The healthcare industry has known for years that the electronic health record (EHR) market, dominated by a handful of EHR vendors but also populated with literally thousands of disparate systems, can't maintain status quo forever. Mergers, acquisitions, consolidations and bankruptcies, though seldom mentioned, are nonetheless inevitable.\nThis belief exists in spite of the government's meaningful use incentive program, which gives hospitals and eligible healthcare providers money if they can demonstrate that they are using an EHR system \u2014 and which, some say, has created artificial demand for EHR software and thrown less-than-stellar systems a much-needed life preserver.\nStage 1 of meaningful use, which began in 2011, was a "low hurdle to get across" for EHR vendors and healthcare providers alike, says John Moore, managing partner of healthcare IT analyst firm Chilmark Research.\nStage 2, which began this year, is much harder, Moore says. There are more clinical quality measures to track and more patient matching and data mapping requirements; vendors must demonstrate interoperability (both creating and pushing records as well as consuming and populating them) with at least one other EHR system built by another vendor, and systems must let patients view, download and transmit their own electronic records.\nAs a result, EHR vendors are struggling with stage 2 \u2014 to the point that only 13 percent of physicians have an EHR that meets stage 2 criteria, according to the Centers for Disease Control and Prevention. Not surprisingly, then, half of physicians think EHR costs outweigh their benefits, according to a survey by cloud EHR vendor Athenahealth, while a RAND Health report says that, "for many physicians, the current state of EHR technology significantly worsen[s] professional satisfaction in multiple ways."\nThe remedy, RAND Health concludes, is better EHR usability. That, experts say, is where the wheat in the EHR market will be separated from the chaff.\nIn Most EHR Systems, the Workflow's the Problem\nReports on the tumultuous state of the EHR market have come hard and fast in the last several months. Black Book, which surveyed close to 900 consultants, analysts and managers last summer, suggested that half of EHR vendors won't make it to meaningful use stage 3; those that placed meeting meaningful use criteria before usability will likely suffer the most, Black Book found.\nMeanwhile, multiple surveys also released last summer said more than one-third of healthcare providers aren't happy with their EHR systems and want to switch, even if it will cost time, money and efficiency.\nPart of the problem, says Dr. Heather Haugen, managing director of The Breakaway Group within Xerox, is that there's a difference between EHR implementation and EHR adoption.\nBecause the EHR incentive timeline is so short \u2014 healthcare providers who are eligible for meaningful use but don't participate will receive reduced Medicare reimbursements starting in 2015 \u2014 corners have been cut, says Haugen, co-author of Beyond Implementation: A Prescription for Lasting EMR Adoption.\n[ Analysis: EHR Implementation Rising, But Hurdles for Healthcare Remain ]\nOrganizations know they should analyze workflow, but they want to get EHR software installed first \u2014 but workflow analysis never happens, providers adopt "a million workarounds" and EHR implementation best practices aren't followed, she says.\nMistakes are common \u2014 copying a note or diagnosis pertinent to Patient A into the record of Patient B, for example, because it's quicker than retyping everything \u2014 and, according to the Office of the Inspector General at least, can constitute EHR fraud, even if a provider's copy-and-paste activity isn't being done with higher reimbursements in mind.\nTraining can solve such issues, Haugen continues, but organizations often focus on generic, event-based training that clashes with clinical schedules. Today's physicians, nurses and technicians learn not through rote memorization but, rather, from "putting their hands on the controls," Haugen says, using a term that describes how airline pilots made the move from analog to digital cockpits in the 1980s. What's more, simply walking users through common EHR software scenarios offers insight into how they perform common tasks, which can help trainers reinforce good habits and in turn help users build "muscle memory as to how it's done."\nEHR Workflow Matters Because EHRs Are Vital Data Source\nWorkflow is so important to the success of an EHR system than Kristin Russell, senior director of product development and marketing with Omnicell, sees workflow integration as the remedy for healthcare IT's longtime nemesis: Interoperability.\nTwo factors force this change, Russell says. The first is the juxtaposition of consumer systems that easily sync with Facebook, the Wii and other services with, say an automated medicine dispensing cabinet that forces a nurse to log in, pull a patient's record and dispense medication, only to enter the same information in the EHR moments later. Nurses want to "close the loop," she says.\n[ News: Can the Feds Make Health IT Systems Talk to Each Other? ]\nThe second factor is the healthcare industry's push toward more coordinated care. Groups such as the Cleveland Clinic, Russell says, now take a "zoom in, zoom out, zoom everywhere" approach to care \u2014 zooming in at the individual level of care, zooming out for the sake of population health management and zooming everywhere to connect to wellness devices and the Internet of Things.\nIn this model, the EHR serves as, well, the data source of record for a range of purposes, including health information exchange, billing and big data analytics. To paint a more accurate picture of a patient's health, an EHR should also collect and display data from medical devices as well as consumer fitness monitors or applications. Here, Russell says, EHR systems built as platforms as opposed to standalone, monolithic systems are better positioned to share data, work together and support workflow needs.\nIll-prepared EHR Vendors Will Fall Victim to Meaningful Use\nThose points are consistent with the Center for Medicare and Medicaid Service's meaningful use stage 2 criteria, which go beyond simply using electronic records to actually sharing them \u2014 with labs within the hospital, with other hospitals, with pharmacies via e-prescriptions and, critically, with patients. (Many have suggested that the patient engagement benchmark is too difficult to achieve, but it's really just about communicating with patients electronically.)\nThe EHR vendors that struggle to do this \u2014 and to present this shared data in a clinical decision support environment, which aims to helps physicians make more informed care decisions \u2014 will have the most trouble with meaningful use stage 2, says Judy Hanover, research director with IDC Health Insights.