Tag Archives: Australia

SPI Digital Health: Western Australia and Tasmania Begin their State-Wide EMR Journeys

Following in the footsteps of other Australian states, Tasmania and Western Australia (WA) recently provided details of their plans to implement state-wide electronic medical records (EMRs) for the first time. 

Earlier this month, the WA government said an A$100M (US$65M), first phase state-wide hospital EMR rollout would include a digital medical record with single sign-on technology and virtual desktop infrastructure at around 80 public hospitals.  

This first phase is part of an A$1.2B (US$782M) digital infrastructure and public hospital capacity upgrade programme in Western Australia. There is, at this stage, no indication of when the first phase contract will go out to tender or be awarded. 

WA’s announcement comes weeks after Tasmania issued a request for proposals (RFPs) for its first state-wide EMR and ambulance electronic patient record. The A$150M (US$97.8M) first phase will, the state government said, be rolled out over four years. It is part of an A$475M ($309.6M), decade-long digital health programme on the island. 

The Signify View 

It was only a matter of time before WA and Tasmania embarked on their journeys towards state-wide EMRs. Signify Research described in this recent Insight how the move to state-wide contracts was shaping the Australian EHR market in 2023, and confirmation that these states are now moving forward reinforces our view. 

The seeds of WA’s EMR plans were sown in 2019 when the state government published its digital strategy vision. A state-wide EMR lay at the heart of this vision, and the state government has set a July 2029 target to have a ‘functional’ system in place. Implementation will take place in four phases, although it is unclear at this stage when vendors will be invited to submit requests for proposals (RFPs) for the first phase contract. 

Tasmania’s story is similar in many ways. The government in Australia’s second-smallest state published its digital health transformation strategy 18 months ago and, as in WA, a state-wide EMR is a central pillar of this. Tasmania, however, has higher aims: it sees an EMR as being the key to creating the first fully-integrated healthcare system in Australia. 

Land of Opportunity 

Tasmania’s goal to establish the country’s first fully-integrated healthcare system is bold but viable. The state’s current system is rudimentary, with most health record inputs still done manually. There is no installed EMR base on the island, although there is a basic patient database that was implemented more than a decade ago by iSOFT (which later became CSC, DXC and now Dedalus). Tasmania has just four large state hospitals, 14 regional hospitals, seven private hospitals and 144 primary care practices with fewer than 1,000 GPs in total. 

Contrast this with other, much more populous states in Australia, like New South Wales and Victoria, which have various iterations of EMR systems spanning more than a decade in some cases. In Tasmania, with a population of little more than half a million, putting in place a system that seamlessly connects hospital and primary care EMRs should therefore be relatively achievable. But, as state-wide EMR deployments in other Australian states have demonstrated, there are clear challenges. 

Inflation’s Curse 

One immediate challenge facing both WA and Tasmanian rollouts is inflation, which ran at 7% for the year to March. Although it is starting to ease, inflation will impact project budgets, scopes and vendor margins. A$100M (US$65M) in WA and A$150M (US$97.8M) in Tasmania will not stretch far in the current high inflation environment and, in other state-wide deployments elsewhere in Australia, funding top-ups have been needed.  

In WA, another challenge is its sheer geographical size. It is the country’s largest state by some distance, and so state-wide EMR implementation in often remote hospitals presents immediate logistical hurdles. Once the EMR is in place, providers in WA face the additional challenges of patient engagement, especially in remote communities that lack good communications networks. 

Muscle Flexing 

Despite their relatively modest value, the contracts in WA and Tasmania will be seen as another good opportunity for international vendors to flex their muscles and experience on state-wide programmes. In WA we’d expect to see the usual cast of contenders to include Epic, Oracle Cerner, Altera, and, InterSystems and MEDITECH, all of whom have experience (both good and bad) on Australian state-wide contracts. These names will probably also be in the frame in Tasmania, but there could also be interest from Telstra, in partnership with Alcidion, a UK-based data aggregator and Dedalus, which also has a sizeable Australian footprint. 

