Tag Archives: Population Health Management

SPI Digital Health: As Patient Activation Remains a VBC Provider Pain Point, is Cisco’s CPaaS the Remedy?

The value-based care (VBC) IT ecosystem continues to evolve and mature. But patient activation and engagement remain the ‘missing links’ on the ‘last mile’ of the VBC chain. Hundreds of vendors are seeking to close this gap, but most solutions fail to find the sweet spot of giving care managers the tactical intelligence to guide their care strategies, while enabling populations to take greater responsibility for their health. 

At last week’s HIMSS2023 show in Chicago, Cisco demonstrated its enterprise communications platform (CPaaS). Having enjoyed some success in the NHS in the UK with it, Cisco now has high hopes for CPaaS in the US, by far the world’s most developed VBC market. 

The Signify View 

A complete PHM/VBC IT solution enables healthcare providers to aggregate all the data from different sources (e g EHRs, claims, social determinants of health) and develop risk stratification, clinical decision support and analytics tools so providers know exactly who their most expensive, highest priority cohorts are (as illustrated below).  

In recent years, IT vendors have developed and delivered an almost complete ecosystem of data aggregation, health insights and care co-ordination tools that are highly valued and used by ACOs, IDNs and other organisations where success under VBC reimbursement is paramount. However, among care management IT buyers patient activation and engagement remains a key challenge in executing on the workflows that these insight tools inform. The tools provided to support this are mostly falling short.  

Complete Integrated Care/PHM Solution

This area remains something of a ‘blind spot’ for providers and vendors. Leaning on the old adage ‘if you build it, they will come’, some providers have discovered (the hard way) that it is not enough to just build a portal or booking management tool and assume patients have the time, inclination or even the basic IT skills to register and log in to access their personal health information, book appointments and view content or care plans. Some providers acknowledge the struggle with their portals’ ‘digital front door’, where it might take several clicks for a visitor to find the information they need. 

Some healthcare providers also still rely on their EHRs to activate and engage patients. But data pulled into EHRs is not broad, particularly around social determinants of health and payer data that would offer an additional layer of information on how to handle different patients. The fact that some providers use multiple EHRs exacerbates the challenge. 

Indeed, all EHR and PHM vendors have a tool that claims to support patient activation and engagement, and EHR vendor marketplaces are awash with software bolt-ons. But most of these solutions fail to address some of the process and IT hurdles providers face in delivering VBC, and the hurdles patients face when interacting with these solutions. Multi-channel bulk communication (e g via SMS or WhatsApp) that triggers calls to action to a patient (for example sending a link to make an appointment) is available on many EHR platforms, and is one step up from asking a patient to log in to a portal or relying entirely on old fashioned calling for patient outreach, but it is still very manual. Providers recognise that good communication and education to change patient behaviour are key enablers in VBC.   

Solutions, therefore, that offer a more strategic and tactical approach to patient activation and engagement are valuable. More than ever, patients need more accurate patient activation and engagement tools with built-in intelligence that can identify care gaps. They also need solutions that improve the patient experience, are secure, are interoperable with different platforms used for patient identification, use software that can find unstructured data more easily and have AI/ML capabilities to identify rising risk patients through predictive analytics. 

Competitive, but no Game Changer 

By all accounts, CPaaS is a highly competitive solution that performs at the same levels of other leading products in this space. Cisco is very well-resourced with a pedigree in US healthcare via Webex and IMImobile (the UK company bought by Cisco in 2021), and the fact that CPaaS is geared towards VBC is another positive. But what would enable CPaaS to really stand out would be more focus on game changing ‘tactical’ intelligence around patient activation and engagement for care management teams. 

Cisco also faces stiff competition from other, more established vendors in the US VBC market. PHM vendors like Innovaccer, Inovalon and 1upHealth (who we wrote about last week in this Insight) – previously focused on data aggregation and workflow tools helping prioritise patients, develop analytics and offer best practice recommendations on how to manage patients with different conditions – are now focusing on patient activation and engagement, with some success. 

Some have achieved success by acquiring specialist technology, especially in the last couple of years. Recognising the opportunities in patient activation, Healthcare Catalyst, a major non-EHR vendor, bought Twistle in mid-2021.  

