Arete Healthcare LLC

Independent Practices | Shared Infrastructure | Clinician-Led Governance

Key Findings

In Pictures

This analysis follows the same 15-specialty comparator structure used in The Organizational Outlier. The earlier paper described chiropractic as both structurally concentrated in small single-specialty organizations and unusually disconnected in NPPES endpoint registration. The figures below examine a second federal signal—participation in QPP Promoting Interoperability reporting using certified health IT—and then use the expanded platform-level extract to ask what technology the participating clinicians actually report.

Figure 1. 2023 certified-health-IT reporting participation rate by EHR platform. The denominator is 176,562 Medicare FFS providers active in 2023. This is a measure of participation in the federal certified-health-IT / Promoting Interoperability reporting ecosystem, not total EHR adoption. Athenahealth is highlighted as the platform adopted by Arete Healthcare in 2024. Visualization was human generated.

Figure 2. 2023 certified-health-IT reporting participation rate by provider specialty. The denominator is the number of Medicare FFS providers active in 2023 for each specialty. This is a measure of participation in the federal certified-health-IT / Promoting Interoperability reporting ecosystem, not total EHR adoption. Consistent with data in the Organizational Outlier paper, chiropractors have the lowest utilization of an ONC certified EHR. Visualization was human generated.

Figure 3. 2019-2023 certified-health-IT reporting participation rate by provider specialty. The denominator is the number of Medicare FFS providers active in each year for each specialty. This is a measure of participation in the federal certified-health-IT / Promoting Interoperability reporting ecosystem, not total EHR adoption. Chiropractors have the lowest utilization of an ONC certified EHR across all years. Visualization was human generated.

Figure 4. Annual chiropractic NPI counts for use of named ONC Certified EHR platform. Out of over 33,000 CMS active chiropractors, all named platforms reported fewer than 100 chiropractic users in each year. Fewer than 400 chiropractors were reported as being affiliated with any ONC Certified platform. Chiropractors use many platforms that are not ONC Certified and that are not included in the data. eClinicalWorks and ChiroTouch reported material reductions in the number of chiropractors. This should be interpreted as changes in reporting volume by the platform, not a reduction in installed base, churn, or evidence of platform exit. Visualization was human generated.

Arete's Take

Table 1. At a Glance

¹ Clinical Social Worker's 2019 extract contains only 1 NPI of 21,775 active providers (0.00%) — a near-empty first reporting year noted in Appendix A1, not a genuine near-zero adoption rate. Excluding Clinical Social Worker, the 2019 rate range is 6.28%–33.58% and the 2019→2023 change range is −9.44 pp to +2.94 pp. Physical Therapy (6.26% in 2023, next-lowest after chiropractic) and Optometry (7.86%) remain individually reported in Table 2 and Appendix A1.

Abstract

This descriptive analysis compares participation in certified health information technology reporting across 15 specialties from 2019 through 2023 and extends the analysis to all available developer and developer-product rows in the supplied extract. The Office of the National Coordinator for Health Information Technology (ONC) Certified Health IT Reported by Clinicians for Promoting Interoperability Performance dataset is paired with annual Medicare provider counts to construct a specialty-level reporting-participation rate. Chiropractic is the extreme low outlier: in 2023, 177 chiropractors appeared in the certified-health-IT reporting data, equal to 0.53% of 33,147 active Medicare chiropractic providers. Physical therapy was next at 6.26%, followed by optometry at 7.86%. The expanded platform analysis adds nuance: Epic was the leading 2023 developer in 14 of 15 specialties and was reported by 42.9% of chiropractic CHIT reporters—nearly identical to physical therapy (41.5%) and orthopedic surgery (42.9%). Chiropractic therefore appears unusual primarily in participation in the federal certified-health-IT ecosystem, not in concentration on a uniquely different mainstream platform among clinicians who participate. The 2023 chiropractic extract contains 24 developers and 63 certified product names; product counts include modules and components and should not be interpreted as 63 independent EHR systems. These findings do not measure total EHR adoption, successful information exchange, or causal relationships.

