By NEIL JENNINGS & VINCE KURAITIS

This entry is an element 5 of 5 within the sequence Platforming Healthcare — The Lengthy View

In earlier posts on this sequence, we’ve got lined 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 discuss by way of the necessities for achievement for a UDHP and which varieties of healthcare organizations are finest fitted 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 beneficial properties

Key Takeaway 3: UDHPs aren’t 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) stands out as the optimum selection for some market segments. EHRs can also be accommodated into cloud-first UHDPs.

Key Takeaway 4 / Guiding Criterion: This submit will concentrate on US regional and native well being programs 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’ve got described the panorama, we’ll name out the important thing segments (group sorts, sizes, and profiles) that we are going to be evaluating.
• At this level, we’ll approximate IT budgets and IT workforce sizes by group sort to find out capabilities of constructing versus relying on companions and distributors.
• Then, we’ll overview the constraints for implementation and possession, outlining the drivers of UDHP match.
• Subsequent, we’ll break down the alternative ways UDHPs might 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 overall US healthcare medical expenditure, totaling ~$4.9 trillion.

Whereas the overall 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 drugs as an alternative of acute, reactive drugs. As the necessity for UDHPs applies to greater than inpatient hospitals, we can even overview the opposite segments highlighted within the pie chart, together with: outpatient clinics and observe teams, and “different well being” containing providers 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 rely of whole entities, their relative breakdown by dimension, estimates of annual income, and subsequent estimates of IT funds. We’re estimating typical IT budgets as being between 2-5%, primarily based on DefinitiveHealthcare and WittKieffer sources; we perceive that just a few 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 sources and desires with the best-fitting UDHP.

Desk 1

United States Healthcare Segments: IT Finances Evaluation

1 (AHA – 1957 (unaffiliated) + 227 (small programs)), 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 doubtless 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 concerning 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 wide selection of healthcare segments that make up the multi-trillion greenback US healthcare market. As these organizations vary from just a few physicians to a whole lot of hospitals spanning huge geographic areas, it mustn’t shock anybody that the organizational wants will range tremendously.

Whereas the UDHP market continues to be in improvement, listed below 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 appropriate resolution for the appropriate group ensures that wasted money and time are averted. 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 observe with just a few hundred thousand {dollars} in annual IT funds shouldn’t be contemplating a multi-million greenback Epic set up, in fact.

Instantly correlated with funds is the scale of your IT workforce. There are staffing ratio discussions, with trade commonplace really helpful 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 (when you have 5 clinicians and three assist employees, you doubtless have a singular IT one that can also be an workplace supervisor), this can be a consideration for the medium to massive organizations. In case your whole workforce dimension is proscribed, including new applied sciences to handle in-house might be daunting. Workers and workforce dimension 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 will probably be applied and maintained.

Present IT Footprint

The group’s present technical footprint can be an essential issue when figuring out the optimum UDHP implementation method. As that is instantly associated to the IT technique, we can even body this part as some high-level guiding questions:

• What are the core programs 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 preserve purposes, portals, and programs from scratch?
• Are present IT programs hosted domestically? Hybrid? On public clouds?
• Does the group have a improvement workforce? A DevOps workforce?

Organizational Wants

The complement to capabilities is the group’s present wants. Overbuilding or overinvesting shouldn’t be the aim; the aim is discovering the appropriate 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 right now’s digital-first world is advanced 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 sophisticated wants. Because the variety of beds enters the 1000’s, 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 places 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 major drugs? Or, are there specialty teams? Is there a mixture of acuity settings? Does the group have pressing care, emergency drugs, 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 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 operating 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 sophisticated than conventional fee-for-service care fashions. This shift has expanded past enterprise well being programs 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, nations (Canadian presence), or different geos (tribal nations, US territories, and so on.)? As organizations increase 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 should be accommodated in EHRs and different programs. That is all on prime of the necessity for referral networks, reference labs, pharmacies, and native well being data 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 sophisticated.

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 massive well being programs and nationwide healthcare suppliers face, and there are a myriad of research exhibiting 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 increase past multi-language assist, 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, personal fairness rollups, regulatory adjustments, and the fixed want for extra patient-centric care – the market and opponents 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 change or owned wholly internally, this method depends on IT infrastructure to securely retailer, course of, safe, and dealer knowledge to related programs.

