I’m not sure all the details of why this is the case (but I’m sure some will tell me why in the comments), but doctors are some of the most independent thinkers that I know. I’m not saying whether this is a good or a bad thing. It’s just an observation based on thousands of interactions with doctors from all specialties. This independence is shown in a plethora of areas from charting to treating to diagnosing to the business of medicine.

Turns out, this independence is part of why I’ve heard doctors say hundreds of times that they basically want their own EHR and not a mainstream one. Doctors want an EHR that fits their unique practice style. Thus they have an expectation that whatever EHR they choose should understand that each doctor is different and naturally adapt to each unique doctors need. Ok, that’s a pretty broad generalization and no one would ever vocalize it that way, but it’s an undercurrent that I’ve seen time and time again.

I believe this is an important characteristic of the EHR market that must be considered. If you don’t accept the broad theory of doctor independence in practice style and approach, then most of you will appreciate that doctors from various specialties have unique needs. The easy to understand examples are Pediatricians and OB/GYNs. Everyone can quite readily see that tracking child growth and pregnancy require different charting and documentation requirements. I believe each specialty could describe similar requirements that are unique to that specialty.

This doctor and specialty independence is why I’ve long argued against what everyone loves to call mass EHR vendor consolidation. Certainly we can all agree that we have too many EHR vendors right now. However, I’ve read many many people argue that there’s only going to be 3-5 EHR vendors left standing after the mass EHR consolidation (or EHR vendor failure). I just don’t believe that’s the case. If we get down to 100 EHR companies, I’ll be impressed.

There are two things that might partially affect my EHR consolidation prediction.

First, I won’t be surprised if some really smart company comes along and scoops up each of the best of breed EHR companies for various specialties. However, instead of sunsetting the acquired EHR software, they continue to offer that same EHR software to a specific specialty. Then, they do this over and over again across all the specialties. So, the larger company would own a pediactric EHR, an OB/GYN EHR, a Family Practice EHR, a Cardiology EHR, a Orthopedic EHR, an Oncology EHR, etc. You get the idea. Instead of getting benefits from software development consolidation, they get the benefits in other areas of their business. It would be really fun to run a company like this.

The other healthcare trends that could have a serious impact on this is the ACO movement and hospitals buying up clinics. I’m still not sure how those two trends are going to play out. However, this type of consolidation of healthcare entities could impact whether a specialty specific EHR is a viable option. Clinics that are bought by a hospital or become part of an ACO lose some of their independence. At least their independence in selecting an EHR software.

Are there things I’m missing? Any other trends that are happening that will change the EHR consolidation landscape?

John Moore at Chilmark Research said, “So Many EHRs, So Little Time: Simply amazing that this market can support so many EMR/EHR companies. How they all survive or will survive is a mystery to me and rationalization will occur. ”

It really is pretty stunning that 300+ EMR vendors are still trying to carve their niche in the EMR market. That’s a lot of friendly (or not so much) competition.

However, I can’t help but sit back and wonder if we’re looking at this the wrong way. Maybe there’s not actually 1 EMR market out there. Maybe there are actually 50 EMR markets.

The case for 50 EMR markets is simple. There is an EMR market for every specialty. Add in regional differences, countries, and I think you could get close to 50 markets. However, the number of markets doesn’t really matter. What matters is that there’s more than 1 EMR market.

Almost every EMR vendor I’ve seen has had the challenge of deciding how they want to market their EMR software. It’s not an easy choice, but more and more we’re seeing EMR vendors focus on specific markets. I think that they’ve found that they can’t be all things to all doctors. Doctors in different specialties are unique and that by focusing on a certain specialty they can provide a real value added service to the doctors in that specialty.

Assuming there’s 50 EMR markets, that means that there’s only 6 EMR vendors per market. That’s a much more reasonable number to consider.

Now there’s no doubt that EMR vendors are working in more than one EMR market. Some of the larger EMR vendors are doing a great job focusing on a number of specialties. So, maybe it’s 10-20 real players in each specialty market. Still too many, but we’ll definitely see a lot of consolidation in this regard.

In fact, I’m a little surprised that we haven’t seen more EMR vendors purchasing up these specialty specific EMR vendors and having them work as kind of subsidiaries of the other company. Then, the large company can provide a variety of very targeted EHR products. The key for that company would be to build amazing interfaces between the various EHR products you own. Show true EHR interoperability between these products and you can sell them as a great package to even the larger hospital owned ambulatory practices. Could be a really interesting play for an EMR vendor I think.

Now, I’m sure that someone will say in the comments that one EMR vendor can serve all 50 markets. They can just build “modules” (or some other similar term) that customizes the EMR to meet the needs of that specialty. The problem is that the “modules” are always limited and lacking. Focusing a “module” of an EMR on a specialty and focusing an EMR on a specialty ends up with very different results.

The other day I was thinking about the way EMR software has been designed. A common complaint by specialists is that a certain EMR was designed for General Medicine, but would not work for [insert specialty here]. Then, I asked myself the question “Why hasn’t an EMR vendor built a core with plugins so that other divisions of their company could focus on specialties?”

Yes, if you are a doctor you can probably stop reading right here.

Anyone who’s participated in a website content management system like WordPress (which I use to run this blog) is familiar with the idea of WordPress being the core and then plugins adding extra functionality that might be specific to a user. I wonder why no EMR vendor has decided to develop their software with this same type of flexibility. I believe this process could even work for a private company. It could have one department in charge of the core EMR functionality. Then, other divisions of the company could focus on creating various “plugins” that would expand the core functionality to meet different needs.

This could be the perfect way to be able to adapt the core EMR functions to meet the needs of various specialty clinics out there. This could even be a good way for an EMR company to adapt a product for different state regulations and requirements.

Of course, this model works even better when we’re talking about open source EMR (see also the open source EMR list on the EMR wiki). I’ve seen some different open source EMR, but I don’t personally know of any that are using this model. I’m guessing there has to be and I just don’t know about it. If anyone knows of an open source EMR that is using this model for development, please let me know in the comments. I’d also love to have someone do a guest blog post about this if it is occurring already.

Just some food for thought. Any EMR companies developing this way and I just don’t know about it? I’d love to hear about it as well.