HIMSS’19: What to Expect, What I Hope to Find
Next week, most of the healthcare IT industry will descend on Orlando to attend HIMSS’19. This is my 12th year attending HIMSS, an event for me that is more about networking and confirming assumptions than actually learning anything new.
For years now, HIMSS and the multitude of vendors exhibiting there have feasted at the trough of federal largesse ($35B plus), via the HITECH Act passed in 2008 to foster adoption of EHRs. The HITECH Act was successful, driving EHR adoption from the low teens to over 90% today. Though some may question the value of that investment, I personally believe that over time (another 7-10 years) we will reap benefits that far exceed that initial investment.
However, now that we’ve reached that level of adoption, the market has plateaued. Sure, there were hopes of a robust EHR replacement market, but that never materialized. Then there was the hope for huge gains (profits) to be made on the shift from volume to value through the sale of PHM solution suites. That didn’t pan out too well either as the fate of the ACA was left in the lurch with a change in administrations. Also, quite frankly, PHM is a complex sell, requiring significant change management that few healthcare organizations were ready to commit to and few vendors had the services to support.
The provider health IT market is going through a significant transition and it’s not going to be pretty. Clearly, the party is over and one has to wonder: Why does HIMSS continue to exist? Why are all these vendors here? Are we on the Titanic, seemingly blind to the economic icebergs that surround us?
But I digress.
What is important is that the EHR has become the central nervous system to provider organizations. Secondly, this market will continue to consolidate rapidly with few independent EHRs surviving the shakeout. Those left standing will attempt a number of different strategies to drive continued growth in a plateauing market.
It remains to be seen how successful these strategies will be but rest assured, even if successful, no EHR vendor is completely safe from a future acquisition.
This sets the stage for what to expect at HIMSS’19:
And what I hope to find at HIMSS’19:
May your trip to HIMSS’19 be a success, however you define it. And if you see us in the halls, do not hesitate to stop and say hello – maybe we’ll have a few quick on-the-fly notes to share.
Matt Guldin · 2 years ago
Liz Gavriel · 4 years ago
John Moore · 3 months ago
John Moore · 3 months ago
John Moore · 2 months ago
Walgreens ‘Front Door to Care’ Strategy is Building Horizontally
Last Tuesday, Microsoft and Walgreens announced a strategic partnership aimed at “transforming healthcare delivery,” including a commitment to a “multiyear research and development investment.” The partnership intends to create new care delivery models, retail innovations, next-generation health networks, integrated digital-physical experiences, and care management solutions.” Additionally, Walgreens will pilot 12 store-in-store “digital health corners” featuring “select health care-related hardware and devices” in 2019.
Through the partnership, Walgreens hopes to improve access to virtual care and other healthcare services, make better use of data with analytics in community settings, and to create personalized healthcare “experiences.” The goal is to improve patient health outcomes, lower overall healthcare costs, and better integrate IT between participants in the healthcare ecosystem. They plan to accomplish this via:
This consumer-focused platform sounds like it will be part of a larger ecosystem aimed at connecting consumers, providers, pharma manufacturers and payers supported by Microsoft’s cloud, AI and IoT technologies. Additionally, Walgreens will transition the majority of the company’s IT infrastructure to Microsoft Azure.
This and other partnerships (see Figure 1) are part of a larger strategy for Walgreens to be the new ‘front door to care’–bringing healthcare to where patients and customers want to receive it. Walgreens can make it easier for patients to access care since 75% of the United States population is within 10 minutes of a Walgreens.
The question now is whether Walgreens can scale its various partnerships quickly enough to contribute to satisfy investors or to attract payers and employers looking to drive cost savings.
Each partnership is different in terms of complexity and will scale at its own pace (see Figure 1). Some will begin to show more immediate results and some will require multiple years to be successful. Here are some of the key observations and unanswered question about the most recent announcement.
At the J.P. Morgan Health conference, management stated it has all of the healthcare services that Walgreens needs at this point through the various partnerships it formed over the past 18 months. The question is how quickly Walgreens can execute on them. Walgreens management stated the partnership with Humana has gone well, but it is still very early days, and the company can’t make projections about the scope of the rollout beyond the initial 2 locations in the Kansas City area. However, the positive results of the LabCorp partnership mean that it will expand to 600 stores over the next few years.