\n[ Feature: Why Fixing Healthcare Requires Netflix-Like Disruption ]\nMarket consolidation is more likely in the ambulatory EHR space, wherefive vendors control more than half the market. Ambulatory EHR vendors who aren't Epic Systems, Allscripts, eClinicalWorks, NextGen Healthcare or GE Healthcare find it increasingly difficult to find new customers, especially for software installations and not perpetual subscriptions, Hanover says.\n\nOn top of that, achieving meaningful use stage 2 certification is an expensive proposition, Hanover says. Consolidation is inevitable, she says, and should continue throughout the year. (Others suggest the EHR market shakeout will last several years.)\nThe mature inpatient EHR market, though also due for consolidation, is likewise due for innovation. Moore says meaningful use created a "false market" that led many providers to implement rigid, inflexible EHR systems (with poor usability and customer service to boot) simply to cash in. Here, the meaningful use stage 2 deadline extension announced in December should therefore help providers who are looking for a new EHR system or who need to "take a breath and catch up," Hanover says.\nIf nothing else, the fact that smaller practices lag in EHR adoption could provide an opening for flexible (or even free) EHR vendors as well as companies providing components, modules or "augmented functionality," Hanover says, adding that platform-based systems outside the EHR itself but interacting closely with it could help those practices meet their patient engagement, quality reporting and population health management needs.\nThe Days of EHR As 'Deposit-only System' Are Numbered\nStage 3 of meaningful use, meanwhile, will further disrupt the EHR market. For starters, Hanover says, it places even more emphasis on interoperability to "bend the cost curve." EHR vendors that have found it to their advantage to be insulated will find that "their excuses are getting smaller and smaller," she says.\nIn addition, stage 3 essentially redefines the EHR as a "collaborative health record," Moore says. In the context of patient-generated data, he asks, how will EHR software bring in this data, validate it, make sure it in fact came from the patient, accept the most appropriate date for clinical decision support and aggregate it from multiple sources \u2014 and, oh, on what frequency? The status quo won't cut it; physicians are "pretty fed up" with their EHRs, Moore says, with one describing the software to Moore as a "deposit-only system."\nDan Riskin, CEO and co-founder of Health Fidelity, suggests that healthcare has built an EHR industry that merely captures data. It's like looking at a bowl of flour and insisting it's a cake, he says; many other ingredients are needed. Getting EHR software up and running, isn't the goal, he says; it's reducing costs and improving care.\nThe logical next step, Riskin says, is getting that full set of clinical data into a data warehouse \u2014 not just for reporting requirements, mind you, but for analytics and population health management. That requires full data sets. Right now, most EHR software provides only a tiny fraction of the data. Thanks to poor workflows, users ignore the myriad dropdowns in their EHR systems and instead make extensive use of free-form text notes that, as unstructured data sets, don't make it into the data warehouse.\n[ Feature: Big Data Analytics Use Cases for Healthcare IT ]\nLike Hanover, Riskin says turnkey systems, not EHR software itself, will be the answer here. (As an example, he points to the meaningful use stage 2 reporting modules popping up in today's EHR systems.) Why? Organizations with underperforming EHR systems face the Catch-22 of solving immediate problems with a bad architecture now or trying to re-architect in a few years' time.\nIf nothing else, market pressures will come into play. There's "no conceivable future," he says, when any EHR module will get an organization where it needs to be and it won't have to improve outcomes or reduce costs, whether it's through the accountable care organization (ACO), Medicare Home Health Compare or another risk- and value-based model.\nOr, as Hanover puts it, "It's about monetizing those EHR investments, and hospitals can't do that without analytics."\nSuccess Stems From EHR Best Practices\nGiven the state of affairs, can anyone succeed in the fragmented EHR market? In Software Advice's ongoing EHR Software User Survey, the top system that respondents use, by a huge margin, is Other.\nAs it stands, the EHR market is poised to grow for a few more years; only about half of U.S. hospitals have an EHR system. The challenge for vendors, of course, is that that segment is harder to convince than EHR early adopters. That said, many hospitals must replace homegrown or legacy EHR systems to meet stages 2 and 3 of meaningful use, as well as the more complex needs of the ACO model.\nThis prompted KLAS Research to conclude that the EHR market isn't as close to saturation as previously reckoned. KLAS also found that Epic Systems, the unarguable market leader, which claims to hold patient records for half of Americans, doesn't win as many contracts as it once did, increasingly losing out to Cerner. On top of that, in the most recent KLAS ranking, Epic lost its best EHR software rating to athenahealth, ending an eight-year reign.\nContracts and rankings, though, aren't going to get physicians to use EHR systems. Four things must happen for this to occur, Haugen says:\n\nEngagement with the clinical leadership team (and not necessarily the C-suite);\nRole-based training focused on what a class of user will be doing 80 percent of the time, not on advanced functionality;\nAn ability to measure success or failure, complete with a feedback mechanism that pinpoints who's using particular functionality, and\nA sustained process, with the backing of clinical leadership, to emphasize EHR adoption and continued training.\n\n[ Feature: 11 Ways to Make Healthcare IT Easier ]\nThe worst thing that can happen, Haugen says, is for those leading the EHR implementation effort to return to their old roles after the go-live date. The work after that point is just as important \u2014 if not even more so \u2014 and involve a different level of engagement.\nOtherwise an organization may find itself in an all-too-familiar position: Less efficient after more than a decade of EHR use than in the era of paper records. That problem is nearly impossible to solve, no matter which EHR vendor you choose.\nBrian Eastwood is a senior editor for CIO.com. He primarily covers healthcare IT. You can reach him on Twitter @Brian_Eastwood or via email. Follow everything from CIO.com on Twitter @CIOonline, Facebook, Google + and LinkedIn.