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 an element 5 of 5 within the collection Platforming Healthcare — The Long View

In previous posts on this collection, we’ve lined the definitions of Unified Digital Well being platforms and whether or not “EHRs can turn out to be UDHPs.” On this follow-on publish, we’ll speak by way 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 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 factors

Key Takeaway 3: UDHPs should not all-or-nothing or mutually unique from EHRs. As we explored in our final publish, 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 may additionally be accommodated into cloud-first UHDPs.

Key Takeaway 4 / Guiding Criterion: This publish will concentrate on US regional and native well being programs and outpatient teams of all sizes.

The Strategy: 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’ve 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 staff sizes by group kind 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 will 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 choice for every phase, based mostly 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 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 complete 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 may also 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 under illustrates the important thing segments as we outline them, together with the tough depend of complete entities, their relative breakdown by measurement, estimates of annual income, and subsequent estimates of IT price range. We’re estimating typical IT budgets as being between 2-5%, based mostly on DefinitiveHealthcare and WittKieffer sources; we perceive that just a few organizations are greater or decrease than this vary. The target, with out spending an excessive amount of time on the science mission, is to tough out IT budgets by phase to align organizational sources and wishes 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 (Precedence Research), 15 (Ibisworld as of 2023), 16 – these firms possible 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 large variance in IT spent throughout the healthcare continuum.

Supply: WittKieffer

Supply: WittKieffer

Defining Match: Segments (and their wants) Are Not Created Equal

Desk 1 above highlights the big selection of healthcare segments that make up the multi-trillion greenback US healthcare market. As these organizations vary from just a few physicians to tons of of hospitals spanning huge geographic areas, it mustn’t shock anybody that the organizational wants will differ tremendously.

Whereas the UDHP market continues to be in improvement, listed below are a few of our concerns 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 correct answer for the correct group ensures that wasted money and time are prevented. The UDHP ought to “match” your group’s capabilities.

Finances & Employees

Finances is an apparent place to begin, with the 2-5% of annual revenues offering clear constraints. A small observe with just a few hundred thousand {dollars} in annual IT price range shouldn’t be contemplating a multi-million greenback Epic set up, after all.

Straight correlated with price range is the dimensions of your IT staff. There are staffing ratio discussions, with trade customary 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 (when you’ve got 5 clinicians and three assist workers, you possible have a singular IT one who may additionally be an workplace supervisor), it is a consideration for the medium to massive organizations. In case your complete staff measurement is proscribed, including new applied sciences to handle in-house will be daunting. Employees and staff 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 also be an essential issue when figuring out the optimum UDHP implementation method. As that is immediately associated to the IT technique, we may also 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 functions, portals, and programs from scratch?
• Are present IT programs hosted domestically? Hybrid? On public clouds?
• Does the group have a improvement staff? A DevOps staff?

Organizational Wants

The complement to capabilities is the group’s present wants. Overbuilding or overinvesting is just not the purpose; the purpose is discovering the correct 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 this moment’s digital-first world is advanced 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 sophisticated wants. Because the variety of beds enters the hundreds, the variety of suppliers exceeds 2,000, and also you begin getting into thousands and thousands of annual visits, each the number of interactions and the amount of interactions improve. 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 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 direction of value-based care and risk-bearing fashions. As supplier organizations shift in direction of risk-bearing fashions, it’s typically 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 forth.)? 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 programs. 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 forms of borders, it will get much more sophisticated.

Geography is extra than simply technicalities associated to information sharing, licensure, and care supply: we can not overlook the folks 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 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 glad with care delivered of their most popular language. Anybody who has labored on an internationalization or localization effort for a product will perceive the complexity, however the implications of languages, regional variations and norms, are far reaching and can’t be underestimated. They increase past multi-language 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, 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 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 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 linked programs.

By way of expectations, whereas sufferers right this moment have extra management of their very own healthcare data, it’s nonetheless not sufficient. Main organizations understand 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 realize 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. Nevertheless, there are some frequent 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 increase or shrink the scope of its IT perform?
• 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 this moment (and notably excluded from roadmaps)?
• The place does organizational management have their sights targeted to extend effectivity, competitiveness, differentiation, and care high quality by way of IT efforts?