While customers may already see benefits from these partnerships, whether investors will have the patience to allow these partnerships to mature is an open question. Management has been under pressure to explain how these various partnerships will contribute to the companies’ financial performance.
Walgreens announced a new digital consumer platform, Find Care Now, last July to help consumers connect to an array of services offered by its provider partners, Walgreens-owned health services, and third-party providers including telehealth services (MDLive and DermatologistOnCall) and on-demand doctor house calls (Heal), where available.
Find Care Now will be hosted on Microsoft Azure with plans to enhance it with chronic disease management and more patient engagement apps. Whether the apps developed with Verily will be included is unclear. Walgreens plans to develop a separate B2B platform with Microsoft with services for payers and device manufacturers.
The overwhelming majority of Walgreens’ 370+ retail health clinics use Epic’s EHR. Announced in Nov. 2015, the rollout was fully completed in March 2017. Walgreens announced 14 new partnerships with healthcare systems, such as Advocate Health Care in Chicago and Swedish Medical Center in Seattle, in which the health system operates clinics inside Walgreens retail stores. These health systems hire the providers, oversee patient care, and bring in their own EHRs. The question is how, and more important if, Verily and Microsoft might work together with Epic to find synergies from the solutions each is creating with Walgreens.
Walgreens has a different strategy to its ‘front door to care’ model compared to Aetna-CVS and Walmart which relies upon a multiple ‘horizontal partnerships.’ The question now is whether Walgreens can scale its various partnerships, especially with Humana, quickly enough to contribute to satisfy investors looking for better financial performance or to attract payers and employers looking to drive cost savings.
Convergence & Divergence Among the Big Three EHR Vendors
This fall, the three largest EHR vendors by revenue, Allscripts, Cerner and Epic, held their user conferences. This research note provides an overview of each vendor’s strategic intent, areas of future focus and our assessment.
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Allscripts — Stabilize, then Proceed with Innovation
At the recent Allscripts Client Experience (ACE, #ACEHHS18) conference, the company gave us a day and a half deep dive into their current strategy and initiatives. As much as Allscripts positioned themselves as the innovative leader among the leading EHR vendors, the fundamental reality was far simpler. This is a company that is seeking to stabilize its base, and that is a good thing.
As most readers know, when CEO Paul Black took over the reins at Allscripts he had quite a mess on his hands. Previous management had grown the company through a series of acquisitions, but little attention was paid to how these various acquisitions would be stitched together to provide a comprehensive and cohesive EHR that extended from hospitals (acute) to small practices (ambulatory).
Clients were not happy, and Allscripts increasingly lost ground to both Cerner and Epic.
Under Black’s leadership losses have been stemmed, costs brought into alignment, and the bottom line has improved. Today, Allscripts has an acute to ambulatory EHR solution in Sunrise, which now represents roughly half of Allscripts’ annual revenue.
The company has also continued its acquisition strategy, picking up two other EHR platforms – McKesson’s EIS business (see our original take here) and Practice Fusion. While hearing little about Practice Fusion at this event – after all it was focused on Allscripts’s acute clients – we did hear from a number of former McKesson (Paragon) clients that they were quite happy to have Allscripts as their new parent. As one Paragon customer told me:
“We have been ignored for years. McKesson failed to address known problems with their software. At least now we have a voice and Allscripts is making progress.”
In another session with two Allscripts customers, each related their thorough evaluation and due diligence research of current acute care EHR solutions. Their conclusion: The EHR has become a commodity with comparable functionality across all major aspects that were important to them. Since EHR software is no longer a key differentiator, the relationship with the vendor and the need to minimize disruption to frontline users of the software become paramount. This is likely true across the industry and why the long purported EHR replacement market never materialized.
The EHR has become a commodity with comparable functionality across all major aspects that were important to them. Since EHR software is no longer a key differentiator, the relationship with the vendor and the need to minimize disruption to frontline users of the software become paramount.
In a brief conversation with Black, he was passionate in stating that he wants this company to be seen as the true innovator of the big three EHR vendors. He pointed to their precision medicine efforts with 2bPrecise, a young company started by the founders of HIE vendor dbMotion, a company Allscripts had acquired several years ago.
