By NEIL JENNINGS & VINCE KURAITIS
This entry is an element 5 of 5 within the collection Platforming Healthcare — The Lengthy View
In earlier posts on this collection, we now have coated the definitions of Unified Digital Well being platforms and whether or not “EHRs can turn out to be UDHPs.” On this follow-on submit, we’ll speak by the necessities for fulfillment for a UDHP and which varieties of healthcare organizations are finest suited to which varieties of UDHPs. This submit will construct on findings from the earlier posts.
The Market Wants UDHPs: Key Takeaways from Earlier Posts
Key Takeaway 1: The healthcare trade wants UDHPs to create a centralized, frequent structure for healthcare organizations
Key Takeaway 2: The healthcare organizations leveraging UDHPs will obtain a myriad of advantages, from aggressive benefits to scientific, monetary, and operational positive aspects
Key Takeaway 3: UDHPs are usually not all-or-nothing or mutually unique from EHRs. As we explored in our final submit, EHRs might increase into UDHPs. These EHRs as UDHPs (or the relative platform of platforms) would be the optimum selection for some market segments. EHRs can also be accommodated into cloud-first UHDPs.
Key Takeaway 4 / Guiding Criterion: This submit will give attention to US regional and native well being methods and outpatient teams of all sizes.
The Method: Market -> Segments -> Choices -> Match
- For this submit, we’ll begin from the top-down market perspective, analyzing the general market panorama.
- As soon as we now have described the panorama, we’ll name out the important thing segments (group sorts, sizes, and profiles) that we’ll be evaluating.
- At this level, we’ll approximate IT budgets and IT crew sizes by group kind to find out capabilities of constructing versus relying on companions and distributors.
- Then, we’ll assessment the constraints for implementation and possession, outlining the drivers of UDHP match.
- Subsequent, we’ll break down the alternative ways UDHPs will be developed and maintained.
- Leveraging an EHR as UDHP
- License from UDHP vendor
- “House grown” cloud-first resolution
- Lastly, we’ll crosswalk the segments and the optimum possibility for every phase, primarily based on their particular wants and estimated IT and budgetary sources.
The Healthcare Market & Main Well being System Segments
Beginning with a compelling graphic from the Kaiser Household Basis, we see a 2023 breakdown of the whole US healthcare medical expenditure, totaling ~$4.9 trillion.
Whereas the whole healthcare spend that occurred in hospitals is an astounding ~$ 1.5 trillion, accounting for 31% of whole healthcare spend, this leaves a lot of care outdoors the 4 partitions of hospitals. This quantity of care occurring outdoors of hospitals aligns with efforts to push sufferers into much less acute care settings, emphasizing preventative, proactive drugs as a substitute of acute, reactive drugs. As the necessity for UDHPs applies to greater than inpatient hospitals, we can even assessment the opposite segments highlighted within the pie chart, together with: outpatient clinics and follow teams, and “different well being” containing companies delivered at different contexts like PACs and SNFs, and Ambulatory surgical facilities.
Desk 1 under illustrates the important thing segments as we outline them, together with the tough rely of whole entities, their relative breakdown by dimension, estimates of annual income, and subsequent estimates of IT price range. We’re estimating typical IT budgets as being between 2-5%, primarily based on DefinitiveHealthcare and WittKieffer sources; we perceive that a number of organizations are larger or decrease than this vary. The target, with out spending an excessive amount of time on the science venture, is to tough out IT budgets by phase to align organizational sources and desires with the best-fitting UDHP.
Desk 1
United States Healthcare Segments: IT Funds Evaluation
1 (AHA – 1957 (unaffiliated) + 227 (small methods)), 2 (Statista), 3 (Futuremarketinsights), 4 (Businesswire), 5 (NIH), 6 (Chartis), 7 (DefinitiveHC), 8 (DefinitiveHC),9 (GrandviewResearch, income per MD) , 10 (AMGA), 11 (Grandviewresearch), 12 (Definitive Healthcare), 13 (Witt Kieffer), 14 (Priority Analysis), 15 (Ibisworld as of 2023), 16 – these corporations probably skew larger as they’re distant first, relying on digital care platforms.
