physicians' take on ehrs - reaction data · users--physicians. we take the temperature of...

Physicians' Take on EHRs

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AN INVITATION TO HEALTHCARE PROVIDERS

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Premium Content Not Included In this report• Net Promoter Scores associated with each supplier

•In depth look at most considered EHR suppliers for replacement business

•Most considered EHR suppliers by first-time adopters

•In depth look at EHR suppliers most ast risk of losing clients

•Detailed outline of top ways EHR suppliers can save “at risk” clients

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Table of ContentsExecutive Summary

Demographics

Ambulatory Care Participants

Ambulatory EHR Adoptions

Main EHR Suppliers Among Acute Care Participants

Primary EHR Suppliers Among Ambulatory Care Participants

Damage Control - The Replacement Market

Top Physician Priorities

The Holdouts

Net Promoter Scores

Conclusion

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7

10

13

15

17

19

24

26

29

33

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Vendors Covered in this Report

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Executive Summary

For years, politicians have pitched the move to EHR as some sort of magic elixir that would solve all of America’s healthcare problems. Less than a decade after the HITECH Act sought to stimulate investment into Healthcare IT, EHRs have become a regular feature of American medicine; but problems still remain.

This report subjects the EHR market to a demanding physical examination from the often ignored frontline users--physicians. We take the temperature of current customers, to see how happy they are with their supplier, send them through a full body CT scan to determine strengths (if any) and weaknesses, and even have them turn their heads and cough, to discover painful problems that are holding back this market from truly meeting real needs an EHR platform ought to be addressing.

In August 2016, we received feedback from 1,053 physicians who gave their unique perspective on the state of the market — and we determined there is nowhere for EHR suppliers to hide. Specifically this report covers:

•Prominent players in both ambulatory and acute EHR settings•EHR replacement market dynamics•How EHR suppliers can save at risk clients•Top EHR frustrations among physicians•Plans of the ever-shrinking first-time adopter market

The results are very revealing. Among other things, this report finds:

•Most physicians are highly dissatisfied with their EHR•Frustrations are driven by poor usability and lack of desired functionality•The EHR market for acute care facilities is consolidating quickly •While fragmented, Epic continues to make inroads in the ambulatory EHR market

As with all things peer60, we recognize that one size does not fit all. Accordingly, this report breaks down the results by title, organization type, size of organization, and IDN a�iliation. The result? A report with lots of information that EHR consumers and suppliers should find enlightening (and those who don’t can go back to sleep).

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Demographics

Reports should never be a black box— you should know where our information is coming from. The following data comes from 1,053 physicians representing a wide range of facilities. Here are the percentages, broken down in a number of ways.

26%

74%

Participants by Organization Type

Acute

Ambulatory

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Demographics Cont.Acute Care Participants

19%

11%

11%

8%

8%

8%

5%

4%

4%

3%

2%

2%

15%

Emergency Medicine

Internal Medicine

Anesthesiology

Orthopedics

Pediatrics

Surgery

Neurology

Radiology

Psychiatry

Physician Leaders

Ophthalmology

Pathology

Other Physicians

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Demographics Cont.Acute Care Participants (by Organization size)Acute Care Participants (by Organization size)

15%

14%

27%

13%

30%

Acute Participant AffiliationAcute Participant Affiliation

74%

26%

IDN

Non-IDN

0-300 beds

300-450 beds

451-600 beds

601-750 beds

751+ beds

10


16%

11%

9%

8%

8%

6%

5%

5%

4%

4%

3%

3%

3%

Pediatrics

Internal Medicine

Orthopedics

Psychiatry

Surgery

Anesthesiology

Family Medicine

Ophthalmology

Otolaryngology

Neurology

Obstetrics and Gynecology

Dermatology

Urology

Ambulatory Care Participants by Most Common Specialties

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Ambulatory Care Participants Cont.

67%

14%

8%

4%3% 3%

67%

14%

8%

4%3% 3%

67%

14%

8%

4%3% 3%

67%

14%

8%

4%3% 3%

67%

14%

8%

4%3% 3%

67%

14%

8%

4%3% 3%

67%

14%

8%

4%3%3% 3%

67%

14%

8%

4%3% 3%

ambulatory care participants (by organization size)

1-10 Physicians

11-50 Physicians

51-200 Physicians

201-500 Physicians

501-1000 Physicians

1001+ Physicians

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34%

66%

Ambulatory Participant Affiliation

Hospital-owned

Independent Physician Group

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Ambulatory EHR Adoptions

EHR Adoption

Not surprisingly, the majority of the “have-nots” in terms of EHR adoption are small clinic organizations that often believe they don’t need an EHR (or just can’t a�ord one). See below. This represents a small growth opportunity; Because lack of adoption is primarily a small practice issue, many top suppliers choose not to vie for this segment of the market.

