Which Platform of Platforms (UDHP) is Proper in your Well being System? A Market Evaluation – The Well being Care Weblog

By NEIL JENNINGS & VINCE KURAITIS

This entry is a component 5 of 5 within the sequence Platforming Healthcare — The Lengthy View

In earlier posts on this sequence, we now have lined the definitions of Unified Digital Well being platforms and whether or not “EHRs can change into UDHPs.” On this follow-on submit, we’ll discuss by way of the necessities for fulfillment for a UDHP and which sorts of healthcare organizations are greatest fitted to which sorts 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 medical, monetary, and operational positive aspects

Key Takeaway 3: UDHPs should not all-or-nothing or mutually unique from EHRs. As we explored in our final submit, EHRs may develop into UDHPs. These EHRs as UDHPs (or the relative platform of platforms) stands out as the optimum alternative for some market segments. EHRs may be accommodated into cloud-first UHDPs.

Key Takeaway 4 / Guiding Criterion: This submit will deal with US regional and native well being techniques and outpatient teams of all sizes.

The Strategy: Market -> Segments -> Choices -> Match

• For this submit, we are going to begin from the top-down market perspective, analyzing the general market panorama.
• As soon as we now have described the panorama, we are going to name out the important thing segments (group varieties, sizes, and profiles) that we are going to be evaluating.
• At this level, we are going to approximate IT budgets and IT group sizes by group sort to find out capabilities of constructing versus relying on companions and distributors.
• Then, we’ll evaluation the constraints for implementation and possession, outlining the drivers of UDHP match.
• Subsequent, we’ll break down the other ways UDHPs might be developed and maintained.
  • Leveraging an EHR as UDHP
  • License from UDHP vendor
  • “Dwelling grown” cloud-first answer
• Lastly, we’ll crosswalk the segments and the optimum possibility for every phase, based mostly on their particular wants and estimated IT and budgetary assets.

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 exterior the 4 partitions of hospitals. This quantity of care occurring exterior of hospitals aligns with efforts to push sufferers into much less acute care settings, emphasizing preventative, proactive medication as a substitute of acute, reactive medication. As the necessity for UDHPs applies to greater than inpatient hospitals, we can even evaluation the opposite segments highlighted within the pie chart, together with: outpatient clinics and observe teams, and “different well being” containing companies delivered at different contexts like PACs and SNFs, and Ambulatory surgical facilities.

Desk 1 beneath illustrates the important thing segments as we outline them, together with the tough depend of whole entities, their relative breakdown by measurement, estimates of annual income, and subsequent estimates of IT finances. We’re estimating typical IT budgets as being between 2-5%, based mostly on DefinitiveHealthcare and WittKieffer sources; we perceive that a number of organizations are greater 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 assets and wishes with the best-fitting UDHP.

Desk 1

United States Healthcare Segments: IT Price range Evaluation

1 (AHA – 1957 (unaffiliated) + 227 (small techniques)), 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 firms seemingly skew greater 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 enormous 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 wide 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 bunch of hospitals spanning huge geographic areas, it mustn’t shock anybody that the organizational wants will range tremendously.

Whereas the UDHP market remains to be in growth, listed here are a few of our concerns 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 suitable answer for the suitable group ensures that wasted money and time are averted. The UDHP ought to “match” your group’s capabilities.

Price range & Workers

Price range is an apparent start line, with the 2-5% of annual revenues offering clear constraints. A small observe with a number of hundred thousand {dollars} in annual IT finances shouldn’t be contemplating a multi-million greenback Epic set up, in fact.

Straight correlated with finances is the scale of your IT group. There are staffing ratio discussions, with trade normal really helpful ratios of IT workers to non-IT workers from 1:50 as much as 1:150 or so. Whereas considerably apparent for the smaller organizations (if in case you have 5 clinicians and three help workers, you seemingly have a singular IT one who may be an workplace supervisor), it is a consideration for the medium to massive organizations. In case your whole group measurement is proscribed, including new applied sciences to handle in-house might be daunting. Workers and group measurement come into play not only for longitudinal upkeep, but in addition for implementation.

