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Market Study of Electronic Medical Record (EMR) Systems in Europe
1. MARKET STUDY OF ELECTRONIC MEDICAL
RECORD SYSTEMS IN EUROPE
Involve to evolve
Results from a survey conducted by Logica and Nordic
Healthcare Group January 2012
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This white paper shows insights of the European
Electronic Medical Record (EMR) systems market
in context of the broader Clinical Information
Systems (CIS) market. The paper is based on an
independent study commissioned by Logica.
The initial study was carried out by Nordic Healthcare Group from October 2011 to January 2012.
All published material available was utilised and interviews were carried out in 19 countries: Finland,
Denmark, Sweden, Netherlands, UK, France, Portugal, Austria, Belgium, Bulgaria, Croatia, Greece,
Hungary, Ireland, Italy, Latvia, Lithuania, Romania and Slovenia. Findings from the study were
released in January 2012.
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Why e
ehealth?
It’s no surprise that healthcare is in the spotlight. It is one of the biggest industry sectors in all
European economies, and gets allocated a high percentage of gross domestic product (GDP) in
every country. The share is expected to increase because population is getting older and medical
technology is developing fast, leading to health expenditure growing faster than GDP.
Demographic change will have a dual impact on healthcare. On the one hand, baby boomers of
healthcare professionals will retire leading to a reduction in workforce (supply side) since not enough
people can be trained as doctors and nurses. On the other hand, baby boomers of all populations
will grow the number of people in need of healthcare (services demand side). Therefore demand
is growing at the same time when the supply is reducing. Eventually, there will not be enough
healthcare professionals to deliver services ‘in the old way’. It means that healthcare providers must
radically change the way they take care of patients. This change offers new opportunities for growth
of businesses and economies in general.
An inability to change processes and utilise technology to its maximum potential does not lead to
skyrocketing expenditures, as some have feared. But it does result in services which do not address
quality or demand. It means people will be left untreated - and that is surely something nobody
wants. In a PricewaterhouseCoopers study 60% of healthcare leaders rated new technology as the
number one way to raise productivity (Figure 1).
60%
60%
50% 54% 53%
40%
40%
30%
30%
20%
10%
0%
Implementation Comparative Cost Competition Competition
of technology effectiveness control (provider) (payer)
programmes
Figure 1. The methods healthcare leaders say they trust to gain efficiency.
Source: PricewaterhouseCoopers. You Get What You Pay For. A Global Look at Balancing Demand, Quality and
Efficiency in Healthcare Payment Reform. Health Research Institute Survey, 2008.
Electronic Medical Records have been used for over ten years in some pioneer countries such as
Finland, Denmark and Sweden. These countries have had 100% penetration in both primary and
secondary care and have been evaluated the best in various reports by the European Commission,
Information Technology and Innovation Foundation (ITIF) and Accenture. These countries have
extensive experience of the benefits IT can create in healthcare, as well as the hurdles that have to
be overcome to succeed. Logica is the number one healthcare IT provider in Finland and Sweden.
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95%
The Nordics (92%)
85% Spain (83%)
Australia (78%)
75%
UK (73%)
65%
US (62%)
Canada (58%)
55%
45% Japan (44%)
Germany (38%)
35%
France (33%)
25%
15%
5%
2009 2010E 2011E 2012E 2013E
Figure 2. Estimated hospital-based EMR adoption rate projections by country
Source: Accenture. Overview of International EMR/EHR Markets. Results from a Survey of Leading Healthcare
Companies. August 2010.
There is emerging scientific data showing how IT can leverage both clinical quality and efficiency.
One must always bear in mind that IT is only a tool, it doesn’t make anything better by itself. But
industry leaders in other sectors have been able to use technology to improve quality and efficiency.
As expectations for improved healthcare continue to evolve, older IT systems increasingly struggle
to deliver a truly integrated flow of information, and healthcare professionals increasingly experience
healthcare technology that is below expectation. Newer EMR systems have become available which
have sophisticated user-friendly cloud based infrastructure (like the iPad), which can easily integrate
to the current clinical IT systems used by hospitals, and which can streamline and automate certain
processes.