Context

Arete's earlier Original Research report, The Organizational Outlier, compared chiropractic with the same broad specialty set on organization size, specialty composition, geographic licensure, and individual-level NPPES connectivity endpoints. Only 2.3% of chiropractors had any individual NPPES endpoint registered—the lowest of the 15 specialties—and 58.2% of chiropractic affiliations were in 1–2 practitioner single-specialty organizations. That paper explicitly stopped short of treating endpoint registration as a direct measure of interoperability.

This follow-up asks whether a second federal dataset—clinician reporting in QPP Promoting Interoperability linked to ONC-certified health IT—shows a similar specialty pattern, and then asks a second question the earlier endpoint analysis could not address: which certified developers and products are reported by the clinicians who do participate? The measures are distinct. NPPES endpoints are self-reported connectivity registrations; this dataset identifies certified technology reported through a federal performance program. Directional concordance strengthens the descriptive evidence of technological separation without converting either measure into proof of actual information exchange.

Methods

Study Design and Data Sources

This is a descriptive study of specialty-level certified-health-IT reporting participation and reported developer/product use. The supplied analysis covers 2019 through 2023 and uses two Mimilabs tables: mimi_ws_1.healthit.chit_cpip for clinician-by-year certified health IT reporting and mimi_ws_1.datacmsgov.mupphy_prvdr for annual active Medicare provider denominators. The underlying federal sources are the ONC Certified Health Information Technology Reported by Clinicians for Promoting Interoperability Performance dataset and the CMS Medicare Physician & Other Practitioners by Provider data product. Every Platform and PlatformProduct row in the supplied workbook is marked ONC CHIT certified = Yes.

This build uses four workbook outputs: Summary (specialty-year participation and ecosystem breadth), Platform (specialty-year-developer detail), PlatformProduct (specialty-year-developer-product-certification-edition detail), and PlatformTop5 (an all-years top-five developer output retained for reconciliation). The principal analyses use the unfiltered Platform and PlatformProduct sheets; no developer-rank or product-rank threshold is applied to the underlying analysis. The reconciliation detail and underlying SQL supporting every reported number in this report are maintained in the internal AI Assistance and Reproducibility Record under Arete's Research Library Governance Framework.

Specialty Mapping

The analysis compares 15 specialties: chiropractic, physical therapy, orthopedic surgery, pain medicine, physical medicine and rehabilitation (PM&R), family medicine, internal medicine, emergency medicine, nurse practitioner, physician assistant, optometry, clinical psychology, clinical social work, podiatry, and psychiatry. Pain medicine combines Pain Management and Interventional Pain Management labels. Psychiatry denominators include Psychiatry and Geriatric Psychiatry. Family medicine in the certified-health-IT dataset uses Family Practice only, which may not fully align with other QPP-derived specialty counts.

Measures

• Certified-health-IT reporting NPIs: distinct NPIs appearing in the ONC-derived certified-health-IT data for a specialty and year.

• Reporting participation rate: certified-health-IT reporting NPIs divided by active Medicare FFS providers in the same specialty and year, multiplied by 100. This rate is not a measure of total EHR adoption.

• Developer NPI count: distinct NPIs within specialty, year, and developer. A clinician can appear under more than one developer, so developer counts are non-exclusive.

• Leading-developer reach: the leading developer's distinct NPI count divided by total CHIT-reporting NPIs for the same specialty and year. Because developer counts overlap, this is a reach measure and not mutually exclusive market share.

• Product NPI count: distinct NPIs within specialty, year, developer, product, and certification edition. Product names include base EHR products as well as certified modules, interfaces, reporting components, and other certified technology.

• Developer and product breadth: distinct developer and product names within specialty and year. Raw breadth is descriptive and is affected by the number of reporting clinicians.