It is worth noting that ambulatory facilities are more likely to have an EHR when they have ties to a larger hospital. That probably comes as part of the relationship, but it means a supplier might be able to find a niche in small, unattached practices.

Note: When looking at data sets showing adoption based organization size, a small percent within larger organizations does not yet have an EHR system in place. This is typically a small facility which is part of a larger health system that has not yet gone live with EHR functionality.

85%

15%

Have EHR

No EHR

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Ambulatory EHR Adoption Cont.

75%

97% 95%100%

95% 96%

25%

3% 5%0%

5% 4%

1-10 11-50 51-200 201-500 501-1000 1001+

EHR Adoption Among Ambulatory Organizations (by Physician Count)

89% 83%

11% 17%

Hospital-owned Independent

EHR Adoption Among Ambulatory Organizations

No EHR

Have EHR

Have EHR

No EHR

15


50%

21%

9%

4%

Epic Cerner Allscripts VistA

Primary EHR Vendors Used by Acute Participants

When it comes to acute care participants, the market leaders were probably not a surprise. Epic, Cerner and Allscripts each distinguished themselves by garnering a significant amount of support. Obviously Epic is the 800-pound gorilla in the room, but it has not been able to box out its competitors entirely. Rather, things become much more competitive in the ambulatory space.

Note: Our participants from acute facilities disproportionately represented large IDNs and other large hospitals. As such, our results here certainly understate the market of many vendors (for example, Meditech mainly caters to smaller acute facilities).

*VistA is a unique case as its focus is on the Veterans Administration and United States Military. Still, we felt its data was interesting, and so it is included in this report.

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59%

53%

45% 44%

55%

24%

9%

27%

16%

21%

3%6%

9% 9% 9%11%

3%6%

0%

6%

0-300 beds 301-450 beds 451-600 beds 601-750 beds 751+ beds

EHR Vendors Used by Acute Participants (by Bed Count)

Epic

Cerner

Allscripts

VistA

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18%

7%6%

5% 4%4%

4%3%

3% 2%

Primary EHR Suppliers Used by Ambulatory Participants

With more than 1,000 participating physicians in this study, it’s hard to argue against Epic’s dominance in the ambulatory EHR market with almost three times the installs among participants than the next closest supplier, Allscripts. We might have expected a little more balance on this side of healthcare among suppliers. This confirms, once again, Epic’s goal of total world domination (and yes, that’s some serious hyperbole on our part, but we couldn’t help ourselves).

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7%

6%

3%

6%

5%

3%

4%

4%

4%

22%

7%

10%

6%

3%

12%

6%

1%

1%

40%

7%

11%

4%

4%

2%

4%

4%

54%

7%

14%

7%

4%

4%

50%

5%

5%

5%

5%

70%

9%

4%

Epic

Allscripts

Cerner

eClinicalWorks

athenahealth

NextGen

Greenway

e-MDs

Practice Fusion

Ambulatory EHR Suppliers (by Physician Count)

Each of the major suppliers appear to have a presence in most if not all sizes of ambulatory organizations. Given its proclivity to work with large organizations, it’s no surprise to see Epic’s install base drop o� significantly as the number of physicians in the organization decreases.

1-10

11-50

51-200

201-500

501-1000

1001+

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9%

91%

Are you actively looking to replace your current EHR (Acute Care Participants)

The market for acute EHR replacement is small, but some opportunity yet remains. As the graph shows, 9% of acute facilities are actively looking to replace their current EHR. Scores found in this study are just the industry standard with no significantly better options available (like in the airline industry)..

Given the amount of money involved in a single EHR deal, this still represents significant potential for new revenue; But the market is clearly settling down with few facilities interested in making a change in any given year.

Finally, this data also makes clear that the change at acute facilities is not being driven by the smaller end of the market. Rather, the move to change appears to be driven by average and large acute systems with over 300 beds.