We’re additionally together with two succinct charts from the Witt Kieffer piece, as a result of they inform a transparent story in regards to the large variance in IT spent throughout the healthcare continuum.
Supply: WittKieffer
Supply: WittKieffer
Defining Match: Segments (and their wants) Are Not Created Equal
Desk 1 above highlights the big selection of healthcare segments that make up the multi-trillion greenback US healthcare market. As these organizations vary from a number of physicians to a whole lot of hospitals spanning huge geographic areas, it shouldn’t shock anybody that the organizational wants will range enormously.
Whereas the UDHP market continues to be in growth, listed here are a few of our issues on what is going to outline profitable architectures and implementations. We summarize the determinants of organizational match into two buckets: Capabilities & Wants
Organizational Capabilities
As proven in Desk 1 above, IT budgets are finite, together with IT and technical groups’ time. Discovering the precise resolution for the precise group ensures that wasted money and time are averted. The UDHP ought to “match” your group’s capabilities.
Funds & Employees
Funds is an apparent start line, with the 2-5% of annual revenues offering clear constraints. A small follow with a number of hundred thousand {dollars} in annual IT price range shouldn’t be contemplating a multi-million greenback Epic set up, after all.
Straight correlated with price range is the dimensions of your IT crew. There are staffing ratio discussions, with trade customary advisable ratios of IT employees to non-IT employees from 1:50 as much as 1:150 or so. Whereas considerably apparent for the smaller organizations (in case you have 5 clinicians and three help employees, you probably have a singular IT one that can also be an workplace supervisor), it is a consideration for the medium to giant organizations. In case your whole crew dimension is restricted, including new applied sciences to handle in-house will be daunting. Employees and crew dimension come into play not only for longitudinal upkeep, but additionally for implementation.
Budgets can be utilized to find out which UDHP choices are possible, however staffing will affect how the UDHP will probably be applied and maintained.
Present IT Footprint
The group’s present technical footprint can also be an vital issue when figuring out the optimum UDHP implementation method. As that is straight associated to the IT technique, we can even body this part as some high-level guiding questions:
- What are the core methods of workflow and of report?
- Which of the next does the IT footprint embody?
- Software program as a Service
- Platforms as a service
- Infrastructure as a service
- Does the group construct and keep purposes, portals, and methods from scratch?
- Are present IT methods hosted regionally? Hybrid? On public clouds?
- Does the group have a growth crew? A DevOps crew?
Organizational Wants
The complement to capabilities is the group’s present wants. Overbuilding or overinvesting shouldn’t be the objective; the objective is discovering the precise match. To outline organizational wants, we’ll break them down into drivers of complexity, the necessity to keep aggressive, and IT technique.
Drivers of Organizational Complexity
Whereas delivering healthcare in at this time’s digital-first world is complicated for all suppliers and practitioners, organizations function at totally different ranges of complexity primarily based on their scale, scope, enterprise mannequin, and footprint.
Beginning with scale, bigger organizations sometimes have extra difficult wants. Because the variety of beds enters the hundreds, the variety of suppliers exceeds 2,000, and also you begin getting into hundreds of thousands of annual visits, each the number of interactions and the amount of interactions enhance. Along with the variety of folks (sufferers, suppliers), the variety of bodily areas is one other main driver of complexity, the place a single, standalone small hospital could also be less complicated than a multi-state, multi-specialty doctor group.
The scope of the group’s care companies is one other main issue. Are there solely outpatient/ambulatory practices? Are they solely main drugs? Or, are there specialty teams? Is there a mixture of acuity settings? Does the group have pressing care, emergency drugs, house well being, hospital outpatient specialties? Does the group have its personal labs, imaging facilities, and surgical procedure facilities? As you proceed so as to add extra varieties of care that may be delivered, the IT infrastructure is challenged in new and thrilling methods.
