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Are Client Server EHR Holding Back Healthcare?

Posted on December 19, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The number one topic of debate on this blog has definitely been Client Server EHR versus SaaS EHR. There are staunch parties on both sides of this aisle. No doubt both sides have a case to make and we’ll see both in healthcare for a long time to come. Although, I think that long term the SaaS EHR will win out.

As I was thinking about this recently, I realized that while client server EHR can do everything a SaaS EHR can do, it definitely makes a lot of things much harder to accomplish.

It’s much harder to create an API that connects to 2000 client server EHR installs.

It’s much harder to make 2000 client server EHR installs interoperable.

It’s much harder to evaluate data across 2000 client server EHR installs.

I’m sure I could keep going with this list, but you get the point. Even though something is possible, it doesn’t mean that they’re actually going to do it. In fact, if it’s hard to do, then it takes extreme pressure for them to do it.

All of this has me begging the question of whether client server installs are holding back the EHR industry. Up until now, many of the things I mention above haven’t been that important. Going forward I think that all three of the things I mention above are going to be very important.

The good thing is that I see many client server EHR moving to some kind of hosted EHR solution. That solves some of the problems mentioned above. At least if it’s a hosted EHR solution, they can control the environment and more easily implement things like API access and interoperability. That’s much harder in the client server world where if you have 2000 EHR installs, you have 2000 unique setups.

Of course, as soon as a large SaaS EHR has a massive breach, healthcare will go running after the client server EHR. The battle lines are drawn and each side knows each other very well. Although, I think the SaaS EHR have the high ground right now. We’ll see how that continues over time. Client server EHR have done an amazing job battling.

Can a Client Server EHR Provide All the Same Benefits of Cloud EHR?

Posted on August 25, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

One of the most popular battles discussions we’ve had on this site since the beginning is around client server EHR software versus cloud EHR software. It’s a really interesting discussion and much like our US political system, most people fall into one camp or the other and like to see the world from whatever ideology their company approaches.

The reality I’ve found is that there are pros and cons to each side. Certainly cloud has won out in most industries, but there are some compelling reasons why cloud hasn’t taken hold in many parts of healthcare.

With that in mind, a client server EHR vendor asked me to list out the reasons why someone should go with a Cloud EHR over client server. Here’s my off the cuff responses:

No IT Support Needed beyond desktop support – This is a big benefit that many like. Plus, they add in the cost of the server, the cost of the local IT person and so they see it as a huge benefit to go with cloud software

Automatic Updated Software – Not always true with the cloud, but they like that the software just updates and they don’t have to go around updating software. Of course, this also has its downsides (ie. when an update happens automatically and breaks something)

Small Upfront Cost – Most Cloud solutions are billed on a monthly charge with little to no upfront cost. We could argue the accounting pieces of this and whether it’s really any better, but it feels better even if many cloud providers require the 1-2 year commitment. In some large organizations this type of payment plan is better for their accounting as well (ie. depreciation of equipment, etc)

More Secure – Obviously this could be argued either way, but those that believe cloud is more secure believe that a cloud provider has more resources and expertise to make their cloud secure vs an in house server where no one might have expertise

More Reliable (backup/disaster recovery) – Similar to the secure argument as far as expertise and ability to provide this reliability

Single Database – There are cool things you can do with data when every doctor is on one database and one standard data structure.

Available Everywhere – At home, office, hospital, etc. (Yes, this can be done by many client server as well, but not usually with the same experience).

I’m sure that a cloud EHR provider could add to my list and I hope they will in the comments. As I was making the list, I wondered to myself if a client server EHR vendor could provide all of the benefits listed above. Let me go through each.

No IT Support Needed beyond desktop support – Some EHR vendors will do all the IT support for the user. Plus, it’s a little bit of a misnomer that you need no IT support with a cloud hosted EHR. You still need someone to service your network and computers. More importantly though, most client server EHR vendors are offering a hosted EHR option which basically provides this same benefit to a practice.

Automatic Updated Software – More and more client server vendors are moving to this approach for updates as well. This is particularly true when they offer a hosted EHR environment where they can easily update the EHR. It’s a different mentality for client server EHR vendors, but it can be done in the client server environment.

