Which Platform of Platforms (UDHP) is Right for your Health System? A Market Analysis – The Health Care Blog

By NEIL JENNINGS & VINCE KURAITIS

This entry is a component 5 of 5 within the collection Platforming Healthcare — The Long View

In previous posts on this collection, now we have lined the definitions of Unified Digital Well being platforms and whether or not “EHRs can change into UDHPs.” On this follow-on publish, we’ll speak by means of the necessities for fulfillment for a UDHP and which forms of healthcare organizations are greatest fitted to which forms 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 business 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 should not all-or-nothing or mutually unique from EHRs. As we explored in our final publish, EHRs may increase into UDHPs. These EHRs as UDHPs (or the relative platform of platforms) often is the optimum selection for some market segments. EHRs can also be accommodated into cloud-first UHDPs.

Key Takeaway 4 / Guiding Criterion: This publish will deal with 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 now we have 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 sort 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 other ways UDHPs may 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 section, 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 complete 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 will 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 complete entities, their relative breakdown by measurement, estimates of annual income, and subsequent estimates of IT funds. We’re estimating typical IT budgets as being between 2-5%, based mostly on DefinitiveHealthcare and WittKieffer sources; we perceive that a couple of organizations are larger or decrease than this vary. The target, with out spending an excessive amount of time on the science undertaking, is to tough out IT budgets by section to align organizational assets and desires with the best-fitting UDHP.

Desk 1

United States Healthcare Segments: IT Price range 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 (Precedence Research), 15 (Ibisworld as of 2023), 16 – these corporations possible 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 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 couple of physicians to a whole bunch of hospitals spanning huge geographic areas, it shouldn’t shock anybody that the organizational wants will range tremendously.

Whereas the UDHP market remains to be in improvement, listed below 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 averted. The UDHP ought to “match” your group’s capabilities.

Price range & Employees

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

Straight correlated with funds is the dimensions of your IT crew. There are staffing ratio discussions, with business 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 (you probably have 5 clinicians and three help employees, you possible have a singular IT one who can also be an workplace supervisor), this can be a consideration for the medium to massive organizations. In case your complete crew measurement is restricted, including new applied sciences to handle in-house may be daunting. Employees and crew measurement 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 shall 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 will 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 improvement crew? A DevOps crew?

Organizational Wants

The complement to capabilities is the group’s present wants. Overbuilding or overinvesting isn’t the aim; the aim 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 right now’s digital-first world is complicated for all suppliers and practitioners, organizations function at totally different ranges of complexity based mostly 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 coming into hundreds of thousands of annual visits, each the number of interactions and the amount of interactions enhance. Along with the variety of individuals (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 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, dwelling 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 forms 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 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 means of massive ambulatory practices, which have distributed footprints and traditionally smaller IT budgets.

Geographic footprint is a serious 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 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 forms 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 overlook 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 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 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, personal 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 so as 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 data 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 linked methods.

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 understand that sufferers don’t wish to work together with separate care contexts, specialties, and amenities individually. As a substitute, they’re prioritizing unified affected person experiences (a element 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 essential, it additionally varies tremendously, relying on the idiosyncratic wants of every group. Nonetheless, there are some frequent themes and selections we are able to usually discern when reviewing a roadmap. We’ll body them as questions under:

• Is the group making an attempt to increase 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 right now (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 precise wants range by group measurement and complexity. Associated, not all implementations of UDHPs will should 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 methods already accommodate the complexity, sensitivity, and technical necessities for working in a regulated business. Among the main tailwinds, as lined in our earlier publish (“Can EHRs be Health System’s “Platform of Platforms” (UDHPS)) are as follows:

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

On account of funds constraints, the EHR often is the solely sensible UDHP possibility for a lot of organizations. Smaller practices and medical teams could have a single IT particular person, answerable for EHRs, {hardware}, software program, printers, fax machines, and the whole lot 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 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 funds, it is sensible 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 prospects want a accomplice 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 follow 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 comfortable to satisfy these organizations’ wants.

Epic’s Connect (previously often called Group Join), for instance, is a selected providing that allows massive well being methods to sublicense their Epic occasion, provisioning entry to regional hospitals or well being methods. Whereas this selection permits smaller healthcare organizations to leverage the advantages of Epic, the fee may 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 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 pricey, and a 2024 publish 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 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 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 change into possible if not obligatory. These massive hospitals and well being methods could start wanting past their EHR to satisfy their UDHP and platform-of-platforms wants. Why?

As highlighted within the earlier post:

• EHRs Carry a Lot of Baggage
• Prospects are Skeptical
• EHR Analytics Are NOT Optimized To Obtain Vital 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-Primarily based Platform

The final publish additionally shared a HIMSS research that confirmed that the common hospital had 16 EHRs in 2016. Whereas this quantity has possible consolidated down previously 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 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 the whole lot that well being methods 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 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 usually 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 places (usually on account of M&A)
4. M&As and rollups are nonetheless working rampant
   1. Mergers and acquisitions mix greater than market footprints and scientific 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 Hall:
      1. 72 complete 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 complete M&A transactions. That’s lots of technical complexity to wash up.

When it comes to licensing an outside-the-EHR platform, the primary post within the UDHP collection features a complete listing of attainable distributors, constructing from Gartner’s authentic list. We have now additionally highlighted in earlier posts that the license method isn’t 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 accomplice to various levels.

Possibility 3: “House-grown” cloud-first resolution

The ultimate possibility 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 companies from AWS, GCP, Azure, InterSystems, or others.

Beginning with a mini case research. We plan to additional expound upon Ascension’s work in a future publish.

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

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

Ascension’s Scope: Inpatient, outpatient, and the whole lot 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 Drawback:

• Sufferers should not conscious of “care contexts,” they anticipate 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 fact
• There have been knowledge variations throughout methods that compound and exacerbate expertise inconsistencies throughout shopper digital touchpoints

The Answer:

• Ascension created an “Enterprise Information Service Layer (EDSL),” mapping knowledge from a number of EHRs right into a unified, centralized FHIR schema to facilitate frictionless shopper entry to normalized and harmonized knowledge
  • 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 supply knowledge on demand to digital functions
• A unified affected person expertise, “AscensionOne” was developed on prime of the EDSL to supply 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 Information 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 inner platform. EDSL represents our dedication to assist form a future the place extremely interoperable and transportable knowledge is quickly accessible to all of our sufferers. To offer 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 out there, simply discoverable, and comprehensible to the sufferers we serve.”

Summarizing the house grown possibility:

Whereas this selection isn’t the optimum selection for all organizations, Ascension is paving a path that shall 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 anticipate that the “homegrown” resolution shall 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 trying out this cloud comparison cheat sheet from ByteByteGo. You’ll be able to rapidly see that the cloud platforms can deal with just about something you possibly can throw at them you probably have the appropriate crew and budgets in place.

Trying forward

At present, 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 essential determination organizations ought to make right now. This platform determination shall be an integral element of organizations’ AI methods, which is a vital lever for brief time period competitors and long-term differentiation. There’s lots 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 knowledge.

As we glance a couple of years out, a extremely attainable situation is that by 2030, cloud-first implementations like Ascension’s shall 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 companies.

For the subsequent cohort down in measurement in the identical interval, it’s extremely possible that EHR-complementing UDHPs shall be licensed by the subsequent 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 ultimate frontier? Ideally, by 2030, we will 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 impartial advisor 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 Blog, 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.