EHR Vendor Marketplace: Which Stars Are Rising—And Which Are Falling
Robin Settle
Partner
Introduction
1
Presentation Overview
The state of the industry
Goals
› How have these developments impacted the marketplace?
› Identify the big players in the EHR marketplace
› What are the new tools? › Gain objective understanding of their customers, reputations and what makes them different
› How can we support existing systems?
› Name new vendors, their offerings and what to ask them in a selection process
› Ask informed IT vendor evaluation questions (e.g., function, response to changing dynamics and technologies)
We’ll provide an unbiased look at who the big players are now, the differentiated disruptors and who plays well with others—or doesn’t
2015 | © Kurt Salmon | 3
Essential Elements of a Fully Integrated EHR
The fully integrated EHR needs to support the continuum of care …
MANAGING FOR CLINICAL EFFECTIVENESS
Traditional focus of hospitals within the “care continuum”
Extension of capabilities to community, teaching, research
Extension of capabilities to ACO, partnerships
PATIENT CARE
CONTINUUM
Primary Care
Prevention
Urgent
Care
Specialist
Treatment Ancillaries
e.g., surgery
Diagnostic
Ancillaries
e.g., imaging
Inpatient
Care
Emergency
Care
Long‐Term
Care
Rehab
Care
Home
Care
Skilled
Nursing
End‐of‐
Life Care
2015 | © Kurt Salmon | 4
2
A Deeper Dive into the Vendor Marketplace
Focus is on patient‐centric, enterprise solutions for clinicals (acute, ambulatory, subacute, departmental, specialties, ancillaries), access and revenue cycle, population health, and analytics
Scope tends toward clinical enterprise/health system, affiliated physicians and patients/families Delivered through unified/single database platform and/or interoperable solutions; in‐house or remote hosted solutions
Small group of dominant commercial vendors; new cloud‐based solutions emerging but immature
2015 | © Kurt Salmon | 5
A Deeper Dive into the Vendor Marketplace (cont’d)
Major functional emphasis on:
 Process/workflow automation to improve quality/efficiency/effectiveness
 Automated information capture and delivery
 Clinical activity based on evidence‐based protocols
 Proactive, “intelligent” alerts to improve patient care
 Analytics to support outcomes management, performance improvement, quality, population health, etc.
 Personalization (not customization) based on user needs/practice
 Integration of multimedia, biomedical devices, wearables, emerging technologies
Vendors enabling faster deployment through robust “starter” systems, prepackaged content and more streamlined implementation methodologies
2015 | © Kurt Salmon | 6
3
EHR Marketplace
The Big Players
Competitive Marketplace
Gartner Magic Quadrant for Global Enterprise EHR Systems
CHALLENGERS
LEADERS
Epic
Cerner
(Millennium)
ABILITY TO EXECUTE
InterSystems
MEDITECH
Cerner (i.s.h.med)
Cerner (Soarian)
Allscripts
NICHE PLAYERS
VISIONARIES
COMPLETENESS OF VISION
As of March 2015
McKesson Paragon product is not marketed outside the US 2015 | © Kurt Salmon | 8
4
User Feedback 2015 | © Kurt Salmon | 9
Healthcare IT News
Total Market Share by Hospital Size
1000
OVER 600 BEDS
401–600 BEDS
201–400 BEDS
800
101–200 BEDS
26–100 BEDS
1–25 BEDS
600
400
200
0
EPIC
MEDITECH
CERNER
© 2014 KLAS Enterprises LLC. All Rights Reserved. www.klasresearch.com
McKESSON
CPSI
SIEMENS
MEDHOST
(HMS)
HEALTHLAND
ALLSCRIPTS
2015 | © Kurt Salmon | 10
5
2014 Market Wins and Losses
Losses, Over 200 Beds
Losses, 1–200 Beds
Wins, 1–200 Beds
Net
Wins, Over 200 Beds
EPIC
+101
CERNER
+79
MEDITECH*
+12
MCKESSON*
‐32
SIEMENS*
‐5
CPSI
‐2
HEALTHLAND
‐17
MEDHOST (HMS)
‐2
ALLSCRIPTS
‐10
QUADRAMED
‐14
GE HEALTHCARE
‐80
‐29
‐60
‐40
‐20
0
20
40
60
80
100
* Legacy to current product migrations are counted in both win and loss columns
2015 | © Kurt Salmon | 11
© 2014 KLAS Enterprises LLC. All Rights Reserved. www.klasresearch.com
Why Vendors Gained or Lost Hospitals
