In 2012, hospitals, healthcare delivery organizations and governments continue to move toward full electronic health record system implementation. We present the results of Gartner’s updated comprehensive evaluation of vendors of integrated enterprise EHR systems for the global market.
Although there are a large number of local electronic health record system (EHRS) vendors, there is definitely a global market for enterprise EHRSs as well. Despite clear differences in ownership, payment schemes and regulatory requirements, the practice of clinical medicine is more similar than different across the globe. There are good reasons to consider a global vendor in addition to considering local ones (increased resources and leveraging of experience, to name two). Given the rapid rate of clinical evolution, clinicians will ultimately require advanced clinical systems. What distinguishes healthcare delivery organizations (HDOs) is whether:
- The HDO is prepared to leverage clinical automation to improve clinical care and is able to buy and use enterprise EHRSs.
- The HDO can afford EHRSs.
- Vendors are selling and supporting EHRSs in their countries.
For the purposes of this Magic Quadrant, we define global enterprise EHRSs as those that:
- Meet Gartner’s definition of an enterprise EHRS (see the Enterprise EHR System Definition section)
- Have attained at least Generation 2 status (see Note 1)
- Are actively marketed and sold in more than one continent (a system sold into more than one country in a single region does not qualify as a global EHRS)
Enterprise EHR System Definition
An enterprise EHRS is an integrated, not interfaced, point-of-care system that provides functionality for an acute care facility — including the emergency department and the intensive care unit (ICU) — and its attached ambulatory/outpatient clinics. The acute care functionality must include the pharmacy. (Gartner recognizes that, in some countries, pharmacists aren’t directly involved in the closed-loop medication process and don’t review every order, yet this is a requirement in many countries and is, therefore, included in the definition.) The enterprise EHRS contains patient-centric, electronically maintained information about an individual’s health status and care, focuses on tasks and events directly related to patient care, and is optimized for use by clinicians.
An EHRS is composed of eight core capabilities:
- EHRS management
- Data model
- Clinical decision support
- Clinical workflow
- Clinical documentation and data capture (for all clinicians)
- Clinical display/dashboard
- Order management, which includes direct entry of both medication and nonmedication orders
A complete enterprise EHRS, in addition to the minimum requirements listed above, will cover the continuum of care — emergency, ICUs, operating theater, behavioral health, labor and delivery suites, home care and long-term care facilities. Not all HDOs will include all care venues, but a global system must address the needs of all clients. These point-of-care solutions must meet clinicians’ requirements in taking care of patients, even when they aren’t physically at a bedside or in a clinic room — for example, by facilitating remote medication ordering, telemedicine and e-visits (see Note 2).
Buyers of Enterprise EHRSs
Gartner estimates that in 2011, healthcare providers spent approximately $14 billion on software, including nearly $7 billion on healthcare vertical-specific software (such as EHRS, health information management systems and PACS) and about $26 billion on IT services (see “Forecast: Enterprise IT Spending for the Healthcare Provider Market, Worldwide, 2010-2016, 2Q12 Update”). EHRS purchasers include:
- Single hospitals.
- Multihospital organizations (for example, integrated delivery systems in the U.S., National Health Service trusts in the U.K., and private hospital chains in Germany and elsewhere).
- Single hospitals and multihospital organizations that include privately and publicly owned facilities, and which may be for-profit or not-for-profit.
- Government health agencies that buy EHRSs regionally on behalf of hospitals under their aegis — for example, Australia, Brazil, China, France, Norway, Spain, Sweden and the United Arab Emirates (UAE). A few countries with small populations and centralized healthcare (such as Oman and Qatar) buy EHRSs on a national basis.
Budgetary issues are causing some HDOs to consider a best-of-breed approach or to purchase a less functionally mature product in hopes this will gradually lead to a full EHRS. It is important for HDOs to set realistic expectations regarding the functionality that can be obtained and the clinical benefits and other benefits that might accrue from using the system. Depending on business drivers, it may be better to wait until a Generation 3 (see Note 1) system can be implemented. However, if waiting isn’t an option, HDOs must ensure that stakeholders are aware of the trade-offs in selecting a less advanced system and recognize that it may be necessary to replace the system if it fails to evolve into a Generation 3 system.