Small Upfront Cost – We’ve seen this same offer from almost all of the client server EHR companies. It’s a hard switch for EHR companies to make the change from large up front payments to reoccurring revenue, but I’m seeing it happening all over the industry. The only exception might be the big hospital EHR purchase. In the ambulatory EHR market, I think everyone offers the monthly payment option.

More Secure – This is one that could be argued either way. Either one could be more secure. Client Server vs Cloud EHR doesn’t determine the security. A client server EHR can be just as secure or even more secure than a cloud EHR. I agree that generally speaking, cloud EHR is probably more secure than client server, but that’s speaking very broadly. If you care about security, you can secure a client server EHR as much or more than a cloud EHR.

More Reliable (backup/disaster recovery) – Similar to secure, you can invest in a client server infrastructure that is just as reliable as a cloud EHR. It’s true that a cloud EHR vendor can invest more money in redundant systems usually. However, a client server EHR vendor that hosts the EHR could invest just as much.

Single Database – This is the one major challenge where I think client server has a much harder time than a single database cloud EHR provider. Sure, you can export the data from all of the client server EHR software into a single database in order to do queries across client server EHR installs. A few vendors are doing just that. So, I guess it’s possible, but it’s still not happening very many places and not across all the data yet.

Available Everywhere – This can be done by client server as well, but the experience is often a subset of the in office experience. Although, this is rapidly changing. Bandwidth and technology have gotten so good, that even a client server install can be done pretty much anywhere on any device.

Conclusion
Looking through this list, it makes a great case for why client server EHR software is going to be around for a long time to come. There’s nothing on the list that’s so compelling about cloud hosted EHR software that makes it a clear cut winner.

As I thought about this topic, I tried to understand why cloud’s been the clear cut winner in so many other areas of technology. The answer for me is that in our lives portability has mattered a lot more to us. In healthcare it hasn’t mattered as much. Plus, new client server technologies have been portable enough.

Long story short, I’m a fan of cloud technologies in general, but if I were a provider and a client server technology provided me more features, functions, better workflow, etc, than a cloud EHR, I wouldn’t be afraid to select a client server EHR either.

Also worth clarifying is that this post outlines how a client server EHR can provide all of the same benefits of a cloud EHR. However, just because a client server EHR can provide those benefits, doesn’t mean that they do. Many have chosen not to offer the above solutions. Although, the same goes for cloud EHR as well.

What do you think? Are there other reasons why cloud EHR technology is so much better than client server? Is there something I’ve missed? I look forward to reading your comments.

What’s Behind the Pri-Med Acquisition of Amazing Charts EHR?

Posted on November 29, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

For those of you who missed the news, Pri-Med acquired Amazing Charts EHR for a currently undisclosed amount. This was a really interesting move in the EHR industry. Anne Zieger suggested that this and other indicators was a sign of EMR consolidation. Turns out there’s a lot more behind the Pri-Med acquisition of Amazing Charts than most people would see on the surface.

In a call I had with Amazing Charts founder and president Dr. Jonathan Bertman, as well as John Mooney, founder and CEO of Pri-Med, I learned a lot about why this acquisition makes sense and how they’re planning to capitalize on the investment.

CME Chart Level Review
One of the most interesting things I learned was that chart level review was the best way to see the gaps and needs that can be satisfied by CMEs. Considering Pri-Med is a major player in the CME space, you can see the value that having relationships with a bunch of doctors using an EHR can be for them. I didn’t dive into how Pri-Med plans to leverage the Amazing Charts EHR charts, but you can see the possibilities. Although, Amazing Charts is a mostly client-server based EHR, so Pri-Med won’t have any access to do chart level reviews without permission from the doctors using the EHR.

Protecting EHR Data
In fact, in my discussion I learned that Dr. Bertman and John Mooney both had no interest in using a physician’s EHR data to make money. That philosophy actually seemed to bring Pri-Med and Amazing Charts together to make this acquisition happen. Both believe that their company should make money providing the software and services a doctor needs as opposed to making money off the data in an EHR. This is nothing new since I’ve heard Dr. Bertman espouse this belief many times before, but does contrast with other EHR vendors in the market.