Analytic Approach

Specialty-level rates and annual developer/product counts were reproduced from the workbook. For 2023, the leading developer for each specialty was identified from the full Platform sheet and divided by the specialty's CHIT-reporting NPI count to calculate developer reach. Chiropractic developer trajectories were constructed for the six developers with the largest summed annual reporting counts over 2019–2023. Missing developer-year rows were treated as zero reported NPIs in the supplied extract for charting and tabulation only; no inference was made about installed base, certification status, or vendor viability. Product-level analysis uses all PlatformProduct rows but treats product names as certified product/component labels rather than a count of independent EHR systems. Where two or more products tied for the highest 2023 NPI count under the same developer, the underlying query does not tie-break deterministically; ties are disclosed in the relevant table note rather than presented as an unambiguous single leader.

Data Quality and Reconciliation

Every headline statistic in this report was independently recomputed directly from the supplied results.xlsx workbook rather than carried forward from the draft narrative, per Governance Framework §9. The full reconciliation record, including the one discrepancy identified and flagged rather than silently resolved, is maintained in the internal AI Assistance and Reproducibility Record under Arete's Research Library Governance Framework.

One data-quality note carries forward from the supplied methods documentation: Integrated Practice Solutions / ChiroTouch is ONC-certified and appears in the workbook (64, 60, 39, and 13 chiropractic reporting NPIs in 2019–2022 respectively), notwithstanding an internal inconsistency in the supplied methods notes that elsewhere listed it among non-certified chiropractic-native systems. This report follows the data and the workbook's own confirmation, not the inconsistent limitation language.

Results

2023 Specialty Comparison

Chiropractic was the clear low outlier in 2023. Only 177 chiropractors appeared in the certified-health-IT reporting data, corresponding to 0.53% of 33,147 active Medicare chiropractic providers. Physical therapy was next at 6.26% (4,638 of 74,061), 11.8 times the chiropractic rate. Optometry followed at 7.86% (2,492 of 31,703), 14.8 times the chiropractic rate. The other twelve specialties ranged from 13.33% for clinical social work to 32.78% for orthopedic surgery.

Table 2. 2023 certified-health-IT reporting participation and ecosystem breadth by specialty.

Developer and product counts are unfiltered distinct names in the supplied annual output.

Longitudinal Participation Pattern

Chiropractic participation fell from 0.96% in 2019 to 0.53% in 2023, a decline of 0.43 percentage points (approximately 44.8% relative). The decline is not unique to chiropractic: several specialties also had lower rates in 2023 than in 2019. The distinctive feature is chiropractic's persistent distance from the rest of the specialty distribution. Across the five supplied years, chiropractic ranged from 0.46% to 0.96%, while the median of the twelve specialties other than chiropractic, physical therapy, and optometry remained far higher.

2023 Developer Mix Across Specialties

Epic was the leading 2023 developer in 14 of the 15 specialties; optometry was the exception, led by NextGen Healthcare. Among CHIT-reporting clinicians, Epic reach ranged from 34.9% in podiatry to 80.7% in clinical psychology among the Epic-led specialties. Chiropractic was not an outlier on this measure: Epic was reported by 76 of 177 chiropractic reporters (42.9%), compared with 1,923 of 4,638 physical therapists (41.5%) and 3,039 of 7,091 orthopedic surgeons (42.9%). Pain medicine (36.1%) and podiatry (34.9%) had lower leading-developer reach, while optometry's NextGen reach was 30.8%.

Table 3. Leading 2023 developer by specialty using the complete Platform sheet.

Developer reach is the developer-specific NPI count divided by total CHIT-reporting NPIs for that specialty. Because clinicians may report multiple developers, reach is not market share and values across developers are not additive.

Chiropractic Platform Detail

The 2023 chiropractic Platform extract contains 24 developers. Epic leads with 76 reporting NPIs (42.9% of the 177 chiropractic CHIT reporters), followed by Cerner with 30 (16.9%), athenahealth with 23 (13.0%), eClinicalWorks with 23 (13.0%), and MEDENT with 14 (7.9%). NextGen has 8; MEDITECH and DrFirst each have 4; Updox has 3; the remaining developers each have one or two chiropractic reporters. These percentages overlap because a clinician may report more than one developer.