Competitive Wins (N = 304)
ADD‐ONS
25%
NEW IDN (hospitals)
32%
MIGRATIONS
11%
NEW STANDALONE
32%
© 2014 KLAS Enterprises LLC. All Rights Reserved. www.klasresearch.com
Competitive Losses (N = 225)
CHANGE OF LEADERSHIP
17%
LEGACY MIGRATION (stayed with vendor)
14%
VOLUNTARY DEPARTURES
69%
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6
Vendor Viability
Marketplace observations
Market Factor
Vendors at Risk
Losing market share
Allscripts, McKesson
Financial viability concerns
Allscripts
Product sunsets
McKesson, Siemens Incomplete product suite
Allscripts
Products in transition
McKesson, MEDITECH
Emerging vendors (e.g., Athena)
McKesson, MEDITECH
Marketplace observations
2015 | © Kurt Salmon | 13
Looking Ahead with Legacy Players
› Cerner’s acquisition of Siemens has accelerated selections
› MEDITECH 6.x offers ambulatory and new look and feel
› Epic is beginning to offer solutions for smaller customers
› Recent DoD contract award to Cerner has increased market speculation
2015 | © Kurt Salmon | 14
7
Emerging Vendors Are Making Waves
Few new market entrants have been successful
Development partnerships with vendors have largely failed
In‐house–developed solutions are largely being replaced with commercial solutions
BUT … the market is ripe for disruption with cloud‐based, leading‐edge technology
2015 | © Kurt Salmon | 15
Product Availability and Integration
8
Vendors Are Moving Toward Fully Unified Platforms
But no vendor yet offers a completely self‐contained solution that provides every IT module
Patient Access, Health Information Management & Revenue Cycle Systems Professional Billing
Bed Management
Enterprise Scheduling
Eligibility Verification
Registration Ambulatory
Contract Management
E‐Health, Mobile Integration & Other Tools Mobile Wayfinding
Telehealth
Device Integration
Patient/Family Portal
Reporting/Analytical Tools
Department, Specialty & Ancillary Systems Behavioral Health
Patient Portal
Retail Pharmacy
Critical Care
Hospice
2015 | © Kurt Salmon | 17
Vendor Interoperability vs. Integration Conclusions
› Cerner, Epic and MEDITECH are moving more and more to integrated solutions vs. interoperability across the continuum of care
› McKesson Paragon is still missing many modules requiring interfaced solutions › Health information exchange is here to stay
 Hospitals will continue to have partnerships with organizations with different EHR vendors
 Meaningful use regulations require the exchange of clinical data with EHR
› Future technologies
2015 | © Kurt Salmon | 18
9
IT Vendor Evaluation Questions
Questions to Ask When Issuing an RFI/RFP
General
Technical
Strategic
› What are the key costs of the system—one time and ongoing?
› What is the vendor’s financial stability?
› Application/module information?
› How many clients has the vendor won/ lost during the last three years?
› What is the vendor’s strategy for hosting vs. on‐premises?
› What are the vendor’s hardware and network requirements?
› Which end‐user devices are supported by the vendor?
› With which of your other vendors has the vendor successfully integrated?
› What is the vendor’s long‐term growth strategy for their products?
› What is the vendor’s long‐term strategy for emerging trends in health care?
› What is the vendor’s strategy surrounding emerging technologies and payment models?
Implementation, Training and Support
› What is the vendor’s implementation strategy?
› What is the vendor’s training strategy?
› What is the vendor’s support strategy? › What is the vendor’s recommendation for your IT support staff structure?
2015 | © Kurt Salmon | 20
10
Appendix
KLAS Enterprise EHR Vendors Ratings
HOW THE SUITES PERFORM AGAINST ALL OTHER ENTERPRISE SUITES
Rank
Summary Score
85.7
73.7
71.6
70.6
69.6
69.5
69.1
65.0
61.4
Sales & Contracting
Implementation & Training
Functionality & Upgrades
Service & Support
Overall Satisfaction
Would You Buy Again?
Recommend to Peer/Friend?