Any involvement by Telstra would be significant in the sense that Australia’s leading EHR vendor (by revenue) has never been involved on a state-wide contract, focusing instead on individual hospital, ambulatory and long-term care markets in Australia where it is the undisputed market leader. Given Tasmania’s goal to create Australia’s first fully-integrated system, and without the ‘baggage’ of legacy EMR systems in other states, Telstra might see this a good opportunity, particularly with its portfolio of integrated care and PHM offerings. 

Among the other vendors who will be competing in both WA and Tasmania, Oracle Cerner may feel it has a point to prove, having lost out last November to arch-rival Epic on a massive triple-digit-million dollar contract in New South Wales. This 220-hospital contract includes the replacement of nine legacy Cerner and Orion Health EMRs and six Cerner and Dedalus (legacy DXC) patient administration systems. Oracle also lost out to Altera in Victoria on a large health information exchange (HIE) project. 

Signify Research stated last month how Altera would need to leverage its position in both Victoria and South Australia (where it is rolling out its Sunrise EMR and PAS solutions) to grow its business elsewhere in the country. WA and Tasmania could be a route forward, 12 long years after winning its Sunrise EMR deal in South Australia. 

InterSystems, which is delivering the first phase of its A$259M Acacia EHR system state-wide in the Northern Territories is also competitively placed on the two new state contracts up for grabs. 

The principal challenge for all vendors in Australia is how to compete with Epic, which continues to gain share in the country at others’ expense. While winning the big New South Wales contract from Oracle Cerner is arguably Epic’s most audacious move in Australia, there are also parallels between Tasmania and its state-wide contract in the Australian Capital Territory (ACT). Like Tasmania, ACT is relatively small in size and population, and at A$151M the contract size is similar to Tasmania. It is reasonable to assume Epic will be in the running both here and in WA. 

Death Knell? 

Although there has been no state-wide EMR procurement in WA or Tasmania until now, there has been intense competition to win new EHR contracts in both states, particularly as hospitals build on the functionality of legacy PAS solutions. EMRs have been procured via individual contracts with hospitals and local health networks. A different set of vendors tend to compete for these smaller acute contracts. For example, Telstra Health, Altera (specifically via its Australian-acquired operation Core Medical Solutions), InterSystems, InfoMedix and Alcidion. In the move to state-wide EMRs in WA and Tasmania, smaller vendors could be left out in the cold unless they partner up (e g like Telstra and Alcidion), particularly in the public hospital market (there will still be opportunity in the private market). 

Greenfield Opportunities 

By global standards, Australia is a relatively small, yet mature EHR market, where administrative and operational EHR implementations are advanced, and a transition to clinical systems and data integration and information sharing is now driving growth. 

The fact that WA and Tasmania are only now moving to state-wide contracts is a bit of a throwback to several years ago when the first state-wide EMRs were being established in other states. International vendors have not found state-wide implementations easy given integration and localisation challenges, but these experiences will be valuable now. Telstra, too, may feel it is time to flex its muscles and local knowledge for the first time on state-wide implementations, with Tasmania the obvious option.

SPI Digital Health: Ask the Analyst: Oceania EHR Market in 2023

Signify Research will publish its latest Oceania EHR Market Assessment later this month. The report, authored by Senior Analyst Arun Gill, will analyse major developments and trends in a market that generated over $500M in revenues in 2022, a figure that is projected to approach $800M in 2027 (see chart below). This is a moderately faster growth rate than we had forecast in the 2021 iteration of the report. 

EMR/EHR Market Revenues: Oceania 

“By global standards, Oceania is a small yet mature EHR market,” says Gill. “Administrative and operational EHR solution implementations are advanced, and a transition to clinical systems and data integration and information sharing now drives growth. 

