I think, in fact, you have it exactly backwards. You are very unlikely to find a decision making authority (person or committee) in a medical practice who gives the slightest bit of consideration for the development practices or code quality of software they're considering.
These people have three things on their mind (in no particular order): 1) does this product meet this organization's requirements under our regulatory compliance policies; 2) does this product (including installation, maintenance, and training costs) fit within my budget; 3) is this product widely known and trusted by my peers at other medical practices.
Notice something? The word "software" doesn't appear in that even once. They literally don't care. The result is that companies develop products (software) on the cheap, and that results in the quality issues that exist.
Improving the quality of the code base and development practices is solving a problem the purse-holders (customers) don't have.
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.
These people have three things on their mind (in no particular order): 1) does this product meet this organization's requirements under our regulatory compliance policies; 2) does this product (including installation, maintenance, and training costs) fit within my budget; 3) is this product widely known and trusted by my peers at other medical practices.
Notice something? The word "software" doesn't appear in that even once. They literally don't care. The result is that companies develop products (software) on the cheap, and that results in the quality issues that exist.
Improving the quality of the code base and development practices is solving a problem the purse-holders (customers) don't have.