Billion Dollar Paywalls

After the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, which incentivized Electronic Health Record (EHR) adoption in the United States, a 2016 American Hospital Association survey found that 75% of its member hospitals had at least some basic EHR in place, up nearly five times from 2010 levels.1 However, EHR systems in the US remain overwhelmingly proprietary, split up into carefully-guarded billion-dollar fiefdoms separated by paywalls.

As of 2016, two-thirds of the 8.6 billion dollar EHR market in the US were held by three major vendors: Epic at 25.8%, Cerner at 24.6%, and Meditech at 16.6%.2 As of December 2017, examination of the 93 vendors with products currently certified by the Office of the National Coordinator for Health Information Technology (ONC) to meet 2015 Meaningful Use guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) found only three vendors releasing open source products3, 4 5 and only two others who are active open source contributors.6 7

Of the three open source products, two are based on Vista developed by the US Department of Veterans Affairs3 5 and the remaining is a former proprietary product that recently became open sourced.4 Vista has not been a shining example of open source, considering its lack of external commits. It's dying now that Cerner won the government contract for replacing the aging Vista. The time is ripe for a national open source EHR to emerge.


  1. Getting Meaningful Use Right. American Hospital Association, 2016
  2. A. Vaidya. Epic, Cerner hold 50% of hospital EHR market share: 8 things to know. Becker’s Hospital Review, 2017. Accessed 3 Jan 2018: https://www.beckershospitalreview.com/healthcare-information-technology/epic-cerner-hold-50-of-hospital-ehr-market-share-8-things-to-know.html
  3. Frequently Asked Questions. Medsphere. 2018. Accessed 3 Jan 2018: http://www.medsphere.com/company/frequently-asked-questions
  4. CAliPR eCQM Solution Made Available As Open-source Technology. Audacious Inquiry. 2016. Accessed 3 Jan 2018: https://ainq.com/news/calipr-ecqm-solution-made-available-as-open-source-technology/
  5. vxVistA. DSS Inc. 2018. Accessed 3 Jan 2018: https://www.dssinc.com/products/integrated-open-source-products/vxvista/
  6. Engineering Health. Cerner Engineering. 2018. Accessed 3 Jan 2018: http://engineering.cerner.com/
  7. K. Chitale. Consolidated-CDA Processing Using NiFi C-CDA Processor Contributed by CitiusTech. CitiusTech Knowledge Hub. 2017. Accessed: 3 Jan 2018: https://www.citiustech.com/knowledge-hub/detail?id=XHxUCys03ro=