“While Australia is the epicentre of activity, it is in the much smaller market of New Zealand that some of the biggest impacts are happening – not least a four-year, NZ$385M scheme to build new healthcare data systems and digital infrastructure,” he adds. 

The Signify View 

Gill points out that the move towards state- and region-wide contracts, along with some key acquisitions, are shaping the Oceania EHR market in 2023.  

“Only this month Altera started implementing its dbMotion Health Information Exchange (HIE) solution across Victoria, part of a wider five-year digital health programme being undertaken by the Australian state,” he explains. 

Under the HIE rollout, dbMotion will initially offer a complete view of patient public pathology reports. There will be an option to expand it to enable other clinical information to be shared at point of care, at a later date.  

Conspicuous Absence 

One of the most striking aspects of Signify Research’s Oceania EHR Market Assessment, Gill notes, is that Telstra – the leading EHR vendor in Australia by revenue – is absent from regional EMR contracts. With home field advantage, it enjoys a strong installed base only in national, individual hospital, ambulatory and long-term care EMR sectors of the market. A position it has solidified over the years via acquisition, such as of MedicalDirector, the market leader in primary care it acquired in 2021. 

But Epic, Oracle Cerner, Altera, Orion Health and InterSystems increasingly find Australian state-wide contracts to be fertile territory.  

Epic moved into this space in July 2020, securing the first state-wide contract issued by Australian Capital Territory (ACT) Health, worth A$151M. The contract is for Epic’s Digital Health Record solution (a suite of products including the Epic Beaker lab information system, Epic Radiant radiology information system, and its Patient Administration System (PAS)). The ACT government recently provided a further A$50M top-up funding to the project, with go-live completed at 45 ACT sites last November.  

Also in November 2022, Epic beat Oracle Cerner to the southern hemisphere’s largest-ever EHR contract covering 220 hospitals and eight million patients in New South Wales (NSW). Under the triple-digit million-dollar deal, Epic will unify core clinical and laboratory information systems (LISs) in a single digital patient record. In doing so, it will replace nine EMRs (Cerner and Orion Health), six PASs (Cerner and Dedalus (legacy DXC)) and five pathology LISs (Citadel and Integrated Software Solutions). 

Competitive Landscape 

“Epic’s dominance is almost a sideshow to the fight for market share taking place below,” Gill says. 

“Oracle Cerner will be smarting from losing out to Epic on the big NSW deal, and to Altera on the Victoria HIE contract, and also the fact it has ceded overall Australian market leadership to Telstra.  

“It will be banking on the benefits of Oracle’s USD$28B acquisition of Cerner in 2022 kicking in soon down under.” 

The vendor continues to make heavy weather of an A$412M ieMR implementation in Queensland, awarded in 2011 but paused in 2019 with a 42% funding shortfall. It was not until June 2022 that the Queensland government injected a further A$300M to re-start and roll the project out over the next five years.  

Gill points out that Altera is another vendor with an uncertain near- to medium-term outlook in Oceania.  

“Harris Computer Corporation’s $700M acquisition of Allscripts’ acute portfolio and parts of its ambulatory portfolio in 2022 (leading to the creation of Altera) has not soothed concerns over Altera’s future direction globally. 

It is, however, making good headway on Australian state contracts. As well as its Victoria HIE launch this month, late last year the vendor completed rollout of dbMotion in emergency departments across Victoria’s Gippsland Health Alliance. Over the next two years, rollout of its Sunrise EMR and PAS solutions will also be initiated across South Australia’s large regional hospitals and local health networks but, like other state-wide contracts in Australia, this scheme has also been beset by delays and funding deficits since being awarded a long 12 years ago. The challenge now for Altera will be leveraging its position in Victoria and South Australia to grow its business across the country. The more recent success in Victoria indicates that dbMotion is suited to the Australian HIE market and is well positioned to win in future contracts. The fact it has been 12 years since the South Australia deal was awarded suggests similar contracts for Sunrise may be the bigger challenge.    