Gartner calls them fourth generation EMR systems (or using Gartner language, CPR) that will replace
systems that pioneer organisations have used for over ten years. In addition to these pioneers there
are plenty of organisations still using paper that are thinking about going electronic - and there are
plenty of reasons for them to do so!
Digital records can hold the full details of an individual’s medical history in a secure and easy
to use interface, accessible everywhere by anybody (qualified), which ultimately helps to direct
diagnostic and therapeutic decisions when a patient enters the healthcare system. New generation
systems provide decision support capabilities, which combine dynamic patient information (such
as diagnoses, allergies, current treatment, etc.) to static medical knowledge. These help clinicians
make the right decisions on how to treat certain conditions (such as pregnant women with epilepsy,
diabetics with a raised risk of lactic acidosis, acutely sick children with genetic predispositions, etc.).
In addition to this, these new generation systems may automate some processes such as referral
qualification, laboratory scheduling and other pre-diagnostic studies and so on. These functions
improve the quality of care delivery, free up time for clinicians to see more patients, and directly
contribute to improved patient safety.
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Even greater benefits will be realised when patients are supported and encouraged to take better
care of themselves using eServices. Patients can see their information, add information they measure
(or have automatically measured for them), and even consult their doctors online. A good example of
this is type 1 diabetes; most type 1 diabetics control their insulin dosages by themselves, and have
an immense level of knowledge of their disease. With the help of IT similar levels of expertise can be
supported for other chronic conditions.
The benefits that IT offers in helping both healthcare professionals and patients would justify its
use in itself, but there is a third category of consequences which may revolutionise healthcare as
we know it now. When all information is in electronic form, when we can - as we now do - combine
patient history into genomic data it will bring options no one could even imagine earlier. We can
research how diseases develop, analyse causalities between risks and results, evaluate how
medications work in real life, who benefits and who does not. All this leads into better understanding
of how diseases are developed, how they can be fought, and how medicine can be personalised.
When it comes to the healthcare industry, Logica really has its finger on the pulse. We understand
healthcare and its processes. We work locally across Europe and know the landscape and recent
trends intimately. We are happy to share this knowledge with you in this study and welcome your
thoughts and ideas in future discussions.
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Overall European EMR market
There is a well-defined demand for new EMR systems in many European countries. Many providers in
various countries are stuck with old legacy systems, and users generally are not very happy with their
current EMR systems. Many people interviewed expressed a need for new, well-functioning solutions.
Most EMR systems used in Europe now are local design or from neighboring countries. Current
R&D efforts for large EMR systems are being mainly conducted in the US. Europe is lacking a pan-
European player. However, due to the differences in how healthcare is financed and provided in
Europe compared to the US there are many reasons to believe that strong localisation is needed by
integrators who have an intimate knowledge of European healthcare organisations, legislation and
processes.
The overall market for Clinical Information Systems (CIS) and Electric Medical Records (EMR) in
Europe is estimated to be €2.9 to €3.4 billion (not covering hardware). The largest markets are in UK,
Germany and France, followed by Netherlands, Italy and Spain. This estimate is based on macro-level
data on total healthcare spend and IT expenditure.
Lower bound Upper bound
5000
4000
3000
2000
1000
0
Denmark
Finland
France
Portugal
Sweden
Netherlands
United Kingdom
Czech Republic
Estonia
Germany
Norway
Poland
Slovakia
Spain
Switzerland
Austria
Belgium
Bulgaria
Cyprus
Greece
Hungary
Iceland
Ireland
Italy
Latvia
Lithuania
Luxembourg
Romania
Slovenia
Figure 3. Estimated EMR market in European countries (in million euros)
There is a large variation in adoption and penetration rates of clinical information systems. In general
Nordic countries have the highest penetration rates, while Eastern Europe is more undeveloped.
Market growth differs, with highest growth in unsaturated markets (where EMR/CIS penetration has
not reached 100%). In saturated markets, growth results from upgraded functionality and upgraded
usability in the form of new-generation systems.
