3. About the study
Accenture conducted a study of average of more than 90 countries. To
leading health care software, hardware account for the leadership of several
and services companies to gauge the niche players, we also interviewed a
attractiveness of eight international number of more localized companies
electronic medical record (EMR) to refine market-specific insights.
markets of considerable size and
EMR maturity. Those markets include We asked survey participants a series
Australia, Canada, France, Germany, of questions regarding the specific
Japan, The Nordics, Spain and the international EMR1 markets and
United Kingdom (UK). Other large discussed key trends emerging in each
markets—namely, India and China— market. Respondents shared deep
were not studied due to conflicting industry insights as well as general
opinions of overall EMR maturity. perceptions of international markets
based on overall potential, market
The companies surveyed have a saturation, local laws and regulations,
combined market capitalization of and cultural norms. This paper
more than $600 billion. As some of summarizes the insights shared and
the largest software vendors, medical reports the results of specific survey
products companies and enterprise questions. Where appropriate, we
software providers in the world, these have also included secondary data to
companies support operations in an support our findings.
1. Electronic medical records (EMRs) are defined as patient treatment records, including a patient’s background information and history of patient care, maintained within a
hospital or clinic. Electronic health records (EHRs) are defined as patient health records that include clinical data and information from multiple sources and that are maintained
outside of a single hospital or clinic.
3
4. Executive Summary
Market forces will drive growth of technologies, such as cloud-based using in some capacity. The shortage
global EMR markets at rates ranging EMR solutions. in Canada, as an example, requires
from 6.6 to 9.7 percent across North 36,000 clinical IT workers to sustain
America, Europe, Latin America and Each country we analyzed represents projects through 2014. Nearly 79
Asia Pacific. The global market is a distinctive EMR market defined percent of current clinical IT workers
slated to be worth $19.7 billion in by different health care systems, will require additional training
2013: competitor landscapes and local experience in the next year to remain
regulations and laws, requiring active.
• North America will experience 9.7 customized market entry strategies.
percent growth in its EMR market— 3. Networking the health system
from $7.4 billion in 2010 to $9.8 billion Four trends will have the most impact across regional, national and a variety
in 2013. With 5,800 hospitals, EMR on EMR growth: of geographic regions will offer
adoption is beginning to accelerate the largest and most challenging
due to ARRA incentives and penalties. 1. Government incentives are believed opportunities.
by 71 percent of respondents to spur
• Asia Pacific’s EMR market is effective health IT adoption. The most 4. Global economic recovery will
expected to grow at 7.6 percent. significant efforts include the United largely impact pace of adoption and
States’ ARRA incentives and penalties sustainability of resources.
• Europe, Africa and Latin America and Australia’s $450 million e-health
will grow at 6.6 percent through 2013 effort.
driven by government incentives and a
refresh of EMR systems. 2. A shortage of clinical IT specialists
will shift EMR maintenance and
Emerging markets may be a primary support strategies to outsourcing and
growth driver globally and may have cloud-based solutions, which over
the potential to implement innovative one-third of health organizations are
Figure 1. Global addressable hospital-based EMR market size (USD Billions)
2010 Addressable market 2013E Addressable market
Total $15.5B Total $19.7B
2010 – 2013 CAGR Asia Pac
Asia North America: 9.7 percent $2.9
Pac EALA: 6.6 percent
$2.3 AsiaPac: 7.6 percent
North North
America America
$7.4 $9.8
EALA EALA
$5.8 $7.0
Source: Accenture analysis
4
5. Introduction
Around the world, electronic percent view global markets as
medical records (EMRs) and an opportunity in the long term
electronic health records (EHRs) (5+ years).
are being implemented to
improve patient care, reduce When asked about expansion
health care expenses and into global markets, most
fundamentally change the way respondents mentioned a
in which medicine is practiced. standard approach: focusing first
The benefits realized by EMRs on their national markets, then
in international markets are identifying regional expansion
largely consistent despite vast opportunities or select countries
variations in health care systems, in which they possess certain
market structures, competitive competitive advantages, and
landscapes and regulatory ultimately shifting to true global
requirements. While international expansion into multiple markets.
expansion remains a challenge
for the companies we surveyed,
71 percent view global markets
as a growth opportunity in the
short term (1–3 years) and 100
Figure 2. How critical are the Global EMR markets to your company’s long-term and short-term strategy?