Continuing with the state-wide theme in Australia, InterSystems went live with the first phase implementation of an A$259M state-wide ‘Acacia’ EHR last August at Katherine Hospital in the Northern Territories. This was followed in January 2023 with a second phase implementation at Gove Hospital in the same state. Four further hospital rollouts are due in the state over the next few years. 

Gill says that, in terms of Telstra Health, it comes into its own in individual hospital, ambulatory and long-term care markets, is present in more than 100 public and private hospitals and acquired MedicalDirector for A$350M in August 2021. The latter deal is, he says, part of Telstra’s broader strategic goal of becoming the leading EHR vendor in Australia across all care settings, by building a cloud-based infrastructure that facilitates interoperability.  

Underwhelming Record 

Signify Research’s Oceania EHR Market Assessment 2023 also picks up on ongoing problems with Australia’s national patient EHR system project. My Health Record was launched 11 years ago but, despite being subject to $2B-worth of investment, less than three million of the 23 million people who opted-in to the service accessed it in 2020-21. In mid-2021 the Australian Digital Health Agency, keen to address complaints by both the public (who couldn’t easily access their information) and GPs (who were having difficulty uploading and finding vital details such as pathology results and diagnostic tests), appointed Deloitte to build a new health information API gateway to replace the existing Oracle gateway. EHRs used elsewhere in Australia must now meet various interoperability standards for data to be shared with the national EHR, but uptake of My Health Record remains weak. 

New Zealand 

Like Australia, the trend in New Zealand is towards regional deployments as well as integrated care and Gill states that the implementation of a three-phase national health information platform is a major market driver. Launched in 2016, paused and ‘rebranded’ as Hira in 2019, the system aims to establish a data and digital services ecosystem to enable access to a virtual EHR by 2026. In 2021 Hira received NZ$385M, the first of three tranches of funding expected to be complete by mid-2024. The 2022 state budget then allocated a further $320M, part of which will support the second Hira tranche. 

Confirming the regional theme, four New Zealand regions are implementing EHR solutions, in which US vendor InterSystems is playing a leading role. It completed a first phase go-live PAS implementation with private hospital group MercyAscot in 2021, and a planned second phase (clinical EMR) was implemented at the end of that year. In January 2022 it began implementing its TrakCare cloud PAS at Auckland District Health Board (DHB) – one of the country’s 20 DHBs. Responsibility for providing or funding district healthcare services shifted from DHBs to the Te Whatu Ora – Health New Zealand agency in July last year.   

Epic, so dominant in Australia, was the chosen supplier for the Northern Region’s Regional Collaborative Community Care (RCCC) integrated care tender. However, integration issues stalled the project in January 2022. A new tender was issued and awarded to Aceso (Pinga platform) last December. 

Oracle Cerner, Epic’s traditional rival, also lacks a significant presence in New Zealand, but Oracle’s close partnership with PwC should help the healthcare business establish a local footprint in time. 

Positive Prognosis 

Given a total 8% CAGR to 2027, Oceania is a small yet opportune market, says Gill.  

“In Australia, unseating Epic will be a major challenge, given Oracle Cerner’s distractions in other markets and local player Telstra’s focus away from region-wide contracts,” he adds. 

“The playing field is more level in New Zealand, where a reorganisation of the health system and significant funding being allocated to digital health initiatives should keep vendors other than Epic on their toes and interested in opportunities,” Gill concludes. 

Signify Premium Insight: Annalise.ai, Fujifilm and the Perils of Living on the Edge

This Insight is part of your subscription to Signify Premium Insights – Medical Imaging. This content is only available to individuals with an active account for this paid-for service and is the copyright of Signify Research. Content cannot be shared or distributed to non-subscribers or other third parties without express written consent from Signify Research. To view other recent Premium Insights that are part of the service please click here.