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Key trends
Market maturity
The wide disparity in sophistication of healthcare IT across markets in Europe has resulted in a
number of problems for healthcare providers. Systems are in desperate need of modernisation to
overcome the challenges that have arisen over the years - disparate mix of software systems that
struggle to share information, infrastructure that hinders rather than helps expansion or growth,
and software that is not optimally aligned with clinical workflows. The market is growing fastest in
unsaturated markets where not everyone uses EMR/CIS systems. Some markets have a number of
competitors while others have only one or few national providers.
States of infrastructure
Although Europe has similarities in the way healthcare is evolving and developing, there are
differences among almost every country’s organisational structures, along with the way their
healthcare is financed and provision of services administered. There is also wide variance and
disparity in levels of adoption of advanced IT solutions that have the potential to improve clinical
processes.
Legislation
The impact of regulations on the healthcare IT markets in Europe makes it complicated to ensure a
holistic approach to the technology. The market will be driven by governments’ financial incentives
and regulations requiring automation in healthcare practices. The market growth is also expected to
be driven by increasing need for hospitals to attain cost efficiencies and growing evidence of use of
IT in healthcare practices.
Buying patterns
Investment in healthcare IT purchases is shifting towards a more coordinated, joint model where
hospital chains within a region or doctors’ associations identify a set of ‘preferred suppliers’. In some
countries hospitals are relatively independent whereas in others decisions are made at the level of
the nation or region. The future might see the private provider hospital market, which is currently not
very large in most European countries, but is growing. Over the past ten years there has also been a
strong move towards closing down unprofitable and unnecessary hospitals and shifting the focus on
improving the profitability of existing hospitals.
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Funding
In most European countries, public bodies still provide the biggest part of funding. However, the
individual hospital structures differ greatly across Europe. It’s interesting that the number and size
of buyers of IT depends not necessarily on the size of the country, but rather the structure of the
healthcare system.
Common standards
In an ever-evolving technology landscape, it is key to set proper standards to define the rules
of engagement between systems - for example, how medical information should be stored
and communicated in the network. As these standards are defined, the benefits are becoming
increasingly tangible. One dramatic benefit which is of fundamental importance to integrated
healthcare networks is the ability to scale IT across facilities. There is a slow but consistent move to
develop common standards for healthcare services across Europe. Although many countries have
tried to design frameworks, there are no functioning examples.
Medical innovation
Western Europe is already moving towards fourth generation EMRs (according to Gartner) and
adoption of advanced technological tools and capabilities are accelerating. In the Baltic countries
however, the overall infrastructure is still being set up with very low penetration rates. All Swiss
hospitals have EMR in place, but less than 50% physicians actually use them, both within the public
and private sectors. Latvia has quite a different problem. They have not been able to attract foreign
players cost-effectively.
Language barriers
Disparate languages have retarded companies’ efforts towards uniform systems adoption.
Overcoming the language barrier has often been a challenge in international healthcare
engagement strategies. So it is that countries that speak English see the most entrants from the
US; German and French speaking countries share competitors, and competitors in Spain restrict
themselves to Latin America and Mexico rather than compete in Europe. Other countries have
specialised local players.
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EU country studies
Finland
In Finland, the organisation and financing of healthcare services - hospitals, primary and outpatient
care - is mainly a public responsibility (75%). Healthcare expenditure in 2011 amounted to €14.8
billion. Of this 2.6% was spent on IT. Electronic Patient Records (EPR) are used virtually in every
health care provider. The current EMR/CIS market size of €70-90 million is estimated to grow at an
annual rate of 4-6%.
Compared to the other Nordic countries the Finnish system is more decentralised. There are 21
hospital districts in the country. District level hospitals are responsible for making decisions. The 320
municipalities are responsible for arranging and taking financial responsibility for primary healthcare
services.
Strong local players
Most of the EMR market is in the hands of Logica and Tieto. In addition there are some small
domestic companies. US based system integrators have practically no role in the health IT in Finland.