EHR Acquisition Options
I was also fascinated to hear about Dr. Bertman’s thoughts on Amazing Charts approach to acquisition. He said that he didn’t want Amazing Charts users to experience what other EHR users had experienced when their EHR was acquired by another EHR company. He didn’t want Amazing Charts to be one of many EHR software in a company’s portfolio. Inevitably, EHR software will get sunset to streamline the company and Dr. Bertman didn’t want that for his users.

What does the Acquisition Mean for Users?
Ont thing users of Amazing Charts can expect is efforts to create clinical training and information at the point of care. John Mooney mentioned their “5 Minute Clinical Consults” as a model of short education that could be integrated into the clinical documentation process. I’ll be interested to see how this evolves. Even 5 minutes seems too long for most doctors to stop their patient workflow. However, it is interesting to bring Pri-Med’s education knowledge, experience and library to the point of care in the Amazing Charts EHR.

I also was fascinated by John Mooney’s suggestion of Amazing Charts possibly integrating a Provider Self Assessment tool into Amazing Charts. Definitely makes sense to have the doctors self assess to get the best CME. While not a perfect match inside an EHR software, it doesn’t seem completely out of place in the EHR if it’s done right.

Amazing Charts User Groups at Pri-Med Events
I also learned that they’ll be working to hold Amazing Charts user group meetings at the various Pri-Med events. This could be a great boon for Amazing Charts users. I know a lot of doctors and their staff won’t or can’t attend the national user group meetings that most EHR vendors hold. I’m not sure where the 6500 Amazing Charts users are found throughout the country, but if planned well it would be great to leverage the existing Pri-Med events for this and engage more of their EHR users close to home.

Post-Acquisition Logistics
They told me that Amazing Charts would maintain a separate entity in Rhode Island to continue developing and supporting the EHR software. Their marketing and sales would come out of Boston where Pri-Med is located. For Amazing Charts users, this sounds like it will be mostly business as usual from their perspective. In fact, it could mean Amazing Charts has more resources available to build our their EHR software. All in all, this seems like a smart move for Amazing Charts and their users.

Full Disclosure: Amazing Charts is an advertiser on this site, but you can be sure I’d cover every EHR acquisition I can find.

The Move to Cloud EHR

Posted on August 21, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’m pretty sure that many people missed the announcement that Amazing Charts now offers a Cloud EHR. For those who don’t eat, sleep and breathe EHR like me, you probably don’t realize that this is a pretty significant announcement on Amazing Charts part and I think represents a larger shift in the EHR industry.

I know the SaaS EHR purists will say that not all “Cloud EHR” are created equal. This is highlighted in the Amazing Charts press release where it says “without a web browser.” It’s an ironic statement when you consider that most SaaS EHR happily say, “with only a web browser.” (Although, the web browser only EHR software companies should read this post by Dr. West) However, my goal here isn’t to highlight the various nuances of hosted or cloud EHR software.

Instead, I wish to highlight how one of the popular, established, client server EHR software vendors was getting enough requests from doctors for a hosted EHR solution that they now offer a cloud based EHR. The reality is that many physician practices want to have to deal with as little IT support as possible. This is the major reason I’ve heard over and over again that many practices want to have a hosted EHR.

It’s worth pointing out that Amazing Charts focuses on the small physician practice market. It’s always been clear that the larger physician practices or hospital owned practices have better capabilities and a greater interest in hosting their EHR in house. While there are strengths and weaknesses to a hosted EHR vs an in house EHR, the hosted EHR is the compelling choice for the IT averse clinic.

Very soon we’re going to see almost all new EHR installs in small ambulatory practices using some sort of hosted EHR software. This doesn’t necessarily spell the death of client server EHR software. Many large practices will continue using and implementing client server EHR software. Not to mention many long time EHR users will continue with their existing client server installs. However, the shift to hosted EHR is happening and will start to really pick up pace in the next couple years.

Full Disclosure: Amazing Charts is an advertiser on this site, but they didn’t know I was doing this post.

Conflicting Indications of the Move to SaaS Based EHR

Posted on November 29, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

One of the really interesting things I noted while attending the NextGen user group meeting had to do with the move to SaaS based EHR and other SaaS based EHR software. I partially mentioned this in the write up I did at the conference, including a tweet where I talk about how Scott Decker really pushed the idea of NextGen making the move into the SaaS based software world.

