Aaron Berdofe, MHI – Health Informatics

Legacy EHR: Any EHR that is not internet-dependent.

How many times have we heard that the HIT market is shifting away from “Legacy” systems and towards web and cloud-based products over the past few years?  Quite often, right?  Hospital systems flaunt how they are migrating away from their legacy systems, and numerous vendors will tout how their products are better than the old applications as seen here, here, here, and here; just to cite a few examples.  Clearly we are at the dawn of a new, internet-based era.

Except, of course if we look at the data.  While market share data is always somewhat sketchy in the EHR Market since it has previously been based primarily on surveys, Meaningful Use reports have given us a more reliable perspective on which EHRs are actually being used in physician offices and hospitals across the nation.  Now if there is a migration, we should be able to see that in the numbers release by the CMS over the past couple of years in the number of physicians who are attesting for Meaningful Use.  However, it turns out that the great migration might be a bit of a ruse, or at least premature.

First, let’s look at the hospital vendors which produce prime examples of legacy products:

Meditech, Epic, Cerner, CPSI: all products which are commonly described as “legacy” are not giving up in terms of market share.  In actuality, Meditech’s apparent gains are probably more reflective of their total number of customers attesting at a slower rate than from other vendors.  What we can’t really discern from the MU data is the number of new sales these vendors are acquiring.  Regardless, there is not a groundswell of web-based EHRs making significant headway.

The ambulatory market is much the same:

Epic still reigns supreme in the number of attesting customers along with eClinicalWorks.  Allscripts is in interesting case since they’ve gone through a whole host of changes as a company, but notably in regards to this information they acquire other EHR companies which adds to their market gain.  Therefore, they have something of a mix of legacy and web-based systems.  Notably, Allscripts acquired Jardogs in March 2013, which is when this information was released.  As with the hospital market, there is not a significant migration from legacy systems to web-based systems no matter how much athenahealth and Practice Fusion wish it were so.  It is also interesting to note that Meditech still cannot crack the top 20 list on the ambulatory market with their offering despite having a stronghold on the hospital market for the past 44 years.

So what does this mean?  It means that despite the talk from industry pundits, we are not going to see a massive consolidation or downfall of big vendors anytime soon.  As Nassim Nicholas Taleb would observe, any company that has been around for decades will most likely exist in the decades to come.  It is interesting that independent physicians are receiving recommendations to look into web-based EHRs which potentially have lower upfront costs or overall costs, but the number of independent physicians is decreasing during this cycle of healthcare system reform.  Therefore, it seems reasonable to assume that behemoth EHR systems that having been sitting in hospital systems for years will not be removed anytime soon as long as physicians are adding to these same hospital systems.  Perhaps when the independent physician becomes popular again and they are aiming to keep overhead down, we will see the prophetic shift towards web-based EHRs.  Until then though, there appears to be no systemic incentive to shift towards “modern” technology.  Meaningful Use, while increasing interoperability, is not incentivizing the update of technology as can  been seen in the lack of technological advancement in legacy products.

It seems apparent that the healthcare industry will still be trudging along on the same technology for the next few years to come.  As long as the industry is geared toward centralization, it will continue to utilize software that is itself a centralized system.  Therefore, for those pundits and vendors who are pushing for the switch to web-based EHRs, perhaps they should be investigating disruptive ways for medicine to be practiced independent of big healthcare systems.  Decentralized industries request decentralized software systems.

Link to the raw data compiled from the CMS MU Attestations in November 2011 and March 2013.