Vendors of Enterprise EHRSs
EHRS vendors include firms that sell only an EHRS, and “megasuite” vendors that offer EHRSs and a broad range of other applications for hospitals (such as departmental, imaging, administrative, financial and analytic applications). Because of the huge R&D investments needed to meet the expectations of end users, only large, well-funded companies will likely be able to survive long term in the EHRS market. Many companies have substantially underestimated the time and effort required to succeed in this market.
Many EHRS vendors serve only one country. Many began selling administrative systems, and their products are designed to meet the specific administrative requirements of their countries (such as scheduling, coding, billing and reporting). However, their EHRS offerings usually lack advanced features, such as medication order entry and clinical decision support.
To gain an international reach, some vendors have pursued a strategy of acquiring many single-country vendors. These firms have tended to maintain their country-specific applications, making needed enhancements but not trying to move customers to a new global application. The risk of this strategy is that customers become impatient with the limitations of the country-specific EHRSs, get tempted by the promise of more-advanced EHRSs from global players and soon look to other vendors to support their needs.
Another category of vendors are those that have built a single enterprise EHRS and deployed it in many countries. One of the biggest challenges these companies face is adapting their EHRSs to meet the clinical needs and other needs of different countries. Too often, they haven’t taken this challenge seriously enough, resulting in deployment delays and disruption to customers’ finances and business operations.
EHRS Drivers and Inhibitors
The adoption of EHRSs continues to be driven by the tangible benefits listed in this Magic Quadrant; however, costs, organizational readiness and willingness to commit to process change have resulted in sluggish progress toward widespread full implementations.
Forces driving HDOs to invest in EHRSs include:
- Market momentum: HDOs are moving from a paper-based system to a digital means of creating, viewing, storing and leveraging medical records, and executing core processes.
- Consumer expectations: Patients expect automation and information accessibility.
- Error reduction and patient safety: These have become visible and political priorities in many countries.
- Support of payment, reimbursement and workload accounting requirements: In many countries, such requirements are becoming more complex, which, in turn, necessitates an EHRS to be able to ensure that the right information is being collected to support these requirements.
- Advanced analytics: There is a need for greater operational efficiency, better public health planning and more-collaborative relationships with medical research organizations.
- Improved financial outcomes: HDOs desire near-term/sustained revenue gains, improved capacity or improved profitability, and cost/productivity improvements.
- Improved patient experience and satisfaction.
- Improved nonpatient stakeholder satisfaction: HDOs have other stakeholders that they must treat as customers, including physicians who decide to refer a patient to a hospital and public/private payers that contract for services.
Inhibitors to EHRS investment include:
- The direct (licensing) and indirect (IT infrastructure upgrades, integration, personnel, support, and so forth) costs associated with an EHRS
- The difficulty of predicting and measuring an EHRS’s clinical and financial benefits.
- Difficulty in developing a business case necessary to procure funds for an enterprise EHRS
- Lack of adequate staffing levels within local hospitals to deploy, sustain and develop an EHRS
- Lack of clinical leadership to help drive implementations of enterprise EHRSs
- The lack of availability of advanced EHRSs in many countries
- The poor track record of EHRS vendors in some countries
- Lack of EHRS commitment from senior executives
- Unwillingness of clinical leadership to change clinical processes to derive value from an EHRS
- The complexity of creating and maintaining clinical content for the EHRS
Source: Gartner (October 2012)
Allscripts is emerging from the expected confusion that resulted from the merger with Eclipsys in 2010 and has made some significant changes in leadership that should result in improving deliverables. With Sunrise Clinical Manager (SCM), Allscripts is targeting English-speaking organizations around the world. In recent years, the company, which is based in the U.S., has had considerable success in the Asia/Pacific region. The company has EHRS contracts in the U.S., Canada, Singapore, Malaysia, Australia and Italy, and it recently signed two contracts in the U.K.
- Allscripts has substantial healthcare IT market experience, including outside the U.S.
- Allscripts is focused entirely on healthcare IT.
- The company’s overall portfolio, gained primarily through acquisitions, is broad but is still not fully integrated, and SCM lacks integrated dedicated functionality for certain care venues (for example, operating room).
- Although the company is taking steps to improve past issues with the stability and complexity of upgrades, it is too early to assess the success of these efforts.