Leveraging more patient behavioural data to bring more intelligence into CPaaS, thereby allowing providers to gain a greater understanding on the best channels and best times for patient outreach and activation, would certainly help the product stand out in this competitive market. Further data on patient support networks and how these can be leveraged to support adherence to care plans, appointment booking and medication adherence, are also tools that buyers would value to enable a more tactical approach to patient activation. 

Big tech companies also enjoy obvious advantages in this market. The likes of Google and Amazon have a wealth of patient behavioural data without needing to rely on an EHR or clinical data. If anyone can manipulate human behaviour to follow care plans etc, it is big tech. Provided patient privacy concerns can be overcome, they could be a very disruptive element in this market. 

Different Routes to Market 

Given the above, and the fact that Cisco is launching CPaaS into a cauldron of a US market, it must choose its route to market carefully. Aside from selling direct to hospitals, what other options exist for Cisco? 

It is noteworthy that the company has a decent position in the US virtual care software market. It competes with telehealth specialists Amwell and Teladoc, video conferencing generalists like (Microsoft) Teams and Zoom and some EHR vendors that have their own virtual care platforms. Selling CPaaS as a provider-patient bridge to an established virtual care customer base could be a viable option. 

Another option would be to partner with a leading VBC IT vendor. As mentioned earlier, many of these vendors have focused on developing data aggregation and care management workflow/analytics tools, to the detriment of good patient activation tools. This is now a focus for many, and Cisco could have a part to play here by partnering with these vendors. Many will have the behavioural data needed to inform more tactical outreach, and the combination of this with CPaaS would offer the potential to really address the needs of provider care management teams.   

Lack of Definition 

Patient activation and engagement is the final piece of the VBC ecosystem jigsaw and is a current focus of technology investment. As IDNs and ACOs seek to arm themselves with the full suite of VBC solutions and close any final remaining care gaps, the patient activation and engagement tools market is ever more fiercely competitive.  

Launching CPaaS into the US now is good timing on Cisco’s part, but it is just one of any number of solutions and product differentiation will be its biggest challenge. How Cisco develops the product to address the points raised above will ultimately determine just how disruptive it can be.  

SPI Premium Insight: Optum’s Date With Destiny as EMIS Acquisition Decision Looms

By tomorrow, Optum Health must respond to the UK’s Competition and Markets Authority (CMA) objections over its planned acquisition of EMIS. If approved, the £1.24B ($1.52B) deal for the UK’s leading primary care EHR vendor promises to have wide-reaching implications for the NHS. 

The Signify View 

The CMA’s principal objections to the acquisition, announced last June, revolve around its potential impact on the competitive landscape of the UK’s drug Clinical Decision Support (CDS) and population health management (PHM) markets. 

To completely address CMA concerns, Optum realistically has two options: sell its UK drug CDS business, or exit from its UK PHM activities. But is either option viable? Investors we have spoken to about this in recent days speculate that United Health/Optum is so fixated on getting the EMIS deal done that it will offer to ‘sell its UK business’ to assuage CMA objections. The question is: what does this actually mean? 

Match Making 

To answer this, it helps to consider why Optum is so ‘fixated’ on EMIS. We wrote shortly after the acquisition was announced (see this Insight) about the magnitude of such a deal, and its potential ramifications for the NHS and UK healthcare. 

We can understand why acquisition would be agreeable for both parties. As part of United Health, Optum has a massive US insurance and provider network footprint, and would bring unparalleled scale, portfolio breadth and financial heft to the table.  

EMIS, meanwhile, sells its EHR solution to an estimated 55% of UK NHS GP practices. The company also leads UK community pharmacy IT, inpatient EDIS and community EHR markets, and provides the patient-facing digital front door, booking management system and virtual care platform for many primary care practices via its Patent Access business. Revenues continue to grow at mid- to high single digits, and in the last three years the company brought its EMIS-X analytics platform to market, supporting Primary Care Networks (PCNs) and Integrated Care Systems (ICSs) in addressing care management analytics and PHM.  

Optum has, to date, achieved limited traction for its PHM products in the UK. But the combination of EMIS-X, Optum’s US PHM products (which, largely, have not yet been localised for the UK market) and EMIS’ broad UK footprint offers several synergies and routes to market for both companies.  