I think there’s little doubt that NextGen sees the value of SaaS based software. I think they see the convenience to doctors of not having to manage a server. Most importantly, I think they see the value of not having the healthcare data stored in EHR in silos.

One thing that Scott Decker mentioned in his keynote was improving their coding rules engine based on the feedback and experience across all of their SaaS based EHR users. I found this really intriguing since it highlighted some of the challenges and limitations of the client server EHR model that’s so prevalent in healthcare.

After hearing these comments about NextGen’s move towards more and more SaaS based software, I wondered what users at the meeting thought about the move by NextGen to SaaS EHR. The nice part of a user group meeting is I had a chance to talk to a number of them.

One company I talked to said basically, “We have 30 Citrix servers in our NextGen EHR installation. That’s a huge investment we’ve made and I don’t see us changing that any time soon.” They’ve got an interesting point. There’s a lot of money invested in training, equipment, software, and general understanding of the current client server EHR installs that NextGen employs (or is it employed?) for its large EHR customers.

It’s quite a stark contrast to consider this entrenched client server user base that is unlikely to change even if NextGen’s direction is headed towards SaaS EHR software. To be completely honest, I’m not exactly sure how this “conflict” is going to play out.

Dragon Medical Enabled EHR – Chart Talk

Posted on July 12, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I recently was asked by Deanna from Mighty Oak to check out a demo of their Chart Talk EHR software (previously called DC talk). It’s always a challenge for me since there are only so many hours in a day to be demoing the more than 300 EHR companies out there. So, instead of doing a full demo, I asked Deanna to highlight a feature of Chart Talk that set them apart from other EHR software companies.

She told me that Chart Talk’s killer feature was its integration with Dragon Naturally Speaking’s voice recognition software. I was very familiar with DNS and other voice recognition software, so I was interested to see if they really could create a deep integration of Dragon Medical over the other EHR software I’d seen that integrated it as well.

I have to admit that I was pretty impressed by the demo. It was really quite amazing the number of things that you could do with your voice in the Chart Talk EHR software. Certainly standard transcription like documentation worked out well in Chart Talk. However, the impressive part was how you could navigate the EHR with your voice. Here’s a demo video that does a decent job illustrating it:

What made the documentation even more interesting (and is partially shown in the above video) is the use of various DNS macros and the even more powerful built in macros for pulling in vital signs, past history, etc. Plus, I like the idea that when you have any issues with Dragon Medical, you don’t get someone at your EHR company who doesn’t really know much about Dragon. Since Chart Talk’s completely focused on Dragon integration, you know they know how to support it properly.

I of course only saw a partial demo of the Chart Talk software. So, I’m only commenting on the Dragon Medical integration in this post. It would take a much longer and more in depth evaluation to know about the other features and challenges to the software.

Plus, there’s no doubt that voice recognition isn’t for everyone. They tell me that some people do the charting with their voice right in front of the patient. That feels awkward to me, but I guess it works for some people. Then, there’s the people who don’t want to go through the learning curve of voice recognition. However, I’d guess that Chart Talk could make a case for being some of the best at teaching people to overcome that learning curve since every one of their users uses it.

I also know that Chart Talk originally started as DC talk. So, anyone considering Chart Talk should likely take a good look at how well the software fits with their specialty. I know the people at Mighty Oak have been making a big effort to work for any specialty. However, like every EHR software out there, they just work better for some specialties better than others.

It’s also worth noting that Chart Talk is a client server EHR. I guess the web browser isn’t quite ready for the processing power that’s required to have a nice voice enabled user experience.

Needless to say I was impressed by the voice recognition integration and how pretty much every command can be performed using your voice. I’d be interested to know of other EHR companies that are striving for that type of deep integration. I’m not just talking about being able to basically dictate into a text field. I’m talking about actual navigating the EMR with your voice.

SaaS EHR Is The Only Option to Show Meaningful Use

Posted on May 3, 2010 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve come across a number of websites and people who’ve made the assertion that with the short time frames for meaningful use, a SaaS EHR is the only option to be able to meet the meaningful use requirements in a timely manner. Let’s see if I can do my part to clarify this idea which isn’t completely accurate.

