American Association for Physician Leadership

Operations and Policy

Best of Breed Electronic Medical Record Comparative Analysis

Nicholas E. Martinez, RHIA | Kendall Cortelyou-Ward, PhD | Hana T. George | Jhon J. Arias | Rohith Sompalli

December 8, 2017


The HITECH Act of 2009 and resulting legislation have required many providers to implement electronic medical record (EMR) software systems into their practices. With this increased demand for systems, a wide variety of full-service and specialty EMR systems have emerged in the market. The overwhelming number of options leaves providers with many choices and little unbiased advice.

The American Recovery and Reinvestment Act of 2009 established incentive payment programs sanctioned by CMS to promote the adoption and integration of interoperable health IT in different health institutions.(1) Since this incentive program took effect, many hospitals and health facilities have acquired electronic medical record (EMR) systems, whether it be through a single-vendor system, multiple disparate systems, or a hybrid EMR system. In this article, the benefits of using a “best of breed,” or modular, customized, and interoperable, EMR system, including time, money, and effort, are weighed against its cost compared with that of a single EMR system or combination of EMR systems.

No single EMR system works for all health organizations.

Each hospital or health organization’s needs differ, and the EMR system is chosen to fit the most needs, typically at the lowest cost. No single EMR system works for all health organizations, which is why there are several types of EMRs used across the nation and world. The specific organization’s or hospital’s specializations typically also are criteria determining how a vendor, EMR system, or a combination of these is chosen. Different providers use different systems to fit their organizations.(2) The best of breed approach is favored because of its desired functionalities, interoperability, and multipurpose use, whereas a single-vendor system caters to only one workflow.

Literature Review

A one-vendor system may not have all the desired modalities or functionalities, and, therefore, may be viewed as inadequate by some organizations.(3) One popular EMR system commonly used, EpicCare Inpatient, is found in more than 50% of large hospital contracts across the United States and has become a monoculture within the health IT world.(4) This product is tailored to CMS documentation guidelines aided by federal incentives or penalties, all of which have contributed to its widespread adoption. However, costs also are significantly higher than those from other vendors or a best of breed EMR system, and do not take into consideration the continuation of costs in training, maintenance, or consultancies. The upgrade costs for this system are 40% to 49% higher than those for its competitors.(5) Single-vendor EMR systems are limited in functionalities, especially in specialty areas such as cardiology or radiology, which may require a best of breed approach when it comes to usability. Also, single vendors have an extensive record of excluding third-party or homegrown software, which reduces opportunities for patient safety interventions.(6)

The best of breed EMR approach has a variety of advantages when compared with a single-vendor system. In specialty areas, which require domain-specific solutions, a best of breed approach is preferred.(3) Cost also is a major reason why the best of breed EMR system is used in hospital settings and or other healthcare settings: some best of breed systems cost from $250 million all the way up to $1.1 billion.(4) When faced with a technical or software issue, a best of breed EMR system’s hospital IT department can troubleshoot and navigate the issue, whereas when there is a system failure with a single vendor such as Epic, results for the faced issue can be delayed and often are overwritten in the awaited software upgrade. Use of a best of breed EMR system can help big hospital systems integrate with smaller hospitals with different systems for keeping patient records better than a monopolized single vendor.

The use of computers in the exam room has been shown to decrease the amount of eye contact doctors can make with patients.

Content management software developers provide multiple reasons why traditional EMR systems fail.(7) The average implementation cost of a best of breed EMR system is less than one fifth that of a traditional single-vendor system; monthly maintenance is less than an eighth of the cost. In addition, traditional EMR systems require doctors to spend time during appointments entering notes into the system. This further hinders efficiency, because physicians often encounter unintuitive interface elements and have to use multiple screens to accomplish tasks, which is disruptive to their workflow.