The Objections 

In the CMA’s objections document, two (of many) points stand out. One relates to the UK’s drug CDS/Medicines Optimisation (MO) software market. Here, Optum’s ScriptSwitch business and competitor First Databank are shared beneficiaries of a £100M ($123M) contract with NHS Shared Business Services for medication cost-optimisation CDS solutions used in primary care. 

The CMA is concerned that Optum and EMIS would wield excessive power over the market by bringing together ScriptSwitch’s cost optimisation tool with EMIS’ clinical safety-focused solution. Many EMIS EHR customers already buy this solution, and the CMA considers that this large installed base could dramatically alter market dynamics. 

A second key objection raised by the CMA makes for more uncomfortable reading for Optum. The CMA notes that the NHS Health System Support Framework, and other frameworks such as GP Futures, mandate open APIs and free data sharing. The CMA argues that, by buying EMIS (which effectively holds 55% of primary care patient data), other vendors will be denied the opportunity to custom-integrate their technologies to the degree they need to, despite the regulations enforcing data sharing.  

This could have the effect of pushing up costs to the NHS. Reinforcing this point, vendors we speak to speculate that Optum could exploit loopholes in these frameworks to block data sharing and aggregation, should it acquire EMIS. Vendors have a vested interest in flagging such concerns: Oracle Cerner, Graphnet, Patients Know Best, Orion and InterSystems have all benefitted from PHM contracts to date and would view an Optum-EMIS portfolio as a competitive threat. This is especially true given EMIS’ massive installed base of customers (to which the combined entity will be looking to upsell their PHM solutions). 

While the CMA acknowledges that Optum is a small player in the UK PHM market at present, it is mindful of its potential should it have a vehicle (i e EMIS) to localise and scale its solutions. 

Hard Sell 

From Optum’s perspective, the most obvious response is to offer to sell ScriptSwitch, which has been steadily losing share to First Databank’s more innovative cost optimisation solution under the NHS Shared Business Services contract. Optum would need to invest to make the product more competitive and, with the five-year contract up for renewal at the end of 2023 (and no guarantee it would be renewed), Optum will feel ScriptSwitch is a suitable sacrificial lamb. 

But selling ScriptSwitch does not address the CMA’s more weighty objections about the impact of the acquisition on the UK PHM market.  

As mentioned previously, Optum is a small player in UK population health at present. It sells a handful of PHM tools to ICSs and PCNs under the NHS Health System Support Framework, partners with some PHM vendors and provides some consultancy services, but little else of note. 

Yet the UK integrated care/PHM market is of great strategic interest to the American company. 

For example, ICSs have signed contracts, leveraging the NHS’ approximately $600M Health System Led Investment (HSLI) programme, for data integration platforms supporting the development of regional shared or integrated care records. Although neither Optum nor EMIS have featured significantly in major shared care record contracts over the last three-plus years, Optum has been involved from an IT consultancy/system integration perspective throughout. EMIS, meanwhile, has been developing its EMIS-X Analytics portfolio of solutions designed specifically for PHM and analytics used by ICSs, PCNs and other agencies involved in supporting a multidisciplinary approach to integrated care. 

Optum will also hope to overcome the challenge of localisation and replicate in the UK the success it has had with its PHM IT solutions in the US, which generate hundreds of millions of dollars in revenues. Combining with EMIS’ expanding local solution set will, in its eyes, help it achieve that. 

Between a Rock and a Hard Place 

This places Optum in a quandary. Ultimately, the fate of the EMIS acquisition will boil down to Optum’s ability to overturn the CMA’s objections. While selling ScriptSwitch is the easy (and most palatable) option for Optum, the CMA might think differently. 

Addressing CMA objections around population health will be far harder. It is unclear how ‘selling Optum UK’ would address this. The CMA’s concerns relate to future PHM products offered by Optum in the UK, not only current solutions, which presumably refers to PHM products the company currently sells in the US and could localise for the UK. This is a substantial business for Optum and one it will not sell to address the CMAs concerns. It’s on this point the decision is likely to pivot. Perhaps Optum can make a credible case to the CMA that it can establish some sort of framework agreement on open access to its data. Outside a strong commitment to continue to provide EMIS data to other PHM providers this appears to be the only option. 