Co-written by Dr Sanjay Parekh & Bhvita Jani

Earlier this month Australian AI vendor Annalise.ai announced that it had partnered with Fujifilm Australia to offer its CXR Edge solution on the Japanese vendor’s portable and stationary X-ray machines.

The move will enable Fujifilm to distribute versions of Annalise’s comprehensive decision support solutions that are made to be embedded on medical imaging hardware in Australia, as well as in other select markets such as New Zealand, the United Kingdom and India.  Two variants of Annalise’s CXR Edge software will be available to healthcare providers. One, CXR Edge Comprehensive, can detect 95 clinical findings and is designed for use in inpatient, outpatient, and emergency settings. The second, Annalise CXR Edge Critical Care detects 35 findings, and is designed to be used in trauma, emergency, and intensive care settings.

The Signify View

Time is the enemy when it comes to many medical conditions. As such there is a great premium placed on devices and technologies which can save clinicians time and allow patients to be treated more quickly. While efficiency is an important consideration for all X-ray exams, it is often most important for those conducted using mobile systems, which are frequently used in emergency rooms and in other trauma settings. In these situations, doctors need to be alerted to time-critical conditions (e.g., pneumothorax) quickly, so embedding an AI solution to identify these conditions directly on the modality makes sense. In doing so, possible bottlenecks stemming from processing delays or network reliability issues are sidestepped, allowing doctors to see the results of the AI seconds after acquisition. What’s more, embedding AI tools on the modality itself also avoids the requirement for any additional IT infrastructure (e.g., dedicated servers), a factor that could be particularly beneficial in some emerging markets such as India in which Fujifilm has a strong presence.

Fujifilm is not the first medical imaging vendor to take this approach, GE Healthcare, for example originally released its Critical Care Suite in 2019 which also embedded medical imaging AI on the device. The key difference however are the tools’ remits. GE’s Clinical Care Suite is focused only a smaller number of findings (endotracheal tube placement, pneumothorax triage, quality assurance tools), while the Fujifilm and Annalise combination addresses up to 95 findings. This could prove far more attractive to providers. Mobile x-ray systems are often not dedicated to one specific department, instead being used for multi-disciplinary purposes amongst different clinical applications. Offering a wider range of solutions could therefore be a competitive advantage. This is especially true given the challenge of embedding multiple solutions from multiple vendors on the same device. It is likely unfeasible to have numerous separate solutions embedded on the modality, so a multipurpose, comprehensive system is arguably a more realistic way for providers to benefit from such a wide range of capability.

Patient Waiting

However, despite these advantages, AI solutions embedded on the scanner still have some drawbacks comparted to their PACS-deployed siblings. One of the main disadvantages is that they are unlikely to receive upgrades as frequently. Whereas a PACS-based system will usually receive both feature updates and refinements remotely, frequently bringing both new capabilities and improvements to AI solutions, edge AI solutions are more likely to be left running older versions. This is particularly true if the modality doesn’t have cloud connectivity. This could not only leave radiologists relying on outdated software, but also makes performance issues more likely. This is a particular issue given the nascency of AI adoption and the impressive rate of development.

While Fujifilm is initially offering Annalise’s CXR solution in Australia, it also has plans to offer it in other parts of the world, including India. Here, and in other emerging markets, this lack of updates is unlikely to be a significant issue. On the contrary, these are likely to be some of the best opportunities for embedded AI systems. Many emerging markets have, after all, a distinct shortage of radiologists, and increasing volumes of images. In some situations, having even an outdated version of a comprehensive solution embedded onto an X-ray system could flag critical cases and expedite treatment, rather than the images languishing until a radiologist is available to read them, possibly resulting in missed diagnoses. This is particularly true for the critical care version of the software, which, although detecting 35 findings compared to 95 for the comprehensive solution, is focused on detecting time-sensitive conditions that require immediate treatment.

