Which Platform of Platforms (UDHP) is Proper to 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 collection Platforming Healthcare — The Lengthy View

In earlier posts on this collection, we have now lined the definitions of Unified Digital Well being platforms and whether or not “EHRs can develop into UDHPs.” On this follow-on publish, we’ll speak by means of the necessities for achievement for a UDHP and which varieties of healthcare organizations are finest fitted to which varieties of UDHPs. This publish 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, widespread 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 factors

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

Key Takeaway 4 / Guiding Criterion: This publish 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 publish, we are going to begin from the top-down market perspective, analyzing the general market panorama.
• As soon as we have now described the panorama, we are going to name out the important thing segments (group sorts, sizes, and profiles) that we are going to be evaluating.
• At this level, we are going to 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 may be developed and maintained.
  • Leveraging an EHR as UDHP
  • License from UDHP vendor
  • “Dwelling grown” cloud-first resolution
• Lastly, we’ll crosswalk the segments and the optimum choice for every phase, primarily based 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 entire US healthcare medical expenditure, totaling ~$4.9 trillion.

Whereas the entire 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 medication as a substitute of acute, reactive medication. As the necessity for UDHPs applies to greater than inpatient hospitals, we may even assessment the opposite segments highlighted within the pie chart, together with: outpatient clinics and apply teams, and “different well being” containing providers 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 finances. We’re estimating typical IT budgets as being between 2-5%, primarily based on DefinitiveHealthcare and WittKieffer sources; we perceive that a couple of organizations are increased 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 Finances 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 firms probably skew increased 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 big selection of healthcare segments that make up the multi-trillion greenback US healthcare market. As these organizations vary from a couple of physicians to tons of of hospitals spanning huge geographic areas, it mustn’t shock anybody that the organizational wants will fluctuate enormously.

Whereas the UDHP market continues to be in growth, listed here are a few of our issues on what’s 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 appropriate resolution for the appropriate group ensures that wasted money and time are prevented. The UDHP ought to “match” your group’s capabilities.

Finances & Workers

Finances is an apparent start line, with the 2-5% of annual revenues offering clear constraints. A small apply with a couple 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 dimensions of your IT crew. There are staffing ratio discussions, with trade commonplace really useful 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 who might also be an workplace supervisor), this can be a consideration for the medium to massive organizations. In case your whole crew dimension is restricted, including new applied sciences to handle in-house may be daunting. Workers 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 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 instantly associated to the IT technique, we may even body this part as some high-level guiding questions:

• What are the core methods 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 preserve functions, 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 is just not the objective; the objective is discovering the appropriate 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 as we speak’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 usually have extra difficult wants. Because the variety of beds enters the 1000’s, the variety of suppliers exceeds 2,000, and also you begin getting into tens of millions of annual visits, each the number of interactions and the quantity of interactions improve. Along with the variety of individuals (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 providers 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, residence 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 function 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 usually an incremental shift with risk-based and fee-for-service fashions operating in parallel. Along with the (comparatively) less complicated configuration of including one other insurance coverage plan, the information 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 huge hospitals and is cascading by means 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, nations (Canadian presence), or different geos (tribal nations, US territories, and so on.)? As organizations develop 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 prime 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 individuals and their cultural and regional variations. The US is an extremely numerous 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 methods and nationwide healthcare suppliers face, and there are a myriad of research exhibiting 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 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 usually 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 adjustments, and the fixed want for extra patient-centric care – the market and rivals are altering rapidly!

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.

When it comes to expectations, whereas sufferers as we speak have extra management of their very own healthcare information, it’s nonetheless not sufficient. Main organizations understand that sufferers don’t wish 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. Nevertheless, there are some widespread themes and choices we will usually discern when reviewing a roadmap. We’ll body them as questions under:

• Is the group making an attempt to develop or shrink the scope of its IT perform?
• 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 as we speak (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 precise wants fluctuate by group dimension and complexity. Associated, not all implementations of UDHPs will must 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 lined in our earlier publish (“Can EHRs be Well being System’s “Platform of Platforms” (UDHPS)) are as follows:

• EHRs Presently Personal the Buyer Relationship
• Many Clients Have an “EHR-First” Choice for New Functions
• Epic and Oracle Well being are Making Robust Actions Towards Changing into UDHPs

On account of finances constraints, the EHR stands out as the solely sensible UDHP choice for a lot of organizations. Smaller practices and medical teams could have a single IT particular person, chargeable for EHRs, {hardware}, software program, printers, fax machines, and all the things else. If IT budgets are beginning round $100,000 per 12 months, 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 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 publish, when EHRs are tailor-made to smaller organizations, distributors perceive that their clients want a associate that fills in gaps. athenaHealth’s athenaOne package deal providing, for instance, consists of 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 apply resolution,” they’re framing the providing as greater than an EHR and supply 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, massive 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 Group Join), for instance, is a particular providing that allows massive 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 associated fee may be an order of magnitude increased 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 implies 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 publish from Becker’s notes that prices could begin within the tens of tens of millions, however can attain a billion {dollars} or extra for bigger well being methods.