Optum will also be well aware that it is just another actor in the long-running ‘US companies profiteering from NHS funding’ show. A £1BN-plus acquisition of a successful UK technology firm by a profit-driven US healthcare insurer/provider was always going to re-stoke the fires of debate around large US organisations extending their tentacles into the NHS. There will almost certainly be an element of political grandstanding at play here, too.  

Tomorrow, the CMA will have its responses, and it will not be long before Optum’s finds out if its fixation with EMIS becomes business reality.  

Signify Premium Insight: MEDITECH’s Expanse-ive Innovaccer tie-up

This Insight is part of the Signify Premium Insights (SPI)-Digital Health service, which will launch on 9 January 2023. From that date, this and all SPI-Digital Health Insights will be available only by paid subscription. Click here for a free one month trial of this service. 

In mid-October, US EHR vendor MEDITECH announced the launch of Expanse Population Insight, a new population health management (PHM) solution powered by Innovaccer.  

The tie-up between MEDITECH, an established tier-1 EHR vendor and Innovaccer, which has a reputation as a PHM/value-based care (VBC) disruptor, is a potentially potent combination.  

But as US hospital EHR buyers converge their procurement around large single-source vendors (like Epic) covering multiple different care settings, what does the future hold for Expanse Population Insight and, more broadly, the MEDITECH-Innovaccer partnership? 

The Signify View 

MEDITECH and Innovaccer both bring plenty to the partnership table. Since bringing the first iteration of its Expanse EHR solution to market in 2018, MEDITECH’s customer base has expanded and its annual revenues have grown. 

The company has carved a solid competitive position for itself, moving away from the point solution model of similar-sized rivals. Unlike CPSI (which only offers an EHR solution for small hospitals) or NextGen and eClinical Works (which offer only an EHR for ambulatory primary care), MEDITECH’s reach is wider and deeper. It serves not only small, independent hospitals (which are its core business) but has also established a foothold among larger health systems and Integrated Delivery Networks (IDNs). Just last month, MEDITECH announced a large-scale Expanse deployment for HCA Healthcare, a large healthcare service provider that manages 182 hospitals and 2,300 care sites across the US and UK. 

With a customer base of around 500 hospitals in the US, MEDITECH now sits behind only Epic, Cerner and Altera Health in the US hospital/health system EHR pecking order. While the company is highly unlikely to unseat its much larger rivals, notably only it and Epic are currently gaining appreciable market share in the US inpatient/health systems/IDNs market (see chart below).  

Innovaccer has a similarly impressive backstory. Its annual revenues have jumped more than five-fold from 2017 to more than $100M in 2022. The company currently has around 70 health systems on its books, and is valued at $3B. Innovaccer has built strong relationships with hospital IT buyers, and is viewed by many as the preferred independent PHM/VBC platform solution.  

Expanse-ive Strategy 

As a data aggregation solution, Expanse Population Insight plays neatly into the integrated care/PHM evolution in the US. Data aggregation remains the biggest PHM revenue driver at present (see chart below) in the US. 

The overall PHM US market is forecast to be worth $10.2B in 2026 ($5.3B in 2021).  

The tie-up also gives Innovaccer a better route to market than it has had historically. Rather than having to reply on selling its solution directly to buyers, Innovaccer can now leverage MEDITECH’s installed base and marketing might via Expanse Population Insight. And in MEDITECH it has a partner which is solidly grounded in the US EHR market covering all main care settings. The relationship has the potential to be expanded outside of the US, into countries such as the UK, where MEDITECH has a sizeable installed base of customers and Innovaccer has ambitions.  

On the face of it, this is an ideal match for both companies. Expanse Population Insight will not propel MEDITECH onto the top table of US EHR, but it will certainly give the current incumbents something to think about, in the short-term at least. There are, however, potential obstacles lurking in the shadows. 