71%
57%
29% 29%
14%
Primary growth opportunity Growth opportunity, not Primary Not currently an opportunity
Long-term strategy Short-term strategy
5
6. Regional markets
Steady growth in hospital-based EMR/ Four primary forces could have a Regional, national and
EHR markets is expected across North material impact on growth projections multicountry integration.
America, Europe and Asia Pacific. in each of these markets:
The level of government funding in
North America will remain the largest
support of regional, national and
market, growing at a 9.7 percent Emerging markets
international integration projects (for
compound annual growth rate (CAGR) Many emerging markets (for example, example, EU mandate 4032) could
from $7.4 billion in 2010 to $9.8 billion Malaysia, Thailand, Brazil, Russia, further accelerate adoption of EMR
in 2013, which is driven primarily by India and China) may experience and other HCIT applications, creating
growth in the US. In Europe, Africa rapid growth and leapfrog developed large-scale opportunities in these
and Latin America—where many nations’ levels of EMR adoption markets.
countries have more mature health and usage by learning from more
care markets—growth will be more developed nations and potentially
modest at a rate of 6.6 percent CAGR
Economic recovery
utilizing innovative approaches such
from $5.8 billion to $7 billion in 2013. Improved economic recovery and
as cloud-based solutions. The future
Asia Pacific is projected to grow at 7.6 improvement in hospitals’ financial
of these markets will be largely
percent CAGR from $2.3 billion to $2.9 performance may boost demand and
dependent on regulatory standards,
billion, which is heavily dependent on funding available for EMR-related
government support and future
the evolution of emerging markets, projects.
trends affecting domestic health care
such as India and China. Other systems.
projections predict much more rapid Labor shortage
growth in Asia Pacific. For instance, Government funding Inability to address labor shortages
Frost and Sullivan states, “Although worldwide could have a negative
Many international governments,
the APAC HIT market represents impact on market growth projections
such as that of Australia, continue to
currently only 2.1 percent of the total in some countries.
announce additional funding packages
health care market, it is very likely that
for EMR and HCIT adoption, further
the figure could double if not triple
driving adoption and presenting EMR-
that in the next 10 years.”
related opportunities.
2. EU Mandate 403 aims to provide a consistent set of standards to address the needs of this rapidly-evolving field for the benefit of future healthcare provision.
Source: http://www.calliope-network.eu/KnowledgeSharing/Standardisation/M403MandateeHealthINTEROP/tabid/353/Default.aspx
6
7. Figure 3. Global addressable hospital-based EMR market size (USD Billions)
2010 Addressable market 2013E Addressable market
Total $15.5B Total $19.7B
2010 – 2013 CAGR Asia Pac
Asia North America: 9.7 percent $2.9
Pac EALA: 6.6 percent
$2.3 AsiaPac: 7.6 percent
North North
America America
$7.4 $9.8
EALA EALA
$5.8 $7.0
Source: Accenture analysis
Figure 4. Additional Factors Impacting Size and Growth of Global EMR Markets
North EALA AsiaPac Comments
America
Emerging
Markets EMR vendor discussions suggest emerging markets may be underrated
Additional
government AsiaPac represents the largest growth opportunity if gov’t funding increases
funding
Multi-country
Integration EALA seeing multiple regional efforts to integrate across country borders
Economic
Recovery US, Canada best positioned to benefit from accelerated economic recovery
Labor
Shortage Impact will be felt disproportionately across US
Very Positive Impact No Impact Very Negative Impact
Source: SMA Interviews, Accenture Analysis
7
8. Global trends
It is clear that each international EMR Figure 5. Which of the following trends seen in the US do you think are active in
market is complex enough to warrant Global markets? (percent of vendors in agreement)
its own discussion and certainly its
own market entry strategy. However, Shortage of clinically trained IT resources will impact 86%
we expect a number of trends to have future markets
an impact across each of the target
markets we studied. 71%
Gov’t funding is main driver of EMR adoption
Labor shortage
As hospitals, primary care physician Physicians continue to resist using EMR technology 57%
offices and clinics around the world
implement and improve EMR systems,
the number of end users is expected Analytics remain a challenge for hospitals 43%
to increase rapidly. This increase will
lead to the need for a greater number
HIEs will evolve with EMR, not after EMR
of clinically trained IT resources to 43%
implementation
support EMR systems. The United
States, Canada, Australia and England,
among other nations, are expecting Mobile technology use is an analog for EMR adoption 43%
and planning for significant shortages
of resources and appropriate training.
