White Paper: Keepers of the Information: Legacy Health IT Systems

Patient information has long been used by the medical community to track and treat illnesses for both individuals and groups of people. How this information was gathered and stored has changed drastically over the years, especially since the dawn of the Internet age. Paper has been replaced by lines of code, and the medical industry has tried to keep up with myriad technical advances in order to provide the best possible care to patients. Though doctors and nurses could benefit from an efficient technological framework, this doesn’t exist.

Bridge Over Troubled Waters

People within the industry understand the significant gap between health and IT and the subsequent headaches and burdens this disconnect creates. The frustrating part (for the involved parties) is that there have been numerous attempts to fix the problem, and quite a bit of time and money spent on bridging the gap. Bob Wachter, dubbed the “Digital Doctor,” has described the “hope, hype and harm” of IT within the healthcare industry.

We were waiting for years for computers to fix the problems of medical mistakes, and they’re doing that to some extent, but they’re also creating other new hazards,” he told Healthcare IT News. Though he expressed dissatisfaction with the way things are, he noted that it’s important to get it right, and he has a small amount of hope that a positive outcome will come to fruition.

“It became clear to me that we can get to a really wonderful place – and we probably will – but we’re not there yet, and the path to getting there is what I was trying to explore,” Wachter said, noting that the book he wrote came about as a response to this health IT quagmire.

As Wachter noted, there has been progress, albeit slow and not enough of it. Broadly speaking, health information technology has been tasked with improving the quality of care through increased accuracy of reporting, procedural correctness, improve operational efficiency for doctors and nurses, and an elimination of a number of tedious administrative processes.

The emergence of this technology and the evolution of patient information tracking have led to the creation of an entire industry devoted to producing and supporting technology for health recordkeeping. But what exactly do these companies do, and what services and products do they provide? The answer lies in the lines of code that make up the software that contains all of the patient information.

What are Legacy Systems?

Plainly put, legacy health IT systems are the software that involve the digital storage of patient information. In the tech world, the word “legacy” implies that this is an older method, as the evolution of technology often makes certain products and services outdated. Newer systems and technologies exist in the healthcare market, and are offered by both the older, established companies and newer startups.

Many of these legacy systems were created when healthcare providers were encouraged to move on from paper patient records and adopt electronic health record (EHR) systems. This adoption was spurred by the introduction of the Medicare and Medicaid Electronic Health Records EHR Incentive Program (Meaningful Use), which promised financial incentives to healthcare providers that could meet criteria set for by the government.

Tangentially associated with the healthcare overhaul, the EHR incentive program is supported by the Health Information Technology for Economic and Clinical Health (HITECH) Act, which itself was passed as part of the American Recovery and Reinvestment Act of 2009 – colloquially known as President Barack Obama’s economic stimulus package, or “ARRA.” Once healthcare providers were incentivized to adopt legacy systems, the market grew significantly and began to solidify its place within the healthcare industry.

Companies saw the need for an EHR system prior to the signing of the legislation – there was a move in the early 2000s to create rules regarding the sharing of health data – but the government’s action definitely spurred adoption of these systems.  

The Main Players

One of these companies, and the biggest player on the field, is Epic Systems Corp., which offers electronic health records systems for ambulatory, inpatient and specialty care settings. Epic offers an integrated suite of software that supports functions related to patient care. These include registration and scheduling, clinical systems, systems for labs and pharmacies and billing systems for insurance companies.

This variety of offerings has allowed Epic to become the largest EHR vendor in the market. The company claims that healthcare groups that use Epic EHRs serve 54 percent of patients in the U.S. Epic primarily deals with large healthcare organizations, which accounts for its significant market presence. The scope of the company, located in tiny, and obscure Verona, Wisconsin, has an almost omnipresent position in the marketplace.

However, competition is increasing steadily, according to SearchHealthIT. Though Epic continues to dominate a large portion of the EHR market, recent numbers from the Centers for Medicare & Medicaid Services show that Cerner Corp. is beginning to catch up. If Epic Systems Corp. is the Coca-Cola of the HER market, Cerner would be the Pepsi Co.

Like these soda companies, the large EHR players acquire smaller companies in order to increase their market share. In 2014, Cerner acquired Siemens AG’s former Soarian EHR unit for $1.3 billion, bolstering its holdings significantly. Not only did it acquire such a large unit, Cerner also signed a multi-billion dollar deal, together with Leidos and Accenture Federal Services, to replace the U.S. Department of Defense’s HER system.

Cerner is also a founding partner in the CommonWell Health Alliance, a health information exchange group built to support interoperability or the passage of information between different vendors’ EHR products. Epic is not part of CommonWell, though other EHR vendors such as athenahealth, Inc., McKesson Corp. and Allscripts are.