Cerner, based in the U.S., has more years of experience in the international market than most of its competitors and was one of the first global megasuite vendors. It continues to have a strong product line and remains innovative in its search for new growth opportunities. The company is actively pursuing and winning deals around the globe. The company has Millennium EHRS implementations in the U.S., Canada, the U.K., Ireland, Australia, France, Egypt, the Gulf region, Germany, Austria, Spain, South America, Mexico, the Caribbean and Malaysia.
- Cerner is a large, entirely healthcare-IT-focused company that has been consistently strong financially, with a solid understanding of global markets and a coherent strategy for penetrating them.
- The top executive/cofounders team has been consistently very strong at long-term business, product and service strategy.
- Perceptions of Cerner’s difficulties in multiple countries, including the U.K. and Australia, continue to hurt its image.
- Clients’ perceptions of development, implementation, operations, service and support are improving, but clients still express the wish that “it was easier.”
In July 2011, CSC acquired the iSOFT product line that included numerous EHRS products, of which only “Enterprise Management” meets the criteria for this Magic Quadrant. Enterprise Management is marketed and implemented in India, South Africa, Asia/Pacific and the Middle East.
- Enterprise Management is a fully integrated product that was organically developed.
- Enterprise Management is an established EHRS with good experience in its targeted local markets.
- CSC is better-known as a system integrator rather than as a software developer; however, with the acquisition of iSOFT, this perception may change.
- Enterprise Management is a Generation 2 EHRS, and while it has some Generation 3 capabilities, it lacks many of the advanced features present in competitors’ Generation 3 products.
Epic, based in the U.S., has one of the most complete enterprise EHRS products, and it has an excellent track record for software development and predictable implementations — a trend that continues as it enters the global market. The company has EpicCare contracts in the U.S., Canada, the Netherlands and the Gulf region and recently announced an impending deal in the U.K.
- Epic has a very strong top executive team that stays in close contact with clients and emerging requirements.
- It has a strong core competency in software, with a consistent track record for making realistic promises and delivering on them in a timely fashion.
- It is too early to see the full results, but Epic continues to improve its analytic and care management solutions (a perceived weakness) and has recently released a formal population management module.
- Its marketing strategy, which is focused on word-of-mouth recommendations, has worked well for the U.S. but has been less successful elsewhere.
InterSystems, headquartered in the U.S., is a global software technology vendor with a great deal of international healthcare experience. It entered the EHRS market with its purchase of Australia-based TrakHealth and its TrakCare system in 2007. TrakCare is not sold in the U.S., but of all the global enterprise EHRS products developed outside the U.S., TrakCare is the most mature and is the only one to reach Generation 3, according to Gartner’s methodology. TrakCare is installed in more than 25 countries, including France, the U.K., Scotland, Italy, the Gulf region, India, China, Thailand, Australia, Brazil and Chile.
- InterSystems has extensive global experience with multiple languages and countries, leverages its global presence, and is financially strong.
- InterSystems has a well-developed analytics capability.
- The TrakCare product lacks a dedicated ICU module, although its clients are using base functionality in those units.
Meditech, a U.S.-based vendor with more than 20 years of global experience, is well-established in the small-and-midsize-hospital market. Please note that this year, we evaluated only the 6.0 platform for this Magic Quadrant, which explains some of the changes in positioning as compared with the previous year. Meditech has one of the most complete fully integrated product suites, although its EHRS product has some gaps. The company has 6.0 EHRS contracts in the U.S., Canada, the U.K., Ireland, the Gulf region, South Africa, Australia, Singapore and South America.
- Meditech has strong, long-tenured top management.
- Meditech knows how to build software, sets accurate expectations for delivery and has a well-established implementation methodology.
- Meditech lacks dedicated modules for ICU, and labor and delivery, although clients are using base functionality in those areas.
- The company lacks experience with large complex EHRS implementations outside of the U.S. and Canada.
Siemens acquired i.s.h.med in 2008. The product is built on SAP technology, requires SAP ERP and Patient Management, and follows the SAP delivery and release cycles. Siemens has i.s.h.med EHRS contracts in Austria, Belgium, Chile, China, Colombia, Germany, Hong Kong, Israel, Italy, Kuwait, Latin America, Mexico, the Netherlands, New Zealand, the Philippines, Russia, Singapore, Spain, Turkey, UAE and the U.K.
- Clinical functionality is fully integrated with administrative and financial functionality.