Defining UDHP Choices for Totally different Healthcare Segments

Whereas healthcare at-large wants UDHPs, the particular wants differ 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

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 publish (“Can EHRs be Health System’s “Platform of Platforms” (UDHPS)) are as follows:

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

On account of price range 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 individual, accountable for EHRs, {hardware}, software program, printers, fax machines, and every thing else. If IT budgets are beginning round $100,000 per yr, and EHRs could take as much as half of that, there isn’t budgetary or workers room for different programs. Elation calls out that the anticipated license value of an EHR per clinician is round $1,200 per yr; Folio3 shares the same quantity. That is earlier than upkeep, 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 price range, 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 clients want a companion that fills in gaps. athenaHealth’s athenaOne bundle 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 assist, to RCM and declare submission assist. Positioned as an “all-in-one observe answer,” 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 joyful to fulfill these organizations’ wants.

Epic’s Connect (previously generally known as Neighborhood Join), for instance, is a particular providing that permits massive well being programs to sublicense their Epic occasion, provisioning entry to regional hospitals or well being programs. Whereas this selection permits smaller healthcare organizations to leverage the advantages of Epic, the associated fee will be an order of magnitude greater than outpatient, license-based EHRs.

In 2024, OhioHealth Van Vert Hospital invested $12MM to transition to Epic by way of CareConnect. Leveraging the identical budgetary assumptions as above, if the EHR is ~50% of price range, and price range is ~2-5% of income, this 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 publish from Becker’s notes that prices could begin within the tens of thousands and thousands, however can attain a billion {dollars} or extra for bigger well being programs.

Because the IT budgets get bigger, technical groups improve in measurement 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 workers 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 the US), these choices begin to turn out to be possible if not vital. 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 post:

• EHRs Carry a Lot of Baggage
• Clients are Skeptical
• EHR Analytics Are NOT Optimized To Obtain Essential Well being System Targets
• EHR Switching Prices are Diminishing
• Cloud Native Platforms Speed up Innovation and Efficiency
• It’s Not in EHR DNA to Develop into A Broad-Based mostly Platform

The final publish additionally shared a HIMSS research that confirmed that the typical 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 this moment. 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 will be the best answer for bigger hospitals and enterprise well being programs.

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 thing 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 desire, 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 (typically 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 medical capabilities; in addition 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 entire image of the final decade+ shines mild onto the actual quantity of those transactions. From 2014 to 2024, there have been 933 complete M&A transactions. That’s a number of technical complexity to wash up.

By way of licensing an outside-the-EHR platform, the primary post within the UDHP collection features a complete listing of doable distributors, constructing from Gartner’s authentic list. We’ve got 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, and so they could use their licensed platform from a UDHP companion to various levels.

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

The ultimate choice that we’ll cowl on this publish 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 information platforms and UDHPs immediately 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 packing containers for a big, advanced group.

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

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

Ascension’s Employees: ~3,000 working in IT (per LinkedIn)

Ascension’s IT Footprint: Heterogenous, 18 EHRs, 40+ affected person portals

Want for differentiation / competitiveness: Excessive, each regionally and throughout the 16 states

The Drawback:

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

The Resolution:

• 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 absolutely adopted by all vendor companions, was made extra accessible utilizing REST APIs and a GraphQL orchestration layer to supply information 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 guide visits, get care, handle their well being data, 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 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 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 offer care to these most weak and in want, we attempt to be good stewards of their information and we work intently with our EHR companions to make healthcare information securely accessible, simply discoverable, and comprehensible to the sufferers we serve.”

Summarizing the house grown choice:

Whereas this selection is just not the optimum selection for all organizations, Ascension is paving a path that shall 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 information mapping and infrastructure optimization. We count on that the “homegrown” answer shall be extra attainable for the highest 50 or so well being programs within the subsequent few years. If there may be ever any doubt about what the cloud programs can do, we’d recommend 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 when you’ve got the correct staff and budgets in place.

Wanting forward

Right this moment, AI and our better-than-ever {hardware} proceed lowering obstacles to entry, and the necessity for UDHPs will rise as organizations improve their IT footprints. Selecting a platform to construct round is the essential determination organizations ought to make right this moment. This platform determination shall be an integral part of organizations’ AI methods, which is a necessary lever for brief time period competitors and long-term differentiation. There may be a number of noise round AI implementation greatest practices right this moment, 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 just a few years out, a extremely doable situation is that by 2030, cloud-first implementations like Ascension’s shall 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 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 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 workers and budgetary limitations of those smaller organizations.

What’s the ultimate frontier? Ideally, by 2030, we may also 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 unbiased advisor with over 35 years’ expertise throughout 150+ healthcare & tech firms. Neil Jennings is a options engineer on the well being care staff 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 evaluation 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.