2bPrecise is now embedded within EHR Sunrise workflow and the company is working with six beta customers, including the Mayo Clinic. Today, Allscripts is the only EHR company that offers the physician the ability to match medication treatment protocols with a patient’s genomic information (e.g., how well a patient can metabolize a given medication) – pretty futuristic and promising work. But there is a fly in the ointment: who pays for this second order derivative to define patient-medication matching? No clear answers yet, though the move to value-based care (capitation) may provide accelerated adoption for certain, complicated diseases (behavioral health, cancer, etc.).
Another innovation they announced at ACE was allowing clinicians from within Sunrise to directly order (prescribe) a Lyft ride for a patient (original partnership announced in March). The use cases for such are numerous, from setting up an appointment (25% of low-income patients cite transportation as a leading cause of missed appointments) to taking a patient home upon discharge. Nice feature for both clinicians and patients.
The company has also been quite progressive on the patient engagement front, first with its vendor agnostic patient portal – FollowMyHealth and its recent acquisition of HealthGrid, a patient engagement tool based on texting.
Lastly, the company is in the process to move its core portfolio of products to a common client user interface (UI) based on progressive web architecture. This effort is in conjunction with their move to hosting their solutions on Microsoft’s Azure platform. Note: the move to hosted cloud services has taken the healthcare IT sector by storm. Three years ago, few CIOs were willing to go “off-prem.” Today, there is literally a tsunami of interest among CIOs looking to off-load the care and feeding of their EHRs and other applications.
The EHR market is dead in the U.S. To grow, one must either acquire other EHR vendors and leverage their maintenance revenues aggressively while cutting SG&A costs or look to the next generation of solutions and services the client base will need.
Allscripts has done a little of both but what concerns me most is their lack of a clear and compelling solution suite to support the migration to value-based care. Their messaging around population health (CareInMotion) was generic and this solution suite to support value-based care modalities still lags competing solutions. They are working to rectify these shortcomings, but they are slow in coming.
Their analytics story, quite surprisingly, was nowhere in evidence – little discussion during the sessions I attended nor highlighted in their product pavilion. Contrasting this with what I experienced this past week at Cerner’s own user conference, CHC, or at Epic’s UGM in late August, was striking.
The innovative efforts at Allscripts are heartening, especially those regarding patient engagement. Yet these efforts will not keep the lights on for most healthcare organizations as we migrate to data-driven care delivery models. The industry migration of clinical care from an art (little to no data) to a science (data-driven) is readily apparent – Allscripts’ own story on this, however, is currently not quite as clear.
Epic Looks to the Cosmos
At Epic’s recent UGM conference in Verona, WI, CEO Judy Faulkner painted a very big vision of the future – “One Virtual System Worldwide.” She was speaking to the Epic faithful on where Epic and its customers would travel next, a place in the cosmos leading to dramatic breakthroughs in clinical science by phenotyping the de-identified EHR data of all Epic clients.
A foundational element to that virtual system is a new platform, Cosmos. Cosmos is a hosted data warehouse built on Caboodle stack and will include a hosted version of Epic’s analytics toolset, Slicer-Dicer that researchers can use to explore the data. That would be incredibly cool as today there are about 200 million patients with health data in an Epic EHR.
But there may be a tear in the Cosmos. While this is a new release, today Epic has only convinced a small handful of customers to participate. Healthcare providers, particularly large academic medical centers, may be wary of submitting their data for others to use, even for research.
Just how open that virtual system Judy speaks of is to other, competing healthcare solutions is unclear. To Epic’s credit, over the last few years, they have opened up to a significant degree – at least relative to their past walled garden approach to the market. Today, over 100 third-party apps are now available within their App Orchard and a couple of hundred more are in the wings (for more on exactly what App Orchard can and cannot do, Chilmark recently profiled it in our report on health care app stores). The company is also aggressively looking to create a store for new ML/AI models. Today, over 200 clients have developed some 500+ models that work within Epic and that number grows daily.