EMR reduces # of applications supported in hospitals 29%
“Canada estimated [it will need] 29,000 to 36,000
workers with 7 to 26 percent growth by 2014. Also
estimated need for further training and experience to
grow by 27 percent now and 38 to 79 percent by 2014
in various scenarios.”
“Australia [anticipates a] shortage, to be addressed
through increased supply, improved productivity and
reduced demand (through system design).”
“England estimated 25,000 FTE out of 1.3 million
workers in English NHS (one IT worker per 52 non-IT
workers). Future people and skill shortages anticipated.”
Oregon Health & Science University
8
9. An additional labor challenge will Government funding organizations should have access to
be a widespread shortage of nurses Seventy-one percent of respondents the same data, implying a reluctance
affecting many nations. Demand agree that government funding is a to send data outside of physician
for nurses and nurse aids in the US primary driver of EMR adoption in offices. Nevertheless, we expect cloud
is expected to steadily grow while global markets. In the US and Canada solutions to have a significant impact
hospitals are already struggling to in particular, hospitals are experiencing on health care organizations in the
retain current staff. Physician and very thin (or even negative) margins, future—especially in a landscape in
nurse shortages are also being seen in making it a challenge to set aside which 80 percent of IT organizations
other countries. In India, for example, funds for EMR-related projects. expect to increase spending on clinical
the shortage is thought to be linked to Recently, Australia announced a $467 IT over the next five years.vii
the US-based phenomenon, as India- million national e-health initiativeiv
trained nurses move to the US and sponsored by the government to link
leave their home market.ii EMR systems and HCIT applications
across the country. Conversely, in
Most survey participants agree that
Japan many hospitals are struggling
to cope with increasing support
to afford ongoing EMR support after
costs and the widespread lack of
a previously government-funded
IT resources, providers will seek to
initiative has gradually slowed.
outsource support functions or use
cloud-based solutions. Recent research
shows that health care companies are
Cloud computing
increasingly turning to cloud-based Cloud-computing solutions in the
services. Almost one-third of health EMR space show a great deal of
care companies are currently using the promise to reduce costs, increase
cloud, which is roughly on par with efficiency and enable redeployment
other, more progressive industries.iii of valuable resources in hospitals’
IT organizations. However, many
health care organizations have yet
Figure 6. How do you expect Global EMR to determine how cloud computing
markets to manage support costs in the will fit into their IT operations. A
long-term?
recent IDC survey states that fifty-
four percent of organizations are
still evaluating how to use cloud
computing in their environment,
while only 21 percent are using cloud
computing for any applications.v While
these solutions represent an attractive
option for health care organizations’
57% 43% IT strategies, a number of concerns
and risks, especially around security
and data sharing, must be considered.
For many, maintaining control of data
and knowing where data resides will
prevent cloud solutions from being
utilized. In addition, transmitting and
sharing data with various locations
Combination of Outsourcing and and institutions proves to be a
Cloud-based Solutions
barrier. A recent Harris Interactive
Outsourcing poll cites that a majority of patients
(78 percent) agree that all physicians
should have access to the information
contained in an EMR.vi However,
only 30 percent agree that insurance
9
10. Target country overviews
Figure 7. Which markets do you see as the top three & bottom three most profitable opportunities in the next three years?
57%
43%
Percent of vendors
naming market 29% 29% 29% 29% 29% 29%
as a top
opportunity
UK Australia Nordics Canada France Japan Germany Spain
Of the eight markets included in the Canada companies. Of Germany’s roughly
analysis, the UK and Australia were Political changes and election cycles in 2,100 hospitals, about 20 percent are
most frequently identified as focus Canada have negatively affected the part of large hospital groups. These
markets based on overall opportunities amount of HCIT spending allocated to groups are in the process of expanding,
in the EMR space. The remaining six each of the provinces. However, overall leading to fewer opportunities for new
markets received an equal number of EMR adoption is expected to rise entrants to have significant market
mentions, revealing mixed opinions on steadily, due in part to Canada Health influence. Most hospitals, within and
whether or not they represent strong InfoWay, which had approved funding outside the large groups, already have
growth opportunities. for 294 different EHR-related projects an EMR system and are currently
as of December 31, 2009.ix working to make full use of their
Australia existing capabilities.
