COTS EHRs are Expensive and Workflow Confining

The market noise around EHR cost as well as their rigidity in workflow capabilities that drive physician and nurse burnout continues unabated. Epic and Cerner represent vendors of enterprise EHRs that are designed to support both financial and clinical workflows for both acute care and ambulatory environments. Many clinicians feel the EHRs are designed specifically to support billing functions and do not provide the necessary functions and features to allow them to deliver higher quality care that drives better outcomes and both patient and physician satisfaction. While these systems are technically sophisticated, they have become bloated solutions that are extremely expensive to acquire and maintain. Provider organizations have the expectation of efficiently automating EHR patient care processes with billing and quality reporting as byproducts. This has rarely been achieved.

I used to debate John Glaser who was the CIO at Partners Healthcare a few years ago about the viability of “plug and play” software components that could be used to create an EHR environment that would best support a provider environment. I liked the concept, but at the time, around 2001, the feasibility of using current technology to provide this solution was not viable. Digital technologies have now evolved that are proving this capability via digital applications that interoperate with enterprise solutions to improve care delivery workflows. I believe we are entering an era where “lite EHRs” (EHRs built on cloud environments that use digital application components connected to AI and speech recognition) will emerge to challenge the current EHR oligopoly.

Using Application Components to Build an EHR

Holy Name Medical Center, a 360-bed hospital in Teaneck, New Jersey, is completing a journey for building an EHR that supports their specific care delivery workflows while maintaining billing integrity. Holy Name is a smaller hospital and felt the solutions provided by Epic and Cerner did not provide the functions and features they needed to support their clinicians as they delivered patient care. They also felt their current EHR solution was driving higher physician burnout. Holy Name used a technology platform from Medicomp Systems as the foundation for their custom EHR and had software developers follow physicians during their rounds to ensure an effective application design. Medicomp Systems has been successful in augmenting clinical processes in legacy EHRs and uses the Quippe Clinical Data Engine to provide semantic interoperability across EHR and clinical application data environments to support their point of care solutions.

If you have used the Build-A-Bear product that allows children to design and build a teddy bear to their liking, this may become a similar process for providers pursuing a “build-a-bear EHR” environment. As healthcare reimbursement moves toward value-based care, the cost of delivering care will become more critical. At this time the EHR cost of care delivery is significant and growing. At the cost tipping point providers may evaluate the cost of developing and maintaining a custom EHR versus continuing to use expensive legacy EHR solutions. Will legacy EHR vendors see this trend and cannibalize their current solutions to maintain market share? Likely not.

Lower EHR Costs and More Flexibility for Supporting Clinicians

As care delivery modalities change to focus on providing patient care in the appropriate environments, EHR flexibility for supporting these care transitions will be critical in driving long term organization success. Many providers are already integrating point of care digital solutions to supplement EHR functions and drive higher levels of clinician satisfaction. As providers continue to add digital applications to the EHR environment they may decide to evaluate their EHR solution relative to long term applicability for supporting their operations. If digital technologies continue to advance to accommodate sophisticated care delivery workflows with a foundation platform that facilitates customized applications at justifiable costs, we may see “build-a-bear EHR” solutions emerge in force.

The Players: Platforms Designed to Deliver Customized Healthcare Solutions

The robust digital technology environment is driving the emergence of vendors who support custom software application development for healthcare. While many of these vendors provide mobile app solutions, the designs will likely support static workstation use. Representative solutions include:

  • MediComp Systems: point of care solutions designed with semantic interoperability.
  • LiGHTiT: creates healthcare applications across all product scales.
  • topflight.: healthcare products that address patient-centered care.

Success Factors

  1. Provider organizations who pursue self-developed EHR solutions must have the technical expertise and a company risk culture to support this effort.
  2. Total cost of ownership studies must establish that self-developed EHRs will be more cost effective than the current EHR solution in use.
  3. The development platform for self-developed EHRs must be provided by a vendor that can maintain market viability in a world where big technology companies could emerge as competitors.


Legacy EHR solutions provided by Epic and Cerner have created a market oligopoly that limits EHR selection choice for most provider organizations. These solutions are also very expensive and may not provide the physician function/feature flexibility needed to support the transformation of care from acute care to ambulatory and home care environments. Historically self-developed EHRs have been expensive to develop and maintain. Few self-developed EHRs built on legacy architectures survive today and many of the providers using these solutions have implemented Epic or Cerner to improve operational outcomes. But the cost of the Epic and Cerner is becoming prohibitive to mid-size and smaller provider organizations. The emergence of new cloud and digital technologies may provide a platform for healthcare organizations to pursue self-developed build-a-bear EHRs once again if the digital development platforms support ease of development and maintenance of custom applications that support clinician workflows at an affordable cost. If these solutions are feasible for small and mid-size healthcare organizations, how long will it take for the larger healthcare networks to move in this direction?

Photo credit: New Africa, Adobe Stock