The company has also made pretty strong headway on the interoperability front, exchanging some 3.5 million records daily – over a third from non-Epic EHRs. Saw numerous examples in presentations by Epic clients of their use of CareEverywhere to enable care coordination across a heterogeneous EHR network, commonly found among today’s Accountable Care Organizations (ACOs).
Epic C.O.O., Carl Dvorak’s keynote was far more pragmatic focusing on how organizations can derive greater ROI from their Epic EHR through benchmarking. Claiming to have over 700 benchmarks developed to date to measure anything from clinical workflows to an analyst’s use of Epic’s analytics tools, Carl provided some good examples of how an organization can improve workforce performance. With ever tightening margins for most healthcare organizations, this message was well-received.
One of the more curious aspects of UGM this year was the near total lack of discussion on the migration to value-based care. Listening to the Epic presentations, visiting the booths of their various modules, looking over the program guide, one was struck by the sheer dearth of attention to this increasing challenge for provider organizations. A provider CEO did confide to me that during the concurrent CEO forum, this topic was discussed at length. But one has to wonder why Epic chose to seemingly ignore this issue, especially for the rank and file users of Epic.
And despite Epic’s growing openness, it did not sit well with me some of the comments Epic executives made regarding patient access to their data via APIs from third-party apps e.g., Apple’s Health app. Epic’s position is that patients don’t necessarily understand the full ramifications of their data being used by others, via various apps, which may end up in nefarious hands.
Epic – let me make that call. Who has access to my health data is my decision, not yours. Your stance harkens back to old, paternalistic modalities in healthcare that are thankfully fading.
No enterprise software vendor is perfect, Epic is no exception, but at UGM one is always struck by the devotion of its users. This comes down to culture – Epic is a company that really does want to do the right thing, though competitors and others may bristle at what that right thing may be. This is best summed up in a conversation I had with an elderly gentleman from Denmark who is the CIO of one of its regional health systems. He stated quite simply:
“I’ve spent my whole life working in enterprise software. Epic is the first company I have ever worked with that truly wants to do the right thing for the customer – they really listen to our input(s).”
That alone is testament enough as to the continuing success of Epic. Will that sense of mission to do the right thing to improve clients’ success and in turn improve healthcare delivery extend beyond Judy’s tenure? Only time will tell, but I sure hope so.
Healthcare App Stores Moving to Mainstream
Update, 9/4/2018: This post was based on research conducted for the report, Healthcare App Stores: Status and Outlook, which is now available.
Apple’s early and fantastic success with its app store spawned imitators. App stores are a relatively new wrinkle in healthcare IT vendor’s approach to relationships aimed at better serving existing customers or finding new ones. Most major IT vendors to payers and providers have partnerships with other companies that provide complementary technology or services. These arrangements allow the partners to reach markets, users, or use cases that either vendor would find challenging on its own.
In the wider economy, successful app stores rely on a widely-accepted set of Web technologies. Chief among these are REST-style APIs offering programmers simple and uniform access to data and functionality across organizations and systems. REST APIs provide the data fuel that transformed consumer and enterprise apps. Most API programs are open in that documentation is available to anyone. Programmers can often use the APIs without any interaction with the API publisher. In other cases, they can use them after getting an API key, usually a simple online process while many API program sponsors monetize access at certain call volume thresholds. Health Level 7, the standards organization, created Fast Healthcare Interoperability Resources (FHIR) to enable modern, REST-style APIs that will be far less unwieldy for programmers than traditional HL7, IHE, or C-CDA APIs. The advent of FHIR-standard APIs and SMART’s use of OAuth supplies the crucial building blocks for effective app stores in healthcare.
While the challenges are daunting, the opportunity to improve healthcare is vast. Healthcare users are eager to discuss their unmet needs. Small and independent developers are eager to address these needs.
App stores facilitate the distribution of applications that add value to some base platform or brand. On the strength of the large volume and variety of data these companies collect for their HCO customers, the EHR is that platform. EHRs also have strong brand recognition among clinicians. The vast majority of HCOs lack the resources to develop their own applications, relying mostly on their EHR vendor for new and better functionality. Ironically, most EHR vendors recognize that they lack the resources or bandwidth to be the sole source for new and better functionality.