Table 4. Complete 2023 chiropractic developer detail; no rank filter.

A clinician may appear in more than one row.

Chiropractic Platform Changes Over Time

The expanded annual developer detail shows different trajectories across platforms. Epic remained comparatively stable—83 chiropractic reporters in 2019, 68 in 2020, 63 in 2021, 59 in 2022, and 76 in 2023. Cerner was 31, 16, 22, 22, and 30; athenahealth was 17, 17, 25, 19, and 23. eClinicalWorks moved from 82 to 72 to 65, then dropped to 4 in 2022 and rebounded to 23 in 2023. Integrated Practice Solutions / ChiroTouch declined from 64 to 60 to 39 to 13 and has no chiropractic row in the supplied 2023 Platform extract. The data do not identify whether those changes reflect reporting rules, participation, vendor certification/product mapping, practice migration, or another mechanism.

Table 5. Chiropractic reporting counts for six high-volume developers.

Zero indicates no developer-year row in the supplied extract, not proof of no users or loss of certification.

Product-Level Detail

The 2023 chiropractic PlatformProduct extract contains 63 distinct product names across the 24 developers. The product field should not be read as a list of 63 independent EHR systems. Epic alone contributes eight product names in 2023, including EpicCare Ambulatory Base plus electronic case reporting, inpatient, infection-control, syndromic-surveillance, laboratory, cancer-registry, and national-healthcare-survey components. Cerner contributes fourteen product names. This explains why product breadth is much larger than developer breadth and why product-level counts can exceed intuition about the number of EHR platforms in use.

Among the highest-count 2023 chiropractic product rows are EpicCare Ambulatory Base (76 NPIs), Electronic Case Reporting from Epic (72), EpicCare Inpatient Base (60), Epic infection-control reporting (58), Epic syndromic-surveillance reporting (55), Epic Beaker reportable-labs reporting (53), and Epic Beacon cancer-registry reporting (47). Outside Epic, five Cerner product rows are tied at 29 NPIs each (HealtheLife, Millennium CQMs, Millennium Immunizations, Electronic Case Reporting, and Millennium Clinical); eClinicalWorks is reported by 23, athenaClinicals by 21, MEDENT by 14, and NextGen Enterprise EHR by 6. The product appendix (Appendix A3) reports all 64 chiropractic product rows rather than limiting the display to the top five.

Table 6. Highest-count certified product row for each of the ten most frequently reported 2023 chiropractic developers.

"Highest-count" is descriptive only; products include modules/components and are non-exclusive. ¹ Cerner's 2023 chiropractic count is a five-way tie at 29 NPIs (see Product-Level Detail above); the underlying query does not tie-break deterministically, so this specific product name should not be read as an unambiguous single leader.

Discussion

This follow-up analysis reinforces the central descriptive pattern identified in The Organizational Outlier while narrowing what the “digital outlier” label should mean. The earlier paper found an organizational outlier—small, predominantly single-specialty groups, low representation in large multi-specialty organizations, few organization links per clinician, and the lowest individual-NPI endpoint registration. The present paper identifies a participation outlier: chiropractic visibility in the federal certified-health-IT / Promoting Interoperability reporting ecosystem is far below every comparator specialty in every supplied year.

The expanded developer data prevent an overbroad interpretation. Among the small subset of chiropractors who participate, the leading platform is not unusually niche. Epic is the leading 2023 developer and reaches 42.9% of chiropractic reporters, almost exactly the same proportion as physical therapy and orthopedic surgery. Chiropractic therefore does not look uniquely fragmented by platform among CHIT reporters. The more distinctive separation occurs before that point: only 0.53% of active Medicare chiropractic providers appear in the certified-health-IT reporting data at all.

The specialty-specific vendor signal remains relevant but is more nuanced than a simple top-five analysis could show. ChiroTouch is demonstrably ONC-certified in the supplied data and was reported by 64 chiropractic NPIs in 2019, 60 in 2020, 39 in 2021, and 13 in 2022. Its absence from the 2023 chiropractic Platform extract is notable, but the dataset cannot distinguish between reporting participation, product/certification mapping, installed-base change, or another cause. Similarly, eClinicalWorks' sharp 2022 decline followed by a 2023 rebound argues against reading annual reporting counts as direct measures of vendor market share or practice migration.