The Australian market, while France
comparatively small, exhibits Japan
Highly competitive and localized,
sophisticated use of EMR in most France is struggling with many of After a wave of government funding
states and is moving forward with a the same issues that other nations in 2000, most hospitals in Japan
national EHR programviii to integrate are facing. Although most hospitals are now using a standardized EMR
systems across the country’s eight have some type of EMR system, HCIT product with little customization.
regions. Aside from the general has been historically underfunded Local competitors, such as Fujitsu and
promotion of national e-health because few large EMR initiatives are NEC, command most of the market.
records, details of exactly how the government sponsored. Roughly 14 percent of hospitals in
nearly $450 million will be spent are Japan have implemented an advanced
still largely undetermined. Germany EMR system.x Meanwhile, without the
help of government funding, the rest
Similar to France, the German EMR face the need to find capital for new
market is highly fragmented and is systems.
dominated primarily by smaller local
10
11. Nordics Additional markets
The Nordic countries (Denmark, Much attention is being paid to EMR
Norway, Switzerland and Finland) are markets outside the scope of this
collectively viewed as leaders in terms survey—namely India and China.
of overall EMR adoption and use. Despite the massive size and potential
Upwards of 90 percent of physicians these markets represent, opinions
are using sophisticated EMR systems conflict about the timelines for
in most Nordic countries.xi Even so, entering these markets. Some study
many still struggle to share data across participants are heavily focused on
multiple locations and between acute these markets and have invested
and ambulatory settings. It should be accordingly. Others view India and
noted, however, that while the Nordic China as still being too premature
countries are often viewed as one for large-scale investments; they cite
market, there are a number of critical critical shortcomings in the health care
differences among the countries. As systems and key differences in care
an example, Denmark and Norway delivery models. As an example, the
are both pursuing regional models, health care systems in India and China
empowering each region to make must support roughly 1,700 and 950
decisions about EMR systems and patients per physician, respectively,
usage. while each physician in the US is
responsible for supporting only 400
Spain patients.xii In many cases, respondents
Spain’s 17 autonomous regions indicated that these emerging markets
manage their own resources across may chart a new path and architecture
the acute and ambulatory settings, given the infancy of their systems and
have their own budgets and are processes.
connecting EMR solutions within their
boundaries—resulting in what is likely
to be the most effectively executed
regional EMR model. Spain’s health
care IT infrastructure and overall
EMR adoption make it a role model
for many other European nations; the
majority of hospitals and primary care
physicians in Spain already have an
EMR solution in place.
UK
The UK has seen great success and
significant failure when it comes to
EMR adoption. In the ambulatory
setting, most physicians have
implemented an EMR, are using
sophisticated functionality and
share clinical data across multiple
offices. However, in the acute space,
the National Health Service’s (NHS)
first attempt at standardizing EMR
solutions across the country did not
immediately yield the desired results.
Many hospitals in the UK are re-
evaluating their EMR strategy, with
some essentially “starting over” with
their implementations.