Other categories of companies could be the platform that establishes and hosts an app store. Payers and providers have the strongest brand name recognition with patients and their caregivers. Medical equipment vendors have large data volumes and established brands among healthcare workers that could provide visibility and attention from users. Companies that provide healthcare transaction or data services have amassed stupendous data volumes but remain mostly unknown to patients and are not top-of-mind for healthcare workers. In theory, any entity that holds large inventories of patient data or has a strong brand could sponsor an app store.
The technical potential already exists to access data or services from any combination of provider, payer, data aggregator, or another source. For now, the willingness to make such capabilities a reality is lacking, given that healthcare’s financial incentives almost demand that organizations hoard, monetize, or closely control the use of their data. While the challenges are daunting, the opportunity to improve healthcare is vast. Healthcare users are eager to discuss their unmet needs. Small and independent developers are eager to address these needs.
While better applications for clinicians and patients are a priority, the demand for more effective use of IT in healthcare is not limited by user category or use case. Some specific examples include:
The recent and widespread adoption of EHRs highlights the need to supplement or enhance the EHR itself. EHRs are not the only opportunity, since only a minority of the healthcare workforce uses an EHR regularly. The need to activate and engage patients with more effective applications is also important for most healthcare stakeholders. Patients have only ever known a disjointed “customer experience” with healthcare. Ideas such as convenience, price transparency, or predictability would never enter into the average patient’s expectations of interacting with any aspect of the healthcare system. But patients are beginning to expect a more conventional “consumer” experience with healthcare. The proliferation of high-deductible plans and rapidly increasing out-of-pocket costs could eventually produce a market or regulatory response that could impose a different approach and processes for consumers.
In theory, an app could discover patient data at multiple organizations using a network-based record location service’s APIs. It could access that data directly from as many organizations as the application and use case demand. It could match pertinent records using an API-accessible master patient index service. It could access workflow from yet another network-based service to support part or all of a patient encounter. This kind of orchestrated functionality using distributed data is increasingly commonplace in consumer and some enterprise apps where the application uses REST-based access to data and functionality from multiple organizations. Healthcare is years away from being able to deploy such a scenario, but many in HIT would like to see it become a reality.
We are preparing a report on the status and outlook of healthcare app stores. For now, EHR vendors have shown strong interest in investing to reach new markets, users, and use cases. Most vendors recruit third-party developers and companies into their developer programs outside of their clinician user base. Third-party experiences with EHR vendors such as Epic, Allscripts, and athenahealth have varied in terms of support, costs, and allowed functionality. This report not only inventories the ways that EHR vendors are expanding functional and organizational app coverage; it also looks at the outlook for some of the other potential app store platform hosts.
HIMSS18 – A Bipolar Experience
A decade of attending the annual HIMSS conference and I leave both excited and depressed. Excited and enthused by meeting so many people who are dedicating their lives to affect positive change by improving healthcare delivery through IT. Depressed as yet again I find a lack of real leadership and vision among many who repeat the years’ worn phrases of interoperability, patient-centered care, reducing physician burden, and the like.
“Oh please, can’t we just get on with it,” I scream to myself.
In keeping with the bipolar theme that is HIMSS, following are my takeaways, in an up-down fashion.
Up: Anthem goes public on its deal with Epic r/e HealthyPlanet. This partnership is an exciting step in enabling provider-payer convergence wherein Anthem will embed IP (risk, prior authorization, claims adjudication, etc.) into HealthyPlanet and take HealthyPlanet to market with wrap-around services.
Down: Head-in-the-sand vendors who are entrenched in FFS model. These vendors told me point blank that the market will revert back to FFS, that value based care is DOA. Gotta wonder what they’re smoking.
Up: Telehealth going mainstream. Saw loads of examples/demos of telehealth with direct or near-direct integration to the EHR. Been hearing about the coming of telehealth since I started this company in 2007. I believe we are finally there.
Down: Almost zero discussions on managing the costs of care/cost containment. There was some discussion on reducing clinical variability – but beyond that, HIMSS was devoid of any deep conversations on this critical variable in the value equation.
Up: Clear demonstrable, scalable use cases for AI. I was particularly impressed with the work 3M has done with Verily, leveraging Deep Mind technology for specific measures. Though just released, 3M has already landed 17 provider clients and 2 payers.