Budgets can be utilized to find out which UDHP choices are possible, however staffing will affect how the UDHP might 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 immediately associated to the IT technique, we can even body this part as some high-level guiding questions:

• What are the core techniques of workflow and of file?
• 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 techniques from scratch?
• Are present IT techniques hosted domestically? Hybrid? On public clouds?
• Does the group have a growth group? A DevOps group?

Organizational Wants

The complement to capabilities is the group’s present wants. Overbuilding or overinvesting shouldn’t be the purpose; the purpose is discovering the suitable match. To outline organizational wants, we are going to break them down into drivers of complexity, the necessity to keep aggressive, and IT technique.

Drivers of Organizational Complexity

Whereas delivering healthcare in right now’s digital-first world is advanced for all suppliers and practitioners, organizations function at completely different ranges of complexity based mostly 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 1000’s, the variety of suppliers exceeds 2,000, and also you begin coming 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 places is one other main driver of complexity, the place a single, standalone small hospital could also be easier 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 medication? Or, are there specialty teams? Is there a mixture of acuity settings? Does the group have pressing care, emergency medication, 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 sorts 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 the direction of value-based care and risk-bearing fashions. As supplier organizations shift in the direction of risk-bearing fashions, it’s typically an incremental shift with risk-based and fee-for-service fashions working in parallel. Along with the (comparatively) easier 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 techniques and enormous hospitals and is cascading by way of massive 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, international locations (Canadian presence), or different geos (tribal nations, US territories, and many others.)? As organizations develop to multi-state footprints, for instance, there are differing rules for licensure (the scope of NPs for instance), e-prescribing, and different localizations like regional language wants: this all have to be accommodated in EHRs and different techniques. That is all on prime of the necessity for referral networks, reference labs, pharmacies, and native well being info exchanges. As well as, there are regional privateness, information sharing, and different necessities that apply to cross-state or multi-region companies. When geographies span a number of sorts of borders, it will get much more difficult.

Geography is extra than simply technicalities associated to information sharing, licensure, and care supply: we can’t overlook 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 massive well being techniques and nationwide healthcare suppliers face, and there are a myriad of research displaying that sufferers are extra engaged, have higher outcomes, and are extra happy with care delivered of their most well-liked 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 develop 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, non-public fairness rollups, regulatory modifications, and the fixed want for extra patient-centric care – the market and rivals are altering rapidly!

Organizations have quickly altering wants with a view 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 information moats, leveraging differentiated information entry and repositories, to stay aggressive. Whether or not accessed as a part of a digital community or change or owned wholly internally, this method depends on IT infrastructure to securely retailer, course of, safe, and dealer information to related techniques.

When it comes to expectations, whereas sufferers right now have extra management of their very own healthcare data, it’s nonetheless not sufficient. Main organizations notice that sufferers don’t wish to work together with separate care contexts, specialties, and services 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 measurement, 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 tasks and budgets for upcoming years.

Whereas this level is foundationally vital, it additionally varies tremendously, relying on the idiosyncratic wants of every group. Nonetheless, there are some frequent themes and selections we are able to sometimes discern when reviewing a roadmap. We’ll body them as questions beneath:

• Is the group making an attempt to develop or shrink the scope of its IT operate?
• Is there a robust desire for constructing vs. shopping for vs. partnering?
• What key unmet wants have but to be addressed and are prioritized?
• What’s working right now (and notably excluded from roadmaps)?
• The place does organizational management have their sights centered to extend effectivity, competitiveness, differentiation, and care high quality through IT efforts?