Hospitals often favor one of the two and the companies are often compared by industry publications. Cerner has been said to have better interoperability by some hospitals, but Epic is defended consistently in that regard. The famous Mayo Clinic recently switched – this was no small feat, as it required a massive allocation of resources and money – from Cerner to Epic, with CIO Cris Ross citing patient engagement and agility as two of the reasons for the transition, according to HealthCareIT News. Such a transition is extremely difficult, even for such a large organization like the Mayo clinic.

Other Players

Outside of the main two players, there are other companies for healthcare institutions to consider. If Epic is Coke and Cerner Pepsi, eClinicalWorks (eCW) would be the Dr. Pepper Snapple Group (occupying the spot of the third-largest company in the vertical). Like the other two companies, eCW offers a breadth of services outside of the basic EHR offerings, including analytics, patient engagement, care planning, a referral network, a health information aggregator and financial and billing management.

In addition to its EHR and these services, eClinicalWorks offers revenue cycle management and patient engagement products that can be used to track all billable healthcare services and help patients become more active in their own care.

A number of other companies have also entered the market and competed with the two biggest players, even in the segments that were all-but fully occupied. Allscripts Healthcare Solutions, Inc.’s TouchWorks EHR system is for use in ambulatory and other medical settings. Allscripts also created an EHR for small and mid-size physician practices. NextGen Healthcare Information Systems Inc.‘s ambulatory EHR is used by more than 85,000 healthcare providers and has earned them more than $550 million in EHR incentive payments.

Successful Integration

Integration with legacy systems often requires a significant injection of resources – both monetary and in terms of personnel – for healthcare companies. Integrating with Epic, for instance, often leads to health providers to create positions and even mini-departments (within IT) to handle the EHR responsibilities.

According to SearchHealthIT, the Everett Clinic in Washington did just that, but noted that using only one EHR vendor had numerous benefits for their organization.

“To have everything in a single data base, there’s just great benefit. There are a lot of advantages to having everything in one system,” said Melanie Vance, Everett’s Epic director.

This is the case because of the daunting task that is EHR integration. A company’s software and IT needs a complete overhaul, as it needs to be prepped for the integration. Then, there is the actual transition of the information to the new system, which requires significant IT expertise and knowledge of the coding and software requirements. Then, there are the rounds of testing and rollout, which require time and money, as well as patient IT personnel.

Once the actual integration occurs, there are the back-end support issues, which again require significant IT attention and resources. Among these many things are workflow redesign, training and hardware procurement, software licensing, maintenance and product support.

What’s Next for Health IT?

The market for healthcare technology is expected to grow, perhaps as much as seven-to-eight percent per year over the next five years. Citing a report from Kalorama, HIT Consultant reported that healthcare companies will continue to adopt new technologies, and trends like “EMR Rip and Replace” – this is a practice where vendors are switched and certain technologies are brought in from other vendors – will continue.  

“There might be a thought now that everyone has their EMR now so the market won’t grow, but I’d argue against that,” said Bruce Carlson, a publisher for Kalorama Information in a statement.  “There are upgrades, vendor switches, and still untapped physician markets for web-based products.  That being said, it’s like any other software market now that the direct incentives are over and as such, vendors need to sell on value.”  

Healthcare IT News reported that the numbers of hospitals and practices with EHR systems will rise steadily, and new investments in technology will rise over the next 12 months, according to Transparency Market Research.

Though EHRs make up a significant part of the overall health IT market, a BCC Research report found that other segments are expected to mirror this growth in the coming years, according to Healthcare Informatics.

“In the past few years, a new category of health IT has begun to emerge, with individual consumers using mobile and wearable electronic devices and software to collect data on and monitor biometric indicators such as weight and heart rate,” BCC Research analyst Andrew McWilliams, said in a press release statement. “These self-monitoring activities are initiated and carried out by the consumers themselves, without a medical prescription or healthcare provider’s directive, as in the case of telehealth.”

The players in the market will remain the same, according to the Transparency Market Research report. It cited the major players as (alphabetically listed): Allscripts Healthcare Solutions, Inc., Cerner Corporation, Epic Systems, Medical Information Technology, Inc. (MEDITECH), McKesson Corporation, NextGen Healthcare (Quality Systems, Inc.), Computer Programs and Systems, Inc. (CPSI), GE Healthcare and eClinicalWorks. According to the report, the future growth of these companies is not only reliant on the U.S. market, as overseas holdings and investments could make up a significant part of their respective revenue streams in the coming years.

Epic is projected to continue its market dominance, with the rest of the field struggling to occupy the second and third place positions. According to Healthcare IT News, Epic is looking to bolster its overall share by targeting smaller organizations.