Down: The preponderance of AI vendors with little sense of scaling their solution. Many of the AI vendors I talked to have ongoing projects with “Big Brand” healthcare systems. That’s great – but disturbingly, few have taken the next step to address how they plan to scale their solution within an organization for widespread adoption and use.
Up: New solutions leveraging FHIR to insert actionable insights directly into clinical workflows. This is near nirvana for me, as it gets beyond the Herculean task of interoperability writ-large and tackles those points where significant friction and opportunity exists.
Down: One policy pundit after another talks yet again about the need for interoperability. Frankly, this is no longer a technical issue. Interoperability is a policy issue and really does not belong at an event such as HIMSS – where we should be talking about the future, not rehashing the past ad nauseum.
Clearly, a lot of work lays ahead for us in the health IT arena, which provides us all meaningful work going forward. And frankly, we are in but the top of the third inning – there is so much to do, it really is an amazing time to be in the healthcare IT market.
Thankfully, we are at last moving beyond the prescriptive use of IT via meaningful use, transitioning to meaningful insights from the data we are collecting and placing into clinical workflows. There is a near unfathomable opportunity to begin leveraging clinical, genomic, and other data sets that will lead us to dramatic improvements in care delivery – improvements that are likely beyond our comprehension at this time.
Despite some of my downer moments at HIMSS18, I could not be more excited for what the future holds for us as an industry – and, personally, in how even I and my care team will leverage new insights to more effectively and efficiently manage my own condition.
What We’ve Been Commenting On
Lately, there have been quite a few big developments in healthcare, including Allscripts acquiring Practice Fusion, Apple’s PHR, and the mysterious Amazon-JP Morgan Chase-Berkshire Hathaway healthcare company. Not all of these developments have enough detail yet for Chilmark to analyze the impact on the future of the health IT market in-depth, but we are commenting elsewhere on the wider possibilities for the healthcare industry.
Blockbuster digital health funding to spill to 2018
Brian Eastwood in HealthcareDive
“’We think next year is when we’ll begin to see [predictive analytics] go beyond simply accounting for and noting social determinants of health and barriers to care and start to use that information to inform care plan decisions,’ Eastwood said. Vendors able to adequately take this on will emerge as key players in the care management and population health markets as the year progresses, he added.”
Health IT eyes M&A as market grows up
Ken Kleinberg in HealthcareDive
“The EHR market is saturated [and] consolidation is very clear…The movement to analytics and population care, that’s where the action is now,” Kleinberg said. “There’s a tremendous amount of innovation still possible.”
Apple debuts medical records on iPhone
Brian Eastwood in HealthcareDive
“Apple is widely accepted as understanding the user experience,” Eastwood said. “If all of the sudden, a substantial chunk of the population has the capability to tap into a patient portal in a way they haven’t before, then it could be a gamechanger.
Why AI tools are critical to enabling a Learning Health System
Ken Kleinberg in HealthcareIT News
“The Learning Health Systems continually improve by collecting data and processing it to inform better decision making. As the amount and complexity of big data continues to increase, organizations are challenged to fully take advantage of it,” said Kleinberg. “AI systems are particularly suited to analyze huge data sets to discover meaningful and actionable insights, and even to carry out actions.”
Apple steps into Epic System’s arena with medical records iPhone app
Brian Eastwood in The Capital Times
“(Health record companies) will still be building their core products,” said Eastwood. “They’ll still be maintaining the records…[Regarding rumors of Apple or Amazon creating EHRs], right now, it’s still a little bit in the realm of fantasy.”
How Amazon, JPM and Berkshire could disrupt healthcare (or not)Health IT eyes M&A as market grows up
John Moore in HealthcareDive
“‘I’m not holding my breath for big changes,’ Moore said. Instead, he expects incremental change are more likely over the next three to five years.”
Will Amazon’s push into health care impact Epic Systems’ future?
Ken Kleinberg in The Capital Times
“Software to power the applications for health care providers come predominantly from a few large players like Epic and Cerner,” Kleinberg wrote. “It’s a great question to ask to what degree they can take their provider and software application expertise and apply it to the needs of payers.”