Part of Long‐Term Plans
Well Above Average/ Above Average
Average
iCare not rated by KLAS
© 2014 KLAS Enterprises LLC. All Rights Reserved. www.klasresearch.com
Below Average/ Well Below Average
2015 | © Kurt Salmon | 22
11
KLAS Research Data: Acute Care EMR
RANK
PREVIOUS RANK
OVERALL SCORE
RATING CHANGE
CONFIDENCE LEVEL
1
1
Epic EpicCare Inpatient EMR
89.3
+1%
√√√
2
2
Cerner Millennium PowerChart
79.1
+1%
√√√
3
3
Allscripts Sunrise Clinical Manager
75.4
+5%
√√√
4
5
MEDITECH C/S Enterprise Medical Record 6.0
67.2
‐5%
√√√
5
6
Siemens Soarian Clinicals
64.9
‐7%
√√√
6
4
McKesson Paragon Clinicals
59.2
‐16%
√√√
VENDOR PRODUCT
iCare not rated by KLAS
Source: Best in KLAS 2014: Software & Services; published 2015
2015 | © Kurt Salmon | 23
Current U.S. EMR Market Share (Live, Installed Systems*) For the purposes of this research, a hospital’s CDR vendor was assumed to be the core clinical information system vendor at that site.
100% Market Share
Misc. Vendors/Systems
30.5%
Epic EpicCare
18.3%
Cerner Millennium
17.0%
CPSI System 2000
8.3%
MedHost HMS
7.3%
MEDITECH 6.X
4.1%
McKesson Paragon
3.9%
Self‐Developed
3.9%
Siemens Soarian (Now Cerner)
3.4%
Allscripts Sunrise
3.3%
HIMMS Analytics, 7/2015 – Clinical Data Repository Vendor – Live & Operational Does not include new contracts or current system implementations
Misc. Vendors/Systems includes legacy systems that are currently supported but no longer offered (e.g., Siemens Invision, MEDITECH MAGIC/Client Server, McKesson Horizon)
2015 | © Kurt Salmon | 24
12
Enterprise EMR Marketplace: Industry Inpatient Adoption
Stage
Cumulative Capabilities
2006
2008
2010
2012
2013
2014 Q4
Stage 7
Complete EMR; CCD transactions to share data; data warehousing; data continuity with ED, ambulatory, OP
0.0%
0.3%
1.0%
1.8%
2.9%
3.6%
Stage 6
Physician documentation (structured templates),
full CDSS (variance & compliance), full R‐PACS
0.1%
0.5%
3.2%
7.3%
12.5%
17.9%
Stage 5
Closed‐loop medication administration
0.5%
2.5%
4.5%
11.5%
22.0%
32.8%
Stage 4
CPOE, clinical decision support (clinical protocols)
3.1%
2.5%
10.5%
14.0%
15.5%
14.0%
Stage 3
Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology
18.7%
35.7%
49.0%
41.7%
30.3%
21%
Stage 2
CDR, controlled medical vocabulary, CDS, may have document imaging; HIE capable
40.0%
31.4%
14.6%
11.4%
7.6%
5.1%
Stage 1
Ancillaries—Lab, Rad, Pharmacy—all installed
17.4%
11.5%
7.1%
4.8%
3.3%
2.0%
Stage 0
All three ancillaries not installed
20.4%
15.6%
10.1%
7.5%
5.8%
3.7%
4,237
5,166
5,281
5,310
5,458
5,467
# Hospitals
AHS is at Stage 6
Source: HIMSS Analytics Database
2015 | © Kurt Salmon | 25
Current U.S. HIMSS Stage 7 Hospitals by EMR Vendor* For the purposes of this research, a hospital’s CDR vendor was assumed to be the core clinical information system vendor at that site.