- A large customer base of hospitals that use SAP for ERP and Patient Management.
- The product is a Generation 2 EHRS, and while it has some Generation 3 capabilities, it lacks advanced features present in competitors’ Generation 3 products. It has limited experience with medication order entry.
- The product lacks dedicated modules for emergency department, ICU, and labor and delivery (except for the German market).
Siemens has developed Soarian from the ground up as a workflow-based Generation 3 product. Siemens has Soarian EHRS contracts in the U.S., Canada, Germany, Austria, the Netherlands, Switzerland, Portugal, Sweden and the U.K.
- Soarian is built around a commercial workflow engine.
- Siemens is a large multinational company with a large presence in healthcare and a highly respected healthcare IT CEO.
- The product lacks dedicated modules for ambulatory, labor and delivery, and the operating room (although development of an ambulatory module is under way).
- Soarian’s complete physician documentation is slated for the next release.
We review and adjust our inclusion criteria for Magic Quadrants and MarketScopes as markets change. As a result of these adjustments, the mix of vendors in any Magic Quadrant or MarketScope may change over time. A vendor appearing in a Magic Quadrant or MarketScope one year and not the next does not necessarily indicate that we have changed our opinion of that vendor. This may be a reflection of a change in the market and, therefore, changed evaluation criteria, or a change of focus by a vendor.
CSC’s Enterprise Management now meets the Magic Quadrant criteria.
Alert did not meet the inclusion criteria for having at least 25 full EHRS contracts representing at least 50 live sites spread over at least two continents. Because Alert did not respond to requests for supplemental information, Gartner’s analysis is based on other credible sources.
Vendors selected for inclusion in the 2012 global enterprise EHR system Magic Quadrant have at least 25 contracts representing at least 50 live sites spread over two or more continents, and they are actively developing, marketing and supporting an enterprise EHRS that, at the time of the report, has at least reached Generation 2. The products must have acute and ambulatory/outpatient care capabilities, including functionality for the emergency department and ICUs. When a vendor has more than one enterprise EHRS product, we have selected the one that we believe is most suitable for larger hospitals or integrated delivery networks, is on the most modern architecture and is the vendor’s primary go-forward product. Siemens is developing, supporting and marketing both Soarian and i.s.h.med, and both systems fully meet all the criteria for inclusion. Therefore, both appear on the Magic Quadrant. Meditech continues to actively develop functionality for all three of its EHRS platforms (Magic, Client/Server and 6.0); however, this year, we have decided to focus only on Meditech’s 6.0 platform, as it appears that most net new sales, especially those outside of the U.S., are for the 6.0 platform. In the case of CSC, Enterprise Management EHRS is included for the first time because it met our criteria; although it is not the company’s sole go-forward EHRS product, the other products (including Lorenzo) do not at this time meet our inclusion criteria. There are a few notable absences in this Magic Quadrant, because the products did not meet the inclusion criteria: GE Centricity Enterprise is not being actively marketed outside the U.S., and McKesson is not currently developing or marketing an enterprise EHRS for the global market. The evaluation period for this report was the third quarter of 2012.
Gartner evaluates a vendor’s Ability to Execute based on the quality and efficacy of the processes, systems, methods or procedures that enable vendor performance to be competitive, efficient and effective, and to positively affect the vendor’s revenue, retention and reputation. Ultimately, vendors are judged on their ability and success in capitalizing on their vision. For this Magic Quadrant, vendors are evaluated based on their Ability to Execute in the overall global market and not on how well they may be doing in any one submarket (for example, a single country). Our assessment of a vendor’s Ability to Execute consists of these criteria:
- Product/service includes core goods and services offered by the vendor that compete in or serve the enterprise EHRS market. This includes current product/service capabilities (partially determined by the Gartner generation rating), quality, feature sets and the number of complete implementations, as determined by the number of sites fully using computerized physician order entry, nursing documentation or physician documentation. This also includes an evaluation of the breadth and depth of product offerings, including coverage of care venues (for example, emergency and operating theaters) and support for unique stakeholders (for example, oncologists and obstetricians). The evaluation also looks beyond enterprise EHRS functionality to see how well the vendor can meet all the IT needs of an HDO.