Supplier organizations’ enterprise fashions additionally play a key position in organizational complexity, with the shift in direction of value-based care and risk-bearing fashions. As supplier organizations shift in direction of risk-bearing fashions, it’s usually an incremental shift with risk-based and fee-for-service fashions working in parallel. Along with the (comparatively) less complicated configuration of including one other insurance coverage plan, the info and care supply coordination of risk-based plans are an order of magnitude extra difficult than conventional fee-for-service care fashions. This shift has expanded past enterprise well being methods and enormous hospitals and is cascading by giant ambulatory practices, which have distributed footprints and traditionally smaller IT budgets.
Geographic footprint is a significant driver of organizational complexity and IT (amongst different) wants. Is the group a singular location or unfold out inside a metropolis? Is it distributed throughout a number of states, nations (Canadian presence), or different geos (tribal nations, US territories, and many others.)? As organizations increase to multi-state footprints, for instance, there are differing laws for licensure (the scope of NPs for instance), e-prescribing, and different localizations like regional language wants: this all should be accommodated in EHRs and different methods. That is all on high of the necessity for referral networks, reference labs, pharmacies, and native well being info exchanges. As well as, there are regional privateness, knowledge sharing, and different necessities that apply to cross-state or multi-region companies. When geographies span a number of varieties of borders, it will get much more difficult.
Geography is extra than simply technicalities associated to knowledge sharing, licensure, and care supply: we can’t neglect the folks and their cultural and regional variations. The US is an extremely various nation the place there are 430 languages spoken throughout the states and territories. Addressing cultural, language, and regional variations is a complexity that many giant well being methods and nationwide healthcare suppliers face, and there are a myriad of research displaying that sufferers are extra engaged, have higher outcomes, and are extra glad with care delivered of their most popular language. Anybody who has labored on an internationalization or localization effort for a product will perceive the complexity, however the implications of languages, regional variations and norms, are far reaching and can’t be underestimated. They increase past multi-language help, impacting content material (care summaries, letters, affected person directions), and even workplace schedules.
Group Must Stay Aggressive / Differentiated
Past simply managing their very own complexities, healthcare organizations are sometimes run as companies (there are some not-for-profit organizations, together with a nationwide chief that we spotlight later). With the shift to decrease acuity care contexts, personal fairness rollups, regulatory adjustments, and the fixed want for extra patient-centric care – the market and rivals are altering shortly!
Organizations have quickly altering wants as a way to keep aggressive and differentiated within the digital-first healthcare ecosystem. Each organizational wants and affected person/supplier expectations are driving initiatives for lasting differentiation.
Beginning with organizational wants, some organizations are constructing aggressive knowledge moats, leveraging differentiated knowledge entry and repositories, to stay aggressive. Whether or not accessed as a part of a digital community or trade or owned wholly internally, this method depends on IT infrastructure to securely retailer, course of, safe, and dealer knowledge to related methods.
By way of expectations, whereas sufferers at this time have extra management of their very own healthcare information, it’s nonetheless not sufficient. Main organizations understand that sufferers don’t need to work together with separate care contexts, specialties, and amenities individually. As an alternative, they’re prioritizing unified affected person experiences (a part of UDHPs) to simplify affected person interactions throughout their technical and operational ecosystem. This transition to affected person consumerism is offering one other level the place organizations compete: affected person engagement and loyalty.
IT Technique
As organizations get bigger in dimension, they’ve extra outlined IT methods, with enterprise organizations sustaining multi-year roadmaps. These roadmaps define the prescribed method to attain organizational priorities and outline the initiatives and budgets for upcoming years.
Whereas this level is foundationally vital, it additionally varies enormously, relying on the idiosyncratic wants of every group. Nonetheless, there are some frequent themes and choices we are able to sometimes discern when reviewing a roadmap. We’ll body them as questions under:
- Is the group attempting to increase or shrink the scope of its IT operate?
- Is there a powerful desire for constructing vs. shopping for vs. partnering?
- What key unmet wants have but to be addressed and are prioritized?
- What’s working at this time (and notably excluded from roadmaps)?