100% Market Share
Epic EpicCare
69.9%
Cerner Millennium
19.4%
MEDITECH Client Server
GE/Self‐Developed
7.3%
3.9%
Allscripts Sunrise
1.0%
MEDITECH 6.X
1.0%
MEDITECH MAGIC
0.5%
HIMMS Analytics, 7/2015 – Reported Clinical Data Repository Vendor –
Live & Operational/Vendor Websites & Kurt Salmon Research
2015 | © Kurt Salmon | 26
13
Allscripts (Sunrise)
Company Overview
› Public HIT company (NASDAQ: MDRX) based in Chicago, Ill.; founded in 1986
› $1.4B 2014 revenue; flat growth 2012–2014
› ~6,000 employees; operating in 11 countries and in over 60,000 facilities worldwide
› Key acquisitions: 2008—Misys; 2010—Eclipsys; 2013—dbMotion
Product Overview
› Fully integrated EMR, Revenue Cycle & Ambulatory; some additional products available (e.g., population health)
› 162 U.S. hospital live installs; 6 additional hospitals contracted/installation in progress (HIMSS database 7/2015)
› 1% of HIMSS Stage 7 U.S. hospitals use Allscripts (2 of 206)
› Ranked #3 of 6 in 2014 KLAS Acute Care EMR (75.4)
› Not ranked in 2014 KLAS Acute Care EMR—Community (68.9)
› Ranked as Visionary in Gartner’s 2015 Magic Quadrant for Enterprise EHR Systems
› Ranked #1 out of 5 in 2014 Black Book EHR Rankings for Academic, Teaching & 300+ Bed Hospitals
Commentary
›
›
›
›
Continued focus on turnaround following leadership change in late 2012
Customers report improved quality, service and implementation
Strategy focused on interoperability, but has not been fully realized
Sales challenges due to issues delivering on plans and organizational instability; flat EHR market share
2015 | © Kurt Salmon | 27
Cerner (Millennium)
Company Overview
› Public HIT company (NASDAQ: CERN) based in Kansas City, Mo.; founded in 1979
› $3.4B 2014 revenue; 27% revenue growth 2012–2014
› ~15,800 employees; 14,000+ facilities worldwide
› Key acquisitions: 2010—IMC Health Care; 2011—Clairvia; 2015—Siemens Health Services
Product Overview
› Fully integrated EMR, Revenue Cycle & Ambulatory Solution; wide array of additional solutions
› 840 U.S. hospital live installs; 117 additional hospitals contracted/installation in progress (HIMSS database 7/2015)
› 19% of HIMSS Stage 7 U.S. hospitals use Cerner (40 of 206); also 1 Stage 7 hospital in Spain
› Ranked #2 of 6 in 2014 KLAS Acute Care EMR (79.1)
› Ranked #1 of 7 in 2014 KLAS Acute Care EMR—Community (74.9) (CommunityWorks Clinical Suite)
› Ranked as Leader in Gartner’s 2015 Magic Quadrant for Enterprise EHR Systems
› Ranked #3 out of 5 in 2014 Black Book EHR Rankings for Academic, Teaching & 300+ Bed Hospitals
Commentary
› Market leader with significant growth in market share
› Fully integrated solution; historical weaknesses in revenue cycle and ambulatory EMR have been focus of development and have improved significantly
› Major improvements in delivery and execution overall
2015 | © Kurt Salmon | 28
14
Epic (EpicCare)
Company Overview
› Private HIT company based in Verona, Wis.; founded in 1979
› $1.8B projected 2014 revenue; 16% growth 2012–2014
› ~7,000 employees; 13,000+ facilities worldwide
› Key acquisitions: None
Product Overview
› Fully integrated EMR, Revenue Cycle & Ambulatory Solution
› 904 U.S. hospital live installs; 193 additional hospitals contracted/installation in progress (HIMSS database 7/2015)
› 70% of HIMSS Stage 7 U.S. hospitals use Epic (144 of 40) (1 Stage 7 hospital in Netherlands)
› Ranked #1 of 6 in 2014 KLAS Acute Care EMR (89.3)
› Ranked as Leader in Gartner’s 2015 Magic Quadrant for Enterprise EHR Systems
› 100% of HIMSS Enterprise Davies Awards past 5 years
› Ranked #2 out of 5 in 2014 Black Book EHR Rankings for Academic, Teaching & 300+ Bed Hospitals
Commentary
› Market leader with significant growth in market share
› Fully integrated solution; historical weaknesses in analytics/reporting have been focus of development and have improved significantly
› Historical concerns about eventual leadership transition and technology platform
2015 | © Kurt Salmon | 29
McKesson (Paragon)
Company Overview
› Public health care company (NYSE: MCK), Technology Solutions division based in Alpharetta, Ga.; founded in 1833
› $179B 2015 revenue (3.1B for Technology Solutions); flat Technology Solutions growth 2012–2014
› ~43,500 employees; 3,100+ facilities worldwide