Ready to upgrade
In the capital area of Helsinki, a new hospital district (HUS) was formed in 2000 in order to improve
efficiency and eliminate overlapping of services by merging two former districts in the capital
area (Helsinki and Uusimaa) as well as the Helsinki University Hospital. After using developed but
independent EMR systems for years HUS region (HUS and municipalities) are looking for next
generation, regional EMR. Together those providers have over 5 million outpatient visits and over
5000 beds.
Most of the IT systems used now are second generation and based on paper processes. The
potential for new and upgraded IT systems is high. After long history of using EMRs these
organisations know the benefits that IT can provide and what is required other than IT.
Denmark
Healthcare in Denmark costs almost €25 billion a year. The National Health IT organisation (National
Sundheds-it, NSI) is responsible for country-level initiatives and setting national standards. Denmark
has a common infrastructure in the form of the National Patient Registry, which contains long-term
comprehensive documentation of its 5.5 million inhabitants. It collects personal data from all hospital
in-patients and Common Medicine Card (which has information on medicine purchases over the
past two years and up to date drug prescriptions). Information is handled in accordance with the
current legislative framework, and EPRs have to be stored for at least ten years.
The 51 public hospitals belong to five regional “networks”. The regions have their own health
IT organisations (Regionernes Sundheds-it, RSI), whose primary purpose is to consolidate and
coordinate supply of Health-IT systems.
The Danish healthcare system is publicly funded. IT investments are funded mostly from the general
budget that is allocated to the regions, and by different development funds. Regions are in charge
of managing their own projects and observing the framework and requirements laid down at the
national level. They can decide use of the funds on IT. Private clinics choose their own systems.
Consolidating healthcare
The path is being paved for consolidating towards a more coherent national technical infrastructure.
The whole healthcare system is under consolidation. At the primary care level 2,100 clinics with
3,400 GPs are being consolidated. IT applications in the field of health are already deeply rooted at a
local or regional level and mature systems are in place not only for communication between health
professionals, but also for patient access and data management.
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Yet there is disparity in sophistication of healthcare IT systems, with some public hospitals still stuck
at first generation EMR not integrated with Health Information System (HIS). Also, over 2,000 Danish
doctors have put their signatures on a protest being unhappy with IT systems that don’t function well
enough. There will be new development on the National Patient Index (NPI), Denmark’s approach
to the creation of a patient summary and the answer to the problem of inadequate access and
overview of patient data. Capital region of Copenhagen is also looking for a modern EMR system to
replace its current one.
There are virtually only five large buyers and a few small private hospitals in the market for CIS. The
ten players catering to the GP market were all originally domestic or offered domestic solutions.
International firms have acquired some of these, and are also predominant in niche markets like
laboratory systems, PACS, medication and booking. The tough competition in the EMR market
does not leave much room for multiple players. However, opportunities arise when regions that are
running old systems want to upgrade.
Sweden
Healthcare delivery and finance in Sweden is mainly a public responsibility. The percentage of private
providers at both hospital and primary care levels is small. The Swedish market, while comparatively
small, exhibits sophisticated use of EMR. Healthcare spend was €28 billion in 2010.
As Sweden mainly has a decentralised healthcare system, the basic responsibility for financing and
organisation of health services rests with the counties. The Swedish government is not at all involved
in the market, and counties pay for their own CIS solutions. The national eHealth programme is also
mostly financed by the counties. The government supports national eHealth programme with small
budget allocation, but does not cover adoption of solutions.
Swedish residents have direct access to their own medical records, but today the information is
manually searched and put together. The carer owns patient records. Patients must give their full
consent before healthcare professionals can access their data.
There will be no large changes in the near future. Progress is expected on the regionalisation of
counties, resulting in six to nine regions instead of 21 counties today.
Moving towards modernising
National eHealth projects are ongoing and solutions will be implemented in the next couple of
years. One example is implementation of the national patient summary. CIS systems will have to
be integrated and share information with national care services and quality registers. There are
70 quality registers for various purposes. The government recently allocated 1.5 billion SEK to
modernise, consolidate and improve these registers.