Clouds Gathering 

MEDITECH’s growth trajectory may be impressive, and it may still be gaining market share, but it is still a far smaller player than heavyweights like Epic and Cerner. Without the resources to develop its platform solutions in-house, MEDITECH’s approach has been to seek high calibre partnerships. Hence Innovaccer, and also its early-2022 link up with Google, with the intention of integrating the tech giant’s CareStudio platform into Expanse. 

The Innovaccer partnership carries some risk. While MEDITECH’s core business leans a little more towards smaller, independent hospitals, Innovaccer’s PHM solution is far better suited to an IDN, where it can manage a whole population across multiple different care settings and where the reach into the community is much deeper. This risk might be mitigated by MEDITECH’s healthy roots in larger health systems, but in reality it is nowhere near as dominant as Epic in this. 

The problem for MEDITECH and Innovaccer is that, as much as they have the solutions to sell to the large healthcare systems and IDNs – and in truth there is still a loyal fanbase of hospital IT buyers who prefer independent vendors like Innovaccer – there is a defined shift in procurement towards large, single-source EHR vendors, and in particular Epic. The big IDNs and hospital health systems are very much Epic and Oracle Cerner territory, and there is a real risk that in this environment MEDITECH will lose out in the medium-term. 

It’s Complicated 

The MEDITECH-Innovaccer tie-up also throws up some other intriguing relationship dynamics. For one, it appears to sound the death knell for MEDITECH’s PHM solution collaboration with Arcadia Healthcare Solutions, whose data aggregation platform had been supporting MEDITECH’s Web EHR and analytics solution since 2018. This is clearly good news for Innovaccer. 

As is MEDITECH’s relationship with Google. The tech giant would have seen CareStudio as the first step towards forging a deeper relationship with MEDITECH. This deeper relationship could have offered other opportunities that utilise Google’s abilities to drive insights from data in VBC (e g via its Healthcare Data Engine (HDE) accelerators). The MEDITECH-Innovaccer deal appears to limit potential for future VBC product development between the companies in this area. That said Google and MEDITECH continue to develop their relationship in other areas. For example it recently announced that it was working with MEDITECH in terms of cloud services for Expanse.  

Innovaccer faces relationship challenges of its own, however, again around the broader trend towards consolidation around a single EHR vendor. We understand that some of Innovaccer’s customers, who are fans of the Innovaccer platform, are also supporting the development of Epic’s Healthy Planet PHM platform in order to support a longer-term strategy of IT consolidation around Epic. The assumption is that, once Healthy Planet’s functionality matches that of the Innovaccer platform, some of Innovaccer’s customers will migrate over to Epic. 

Measured MEDITECH 

MEDITECH is taking a measured, partnership-based growth approach. In the short-term, these partnerships will bear fruit and enable the company to compete with its larger rivals, and the Innovaccer tie-up will give it a sharper edge in PHM. While momentum is with MEDITECH and Innovaccer right now, the complex and ever-changing nature of the EHR and Value-based Care IT market in the US means that both will need to continue to innovate to stave off Epic.  

Signify Premium Insight: InterSystems and the great PHM cultural shift

This Insight is part of the Signify Premium Insights (SPI)-Digital Health service, which will launch on 9 January 2023. From that date, this and all SPI-Digital Health Insights will be available only by paid subscription. Click here for a free one month trial of this service. 

In theory, recent contracts that data technology provider InterSystems has secured with two Integrated Care Systems (ICSs) in the UK lays solid foundations for forays into embryonic European PHM markets. But they also raise wider questions on where exactly the UK PHM market is heading, how fast and, ultimately, where the likes of InterSystems fit in. 

The Signify View 

The two recent deals for InterSystems will consolidate data from siloed systems in the North West London and West Midlands ICSs. This is part of a broader drive by ICSs in the last few years to put in place ETL and shared care record solutions, bringing together EHRs from GP/primary care practices, social care councils, hospital trusts, mental health trusts and other hospitals.  

The five-year North West London contract, in partnership with Amazon Web Services (AWS), will enable social care, mental health and community trusts, local authorities and third-parties, to migrate their on-premises workloads to InterSystems’ HealthShare Health Connect Cloud on AWS. Ultimately, it will provide a better view of the health records of around 2.1 million people. Similarly, the West Midlands ICS deal will bring together around 400 health and social care providers from six local authorities in that region.  