Yes

No

Acute EHR Replacement Market

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7% 12% 14% 9%

100%93% 88% 86% 91%

0-300 beds 301-450 beds 451-600 beds 601-750 beds 751+ beds

Acute EHR Replacement Market (by Bed Count)

No

Yes

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11%

89%

Are you actively looking to replace your current EHR? (Ambulatory Participants)

Ambulatory EHR Replacement Market

As you will see later in this report, despite extremely poor Net Promoter Scores across the board for all EHR vendors (yes, even Epic), providers aren’t planning a mass exodus (as evidenced by only 11% who have plans to kick their current EHR supplier to the curb). However, if things stay as they are, physician dissatisfaction will metastasize to encompass the majority of the organization and replacement rates will almost certainly increase in coming years. We’ve said it before—physicians and other caregivers are the sleeping giants of healthcare. So all suppliers, even Epic, should be forewarned—you can only disappoint physicians and other caregivers for so long…eventually, you will pay the piper.

Yes

No

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10% 14%20%

7% 11%5%

90% 86%80%

93% 89%95%

1-10 11-50 51-200 201-500 501-1000 1001+

Ambulatory EHR Replacement Market (by Physician Count)

No

Yes

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10%

14%

14%

8%

14%

8%

11%

12%

9%

15%

5%

19%

13%

8%

9%

11%

13%

20%

33%

90%

86%

86%

92%

86%

93%

89%

88%

100%

91%

85%

95%

81%

88%

92%

100%

91%

100%

89%

100%

88%

80%

67%

Pediatrics

Internal Medicine

Orthopedics

Psychiatry

Surgery

Anesthesiology

Family Medicine

Ophthalmology

Otolaryngology

Neurology

Dermatology


Urology

Endocrinology

Administration

Plastic Surgery

Gastroenterology

Rehab

Radiology

Pathology

Nephrology

Infectious Disease

Cardiology

Ambulatory EHR Replacement Market (by Specialty)

Cardiology centers appear to present the biggest replacement business opportunities with 33% suggesting they are looking for a replacement EHR.

No

Yes

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Top Physician Priorities

22%

30%

25%

15%

6%

Alternative payment models

Patient satisfaction data Accountable care Patient portal None

Top Priorities of Acute Care Physicians

Additional Needs

Physicians have several key future needs and it’s natural for them to first look to their existing EHR suppliers for these. This set of graphs gives suppliers a peek into what they need to address next: patient satisfaction, accountable care, and alternative payment models. While there is some variation by specialty, acute facilities of all sizes seem to agree on these priorities. (Hint: It is probably time for suppliers covered in this report to forward these three items to their development teams.)

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Top Physician Priorities Cont.

24%

21%

15%

26%

33%

28%

29%

31%

35%

23%

20%

32%

24%

26%

23%

8%

21%

20%

21%

7%

9%

13%

3%

0-300 beds

301-450 beds

451-600 beds

601-750 beds

751+ beds

Top Priorities of Acute Care Physicians (by Bed Count)

Alternative Payment Models

Patient Satisfaction Data

Accountable Care

Patient Portal

None

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The Holdouts

34%

66%

First-Time Adoption Plans of Ambulatory Organizations

While the market for first time EHR adoption is not significant in terms of size, one third of these holdouts appear to be jumping on the bandwagon with plans to acquire an EHR in the near future. This represents about 6% of our ambulatory participants who don’t have an EHR but are seriously considering adoption.

Considering an EHR Solution

Not Considering an EHR Solution

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The Holdouts Cont.

46%

28%

25%

22%

17%

12%11%

7% 7%

Major Obstacles for First-Time EHR Adopters (Ambulatory Participants)

As we’ve seen in previous sections, there is a definite group of providers who won’t even consider adopting an EHR and are decidedly against ever doing so. So what keeps these first-time adopters (or non-adopters, more accurately) from moving forward? Several of their reasons for not acquiring an EHR are given below. The biggest reason, most understandably, is that it’s just too expensive and has no demonstrable ROI (even with government incentives and penalties). Could suppliers find a way to make the cost and go-live worth it for providers? Stated di�erently, is there a way to lower the TCO so true ROI is identifiable, realistic, and achievable?