Because the IT budgets get bigger, technical groups improve 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 enough IT budgets and employees to architect, construct, and handle their very own system. However, for big well being methods with greater than a billion {dollars} in annual income (estimated at ~175 or so in the US), these choices begin to develop into possible if not crucial. These massive 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 publish:

• EHRs Carry a Lot of Baggage
• Clients are Skeptical
• EHR Analytics Are NOT Optimized To Obtain Crucial Well being System Goals
• 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-Based mostly Platform

The final publish additionally shared a HIMSS examine that confirmed that the common 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 as we speak. Specializing in the complexity angle on this piece, we are going to spotlight 4 extra, complementary factors as to why an outside-the-EHR UDHP may be the perfect resolution for bigger hospitals and enterprise well being methods.

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 all the things that well being methods have to 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 on account of M&As, IT or clinician desire, or different causes, some well being methods nonetheless use a combined EHR footprint.
   2. This presents in numerous methods, however is often one of many following:
      1. One system for inpatient, one for outpatient
      2. One system for clinicals, one for RCM
      3. Or, distinct methods at distinct areas (usually on account of M&A)
4. M&As and rollups are nonetheless operating rampant
   1. Mergers and acquisitions mix greater than market footprints and scientific capabilities; in addition they convey IT groups and infrastructure. That is the place we start to see the true 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 could not appear that top in a vacuum, the entire image of the final decade+ shines mild onto the true 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 scrub up.

When it comes to licensing an outside-the-EHR platform, the primary publish within the UDHP collection features a complete record of doable distributors, constructing from Gartner’s unique record. We’ve additionally highlighted in earlier posts that the license method is just not an all-or-nothing method, and usually includes a hybrid mannequin, constructing on prime of 1 or a number of EHRs. Every group’s particular wants are totally different, they usually could use their licensed platform from a UDHP associate to various levels.

Choice 3: “Dwelling-grown” cloud-first resolution

The ultimate choice that we’ll cowl on this publish 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 instantly inside cloud environments, leveraging cloud providers 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 publish.

The State of affairs: Ascension checks the entire containers for a big, complicated group.

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

Ascension’s Scope: Inpatient, outpatient, and all the things 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 Downside:

• Sufferers will not be conscious of “care contexts,” they count on a unified expertise.
• Ascension’s numerous set of EHRs and myriad of different methods weren’t tightly built-in
• No singular EHR nor operational system was an entire supply of reality
• There have been knowledge variations throughout methods that compound and exacerbate expertise inconsistencies throughout client digital touchpoints

The Answer:

• 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 offer knowledge on demand to digital functions
• A unified affected person expertise, “AscensionOne” was developed on prime of the EDSL to offer a singular place for sufferers to e-book visits, get care, handle their well being information, 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 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 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 moveable knowledge 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 knowledge and we work carefully with our EHR companions to make healthcare knowledge securely obtainable, simply discoverable, and comprehensible to the sufferers we serve.”

Summarizing the house grown choice:

Whereas this feature is just not the optimum selection 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 knowledge mapping and infrastructure optimization. We count on that the “homegrown” resolution might 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 counsel testing this cloud comparability cheat sheet from ByteByteGo. You possibly can rapidly see that the cloud platforms can deal with just about something you may throw at them in case you have the appropriate crew and budgets in place.

Trying forward

At present, AI and our better-than-ever {hardware} proceed decreasing obstacles to entry, and the necessity for UDHPs will rise as organizations improve their IT footprints. Selecting a platform to construct round is the vital resolution organizations ought to make as we speak. This platform resolution might be an integral part of organizations’ AI methods, which is a vital lever for brief time period competitors and long-term differentiation. There may be a whole lot of noise round AI implementation finest practices as we speak, 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 couple of years out, a extremely doable state of affairs is that by 2030, cloud-first implementations like Ascension’s might be commonplace not simply among the many prime 7 well being methods, 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 providers.

For the following cohort down in dimension in the identical interval, it’s extremely probably that EHR-complementing UDHPs might be licensed by the following prime 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 remaining frontier? Ideally, by 2030, we may even start seeing uptake in openEHR and open-syntax, cloud-first platforms in the US. Epic isn’t going wherever, but.

Vince Kuraitis JD/MBA is an impartial advisor with over 35 years’ expertise throughout 150+ healthcare & tech firms. 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 publish first appeared. The authors thank a number of colleagues for his or her assessment and commentary on an earlier draft of this publish: 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.