I agree that all the factors you've listed are in play, but they are far from the only ones involved in decision making. Perhaps this is a regional thing, I've

I agree that all the factors you've listed are in play, but they are far from the only ones involved in decision making. Perhaps this is a regional thing, I've never experienced (and have no wish to) what the US EMR market is like. Some complaints/feedback I did receive from doctors and clinic admins while working for an EMR vendor: 1. Your system is buggy/unintuitive and we hate using it. 2. We're not upgrading or moving to your new system because of 1). 3. We're moving to competitor X because they have Y feature. 4. [conversely] We came from competitor X because their EMR is slow/buggy/lacks features. 5. We signed up because the docs/office assistants liked [hero feature] in the sales demo. So yes, 0 mentions of the word "software". However, all of these are directly related to the software itself. There's a reason flashy new companies can swoop in and steal some market share (at least where I am). Even more importantly, there are many tech-related reasons why some companies start floundering and drop out of the market: - bad foundations (most EMRs were created by doctors with limited dev experience) - rampant tech debt driven by feature-driven development - lack of knowledge about testing/CI These are not theoretical problems. More than once, we incurred regulatory fines and SLA penalties in excess of the "cost of doing business" threshold. After a pretty major patient data screw-up, upper management even relented and gave the dev(ops) team time/money to clean up their act. Regulatory and bureaucratic inertia may insulate health IT companies from software engineering issues, but there's a limit to everything and they can sure as hell bleed.