Currently all of Sweden’s EMR solutions are locally developed systems, which most organisations and
users feel unhappy about. There is growing need for investments in next generation IT.
Netherlands
Healthcare in the Netherlands costs €63 billion a year. Unlike Northern Europe and some other
nations, the Netherlands has a private health care system for its 16.6 million inhabitants. The
majority of hospitals in the Netherlands are private and non-profit.
Dutch hospitals are organised into academic and non-academic. The latter buy modules for each
department that their IT department then integrate. This is not an efficient or cost effective model.
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Most family physicians and other primary care professionals work in small groups. Today, almost
97% of Dutch GPs use an EMR system - a utilisation rate similar to those being achieved in Nordic
countries. Dutch GPs can choose among seven suppliers offering clinical information systems. In
practice, they are organised within regions, and EMR choices are made as a group rather than by
individuals.
The government has put a law in place mandating the use of electronic patient records, but is
not directly involved in CIS. Organisations choose and pay for CIS systems themselves. There is a
national network in the Netherlands covering 50% of the pharmacists and GPs. This results from a
national EHR programme, which fell through because public financing was no longer available.
Shifting to a new way
Hospital budget based finance will give way to result-based financing. There is also a move towards
more additional private insurances on top of the obligatory national insurance with basic care.
There is a perceptible trend where IT spend is moving to a strategic level where IT enables
healthcare processes instead of just supporting them.
Empowering patients
The degree of automation of national registration bodies is low. Patient data is not stored at a central
point. All medical data is to remain in local repositories under responsibility of individual hospitals,
but Dutch patients have the right to inspect their EHR and ask for copies. In a new law that is still
not binding, healthcare providers are obliged to inform patients. Images are sometimes stored in
a private cloud. Aggregated data for inspection is required by hand and collected by inspection
systems.
Only healthcare professionals who are directly involved in treatment are allowed to share patient
data without consent. For most other purposes, informed consent is needed. Patient empowerment
will change the position of the information chain and the importance of information delivery, and thus
IT.
It is anticipated that a more modular approach – possibly from the bed of the patient, or by the drive
of mobile devices – will force infrastructures to open up to these new applications.
United Kingdom
Most healthcare in England is provided by the National Health Service (NHS), England’s publicly
funded healthcare system, which accounts for most of the Department of Health’s budget
(€120 billion). The national programme for IT (NPfIT) is currently focused on providing a set of
national services like a national summary patient record, access control record (authorisation and
identification of healthcare professionals), booking programme for GP’s appointments, national HR
and payroll services for NHS and financial and payment systems.
The UK is organised into 172 acute trusts, of which 82 are foundation trusts that enjoy more
independence. There are 60 mental health trusts and 147 primary care trusts. There is a wide
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disparity in systems within the trusts. There are large segments of legacy systems, some have
advanced systems, and only a few systems for mental health trusts. Primary healthcare services
choose systems from a standardised supplier list (GPSOC). New entrants will face tough competition
in the mature GP market. In the UK, legislation protects the privacy of patient information, allowing
only clinicians with a relationship to see the data. Data cannot leave the shores.
Wales and Scotland are attempting to centralise framework purchases of key systems like operating
theatres, radiology and EPR. In England the attempt to do this failed, leaving the responsibility of CIS
purchases to trusts. The future will see efforts to consolidate regionally, for example in pathology
systems.
Changing fund system
IT investments are funded by the trusts, who need to persuade payers to provide money for
investments. Foundation trusts have more independence and can collect savings and increase
revenues by increasing demand.
The funding system is changing. Money, other than capital spending, will be managed by GPs who
can contract trusts.
Keeping an eye on costs
There is a move to reduce costs by limiting treatment options and referring patients to social care.
The acute sector will try and attract private patients. In the CIS markets, there will be large reductions
in national level initiatives, which may leave more money for IT investments in trusts. Hospital IT in
the UK has large chunks of legacy systems that need immediate attention or tactical changes. Many
trusts are running outdated systems. This offers a window of opportunity to potential entrants.