Earlier is Better

Further, the use of embedded AI is also likely to bring financial benefits to providers. Early detection isn’t only good for patients, it will also facilitate the earlier treatment of patients, which in many cases will save a patient having to undergo more serious, and more expensive treatments.

This will be especially true in single-payor health systems where there is a greater incentive to reduce costs, but private markets such as the US could also benefit. Missed radiological findings can be very costly. Not only because of the added care costs, but also because of the costs of litigation. The fact that the embedded AI tools may help to note findings missed or seen at a more progressive stage by a radiologist, therefore have the potential to save providers considerable amounts of money lost in lawsuits.

Despite this potential, how willing providers will be to pay for such capability remains to be seen. This could depend on how Fujifilm chooses to offer embedded AI. The vendor could add the capability at no extra cost as a way to sweeten a deal and encourage a hardware purchase, alternatively, Fujifilm may choose to only offer it on its highest-end systems in a bid to differentiate the systems in its lineup and encourage customers to spring for the more expensive, higher-tiered systems. Additionally, Fujifilm may also consider upselling these edge solutions across its install base, generating a new source of revenue and enticing potential customers to its AI-enabled premium fleet when their contracts are up for renewal.

Taking the Subscription

The Japanese vendor may also explore some more innovative options such as ongoing subscriptions. Such deals could result in more of a partnership between Fujifilm, Annalise.ai and the customer, ensuring that providers have the support they need to maximise the value they are deriving from the systems. This could also benefit the vendors by turning transactional hardware sales into sticky subscription revenues. It would also overcome the issues of upgrades and would ensure that customers continually benefit from the latest version of the software.

Such a move would be particularly valuable at present. Fujifilm, as with other vendors which offer mobile X-ray systems, capitalised on the demand for the modality during the Covid-19 pandemic. As detailed in Signify Research’s General Radiography and Fluoroscopy Equipment report, global revenues derived from mobile digital radiography systems increased to almost $750m in 2020, up from $413m in 2019 as a result of pandemic-induced demand. Fujifilm, like other vendors will look to continue to capitalise on this spike, and will hope to continue to derive revenues from this expanded install base. Offering AI solutions under a subscription could be one tool that helps the vendor achieve it.

However, regardless of which options are utilised, embedding AI on modalities will not be a huge revenue generator in and of itself for either Fujifilm or Annalise. Fujifilm will boast of the capability to snag some extra deals and upsell to some customers in Australia, but the bigger opportunity lies when it is able to sell its products in India and other emerging markets. Fujifilm has some form in these regions, with its products tending to be more affordable than those of the likes of GE Healthcare, Philips and Siemens Healthineers, while it has also shown it is happy to use innovative methods to try to create business in these areas. In this context, offering embedded AI which seamlessly supplements a limited number of radiologists could be very beneficial. This is particularly true given that Fujifilm has adopted a partnership model. This will give the vendor flexibility to offer different tools in different regions (e.g., Fujifilm has already partnered with Lunit in Mexico and across some regions of South America) or abandon partnerships should better alternatives become available elsewhere.

For Annalise on the other hand, its focus remains on its fuller enterprise-based offering. Offering mobile versions of its solution embedded on mobile X-ray systems will help grow its market share and could serve as an introduction to the company for some providers, but, in isolation, such deals will never allow the vendor to live up to its lofty valuation. Instead, it must focus on selling to providers, with any embedded deals merely an additional revenue stream.

Ultimately it is a smart move, but not one that will have a huge market impact. More significantly, it shows how AI can be embedded into solutions, but these best of breed integrations represent only a small part of a market blessed with numerous approaches. Living on the edge remains a choice not a necessity.

About Signify Premium Insights

This Insight is part of your subscription to Signify Premium Insights – Medical Imaging. This content is only available to individuals with an active account for this paid-for service and is the copyright of Signify Research. Content cannot be shared or distributed to non-subscribers or other third parties without express written consent from Signify Research. To view other recent Premium Insights that are part of the service please click here