Unintended Consequences of Nationwide Electronic Health Record Adoption: Challenges and Opportunities in the Post-Meaningful Use Era

This follow-on article moves the discussion forward by adding further dimension to the issue of unintended consequences from the perspective of the United States health system.

Unintended Consequence 2: Electronic Health Record Market Saturation

The Path Forward

As new, expensive EHR implementations become rarer, EHR vendors will be forced to find new business models to remain profitable. This path is evolving through initiatives such as the Substitutable Medical Applications & Reusable Technologies (SMART), which coupled with data standards, such as Fast Healthcare Interoperability Resources (FHIR), is enabling development of third-party applications seamlessly connected to commercial EHRs. Such applications have the potential to replace or augment commercial EHRs' functionality, in a model similar to the mobile phone industry. To providers, such an approach represents an interesting opportunity to expand, customize, or replace EHR functionality as needed; to EHR vendors, it represents an opportunity to diversify their products, solutions, and sources of income. However, the saturation of the national market has produced a situation analogous to an oligopoly, and the path to producing new business models is unclear. Although some vendors seem to be open to the idea of having external applications connected to their EHR, others intend to charge providers per FHIR transaction, which will eventually hamper use of external applications. In addition, the 2 leading US EHR vendors are increasing their global presence, which may help to keep them financially sustainable and postpone the development of new business models. With an increased bargaining power of these vendors, the success of initiatives such as SMART on FHIR may emerge from the tension between providers' needs and vendors' desire to keep control over their products.

Some researchers have suggested that the use of similar systems across the country will create opportunities for human factors researchers by facilitating comparison of similar functionality; however, such opportunities may not reach fruition because of local configurations that allow the same product to be implemented in completely different ways across clients. Overcoming the vendor oligopoly will demand development of informatics solutions proved to be more effective than current systems' functionality, which leads us to the next UC: innovation vacuum.