The EMR/EHR market is actually a collection of different markets. The institutional one is a lost cause -- you are not going to get Kaiser to back out of its $

The EMR/EHR market is actually a collection of different markets. The institutional one is a lost cause -- you are not going to get Kaiser to back out of its $5B investment in Epic. These are enterprise systems with ancient cores who are largely sold on the golf course, under cover of RFPs and checklists so buyers can compare "apples to apples". No usability or modern technology considerations apply. You will take your Citrix and love it. Like most enterprise apps they have to do it all (billing, HR, compliance, security, and on yeah, some sort of medical charting) simply to be competitive, and as developers we know how that works out. The small-practice market is where a lot of innovation is happening -- PracticeFusion, DrChrono, athenaHealth, eClinicalWorks, etc. It's competitive but the dollar amounts tend to be fairly low and the small-practice market is drying up as doctors ally themselves with hospital groups in advance of the freight train that is health reform. The really bloody (and interesting) battle is in specialty EHRs, as others have mentioned. Generic records just don't fit for optometrists and dentists and therapists and the like. There's huge opportunity here for competition and the markets can be small and cozy enough that UX, SaaS, good service, etc becomes a big differentiator. Jae doesn't get into constraints against ground-up reinvention too much, which are almost comically enormous. For example HIPAA (and "Son of HIPAA" from ARRA) is married to a wide variety of state-specific privacy regulations that go above and beyond the Federal regulations. The biggest constraint of them all is something called "Meaningful Use" (ONC-ATCB EHR Certification), which determines if your software makes you (the doctor) eligible for federal incentive dollars. It's the primary driver of EHR sales at the moment and creates a bunch of onerous and potentially user-unfriendly requirements on the part of the vendors who have to spend hundreds of thousands of dollars to comply, taking R&D budget away from actual innovation. Just to give one example, Jae says "Your EMR does not need to have every single drug and its dosages installed in its database, with an automatic checker to make sure there are no negative drug reactions" -- as a matter of fact ONC EHR Certification (which, again, is driving the industry) calls for exactly that. While I certainly agree with almost every one of Jae's suggestions, it's difficult to see them getting adopted under todays' market incentives. Clinicians don't buy EHRs. Administrators aren't interested the things he lists. And even when clinicians do purchase the systems, the game is heavily rigged towards large, legacy vendors pushing shitty, ugly software with their huge sales forces who can spend money complying with complicated regulations. In closing, it's all sort of a clusterfuck.