Defining UDHP Choices for Totally different Healthcare Segments

Whereas healthcare at-large wants UDHPs, the particular wants range by group measurement 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

Possibility 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 techniques already accommodate the complexity, sensitivity, and technical necessities for working in a regulated trade. Among the main tailwinds, as lined 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” Choice for New Purposes
• Epic and Oracle Well being are Making Robust Actions Towards Changing into UDHPs

Because of finances constraints, the EHR stands out as the solely sensible UDHP possibility for a lot of organizations. Smaller practices and medical teams might have a single IT individual, liable for EHRs, {hardware}, software program, printers, fax machines, and every part else. If IT budgets are beginning round $100,000 per 12 months, and EHRs might take as much as half of that, there isn’t budgetary or workers room for different techniques. Elation calls out that the anticipated license price of an EHR per clinician is round $1,200 per 12 months; Folio3 shares an identical 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 finances, it is smart 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 prospects want a companion that fills in gaps. athenaHealth’s athenaOne bundle 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 observe answer,” 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 techniques, IT budgets get bigger as income grows and care contexts get extra difficult. As we start to see multi-state footprints, massive multi-specialty teams, and acute care settings, organizations might 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 often known as Neighborhood Join), for instance, is a particular providing that permits massive well being techniques to sublicense their Epic occasion, provisioning entry to regional hospitals or well being techniques. Whereas this selection permits smaller healthcare organizations to leverage the advantages of Epic, the associated fee might be an order of magnitude greater 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 finances, and finances 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 might begin within the tens of hundreds of thousands, however can attain a billion {dollars} or extra for bigger well being techniques.

Because the IT budgets get bigger, technical groups enhance in measurement and capabilities, and it naturally follows that extra superior choices are explored or required.

Possibility 2: License from UDHP Vendor

As denoted above, not all organizations have adequate IT budgets and workers to architect, construct, and handle their very own system. However, for giant well being techniques with greater than a billion {dollars} in annual income (estimated at ~175 or so in the US), these choices begin to change into possible if not obligatory. These massive hospitals and well being techniques might 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 Essential Well being System Goals
• EHR Switching Prices are Diminishing
• Cloud Native Platforms Speed up Innovation and Efficiency
• It’s Not in EHR DNA to Change into A Broad-Based mostly Platform

The final submit additionally shared a HIMSS examine that confirmed that the typical hospital had 16 EHRs in 2016. Whereas this quantity has seemingly consolidated down up to now decade, multi-EHR and multi-system-of-workflow architectures are very a lot a actuality right now. Specializing in the complexity angle on this piece, we are going to spotlight 4 further, complementary factors as to why an outside-the-EHR UDHP might be the perfect answer for bigger hospitals and enterprise well being techniques.

There are 4 main causes that we are going to spotlight the necessity for a UDHP to exist past the core EHR:

1. No singular EHR can accommodate every part that well being techniques must do
2. Some level options are nonetheless higher than their EHR-native competitor
3. Some organizations leverage a number of core EHRs (there are organizations that use each Cerner and Epic throughout their hospitals)
   1. Whether or not as a consequence of M&As, IT or clinician desire, or different causes, some well being techniques nonetheless use a blended EHR footprint.
   2. This presents in several methods, however is usually one of many following:
      1. One system for inpatient, one for outpatient
      2. One system for clinicals, one for RCM
      3. Or, distinct techniques at distinct places (typically as a consequence of M&A)
4. M&As and rollups are nonetheless working rampant
   1. Mergers and acquisitions mix greater than market footprints and medical capabilities; additionally they deliver IT groups and infrastructure. That is the place we start to see the actual glimpses of Frankstein’s monster.
   2. Some stats from Kaufman Corridor:
      1. 72 whole transactions in 2024, with 27 not together with a divestiture. Whereas this quantity might not appear that top in a vacuum, the whole image of the final decade+ shines mild onto the actual quantity of those transactions. From 2014 to 2024, there have been 933 whole M&A transactions. That’s a whole lot of technical complexity to wash up.

When it comes to licensing an outside-the-EHR platform, the primary submit within the UDHP sequence features a complete checklist of doable distributors, constructing from Gartner’s authentic checklist. We have now 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 prime of 1 or a number of EHRs. Every group’s particular wants are completely different, and so they might use their licensed platform from a UDHP companion to various levels.

Possibility 3: “Dwelling-grown” cloud-first answer

The ultimate possibility that we’ll cowl on this submit is for the main well being techniques, and certain restricted to the highest 15-20 techniques as a consequence of complexity, expense, and staffing necessities. Progressing past the cloud and platform vendor partnerships talked about above, these techniques are constructing enterprise information platforms and UDHPs immediately 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 the entire packing containers for a big, advanced group.