Furthermore, the use of computers in the exam room has been shown to decrease the amount of eye contact doctors can make with patients, which, in turn, reduces dialogue and emotional responsiveness between them. This can even prevent the patient from fully disclosing information pertinent to his or her care. To avoid this, some doctors simply take notes on paper during appointments and enter them into the system afterwards. This, however, presents the risk of using existing appointment time to enter notes, which reduces patient satisfaction and decreases the number of patients a doctor can see in a given time, thereby decreasing his or her profit within that period.(7) Many healthcare providers have enabled their institutions to operate more efficiently by adopting a hybrid EMR system.

In one case study, a California-based gastroenterologist, Brian Hanson, and his staff were considering implementing a traditional EMR system to improve record keeping. They decided against doing so due to budget constraints, difficulty of customization, and the need to make complicated changes to the practice’s workflow. Hanson’s practice manager later discovered a best of breed EMR system and believed it could satisfy the office’s demand for a customizable, user-friendly EMR system lacking the previously mentioned drawbacks whose use would avoid disrupting patient care. Within a week of purchase, the best of breed EMR system was installed in Hanson’s practice, and the staff was trained on its use. Since then, Hanson has had real-time access to patient records remotely from a tablet PC, which allows him to respond immediately to urgent issues at his office. His practice’s EMR system also is configured to store scanned patient records, automatically send Hanson patient updates as soon as they are entered into the system, process records quickly, and ensure compliance with HIPAA by tracking the flow of information. In addition, Hanson’s practice has saved money due to the decreased cost of storing and managing paper records.

Despite the advantages that best of breed EMR systems have over traditional systems, they possess a major drawback in that they lack both preliminary and advanced diagnostic capabilities. However, best of breed EMR systems have additional desirable features such as being able to scan handwritten notes into the system and the ability to send automatic notifications to providers with updates to individual patient records. They also allow for the digitization of a health system’s personnel files and files pertaining to dealings with other organizations, improving the accessibility and security of those files as well. In preparation for a disaster, all records contained within a best of breed EMR can be backed up to various forms of media (e.g., CDs and DVDs) to expedite system recovery. The benefits of a best of breed EMR system also were tested in a study carried out by doctors in Norway through surveys and interviews with physicians employed by Aust-Agder Hospital.(8) Once the results from the surveys were compiled and analyzed, along with the interviews, it was shown that the physicians involved in the study generally used the only nine of the eleven functions of the EMR system related to the retrieval of patient data. Furthermore, 22% of the physicians surveyed reported increased difficulty in retrieving patient data from the system—a figure that was even higher (33%) among internists. However, most of the physicians surveyed were satisfied with the system’s handling of electronic data; their main problem was with the way the system handled scanned images of documents, which the internists reported was extremely time-consuming.

A result such as this throws the document scanning feature that best of breed EMRs possess into question, implying that the difficulty in navigating through previously scanned documents would waste a physician’s time in a similar manner to having to enter notes manually into a traditional EMR system. Consequently, the researchers in Norway acknowledged the possibility that best of breed EMR systems could eliminate the need for paper records. The researchers found that the system’s document scanning feature was considered to be simply an intermediate in the development of a fully electronic medical record. However, they also stated that this feature could be justified, as it increases the availability of patient data to physicians and assists with the transition to full utilization of the system and that they expected that the disadvantages of this function would decrease over time as the contents of scanned documents become outdated.(8)

A significant issue to be taken into consideration with a best of breed EMR compared with alternatives is the maintenance and implementation efforts associated with long-term use of such a system. While the training and outright costs are mitigated, there often is greater stress and more effort involved in maintaining a best of breed system. Adjusted, the costs are mitigated compared to a traditional EMR system, however the “out-of-the-box” systems typically are easier to maintain. This leads to the extended service level agreement and maintenance costs. Issues such as interoperability with multiple vendors, who typically blame one another when problems arise, and as many as 200 interfaces running at any time can become resource intensive and expensive when using the best of breed model.(9) Another factor to take into consideration is that while the cost of a single solution can, at times, be considerably higher, the convenience and savings of an internal IT department can make up the difference.(10) The scale of the organization helps determine what could be a better fit for a facility, varying greatly between, for example, small rural 50-bed hospitals and multiregional 50-hospital chains that span the country. In small to medium-sized health organizations, this exclusion of internal IT typically works better for both short- and long-term solutions. In larger hospitals, these wide-scale system replacements tend to be considerably more affordable compared with the alternative of a long-term and highly complex integration process.(10)