- Overall viability includes an assessment of the vendor’s overall organizational financial health, its financial and practical success as it affects long-term revenue and profitability, and the ability and likelihood of the individual business unit to continue sufficient investment in the product, continue offering the product and continue advancing the state of the art in the organization’s portfolio of products.
- Sales execution measures vendor capabilities in all presales activities and the structure that supports them. This includes deal management, pricing and negotiation, presales support, and the overall effectiveness of the sales channel.
- Market responsiveness and track record shows the ability to sense and respond to changing market and competitive conditions, change direction, be flexible and achieve competitive success as opportunities develop, competitors act, customer needs evolve, and market dynamics change. This criterion also considers the vendor’s history of responsiveness.
- Marketing execution measures the clarity, quality, creativity and efficacy of programs designed to deliver the organization’s message to influence the market, promote the brand and business, increase awareness of the products, and establish a positive identification with the product/brand and organization in the minds of buyers. This mind share and “heart share” can be driven by a combination of publicity, promotional activities, thought leadership, word of mouth and sales activities. In healthcare, once a product market has formed, industry word of mouth is a powerful force influencing decisions in market subsegments (such as children’s hospitals, large integrated delivery systems [IDSs], academic medical centers and community hospitals).
- Customer experience measures relationships, products and services/programs that enable clients to be successful with the products evaluated. Specifically, this includes the ways customers receive technical support or account support and deployment of new releases. This can also include ancillary tools, customer support programs (and the quality thereof), the availability of user groups and other means to collaboratively define future product direction and service-level agreements.
- Operations measures the ability of the organization to meet its goals and commitments. Factors include the quality of the organizational structure, including skills, experiences, programs, systems and other vehicles that enable the organization to operate effectively and efficiently on an ongoing basis. This includes the quality of software engineering, because this must be a core competency in the development and management of complex EHRSs.
Source: Gartner (October 2012)
Gartner evaluates a vendor’s vision on its ability to convincingly articulate logical statements about market direction, innovation, product improvements, customer needs, competitive forces and how well they map to Gartner’s understanding of market needs. Ultimately, vendors are rated on their understanding of how market forces can be exploited to create opportunity for the vendor. For this Magic Quadrant, vendors are evaluated based on their overall global vision and not their vision for any one submarket (for example, a single country). Our assessment of a vendor’s Completeness of Vision consists of these criteria:
- Market understanding measures the ability of the vendor to understand buyer needs and translate these needs into products and services — more specifically, to understand significant healthcare trends and anticipate the product requirements that will result. Vendors that show the highest degree of vision listen, understand buyer wants and needs, and can shape or enhance those wants with their added insight. It is especially important for vendors competing in the global EHRS market to understand local nuances. This year, we also added the understanding of what the market is demanding of the core competencies of the vendor to this evaluation (for example, how much effort is being placed on becoming and consistently staying a top-notch software development company).
- Marketing strategy indicates a clear, differentiated set of messages consistently communicated throughout the organization and externalized through the website, advertising, industry, prospect and customer programs, as well as positioning statements.
- Sales strategy is the strategy for closing sales that creates and manages the appropriate network of direct and indirect sales, marketing, and sales support functions.
- Offering strategy is the approach to product development and delivery that emphasizes differentiation, functionality, methodology, and feature sets as they map to current and future requirements.
- Business model measures the soundness and logic of a vendor’s underlying business proposition.
- Industry strategy is the vendor’s strategy to direct resources, skills and offerings to meet the specific needs of the hospital/IDS markets.
- Innovation measures direct, related, complementary and synergistic layouts of resources, expertise or capital for investment, consolidation, defensive or pre-emptive purposes. While product enhancement is part of the equation, this category includes more than the addition of new features and functions to the core EHRSs. This year, we also included whether or not the vendor has a formal strategy for innovation (for example, the Pace-Layered Application Strategy; for more information, see “How to Get Started With a Pace-Layered Application Strategy”).
- Geographic strategy measures the vendor’s strategy to direct resources, skills and offerings to meet the specific needs of geographies outside the “home” or native geography, directly or through partners, channels and subsidiaries, as appropriate for that geography and market.
Leaders are defined as companies that are doing well today, as manifested by significant market penetration, appropriate product functionality, continued growth in product sales and high customer service ratings. Leaders have great prospects for the future.
