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The American Journal of Managed Care September 2014
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HITECH Spurs EHR Vendor Competition and Innovation, Resulting in Increased Adoption
Seth Joseph, MBA; Max Sow, MBA; Michael F. Furukawa, PhD; Steven Posnack, MS, MHS; and Mary Ann Chaffee, MS, MA
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HITECH Spurs EHR Vendor Competition and Innovation, Resulting in Increased Adoption

Seth Joseph, MBA; Max Sow, MBA; Michael F. Furukawa, PhD; Steven Posnack, MS, MHS; and Mary Ann Chaffee, MS, MA
This is the first empirical evidence to demonstrate increased competition and innovation in the EHR industry as a result of the HITECH program.
The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted to increase electronic health record (EHR) adoption by providers and hospitals. Experts expressed skepticism about whether the program would indeed hasten adoption and could be implemented in time for the initial reporting period. Could EHR vendors meet the certification requirements, and could the industry innovate to meet small-practice needs? This study, in addition to documenting increased provider adoption, provides the first evidence of increased competitiveness and innovation in the EHR industry spurred by HITECH. For example, the number of EHR vendors certified for e-prescribing with Surescripts increased from 96 to 229 over the program's first 3 years. We also find that prescribers in small practices increasingly adopted lower-cost, Web-based e-prescribing and EHR applications at significantly higher rates (15%-35%) than did large practices (3%-4%), which generally have more human and capital resources to make significant investments. These findings suggest that EHR vendors were highly responsive to HITECH requirements and have been adapting their strategies to meet nuanced market needs, providing reason to be optimistic about the Programs’ future.

Am J Manag Care. 2014;20(9):734-740
Our study addresses questions about how the Health Information Technology for Economic and Clinical Health (HITECH) program has affected innovation and competition in the electronic health record (EHR) market. We provide the first empirical evidence that demonstrates:
• The HITECH Certification Program has driven fundamental market changes that increase the likelihood that physician use of HIT as a clinical tool will become a central component of medical practice.

• Proliferation of E*HR vendors under HITECH has spurred increased competition and business model innovation.

• Innovation has improved the match between physician market needs and industry offerings.
The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted by Congress in 2009 to promote the adoption and meaningful use of certified electronic health record (EHR) technology.1 A number of factors contributed to the particularly low adoption rates among providers in small practices prior to HITECH, including limited access to capital, lack of perceived benefits, and hesitation to adopt significant work flow changes.2-4 Establishing different programmatic tactics was required to address these various barriers to adoption.5

HITECH authorizes significant financial incentives to offset EHR adoption costs for eligible healthcare providers if they demonstrate “meaningful use” of certified EHR technology. Regional Extension Centers (RECs) were created to disseminate best practices and technical assistance for small office practices, critical access hospitals, and other providers in rural areas.6 A health information technology (HIT) certification program was established to assess EHR vendor compliance with certification criteria and standards, to provide assurance to eligible providers that such products could support Meaningful Use (MU) measures.7

The HITECH Act required a substantial and multifaceted approach to implementation. Furthermore, the relatively short time between the law’s passage and the deadline for program implementation added significant challenges.8 The impact of these combined issues on providers and EHR vendors created uncertainties and risks for both.9 For example, prior to the final rule for MU measures, all parties had uncertainty about what types of standard functionality would be required to meet MU, how eligible professionals could qualify for MU, what EHR vendors needed to do to become certified, and what the certification criteria and process would be.10

Many have noted the myriad challenges associated with implementing HITECH. Potential problematic questions11,12 raised include: would financial incentives be enough to prompt providers to adopt EHRs13; should the federal government push for more stringent and faster compliance with standards14; would the federal government directly or indirectly pick “winners” and “losers” in the EHR industry15,16; and would the EHR industry consolidate or expand to meet different provider market needs?

Early evidence suggests that HITECH is addressing these challenges: CMS had paid $9 billion to more than 177,000 eligible professionals and hospitals as of December 2012.17 Given this significant uptake, important questions remain about the impact of HITECH on competitiveness and innovation in the EHR market. For example, a decreasing number of EHR vendors with certified products over the long term could indicate that certain aspects of the certification process are too challenging or costly, or that market forces are naturally leading to consolidation; alternatively, an increase in the number of EHR vendors with certified products could indicate increased competition, greater alignment with market needs, and evidence that the certification process is providing value to both vendors and purchasers.

To understand the EHR market and the implications of HITECH, we investigated several key measures prior to and during HITECH’s implementation, including: 1) the number of providers who have adopted EHR; 2) the number of certified EHR vendors; 3) market concentration ratio among the top 10 EHR vendors; 4) type of technology adopted by physician market segments; and 5) whether there is a difference in market focus by vendor, using vendor technology type as a predictor.

METHODOLOGY

Data Source

The study data were obtained from the Surescripts network, which electronically connects and certifies systems used by prescribers, pharmacies, payers, and pharmacy benefit managers. The network connects more than 40 payers and pharmacy benefit managers, more than 62,000 community pharmacies, and roughly 490,000 prescribers using more than 250 e-prescribing and EHR systems representing over 400 applications.