While both deals further affirm the success of InterSystems’ HealthShare solution, they should also now be viewed in the wider context of the UK PHM market. 

The PHM Maturity Model (see below) shows the market’s expected evolution over the coming years. Currently, it is still in its formative years, with investment concentrated on data consolidation. Most of this investment has already taken place, thereby limiting the upside potential for the likes of InterSystems in this space going forward. 

Next Steps 

The focus will move to ICSs, Primary Care Networks (PCNs), acute trusts and other primary/community NHS providers examining how to leverage new harmonised patient data pools to support integrated care, and upscale a care management process that is, at present largely manual.  

To date, funding has concentrated on data aggregation tools that give a single view of the patient across different settings. A nice view to have, but not one that will save money for the NHS. The real savings will be in predictive, preventative tools for risk stratification, better care management workflows and clinical decision support. This is where we expect more funding from the likes of the Unified Tec Fund. 

In this regard, vendors and the ICSs say the risk stratification technology (developed by the likes of InterSystems, Oracle Cerner and Orion) is now in place to support the move into predictive analytics. 

Furthermore, PHM lies at the heart of the NHS Long Term Plan, which was launched in 2019. PHM is a critical building block for ICSs, and as a result government IT investment in this area should largely escape the expected swathe of cuts the NHS will be forced to make in the coming months and years. 

But, at last month’s InterSystems conference, we attended presentations by the West Midlands and Cumbria and the North East ICSs. While both insisted they had all the building blocks, and the integrated care records in place, they were unable to confirm when they would, or could, move on to the analytics and predictive phase. We published an insight following the InterSystems 2019 conference (see Insight here), and the narrative does not seem to have progressed much since. 

The Bottleneck

The barriers to progress appear to come from within the NHS at this stage. Achieving the first phase of the PHM journey was relatively easy for the provider, because it did not require healthcare professionals to fundamentally change the way they work. Using aggregated data is a similar process to that which preceded it. With overlay systems, healthcare professionals simply get a better, bigger picture of a patient’s history. The problem now is that, to make use of the more sophisticated tools now being developed, the NHS will have to undertake a cultural shift. It will need to move on from platforms, and invest in people and processes to proactively make use of the tools. This change will not come easy for the NHS. 

The UK healthcare infrastructure at large will also need to adapt to move this process forward. It will not be solely the ICSs responsible for driving change: PCNs will increasingly take the baton to make use of the predictive analytics tools at their disposal, and unlock the market. Given this, it will be PCNs that must be the focus of funding if the PHM market is to move forward at any speed.  

Hand Holding 

So, what is the role for the likes of InterSystems, Oracle Cerner, Graphnet, Patients Know Best and Orion in this PHM evolution?  

In the UK, these vendors have the analytics, care management and health insights-type solutions for PHM available to sell to the PCNs and ICSs when they are ready. In the meantime, however, the vendors will need to identify opportunities to drive new revenue streams. There are two potential ways this could happen. 

First, during last month’s InterSystems conference, we got the sense that the PCNs, ICSs and other stakeholders in the industry need some sort of guidance from vendors on how to take the next steps on this journey. The vendors therefore have an opportunity not just in analytics solutions, but also to becoming more embedded with the PCNs and ICSs to consult on and navigate IT strategies. 

Second, as the various PHM stakeholders work out how to move forward in the UK, Europe could still prove to be a happy hunting ground for data aggregation solutions vendors. Value-based care is in its infancy in Europe (especially compared to the US), and France, Germany and the Nordic countries are all embarking on journeys in this regard. The proven track records and experiences of Oracle Cerner, InterSystems and Orion in the UK could be a welcome springboard for them into new geographical markets.  

Leap Of Faith?

The UK ICS network is establishing a more connected, predictive, preventative healthcare system. This is paving the way for a transition to analytics, which is where the NHS will have real opportunities to save money. 

However, despite many of the ingredients being in place, this process has hit a roadblock. This roadblock will only be overcome if the NHS can overcome entrenched ways of working (and it is very much in its interests to do so), and if all stakeholders in the industry can find new ways to work together to drag the PHM market into a new era.  

The industry is talking the talk, but it is not clear if it is yet ready to walk the walk.

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