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How Your EMR is — Or Isn’t — Like

Is it safe yet? After a year, have emotions died down enough to write a blog comparing EMRs to the troubled launch of I hope so, but if your first reaction to the title above is “How are those two things different?! They’re both destroying America!” then you might want to stop reading. The rest of this will be boring. It’s about technology.

Amidst all the policy, politics, and controversy surrounding, some observers noted that the decision to use a NoSQL database contributed to the website’s difficulties. The first issue was scalability, but that was a relatively easy “throw-hardware-at-it” problem. A more interesting challenge was the lack of skilled workers with experience in NoSQL programming.

In a November 22, 2013, article, The New York Times noted, “Another sore point was the Medicare agency’s decision to use database software, from a company called MarkLogic, that managed the data differently from systems by companies like IBM, Microsoft and Oracle. CGI officials argued that it would slow work because it was too unfamiliar. Government officials disagreed, and its configuration remains a serious problem” (“Tension and Flaws before Health Website Crash,” November 22, 2013).

With KLAS having just published a special report on the impact of EMRs’ underlying technology, the word “unfamiliar” sounded awfully familiar to me. Consider this observation from an Epic customer:

The implications of Epic's complicated system drive a lot of staffing decisions. There are several people who seemed okay with working on our previous system but that cannot cut it with Epic. I want to replace a database administrator who does not have a great work ethic, but am hesitant to do so because it is so difficult to find a Cache database administrator. Epic teams need to be so big because it takes more people to run Epic than it does for another system, not because we are so much more focused on the end user. It is just harder to accomplish basic IT maintenance tasks in Epic.

Now compare that with this comment from an Allscripts customer:

"We hired a database specialist to develop advanced clinical functionality in Allscripts Sunrise Clinical Manager. He wasn't familiar with Allscripts, but he is an SQL person, and once he got in here, he just ripped right through it. I thought it would take him a year to familiarize himself with the database, but he was in there within months. He got the hang of it, and he also saw some of the flaws in the logic we had written a long time ago for activations."


KLAS Image: EMR Functionality Chart


There is a war of words going on between the major EMR vendors about the merits and disadvantages of their different technology platforms. To summarize the perceptions . . .

1. Epic and MEDITECH use databases that can trace their roots all the way back to MUMPS. They are seen as being fast and reliable but also complex and inflexible.

2. Allscripts, Cerner, McKesson, and Siemens use more mainstream technologies (e.g., Oracle and Microsoft). They are familiar and configurable but slower and less dependable.

For many, these differences boil down to two issues: cost and extendibility. These people would say that Allscripts, Cerner, McKesson, and Siemens have the advantage.

But if it’s that simple, why is Epic winning the most market share these days? And MEDITECH at least holding their own? Among the other vendors, all but Cerner have been losing market share year after year.

The truth is, it’s not about the technology. Increasingly, providers tell KLAS they don’t want to customize their EMRs any more than they must. They just want their EMRs to work, and they want vendors that will reliably handle development for them. One provider likened EMRs to automobiles:

I don’t think most people care if a car has fuel injection, runs on diesel, or is carbureted. People just want to turn the key on and have the car get them to the grocery store. The system's guts might be something that the geeks want to play with, but the end user doesn’t care. That is not to say that technology isn’t a factor, but that would be number 999 on a list of 1,000.

This theme pops up repeatedly in our research. Most recently, it tells a lot about the story behind Cerner’s pending acquisition of Siemens. We also just published a report on EMR interoperability that emphasizes how technical excellence is not the same thing as customer success.

To close, here’s an interesting bit of trivia:’s ultra-modern NoSQL database has more in common with the decades-old MUMPS platform than a scarcity of experts looking for a job. If you are a geek, catch up on the technical similarities here: “MUMPS: The Universal NoSQL Database.”