E-prescriptions generated by a provider using a “Surescripts-certified” system are processed by Surescripts and routed electronically to a community pharmacy. Surescripts estimated that, as of the end of 2012, more than 50% of all eligible prescriptions in the United States were electronically routed through its network.18,19 Others have validated the use of Surescripts data to track EHR adoption.20 We tested the credibility of using Surescripts data for this study by comparing EHR and eprescribing vendors certified on the Surescripts network against a list of vendors certified by the Office of the National Coordinator (ONC).21 First, we used a VLOOKUP function in Microsoft Excel to find exact matches of vendor names provided by Surescripts and Data.Gov; second, we manually reviewed the unmatched vendors and searched ONC’s Certified Health IT Products List website for instances in which the vendor’s product classification was “Modular EHR” and used a Surescripts-certified vendor for e-prescribing.22 We were able to find a positive Surescripts vendor match for 97.3% of ONC-certified vendors, as outlined in the Table.

Observation Periods

We measured the number of active prescribers and Surescripts-certified vendors on the Surescripts’ network during the first quarter of each year on a longitudinal basis using data from 2008 to 2012. We calculated the number of vendors as those with active prescribers in any measurement period, as this is best proxy for the number of active vendors in the marketplace at any one time. A prescriber is characterized as “active” if he or she has written and routed at least 1 prescription electronically in a 30-day period.

Study Variables

To determine industry competitiveness, we conducted 2 calculations during each measurement period: collective market share of vendors (grouped by 10) by share of active prescribers; and the Herfindahl-Hirschman Index (HHI), which provides insight into industry competitiveness and is used by the Federal Trade Commission (FTC) for the purpose of measuring market concentration in antitrust cases. We calculated HHI index by determining market share of each EHR vendor, as established by share of active prescribers.

To assess innovation occurring in the market and industry, we measured the type of EHR technology—as defined in dichotomous terms as either Web-based or traditional software—adopted by different market segments (defined here as physician practice size). We chose these 2 measures because Web-based technology tends to allow for more rapid technology innovation and deployment and more flexible business models than traditional software. Because we could not positively identify all vendor applications by type, we categorized applications into either 1) Web-based, 2) traditional software, or 3) unclear. We present a range of results based on possible variations of inclusion and exclusion in the “unclear” category. In addition, we matched Surescripts provider data to data from SK&A, the large healthcare information solutions firm, to obtain and verify practice-size information. We categorized EHR providers by the sizes of the practices they serve. For the purpose of tracking EHR application type by practice size, these sizes were defined as small (1-5 providers), medium (6-25 providers), and large (more than 25 providers).

RESULTS

Early data indicate that a substantial number of EHR vendors have successfully completed the ONC certification process—396 as of September 2012, each of which had at least 1 eligible professional who has successfully attested to MU requirements.2 Figure 1 shows that the number of certified vendors on the Surescripts network increased by 133 from the first quarter of 2009 (when HITECH became law) to the first quarter of 2012, from 96 to 229. Notably, the number of new vendor entrants in the industry increased each year, with 58 entering between 2011 and 2012; this is more than the total number of vendors, 52, in 2007. (Also of note is that several of the Surescripts-certified vendors partner with and provide e-prescribing services to many ONCcertified vendors, which explains the difference in vendor numbers between Figure 1 and Table 1.) Prescriber adoption increased at a rapid pace as well in the 3-year period following HITECH, from 40,759 in early 2008 to 401,651 in early 2012, reflecting a compound annual growth rate of 58%. The number of new adopters increased each year, from approximately 70,000 in the year immediately following HITECH’s adoption to nearly 140,000 between Q1 2011 and Q1 2012. Reflecting the rapid growth, 74% of active e-prescribers on the Surescripts network as of the first quarter in 2012 had adopted EHRs post HITECH.

Among the top 10 vendors (as measured by market share) during this same 3-year period, the average number of active e-prescribers per vendor increased from 7864 in 2009 to 31,120 in the first quarter of 2012; the average vendor’s e-prescriber base increased from 1078 users to 1754 during that time (Figure 2). A top-10 vendor in early 2012 was 75 times larger than the average vendor, up from 27 times the size of the average vendor in early 2009.

Despite the top 10 vendors’ faster growth rate, however, they did not collectively gain market share: the top 10 EHR/e-prescribing vendors had 72.4% market share in Q1 2008, 76.0% in 2009, and 77.5% in Q1 2012—relatively stable growth (Figure 3). The HHI index for the EHR/e-prescribing industry increased from 814 in Q1 2008 to 1022 in Q1 2009 before decreasing again to 876 in Q1 2012. Based on the definition provided by the FTC, this suggests that the EHR industry remained a “highly competitive” industry throughout the study period.

We have seen evolution in the types of HIT providers have adopted. In early 2008, the majority of providers (59%) across practice settings had chosen stand-alone e-prescribing systems. By early 2009 (when HITECH was signed into law), the numbers had changed significantly, with the majority (54%) of providers choosing EHRs.25

Among providers who adopted an EHR in 2008, very few (3.6%-6.2%) opted for Web-based EHRs. Adoption of Web-based EHRs was highest among small office providers (6.0%-11.7%) and lowest among providers working in large practices (1.8%-2.9%), as noted in Figure 4. The overall prevalence of Web-based EHRs increased to between 9.9% and 19.5% among providers who adopted in 2011. Web-based EHRs were most popular with small office practice providers, with between 15.0% and 34.5% of this cohort selecting Web-based applications in 2011. During the same period, providers in medium and large practices increasingly selected traditional software-based EHRs.

Limitations

 
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