Relationship to The Organizational Outlier

The Organizational Outlier asked whether the structural attributes that helped chiropractic remain independent might also limit access to technology, contracting leverage, data infrastructure, and care-integration capabilities. This paper adds a second empirical layer. Structural isolation and very low certified-health-IT reporting participation occur in the same specialty, against the same broad comparator set, in different federal data sources. The expanded platform detail also suggests the gap is not simply explained by participating chiropractors choosing fundamentally different mainstream EHR vendors. That convergence is consistent with—but does not prove—the hypothesis that organizational structure and access to shared infrastructure are related.

Implications

• For independent practices: the challenge may be less about selecting a particular mainstream EHR vendor and more about obtaining the scale, certification, connectivity, governance, and reporting infrastructure needed to participate in the wider health-IT ecosystem.

• For technology vendors: specialty-specific workflow remains valuable, but certification and connectivity strategy determine whether products and users are visible in federal interoperability programs. ChiroTouch's historical presence shows chiropractic-native certification is possible.

• For payers and health systems: low visibility in federal interoperability datasets should not be interpreted as absence of EHR use, but it may signal that small independent practices require different integration pathways and shared infrastructure.

• For future research: the highest-value next step is to link organizational setting, QPP participation, certified-health-IT reporting, developer/product use, and endpoint registration at the clinician or organization level to test whether practice structure predicts technology participation after accounting for specialty and observable provider characteristics.

Key Limitations

• Selection into Promoting Interoperability. The ONC-derived dataset captures clinicians who reported certified health IT as part of QPP Promoting Interoperability participation. It is not a census of EHR users.

• Not a direct interoperability-performance measure. A 0.53% chiropractic reporting participation rate does not mean only 0.53% of chiropractors use an EHR and does not establish successful exchange, FHIR or Direct use, query volume, information blocking, or patient-level interoperability.

• Certified-only product universe. Every row in the supplied Platform and PlatformProduct extracts is marked ONC CHIT certified = Yes. Non-certified systems cannot appear. ChiroTouch is an important exception to the generic “chiropractic-native systems are non-certified” framing because it is ONC-certified and appears in the supplied data.

• Products are not equivalent to independent EHR platforms. The product field includes base EHRs, modules, interfaces, public-health reporting components, and other certified technology. Counting product names therefore overstates the number of distinct stand-alone EHR systems.

• Multiple products and developers per NPI. Developer and product counts are non-exclusive. A clinician may report more than one developer or product, so counts should not be summed and developer reach should not be treated as mutually exclusive market share.

• Reporting counts are not installed-base counts. Annual changes by developer can reflect reporting participation, program rules, product mapping, certification edition, or other factors. The data do not support conclusions about customer churn, vendor exit, or market share change.

• Medicare-based denominator. Annual participation rates use active Medicare FFS providers as the denominator. The denominator does not represent the entire licensed workforce and may differ systematically by specialty.

• Year-over-year comparability. The supplied methods note a dataset-structure change around 2020–2021. Trends should therefore be interpreted descriptively.

• Specialty mapping differences. Family medicine, psychiatry, and pain medicine use mapped or combined labels that can affect comparability; exact mappings are stated in Methods.

• Data vintage. The supplied reproducibility file covers 2019–2023. No later data have been added since that file was received.

• No causal inference. The study does not test whether small practice size, organizational isolation, reimbursement, QPP eligibility, vendor choice, or another mechanism causes the observed specialty differences.