Challengers have focused significant resources on this market. They have a somewhat narrower focus but are executing their vision well. In the global EHRS market, this might mean seeking opportunities in fewer regions, producing a product in only one language, or intentionally limiting the complexity and scope of the product to prevent overwhelming a given submarket.
Visionaries have great ideas for tomorrow, have products that partially implement that vision, but are not executing consistently or well in all areas.
Niche Players are those companies that focus on a small segment of the market and do it well, newcomers that are focusing on delivering a narrower range of product, or those that do not focus on a particular segment but have modest horizons and possibilities because of their inability to overcome performance, management or market constraints.
Around the world, many HDOs are seeking to implement commercial enterprise EHRSs (see Note 3) either from local vendors or from those that have global offerings. Although some entities are opting to build their own systems, this is decidedly not the norm. In addition to developing an enterprise EHRS, most of the vendors in this Magic Quadrant qualify as healthcare megasuite vendors, because their healthcare IT product portfolios include the cornerstone products of patient access, revenue management and advanced clinical applications (as well as departmental and other applications). This Magic Quadrant is restricted to an evaluation of global enterprise EHRSs.
Although functionality is important for placement on the global EHR system Magic Quadrant, it is essential to understand that vendor evaluations include criteria other than functionality. As the products in the market mature and vendors compete for business within this market, they become functionally similar. It is important to look at the level of innovation and predictable delivery of product enhancements, the reliability of product enhancements, the predictability of support, and the completeness of product suites beyond the core clinical requirements. It is equally important to recognize that the connection between an HDO and a vendor will be a long-term relationship, and it is important to take into consideration the vendors’ abilities to meet and anticipate future market requirements, and to put forth and deliver on a technical and business vision that will enable their clients to excel in the years to come.
For the purposes of this Magic Quadrant, vendors were evaluated based on their vision and ability to execute in the global market, not on their efforts, successes or vision in any one market. In particular, the criteria used for evaluation were developed in a manner that did not stress a vendor’s experience and track record in the mature U.S. market, because we have seen that the activity in the U.S. has not necessarily translated well in other countries.
HDOs seeking an enterprise EHRS have qualitatively better options to choose from today than previously. With vendors continuing to focus considerable resources toward their development efforts, it is critical that HDOs match their needs and timetables with vendors’ product road maps. HDOs that have selected or implemented an EHRS can use this Magic Quadrant as a gauge to determine whether their vendor of choice is keeping pace with competitors or whether there may be a possible problem that needs attention.
Although the Magic Quadrant can be a useful tool for vendor evaluations, it should never be used as the sole selection criterion. Placement on the Magic Quadrant is dependent on the scope of a vendor’s vision and how well it is executing on that vision. There are good business reasons why vendors might choose a narrower focus than some of their competitors and, therefore, be placed on the left side of the Magic Quadrant. Similarly, vendors that have less mature products may not yet be executing at peak level. It is critical to understand that there is no reason to reject Niche Players or Visionaries out of hand, and it is not always correct to automatically choose a Challenger or Leader. What matters most is the match — or mismatch — among vendor performance, product capabilities and customer needs. How well the vendor is able to deliver an effective solution for the client’s business issues, in terms of the product and the underlying support and services, is the determining factor.
With rising pressure to cut healthcare costs while enhancing the quality of care, private and government-owned HDOs are increasingly implementing clinical automation solutions, especially enterprise EHRSs. Some countries are further along. In the case of the U.S., approximately 80% of hospitals have at least selected and started implementing an EHRS, although only roughly 20% have reached the point at which more than 75% of all nursing and physician documentation, as well as potential medication and nonmedication orders, is directly entered into the system by clinicians. Other countries with extensive use of enterprise EHRSs include Canada, Australia, the Netherlands and the Nordic countries. Interest in enterprise EHRSs is growing in the rest of Western Europe, as well as in the Middle East and Latin America and certain countries in the Asia/Pacific region. Some entities are opting to build their own systems, but most seek commercial products from local vendors or those with global offerings. In many cases, a global EHRS may provide more stability and functionality in the long run.
Outside the U.S., there’s still confusion about the definition of an EHRS and whether an integrated enterprise EHRS (see Note 4) is preferable to linking disparate systems through HL7 messaging or clinical portals. We believe that integrated EHRSs will prevail, but it will take time. In terms of EHRS adoption, hospitals in much of the rest of the world are 10 to 15 years behind their U.S. counterparts.