the market in ambulatory," says Hoyt.
On the untethered side - at least for practices with more than 25 physicians - they're very solid too. But for those myriad smaller shops nationwide, the Verona, Wis.-based behemoth isn't part of the plan. When Epic shows up in the HIMSS data it's in the "other" category.
Those ambulatory practices make use of an array of smaller specialty vendors, of course: dermatology, ophthalmology, gastroenterology. "No dermatologist is going to go out and buy Epic or Cerner," says Hoyt.
It's an interesting and perhaps understudied space out there for those small and specialty practices: "There's more than 100 vendors selling ambulatory systems, yet we sit here and we can probably name eight or 10," he says. "Who are these other guys? They're really small local guys."
Small, perhaps, but well suited to the needs of their highly specified clients. And perhaps, if they're able, well situated to make a run for the still-huge number of paper-based practices.
HIMSS Analytics' Ambulatory EMR Adoption Model shows that a whopping 50.11 percent of tethered practices - some 9,563 of them - are still primarily reliant on pens, pads and fax machines.
That "will change," says Hoyt. "The hospitals want the docs to earn their meaningful use money, and they're running out of time."
After all, if a hospital wants to survive bundled payments and accountable care, "they're crazy to have a paper-based office," he says. Duplicate testing and all the other perils of paper-based practices just won't cut it. "They've gotta' get that stuff automated or they won't survive."
HIMSS Analytics only tracks tethered practices for its Ambulatory EMRAM data. But what about all those solo docs out there on their own? If fully half of tethered practices are still without EHRs, what of those who have no real compulsion to move towards digitization? Well, it depends on a few different factors.
If a physician doesn't have a lot of Medicare patients - a dermatologist, say - then, what do they care? They could conceivably comfortably ride out whatever federal penalties they might have coming to them and keep on with business. Or a physician pushing retirement age, with kids nearly out of school? Time to retire, rather than deal with the headaches.
"But what about a gastroenterologist or an internist whose got a bunch of Medicare patients, and they're untethered?" asks Hoyt. "They're going to have to do this or suffer the consequences. Because they're going to get competitive push: 'I don't want you in my ACO because you can't participate electronically.'"
For those practices, the answer might be just to start reading up and asking around, trying to make an informed decision with the best help they can get.
It's not easy. After all, "they're busy trying to run a medical practice," says Hoyt. That's why there's a "world of opportunity for consultancies to get out to the non-tethered practices and teach them how to shop for a system."
Tip number one? "Do not sit there and get a demo like it's Disney World. You need to tell them what your biggest problems are and what you want your future state to look like. And put it in writing. You've got to direct them to serve your needs."