- The place does organizational management have their sights targeted to extend effectivity, competitiveness, differentiation, and care high quality through IT efforts?
Defining UDHP Choices for Completely different Healthcare Segments
Whereas healthcare at-large wants UDHPs, the particular wants range by group dimension and complexity. Associated, not all implementations of UDHPs will have to be the identical, and we see three main paths for organizations to implement and architect their UDHPs.
Mapping UDHP Choices to Market Segments
Choice 1: Leveraging an EHR as a UDHP
There are a number of drivers that push healthcare organizations towards their EHR because the default UDHP. These methods already accommodate the complexity, sensitivity, and technical necessities for working in a regulated trade. Among the main tailwinds, as coated in our earlier submit (“Can EHRs be Well being System’s “Platform of Platforms” (UDHPS)) are as follows:
- EHRs At present Personal the Buyer Relationship
- Many Clients Have an “EHR-First” Desire for New Purposes
- Epic and Oracle Well being are Making Sturdy Actions Towards Turning into UDHPs
As a result of price range constraints, the EHR would be the solely sensible UDHP possibility for a lot of organizations. Smaller practices and medical teams could have a single IT individual, accountable for EHRs, {hardware}, software program, printers, fax machines, and every little thing else. If IT budgets are beginning round $100,000 per yr, and EHRs could take as much as half of that, there isn’t budgetary or employees room for different methods. Elation calls out that the anticipated license value of an EHR per clinician is round $1,200 per yr; Folio3 shares the same quantity. That is earlier than upkeep, help, coaching, and different bills associated to the EHR, and earlier than different IT-related bills not associated to the EHR. When the EHR makes up a considerable portion of the price range, it is sensible to look there first.
Along with these factors talked about within the earlier submit, when EHRs are tailor-made to smaller organizations, distributors perceive that their clients want a companion that fills in gaps. athenaHealth’s athenaOne package deal providing, for instance, contains add-ons that complement the core EHR throughout the group: from affected person engagement and communication, to pre-visit and sched/reg help, to RCM and declare submission help. Positioned as an “all-in-one follow resolution,” they’re framing the providing as greater than an EHR and provide many UDHP advantages.
Shifting upmarket to bigger doctor teams and small hospitals or well being methods, IT budgets get bigger as income grows and care contexts get extra difficult. As we start to see multi-state footprints, giant multi-specialty teams, and acute care settings, organizations could outgrow the ambulatory-focused EHRs like athenaHealth, ECW, and others. That is the place Epic and Cerner step in and are completely happy to fulfill these organizations’ wants.
Epic’s Join (previously generally known as Neighborhood Join), for instance, is a particular providing that permits giant well being methods to sublicense their Epic occasion, provisioning entry to regional hospitals or well being methods. Whereas this feature permits smaller healthcare organizations to leverage the advantages of Epic, the price will be an order of magnitude larger than outpatient, license-based EHRs.
In 2024, OhioHealth Van Vert Hospital invested $12MM to transition to Epic through CareConnect. Leveraging the identical budgetary assumptions as above, if the EHR is ~50% of price range, and price range is ~2-5% of income, this means that the hospital has >$480MM in annual income ($12M * 2 / .05). Implementing Epic as a standalone well being system or hospital group is pricey, and a 2024 submit from Becker’s notes that prices could begin within the tens of hundreds of thousands, however can attain a billion {dollars} or extra for bigger well being methods.
Because the IT budgets get bigger, technical groups enhance in dimension and capabilities, and it naturally follows that extra superior choices are explored or required.
Choice 2: License from UDHP Vendor
As denoted above, not all organizations have ample IT budgets and employees to architect, construct, and handle their very own system. However, for giant well being methods with greater than a billion {dollars} in annual income (estimated at ~175 or so in the USA), these choices begin to turn out to be possible if not crucial. These giant hospitals and well being methods could start wanting past their EHR to fulfill their UDHP and platform-of-platforms wants. Why?
