At my institution, they developed their own EMR in house. And it works really well, presumably because 1) incentives are as well aligned as they could be, and 2) it allows incremental improvement. This latter point is crucial - the basic system went out, everyone could use it and make suggestions, and then other services were gradually integrated (radiology, pathology). The same people working on the EMR keep working on it over (thus far) 7 years. It also was dramatically less expensive than say getting a product from Epic, which is what the next iteration will be. Everyone is worried.