Conclusion

Across 15 specialties, chiropractic is an extreme outlier in federal certified-health-IT reporting participation: 0.53% in 2023 versus 6.26% for physical therapy, 7.86% for optometry, and 13.33%–32.78% for the remaining specialties. The expanded platform detail sharpens rather than weakens that conclusion. Among the chiropractors who do participate, Epic is the leading developer and reaches essentially the same proportion of reporters as it does in physical therapy and orthopedic surgery. Chiropractic's digital separation therefore appears to be primarily one of participation in the certified-health-IT ecosystem, not a uniquely fragmented platform pattern among participants. As a follow-up to The Organizational Outlier, the analysis adds a second, independent signal of technological separation while showing that virtual scale through shared infrastructure—not simply changing vendors—may be the more relevant structural question.

Disclosures and Publication Status

Funding and Sponsorship

This analysis was prepared by Arete Healthcare Research & Analytics. No external funding source was identified in the materials supplied for this draft.

Conflict and Perspective

Arete Healthcare operates shared technology, data, contracting, and administrative infrastructure for independent outpatient practices. That operating model creates an institutional interest in interoperability and shared infrastructure. Descriptive findings are presented separately from Arete's institutional interpretation in the “Arete's Take” section.

AI Use Disclosure

ChatGPT (OpenAI, GPT-5.6 Sol) materially assisted with workbook reconciliation, expanded platform/product analysis, draft narrative development, chart generation, and initial document assembly under human direction. Claude (Anthropic, Claude Sonnet 4.6/5) subsequently and independently re-derived every headline statistic in this report directly from the supplied results.xlsx workbook and rebuilt the document structure fresh through Arete's shared document-build module, per Arete's Fresh-Rebuild Process. The “Arete's Take” section is human-drafted per Governance Framework §12; AI use there was limited to incorporating already-written text into the manuscript. This report has been reviewed and approved for release by Arete's Data Analysis Work Group (DAWG) per Arete's Research Library Governance Framework. The internal AI Assistance and Reproducibility Record maintained under that Framework contains the full detail of both AI passes and the underlying independent verification.

Recommended citation: Arete Healthcare. The Digital Outlier: Certified Health IT Reporting, EHR Platforms, and Products Across Fifteen Specialties. Arete Original Research ARETE-OR-2026-007, Version 1.1. Published September 2026. https://doi.org/10.13140/RG.2.2.23917.76001

Data Sources and References

1. Office of the National Coordinator for Health Information Technology. Certified Health Information Technology Reported by Clinicians for Promoting Interoperability Performance. https://healthit.gov/data/datasets/certified-health-information-technology-reported-clinicians-promoting/ (source page; accessed August 2026).

2. Centers for Medicare & Medicaid Services. Medicare Physician & Other Practitioners — by Provider. https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-provider (source page; accessed August 2026).

3. Arete Healthcare. The Organizational Outlier: Group Size, Specialty Composition, and Multi-Specialty Scaling of Chiropractic Compared to Fourteen Professions and Specialties. Arete Original Research. https://arete.healthcare/research/the-organizational-outlier (August 2026).

4. Mimilabs. Curated data tables used for this analysis: mimi_ws_1.healthit.chit_cpip and mimi_ws_1.datacmsgov.mupphy_prvdr. The underlying query logic is maintained in the internal AI Assistance and Reproducibility Record under Arete's Research Library Governance Framework.

Appendix A. 2019–2023 Specialty-Level Results

Source: Summary sheet in supplied results.xlsx generated from the longitudinal SQL maintained in the internal AI Assistance and Reproducibility Record under Arete's Research Library Governance Framework. Clinical Social Worker has no 2020 or 2021 rows in the supplied output; no values were imputed. Clinical Social Worker's 2019 row (1 NPI of 21,775 active providers, 0.00%) reflects a near-empty first reporting year, not a data-entry error — see the At a Glance footnote.

Appendix A2. Complete 2023 Chiropractic Developer Detail

All 24 developer rows from the 2023 Chiropractic subset of the Platform sheet are shown; no top-N filter was applied.

Appendix A3. Complete 2023 Chiropractic Product Detail

All 64 chiropractic PlatformProduct rows (63 distinct product names — Epic and Cerner each report one product name shared with another developer's row in the underlying extract) are shown; no top-N filter was applied.