“We’re trying to build a Silicon Valley-like, enduring company in Miami. It’s not the kind of company that we’re going to build and sell in a couple of years,” Santalo said.

But CareCloud faces plenty of competition from such industry leaders as Kansas City-based Cerner, Epic Systems in Verona, Wis., and Greenway Medical Technologies in Carrollton, Ga. The EHR industry also is populated with less successful companies that have stayed in business largely because of the buyer subsidies authorized by the HITECH Act. The Health Information Technology for Economic and Clinical Health Act is part of the American Recovery and Reinvestment Act of 2009, the far-reaching economic stimulus legislation that President Obama signed into law shortly after his first term in office began.

“Companies that should have gone out of business, or been impaired through natural competitive forces, were basically given a heart transplant by the HITECH Act and the way it was implemented,” Santalo said. The CareCloud CEO also said many EHR vendors sold outdated software to unwitting doctors who had to buy a second system. “Now there’s this kind of rip-and-replace market,” he said, “where companies like us are coming in and helping to replace those old systems with something that’s a lot better.”

Some companies are digging into defendable niches in the EHR field, which extends beyond the realm of digital text. One of the niche players is Miami-based itMD, which markets cloud-based storage and retrieval of such medical images as X-rays and CT scans. “You have the EMR [electronic medical records] technology to transport documents, and now you have the ability to transport images,” said Barbara Perez Deppman, president of itMD, which she and her partners started in July 2010. Among other initiatives, itMD is developing software features “to enable patients to sign up for an account online, so they’ll be able to aggregate all their images online,” Deppman said. The images then “can be downloaded on their 3G iPhone or their iPad.”

Voice communication is at the heart of Consult A Doctor, a Miami Beach-based company that facilitates paperless telemedicine services. Users can call anytime to consult a physician by phone rather than wait days or weeks to visit a physician’s office. The company makes digital copies of the conversations available to the physicians and patients. The company’s CEO, Wolf Shlagman, said 17 states now require insurers to treat telemedicine and face-to-face exams equally for reimbursement purposes, and similar laws have been proposed in seven other states, including Florida. For non-emergency care, “it takes days and days to see a doctor,” he said. “If you can get care quicker [by telephone], and the provider gets paid, everybody wins ... There is a tremendous amount of primary care that could be handled through virtual care.”

Miami-based Kipu Systems is an EHR vendor with specialized systems for behavioral and substance abuse treatment facilities flooded with paperwork. One patient who spends one week in a treatment facility can generate “up to 300 pieces of paper. All that disappears,” said Natasha Duwin, president of Kipu Systems. The company is planning to expand its staff of six employees to 18 by the end of the year.