As highlighted within the earlier submit:
- EHRs Carry a Lot of Baggage
- Clients are Skeptical
- EHR Analytics Are NOT Optimized To Obtain Vital Well being System Targets
- EHR Switching Prices are Diminishing
- Cloud Native Platforms Speed up Innovation and Efficiency
- It’s Not in EHR DNA to Turn out to be A Broad-Primarily based Platform
The final submit additionally shared a HIMSS examine that confirmed that the typical hospital had 16 EHRs in 2016. Whereas this quantity has probably consolidated down prior to now decade, multi-EHR and multi-system-of-workflow architectures are very a lot a actuality at this time. Specializing in the complexity angle on this piece, we’ll spotlight 4 further, complementary factors as to why an outside-the-EHR UDHP will be the perfect resolution for bigger hospitals and enterprise well being methods.
There are 4 main causes that we’ll spotlight the necessity for a UDHP to exist past the core EHR:
- No singular EHR can accommodate every little thing that well being methods have to do
- Some level options are nonetheless higher than their EHR-native competitor
- Some organizations leverage a number of core EHRs (there are organizations that use each Cerner and Epic throughout their hospitals)
- Whether or not on account of M&As, IT or clinician desire, or different causes, some well being methods nonetheless use a blended EHR footprint.
- This presents in several methods, however is often one of many following:
- One system for inpatient, one for outpatient
- One system for clinicals, one for RCM
- Or, distinct methods at distinct areas (usually on account of M&A)
- M&As and rollups are nonetheless working rampant
- Mergers and acquisitions mix greater than market footprints and scientific capabilities; in addition they deliver IT groups and infrastructure. That is the place we start to see the actual glimpses of Frankstein’s monster.
- Some stats from Kaufman Corridor:
- 72 whole transactions in 2024, with 27 not together with a divestiture. Whereas this quantity could not appear that prime in a vacuum, the whole image of the final decade+ shines gentle onto the actual quantity of those transactions. From 2014 to 2024, there have been 933 whole M&A transactions. That’s lots of technical complexity to wash up.
By way of licensing an outside-the-EHR platform, the primary submit within the UDHP collection features a complete listing of doable distributors, constructing from Gartner’s authentic listing. We now have additionally highlighted in earlier posts that the license method shouldn’t be an all-or-nothing method, and sometimes entails a hybrid mannequin, constructing on high of 1 or a number of EHRs. Every group’s particular wants are totally different, and so they could use their licensed platform from a UDHP companion to various levels.
Choice 3: “House-grown” cloud-first resolution
The ultimate possibility that we’ll cowl on this submit is for the main well being methods, and sure restricted to the highest 15-20 methods on account of complexity, expense, and staffing necessities. Progressing past the cloud and platform vendor partnerships talked about above, these methods are constructing enterprise knowledge platforms and UDHPs straight inside cloud environments, leveraging cloud companies from AWS, GCP, Azure, InterSystems, or others.
Beginning with a mini case examine. We plan to additional expound upon Ascension’s work in a future submit.
The State of affairs: Ascension checks all the containers for a big, complicated group.
Ascension’s Scale: 16 States, 94 wholly owned or consolidated hospitals, 27 further hospitals by partnerships. 99,000 associates, 23,000 suppliers.
Ascension’s Scope: Inpatient, outpatient, and every little thing in between.
Ascension’s Employees: ~3,000 working in IT (per LinkedIn)
Ascension’s IT Footprint: Heterogenous, 18 EHRs, 40+ affected person portals
Want for differentiation / competitiveness: Excessive, each regionally and throughout the 16 states
The Downside:
- Sufferers are usually not conscious of “care contexts,” they count on a unified expertise.
- Ascension’s various set of EHRs and myriad of different methods weren’t tightly built-in
- No singular EHR nor operational system was an entire supply of fact
- There have been knowledge variations throughout methods that compound and exacerbate expertise inconsistencies throughout client digital touchpoints
The Resolution:
- Ascension created an “Enterprise Knowledge Service Layer (EDSL),” mapping knowledge from a number of EHRs right into a unified, centralized FHIR schema to facilitate frictionless client entry to normalized and harmonized knowledge
- This depends on deep partnerships with EHR distributors and different companions.