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The Holdouts Cont.50%

50%

50%

38%

50%

60%

75%

50%

100%

44%

67%

100%

25%

50%

25%

8%

38%

20%

33%

75%

50%

50%

33%

33%

50%

50%

23%

13%

40%

33%

44%

25%

54%

25%

20%

33%

25%

11%

33%

50%

15%

25%

50%

25%

33%

8%

25%

25%

22%

33%

25%

23%

25%

33%

15%

25%

11%

8%

25%

25%

11%

Pediatrics

Internal Medicine

Orthopedics

Psychiatry

Surgery

Anesthesiology

Family Medicine

Ophthalmology

Otolaryngology

Neurology

Dermatology


Urology

Major Obstacles for First Time Adopters (by Specialty)

Too Expensive

Reduces Efficiency

Unnecessary

Retiring Soon

Reduces Patient Contact

Not-User Friendly

High Switching Costs

Security/Privacy Concerns

None that Fit Our Needs

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Net Promoter ScoresNet Promoter Score Methodology:

The Net Promoter Score (NPS) measures customer satisfaction by asking one simple question: “How likely are you to recommend your EPR vendor to a peer or colleague?” and yields results that major academic research suggests is the most accurate measure of overall satisfaction.

A Net Promoter Score is displayed as a single number by subtracting the percent of detractors (those most likely to speak out negatively about the business) from the percent of promoters (those who sing praises). Passives are tossed out of the equation as they contribute no detriment or benefit to the overall equation. The formula looks like this:

% Promoters - % Detractors = Net Promoter Score (NPS)

With scores that range from -100 to 100, it’s pretty telling that physicians are extremely unhappy with all the major EHR suppliers, as you’ll see in the next page. None had glowing NPS scores— in fact, customer satisfaction from the physician perspective among all suppliers in this study were quite the opposite of glowing. This incredibly important finding is in stark contrast to almost all of the other customer satisfaction reports out there which are primarily from the perspective of IT leadership. The only bright side to this narrative is that providers are willing to say why they are so disappointed with their current EHR solution while also o�ering a chance at redemption.

14%

24%

11% 11% 10%13% 15%

9%

40%

18%

27%

8%

19%

33% 31%27%

9%

25%

65%

48%

78%

70%

57% 58% 58%

82%

35%

Ambulatory Promoters, Passives, and Detractors

Promoters Passives Detractors

Above graph includes (not in respective order):

Allscripts e-MDs Greenwayathenahealth eClinical Works NextGenCerner Epic Practice Fusion

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Net Promoter Scores Cont.It’s worth noting that despite what many would assume, Epic does not have the high watermark NPS score of 5. It is in significantly negative territory. Yes, it’s more than a little comical that a score ever so slightly above neutral is worth bragging about but with almost all suppliers deeply in the negative among physicians, this supplier has a little breathing room.

-45

-51

-68

-48

-24

-73

-42

-59

5

Ambulatory EHR Net Promoter Scores

Above graph includes (not in respective order):

Allscripts e-MDs Greenwayathenahealth eClinical Works NextGenCerner Epic Practice Fusion

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Net promoter scores cont.

4%

26%

70%

5%

23%

70%

18%

29%

56%

42%

17%

42%

Acute ehr promoters, passives and detractors

Promoters Passives Detractors

Above graph includes (not in respective order): Allscripts, Cerner, Epic, VistA

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Net promoter scores cont.Once again, it would be natural to assume Epic fares most favorably among acute care physicians compared to its competitiors, but again, this is not the case. Epic indeed has an Achilles heel—physicians.

-65 -64 -38 0

Acute ehr net promoter score

Above graph includes (not in respective order): Allscripts, Cerner, Epic, VistA

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ConclusionFor years, caregivers’ satisfaction with clinical documentation systems has been regarded as second class perspective. While the level of importance placed on improvements to EHR systems should be #1 patients, #2 caregivers, and #3 IT leadership, it feels as though caregivers and patients take a backseat to meeting the requirements of other stakeholders.

The EHR supplier that cracks the code of frontline user satisfaction (which doesn’t exist anywhere today) will have a competitive advantage unparalleled in this segment of healthcare. Imagine a supplier that had an army of caregivers behind it, spreading the sweet, sweet message of real usability? The bubble-up e�ect would be impossible to ignore. Until then, we’ll continue to ask key questions and o�er up the findings, and hope a small piece of the message being sent by providers will be given its proper weight.

For now, the story is that caregivers are almost universally unsatisfied with their EHR system, yet they have very few expectations of anything better on the horizon, which is confirmed by a very low replacement rate. In Economics 101, this is a rare occurrence. Look at it this way: what happens when your kids spot a better tasting cereal at the grocery store? Is there any end to their incessant pleas and complaints for something better, when it’s right in front of them? Alternatively, if everything tasted like cardboard any variation will do. It’s about taste, not the tiger, ephrechaun, or even Snap, Crackle, or Pop.

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