However it is expected that local IT spend will continue to feel the pressure to reduce costs, and is
unlikely to exceed 2.5% of revenue spend. In the same vein, major enterprise HIS initiatives will be
limited by cost. Providers will also need to consider the British scepticism to examples from other
countries, risk aversion and inclination to build on old systems than change completely to new ones.
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Portugal
In Portugal, like the United Kingdom, there is both a public and private healthcare system. The public
sector dominates service provision in the hospital sector in Portugal. Approximately 85.7% of beds
belong to the public sector, the remainder are provided by private hospitals. Primary care is provided
wholly by private practitioners.
As part of the government’s intention to modernise and revitalise the health services it is studying
the feasibility of implementing a national Electronic Health Record (EHR) system. This will have a
combined portal for professionals and patients, giving them secure and smooth access to health
information.
There is also a move towards national databases for surgical procedures and vaccinations. An EPR is
being developed for the whole primary care network. This will take care of the poor adoption of CIS
by the 345 social healthcare centres and 1,180 social healthcare centres’ extensions that comprise
the primary healthcare services.
Portuguese law is strict on the privacy of patient information, and prohibits patients from accessing
their records. There is virtually no electronic transfer of records among hospitals, but healthcare
professionals have almost unlimited access to records of patients being treated in their hospital.
Watching costs
The government does not interfere in the market and does not sponsor programmes to support the
adoption of CISs. Public hospitals receive a percentage upon production of expenditure intended to
promote renewal/investment. In reality most of this finance goes to cover current expenses. Overall,
budgets are being cut and efficiency and waste reduction is called for. The expectations are that
investments must demonstrate proof of high returns.
Most hospitals have EMR systems (some of which are very sophisticated) and are active in
introducing new features. Portugal is undergoing major reforms at the moment. 25-30 hospital
groups are integrating to have a unified EMR software per group. The poor adoption in the
primary care network is expected to turn around with the upcoming implementation of a national
EMR software. The near future sees a possibility of new entrants from Spain. Meanwhile, system
development/upgrades will be delayed by financial constraints and the shortage of public funding
may impede all IT investments.
Acquisition is the easiest entry into this tough market. In order to compete it is important to offer
visually attractive user interfaces and innovation (for example, develop mobile applications). Gaining
the confidence of the hospital boards is an uphill task because doctors tend to trust the systems
they have used themselves.
France
The French healthcare system features a mix of public and private services. With a contribution of
80% the State is the main payor in the national health system. About 68% of hospital beds in France
are provided by public hospitals. Both public and private hospitals make their own buying decisions.
Primary care is wholly taken care of by private services, who make their own independent decisions
on purchases.
Room for change
France spends 1.7% of their total healthcare expenditure of €218 billion on IT. Although 80%
hospitals and about 68% primary healthcare services have EMR systems, there is room for EMR/
CIS adoption, which is expected to rise by 5-6% annually (from its current market size of €700-800
million).
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Conclusion
Health is on everyone’s mind and healthcare is big news. In most European economies healthcare
is among the biggest industry sectors and offers new opportunities for growth for businesses and
economies in general. However, healthcare is not just about business, it’s about health - and health is
what we all care for. Due to the retiring of baby boomers there is a rising need for healthcare services,
while its workforce is declining. If the healthcare providers cannot change the way they provide
services, we won’t have enough of care. Fortunately there is a huge potential in IT enabling new,
citizen-centric, high-quality and more effective processes. Let’s do IT!
Currently, for various reasons such as language barriers or differences in healthcare systems, the
EMR business is ruled by local players in most European countries. Most of the systems are old, first
to second generation products, which lack new intellectual features and support for patient-centric
care. It is most probable that in future international systems and providers will take a major share of
markets in healthcare IT just as they already lead business in ERP systems and most other IT.
Logica has its finger on the pulse of the current healthcare industry, just as we’ve always had over all
these years. We know and understand the European healthcare market and we know what modern
technology offers. We can be your trusted partner who will utilise smart ideas and technology to
deliver real benefit to you.