- FHIR, not absolutely adopted by all vendor companions, was made extra accessible utilizing REST APIs and a GraphQL orchestration layer to supply knowledge on demand to digital purposes
- A unified affected person expertise, “AscensionOne” was developed on high of the EDSL to supply a singular place for sufferers to guide visits, get care, handle their well being information, and pay for care.
The Outcomes So Far:
After one yr, over 400,000 members are utilizing the unified affected person expertise, constructed on high of the Enterprise Knowledge Service Layer. The appliance is averaging 4.8 stars within the app retailer.
Ideas from a frontrunner on EDSL efforts:
MJ Barrois, Senior Director of Product Administration:
“Our mission to higher serve our communities was a key driving issue behind our funding in constructing our inside platform. EDSL represents our dedication to assist form a future the place extremely interoperable and moveable knowledge is quickly accessible to all of our sufferers. To supply care to these most weak and in want, we attempt to be good stewards of their knowledge and we work carefully with our EHR companions to make healthcare knowledge securely accessible, simply discoverable, and comprehensible to the sufferers we serve.”
Summarizing the house grown possibility:
Whereas this feature shouldn’t be the optimum selection for all organizations, Ascension is paving a path that will probably be simpler for others to observe. As we revisit the maturity curve proven above, the technical capabilities and necessities will get simpler yr after yr. AI is accelerating knowledge mapping and infrastructure optimization. We count on that the “homegrown” resolution will probably be extra attainable for the highest 50 or so well being methods within the subsequent few years. If there’s ever any doubt about what the cloud methods can do, we’d recommend testing this cloud comparability cheat sheet from ByteByteGo. You’ll be able to shortly see that the cloud platforms can deal with just about something you possibly can throw at them in case you have the precise crew and budgets in place.
Wanting forward
Right now, AI and our better-than-ever {hardware} proceed lowering obstacles to entry, and the necessity for UDHPs will rise as organizations enhance their IT footprints. Selecting a platform to construct round is the vital determination organizations ought to make at this time. This platform determination will probably be an integral part of organizations’ AI methods, which is a necessary lever for brief time period competitors and long-term differentiation. There may be lots of noise round AI implementation finest practices at this time, however the consensus (per AIDoc) seems to be {that a} centralized, ruled platform method is finest, which depends on unified digital well being platforms and knowledge.
As we glance a number of years out, a extremely doable state of affairs is that by 2030, cloud-first implementations like Ascension’s will probably be commonplace not simply among the many high 7 well being methods, however the high 50. Internet hosting EHRs (like Epic and Cerner) on public clouds, pioneered by Geisinger, has been de-risked. As soon as within the cloud, it’s solely a matter of time earlier than the opposite cloud-first capabilities are evaluated and deemed a step ahead from legacy, healthcare-specific platforms and companies.
For the following cohort down in dimension in the identical interval, it’s extremely probably that EHR-complementing UDHPs will probably be licensed by the following high 150 well being methods and hospitals. These already cloud-first methods will play properly with cloud-hosted EHR methods and supply entry to cloud advantages not attainable on account of employees and budgetary limitations of those smaller organizations.
What’s the last frontier? Ideally, by 2030, we can even start seeing uptake in openEHR and open-syntax, cloud-first platforms in the USA. Epic isn’t going anyplace, but.
Vince Kuraitis JD/MBA is an impartial guide with over 35 years’ expertise throughout 150+ healthcare & tech corporations. Neil Jennings is a options engineer on the well being care crew at Akamai Applied sciences. Vince publishes The Healthcare Platform Weblog, the place this submit first appeared. The authors thank a number of colleagues for his or her assessment and commentary on an earlier draft of this submit: M.J. Barrois, Senior Director of Product Administration at Ascension; Jim Sabogal, Healthcare Vertical Lead at CDW; and Taylor Gartley, Director at Fold Well being.