The main finding of the research review was that there is no such thing as a best solution for all scenarios. Whereas some smaller, general facilities may be able to operate using a single-vendor solution due to their reduced needs and the greatly reduced cost of a single solution, others may need more robust components. Larger, more complex organizations could need highly specialized components across multiple disparate systems. Such organizations are both able to afford and willing to bear the enhanced cost for two or more systems with up to 90% duplicated components, simply for their specialized needs to be met. Most small to medium facilities, however, with the need for specialization but a lack of resources, could have their needs met by a best of breed hybrid system that takes disparate systems and combines them through interoperable connections. The first issue with this set-up is that it could be overkill for a small rural area that has only minimal needs, or that it could be not robust enough for a national hospital chain with multiple distinct specializations. The other trade-off for this type of setup is that the maintenance of such a system typically is prone to issues ranging from lack of internal IT resources to properly schedule and maintain the implementation, to third parties pointing fingers at each other about delays or loss of service.(10) Taking all this into account, it can be seen that in lieu of a best solution for all scenarios, a best of breed solution with minimal integration points is going to work for most of the organizations out there, but typically not for facilities with either too specialized or too general a design.


The aim of our research was to assess all the costs and benefits of using a hybrid/best of breed EMR system versus the utilization of either a single-vendor solution or multiple disparate systems. We reviewed not only the monetary costs of both the solutions themselves, but also the associated cost of maintenance, upgrades, and replacement. Additionally, we looked at the “boots on the ground” who work on the implementation of large-scale, enterprise-wide systems of varying complexity and the common issues with such an undertaking. In the end, our conclusion is that large enterprises with considerable resources can essentially make any choice work, but small to medium-sized institutions are more likely to need to either invest large amounts of money into a single system or invest time and effort in maintaining the components of a hybridized system through an IT department and multiple vendor interactions.


  1. Electronic Health Records (EHR) Incentive Programs. Centers for Medicare & Medicaid Services. Accessed April 24, 2017.

  2. Perna G. KLAS: Urgent care providers have no set EMR preference. Healthcare Informatics. Accessed April 24, 2017.

  3. Amatayakul M, Cohen M, Joslyn J. Best of breed for clinical systems? Healthcare Informatics. Accessed April 24, 2017.

  4. Koppel R, Lehmann CU. Implications of an emerging EHR monoculture for hospitals and healthcare systems. J Am Med Inform Assoc. 2015;22:465-471.

  5. Gregg H. 10 things to know about Epic. Becker’s Hospital Review. . Accessed April 24, 2017.

  6. Murphy K. Epic Systems gets open with its EHR system, at least sort of. . . Accessed April 24, 2017.

  7. Laserfiche demos “natural approach to EMR” at MGMA. . . Accessed April 24, 2017.

  8. Laerum H, Karlsen T, Faxvaag A. Effects of scanning and eliminating paper-based medical records on hospital physicians’ clinical work practice. J Am Med Inform Assoc. 2003;10:588-595.

  9. Campbell J. CHIME Fall Forum Interview Series: Susan Carman, CIO, United Health Services. Health IT and mHealth. . Accessed April 24, 2017

  10. Zieger A. Are best of breed EMRs going out of fashion? Hospital EMR & EHR. . Accessed April 24, 2017.

Nicholas E. Martinez, RHIA

Health Care Informatics, University of Central Florida, Orlando, Florida.

Kendall Cortelyou-Ward, PhD

Associate Professor, Health Care Informatics. University of Central Florida,12805 Pegasus Drive, Orlando, FL 32816-2200; phone: 407-823-2639; e-mail:

Hana T. George

Health Care Informatics, University of Central Florida, Orlando, Florida

Jhon J. Arias

Health Care Informatics, University of Central Florida, Orlando, Florida.

Rohith Sompalli

Health Care Informatics, University of Central Florida, Orlando, Florida.

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