11
12. Summary of target EMR markets
Country 2013E # of Comments / Opportunities
Addressable Hospitals
Market (CAGR)
• Hospitals under increasing financial pressure
$8.5B • ARRA incentives & penalties driving adoption
US (7.4 percent) 5,800 • Lack of funding and adequate resources
Tier 1 $1.6B • Largest market; many hospitals starting over and refreshing EMR systems
UK (6.2 percent) 1,100 • High risk, high reward bet
$1.0B • Large market, with potential for growth – market entry most likely via partnership / acquisition
Germany (5.4 percent) 2,100 • Clinical support / maintenance often outsourced (typically conducted by smaller players)
$0.6B • We are currently supporting HIT in 5 of the 17 regional systems
Spain (5.4 percent) 800 • Open to outsourcing – decisions made at the regional level
Tier 2 $0.4B • Comparatively low levels of spend and regional model prevents rapid adoption
Australia (4.6 percent) 1,000 • We currently have a mostly MCIM presence versus SI&T (related to EMRs)
$1.5B • Adoption slowed once government funding programs expired and funds disappeared
Japan (1.2 percent) 9,000 • High costs are the primary barrier for hospitals
Tier 3 $0.6B • Local companies and cultural norms prevent large IT service providers from winning
France (4.8 percent) 3,000 relationships
• Maintenance and support of clinical systems typically done by local firms
$0.6B
Canada (4.4 percent) 1,000 • Insufficient government funding and poor financial performance of hospitals has slowed
adoption
$0.6B • High EMR adoption with sophisticated users
Nordics (5.1 percent) 240 • Still struggle with sharing data across hospitals and regions, as well as analytics
12
13. Projected EMR adoption rates
While most of the developed
markets have long encouraged EMR
implementation, countries across the
globe exhibit various EMR adoption
rates. An analysis of hospital EMR
adoption rates projects the Nordics,
Spain and Australia to be global
leaders in overall EMR implementation
in 2013, while France, Germany and
Japan are expected to be market laggards
with lower rates of adoption.xiii The
United States is expected to leapfrog
a number of countries in terms of
hospital-based EMR adoption by 2013
and exhibits the highest projected
growth rate of the nine focus markets.
Figure 7. Estimated Hospital-based EMR Adoption Rate Projections by Country
95% The Nordics (92 percent)
85% Spain (83 percent)
Australia (78 percent)
75% UK (73 percent)
65%
US (62 percent)
Canada (58 percent)
55%
45% Japan (44 percent)
Germany (38 percent)
35% France (33 percent)
25%
15%
5%
2009 2010E 2011E 2012E 2013E
EMR Adoption projections are based on current and expected hospital adoption rates and reflective of hospitals’ use of advanced functionality, including CPOE.
Source: Markets and Markets, Accenture Analysis
13
14. Conclusion
Key considerations and France are all known to be
Each of the target markets analyzed extremely competitive, localized
possesses unique characteristics, and markets, presenting an advantage to
many are employing very different companies with superior partnership
strategies to drive countrywide or acquisition capabilities. Also,
EMR adoption (for example, relationships with regulatory bodies
regional versus centralized models). and understanding of local laws will
Local trends, differing health care serve companies well in markets with
systems, cultural norms and unique stringent controls over security, data
regulations will continue to shape sharing and confidentiality.
these diverse markets. Compared to
Market maturity
the US, markets in most countries may
Consider the time elapsed since each
appear significantly smaller; however,
EMR market has begun government-
international markets still boast a
sponsored EMR programs. ARRA and
range of opportunities and significant
HITECH have recently changed the way
growth potential.
the US EMR market operates, while
A few areas should be considered the Nordics have had many years to
when anticipating how these markets drive overall adoption and ongoing
will evolve: enhancements.
Differentiating capabilities
For many markets, a specific set
of capabilities will be required to
successfully enter and operate.
For example, Japan, Germany
14
15. Reference
i Accenture Analysis
Center for Nursing Advocacy, http://
ii
www.nursingadvocacy.org/faq/
migration.html
iii Accenture Analysis
iv2010-11 Australia National Budget
Summary, http://www.budget.gov.
au/2010-11/content/glossy/health/
html/health_overview_03.htm
vCustomer Perception on the Impact
of Cloud Computing on Support, IDC
viHarris Interactive Poll, http://www.
harrisinteractive.com/NewsRoom/
HarrisPolls/tabid/447/mid/1508/
articleId/414/ctl/ReadCustom%20
Default/Default.aspx
Health Leaders Media, Technology
vii
Industry Survey, http://www.
healthleadersmedia.com/pdf/survey_
project/2010/Technology_pages_2010.
pdf
2010–11 Australia National Budget
viii
Summary, http://www.budget.gov.
au/2010-11/content/glossy/health/
html/health_overview_03.htm
ix Canada Health InfoWay, http://www.
infoway-inforoute.ca/about-ehr/ehr-
progress-map
x Seed Planning 2008 Edition Latest
Electronic Medical Record Market
Trend Survey
xi 2009 Commonwealth Fund
International Health Policy Survey of
Primary Care Physicians
Number of Inhabitants per
xii
Doctor, Doctors of the World
http://strangemaps.files.
wordpress.com/2007/10/276540-
poster594x420mm_eng.jpg
xiii Accenture Analysis
15