Ascension’s Scale: 16 States, 94 wholly owned or consolidated hospitals, 27 further hospitals by way of partnerships. 99,000 associates, 23,000 suppliers.

Ascension’s Scope: Inpatient, outpatient, and every part in between.

Ascension’s Workers: ~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 Drawback:

• Sufferers should not conscious of “care contexts,” they anticipate a unified expertise.
• Ascension’s various set of EHRs and myriad of different techniques weren’t tightly built-in
• No singular EHR nor operational system was a whole supply of fact
• There have been information variations throughout techniques that compound and exacerbate expertise inconsistencies throughout shopper digital touchpoints

The Answer:

• Ascension created an “Enterprise Information Service Layer (EDSL),” mapping information from a number of EHRs right into a unified, centralized FHIR schema to facilitate frictionless shopper entry to normalized and harmonized information
  • This depends on deep partnerships with EHR distributors and different companions.
  • FHIR, not totally adopted by all vendor companions, was made extra accessible utilizing REST APIs and a GraphQL orchestration layer to offer information on demand to digital purposes
• A unified affected person expertise, “AscensionOne” was developed on prime of the EDSL to offer a singular place for sufferers to ebook visits, get care, handle their well being data, and pay for care.

The Outcomes So Far:

After one 12 months, over 400,000 members are utilizing the unified affected person expertise, constructed on prime of the Enterprise Information Service Layer. The applying is averaging 4.8 stars within the app retailer.

Ideas from a pacesetter on EDSL efforts:

MJ Barrois, Senior Director of Product Administration:

“Our mission to raised 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 transportable information is instantly accessible to all of our sufferers. To supply care to these most weak and in want, we attempt to be good stewards of their information and we work carefully with our EHR companions to make healthcare information securely obtainable, simply discoverable, and comprehensible to the sufferers we serve.”

Summarizing the house grown possibility:

Whereas this selection shouldn’t be the optimum alternative for all organizations, Ascension is paving a path that might be simpler for others to observe. As we revisit the maturity curve proven above, the technical capabilities and necessities will get simpler 12 months after 12 months. AI is accelerating information mapping and infrastructure optimization. We anticipate that the “homegrown” answer might be extra attainable for the highest 50 or so well being techniques within the subsequent few years. If there’s ever any doubt about what the cloud techniques can do, we’d counsel testing this cloud comparability cheat sheet from ByteByteGo. You’ll be able to rapidly see that the cloud platforms can deal with just about something you’ll be able to throw at them if in case you have the suitable group and budgets in place.

Wanting forward

Right this moment, AI and our better-than-ever {hardware} proceed lowering boundaries to entry, and the necessity for UDHPs will rise as organizations enhance their IT footprints. Selecting a platform to construct round is the vital choice organizations ought to make right now. This platform choice might be an integral part of organizations’ AI methods, which is an important lever for brief time period competitors and long-term differentiation. There may be a whole lot of noise round AI implementation greatest practices right now, however the consensus (per AIDoc) seems to be {that a} centralized, ruled platform method is greatest, which depends on unified digital well being platforms and information.

As we glance a number of years out, a extremely doable situation is that by 2030, cloud-first implementations like Ascension’s might be commonplace not simply among the many prime 7 well being techniques, however the prime 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 subsequent cohort down in measurement in the identical interval, it’s extremely seemingly that EHR-complementing UDHPs might be licensed by the subsequent prime 150 well being techniques and hospitals. These already cloud-first techniques will play properly with cloud-hosted EHR techniques and supply entry to cloud advantages not attainable as a consequence of workers and budgetary limitations of those smaller organizations.

What’s the closing frontier? Ideally, by 2030, we can even start seeing uptake in openEHR and open-syntax, cloud-first platforms in the US. Epic isn’t going anyplace, but.

Vince Kuraitis JD/MBA is an unbiased marketing consultant with over 35 years’ expertise throughout 150+ healthcare & tech firms. Neil Jennings is a options engineer on the well being care group 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 evaluation 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.