When it comes to expectations, whereas sufferers right now have extra management of their very own healthcare information, it’s nonetheless not sufficient. Main organizations notice that sufferers don’t need to work together with separate care contexts, specialties, and amenities individually. As a substitute, 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 essential, it additionally varies tremendously, relying on the idiosyncratic wants of every group. Nonetheless, there are some frequent themes and choices we will usually discern when reviewing a roadmap. We’ll body them as questions beneath:

• Is the group attempting to increase or shrink the scope of its IT perform?
• Is there a robust choice 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 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 should be the identical, and we see three major 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 programs already accommodate the complexity, sensitivity, and technical necessities for working in a regulated trade. A number of 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 the moment Personal the Buyer Relationship
• Many Prospects Have an “EHR-First” Desire for New Purposes
• Epic and Oracle Well being are Making Sturdy Actions Towards Changing into UDHPs

On account of funds constraints, the EHR stands out as the solely sensible UDHP possibility for a lot of organizations. Smaller practices and medical teams could have a single IT individual, chargeable for EHRs, {hardware}, software program, printers, fax machines, and all the things 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 programs. Elation calls out that the anticipated license price of an EHR per clinician is round $1,200 per yr; Folio3 shares the same quantity. That is earlier than upkeep, assist, 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 funds, 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 accomplice 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 assist, to RCM and declare submission assist. Positioned as an “all-in-one observe 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 programs, IT budgets get bigger as income grows and care contexts get extra sophisticated. 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 pleased to fulfill these organizations’ wants.

Epic’s Join (previously referred to as Group Join), for instance, is a selected providing that allows massive well being programs to sublicense their Epic occasion, provisioning entry to regional hospitals or well being programs. Whereas this feature permits smaller healthcare organizations to leverage the advantages of Epic, the fee might 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 funds, and funds 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 dear, 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 programs.

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 adequate IT budgets and employees to architect, construct, and handle their very own system. However, for big well being programs with greater than a billion {dollars} in annual income (estimated at ~175 or so in america), these choices begin to turn out to be possible if not obligatory. These massive hospitals and well being programs could start trying 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
• Prospects are Skeptical
• EHR Analytics Are NOT Optimized To Obtain Vital Well being System Aims
• EHR Switching Prices are Diminishing
• Cloud Native Platforms Speed up Innovation and Efficiency
• It’s Not in EHR DNA to Turn into A Broad-Based mostly Platform

The final submit additionally shared a HIMSS examine that confirmed that the common hospital had 16 EHRs in 2016. Whereas this quantity has doubtless consolidated down prior 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’ll spotlight 4 further, complementary factors as to why an outside-the-EHR UDHP might be the perfect resolution for bigger hospitals and enterprise well being programs.

There are 4 major 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 programs 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 choice, or different causes, some well being programs nonetheless use a combined EHR footprint.
   2. This presents in several 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 programs at distinct places (usually as a consequence 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 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 could not appear that prime in a vacuum, the overall 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 lots of technical complexity to scrub up.

When it comes to licensing an outside-the-EHR platform, the primary submit within the UDHP sequence features a complete listing of doable distributors, constructing from Gartner’s authentic listing. Now we have additionally highlighted in earlier posts that the license method shouldn’t be 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, and so they could use their licensed platform from a UDHP accomplice 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 programs, and certain restricted to the highest 15-20 programs as a consequence of complexity, expense, and staffing necessities. Progressing past the cloud and platform vendor partnerships talked about above, these programs 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 submit.

The State of affairs: Ascension checks all the bins 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 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 aren’t conscious of “care contexts,” they count on a unified expertise.
• Ascension’s various set of EHRs and myriad of different programs weren’t tightly built-in
• No singular EHR nor operational system was a whole supply of fact
• There have been knowledge variations throughout programs 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 purposes
• 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 yr, 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 pacesetter 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 inner 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 susceptible 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 comply with. 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 programs within the subsequent few years. If there’s ever any doubt about what the cloud programs can do, we’d counsel testing this cloud comparability cheat sheet from ByteByteGo. You may shortly see that the cloud platforms can deal with just about something you’ll be able to throw at them when you have the appropriate workforce and budgets in place.

Wanting forward

As we speak, 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 essential choice organizations ought to make right now. This platform choice will probably 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 lots of noise round AI implementation finest practices right now, 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 just a few 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 prime 7 well being programs, 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 doubtless that EHR-complementing UDHPs will probably be licensed by the following prime 150 well being programs and hospitals. These already cloud-first programs will play properly with cloud-hosted EHR programs and supply entry to cloud advantages not attainable as a consequence of employees and budgetary limitations of those smaller organizations.

What’s the remaining frontier? Ideally, by 2030, we can even start seeing uptake in openEHR and open-syntax, cloud-first platforms in america. 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 workforce 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 overview 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.