First, there is still plenty of time for a clinic to implement an EMR of any type and get EMR stimulus money. At some point this might change, but at this point we are still far enough out that time is not an issue. Although, I’ll admit that it would be helpful if CMS and HHS would finally get some EHR software certified and provide some practical meaningful use details. Of course, these details shouldn’t be stopping doctors from evaluating and planning for their EMR implementation.

Second, it is worth acknowledging that in general a clinical practice can implement an EMR faster if it’s a SaaS EMR and not a client server EMR. The time for the server to be shipped to your office alone just takes time not to mention getting an IT person or your EMR vendor to install the server in your office. However, if you need more computers and a laptop to be able to use your SaaS EMR, you’re going to be waiting for computers to arrive anyway. Generally though, SaaS EMR is faster to implement than client server.

Of course, this doesn’t mean that you can’t quickly implement a client server based EMR. For example, I implemented a local doctors office in a week from when the server arrived. It was an incredibly fast implementation. Other than ordering time (which they had to order workstations also), it was as fast as any SaaS EMR implementation. So, it’s certainly possible. You just better make sure you have the right IT people supporting your implementation.

My point in this post is that it’s mistaken to say that SaaS EMR is the only option that’s fast enough to implement in time for meaningful use. Many of the client server EMR companies out there have really streamlined the process for installing a server in a clinic. Although, this is not true for all of them. So, it’s a question worthy of asking any EMR company if you’re looking at compacted time lines.

At least for now, it’s a mistake to rule out a great client server EMR just based on the meaningful use time line. We’ll leave the other arguments for ruling out a client server EMR in favor of a SaaS EMR for another post.

Type of EMR Poll – SaaS, Web Based Client Server, or Client Server

Posted on June 1, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I thought it would be interesting to see which type of EMR setup readers of EMR and HIPAA preferred. If you’re not sure what I mean by the various options, I put a short description of each EMR setup below. Also, feel free to leave a comment about why you made the choice you did.

Hosted Web Based EMR (SaaS/ASP) – This is where the EMR company (or some outside entity) hosts the EMR and provides you access to the EMR usually through your web browser. Data is stored in their location and requires an internet connection to access the EMR.
Client Server EMR (Web Based) – This is where you host the server for your EMR in your office, but you can access your EMR server using a standard web browser. Data is stored on the server in your office, but access to the server using a standard web browser can be available anywhere.
Client Server EMR (Client Install) – This is the traditional model of EMR where you have a server in your office and you install a client which you use to access your EMR. Data is stored on the server in your office and is only accessible from outside the office using some sort of remote desktop connection.

Prepare for the Failure of Many EHR Vendors

Posted on April 16, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Just sitting back and taking a look at the current EHR and EMR market, I have a strong feeling that we’re going to see a number of EHR vendors close up shop. Many of them may be disguised as purchases by bigger vendors who are trying to gain market share. Others will probably just close their doors completely and users of that EHR system will wonder why their support requests aren’t getting the response from their EHR vendor that they’re use to receiving.

I’ve talked previously about how EHR adoption will be slowed by the HITECH act. This slowing of EHR adoption is going to put a number of EHR vendors out of business. I have a feeling that far too many EHR vendors based their burn rate on their previous sales. Now that sales have slowed, they’re going to have to really fight to stay above water.

For those concerned, you might want to take a look back at my post on assessing your EHR vendor’s financial situation. Plus, I think it’s definitely worth taking a look at some contingency plans you have in case your EHR vendor does fail or get bought out.

The nice part of client-server based EHR systems is that you can usually keep using the EHR regardless of the financial viability of the EHR company itself. Granted, you’ll stop getting upgrades, but at least you can maintain the status quo. If you’re using an SAAS EHR, I’m not sure exactly what options you have available.

I should say that most EHR vendors won’t just shut their doors and leave. Most failing EHR companies will salvage what they can by selling to an EHR vendor that wants their customer base. However, when this happens, expect the new vendor to provide very light support for the purchased EHR software and a clear path to move to their software.

All of this said, I’m predicting a number of EHR companies to fail in the coming year.