Product Overview
› EMR, Revenue Cycle, Ambulatory & ERP available, though some products are very immature or come from Horizon or other legacy platforms
› 195 U.S. hospital live installs; 5 additional hospitals contracted/installation in progress (HIMSS database 7/2015)
› No HIMSS Stage 7 U.S. hospitals using McKesson Paragon › Ranked #6 of 6 in 2014 KLAS Acute Care EMR (59.2)
› Ranked #4 of 7 in 2014 KLAS Acute Care EMR—Community (69.2)
› Not Ranked in Gartner’s 2015 Magic Quadrant for Enterprise EHR Systems
› Ranked #4 out of 5 in 2014 Black Book EHR Rankings for Academic, Teaching & 300+ Bed Hospitals
Commentary
› Significant concern among customers regarding future; some success moving customers from Horizon to Paragon
› Paragon is primarily focused on smaller standalone community hospitals; development is planned to build out functionality required for larger (400+ beds) enterprises
› Not all products yet available on Paragon (e.g., ambulatory)—significant development underway/planned; requires 2015 | © Kurt Salmon | 30
other McKesson solutions
15
MEDITECH (6.X)
Company Overview
› Private HIT company based in Westwood, Mass.; founded in 1969
› $517M 2014 revenue; 13.5% revenue decline 2012–2014
› ~4,000 employees; 2,400+ facilities worldwide
› Key acquisitions: 2011—LSS
Product Overview
› Fully integrated EMR, Revenue Cycle & ERP Solution; Ambulatory Solution not fully integrated
› 233 U.S. hospital live installs; 28 additional hospitals contracted/installation in progress (HIMSS database 7/2015)
› 424 and 394 U.S. hospitals still on legacy MAGIC & Client Server platforms, respectively (HIMSS database 7/2015) › 9% of HIMMS Stage 7 U.S. hospitals using MEDITECH (18 of 206), 2 are 6.0, as is 1 Canadian Stage 7 hospital
› Ranked #4 of 6 in 2014 KLAS Acute Care EMR (67.2)
› Ranked #2 of 7 in 2014 KLAS Acute Care EMR—Community (71.6)
› Ranked as Visionary in Gartner’s 2015 Magic Quadrant for Enterprise EHR Systems
› Not Ranked in 2014 Black Book EHR Rankings for Academic, Teaching & 300+ Bed Hospitals
Commentary
› Highly successful, but generally with smaller organizations (e.g., < 200 beds)
› Some attrition due to small hospitals becoming part of large IDNs, as well as need to migrate from legacy platforms
› Ambulatory EMR not fully integrated and perceived as having limited functionality and clinical content to date; 2015 | © Kurt Salmon | 31
new integrated Web‐based module in development
Questions to Ask When Issuing an RFI/RFP—General Questions
› What are the key costs of the system—one time and ongoing?
 Application and system software  Third‐party software
 Hardware
 Implementation and other consulting fees
 Interfaces
 Training
 Other
› What is the vendor’s financial stability?
 What are the vendor’s key financial metrics?
› What should I know about the application/module information?
 What is the current installed base of each application/module?
 When was each application/module developed?
 Is each application/module fully integrated into the product suite?
› How many clients has the vendor won/lost during the last three years?
2015 | © Kurt Salmon | 32
16
Questions to Ask When Issuing an RFI/RFP—Strategic Questions
› What is the vendor’s long‐term growth strategy for their products?
 What is their 10‐year roadmap?
 Ask questions specifically surrounding new acquisitions and/or mergers (e.g., Cerner’s acquisition of Siemens Soarian).
› What is the vendor’s long‐term strategy for emerging trends in health care?
 What is the vendor’s strategy for population health and how does that enable your organization to pursue your goals?
 What is their strategy for health exchanges and, specifically, within your organization’s region?
 What is their big data/analytics strategy and how does that align with your organization’s goals and go‐forward strategy?
› What is the vendor’s strategy surrounding emerging technologies and payment models?
 What is their go‐forward strategy with mobile and tablet integration?
 How do they integrate with wearables (e.g., Apple WatchKit, Fitbit)?
 What are they doing with new patient payment models such as Apple Pay?
 What is the vendor’s strategy with payment reform, bundled and capitated payments?
2015 | © Kurt Salmon | 33
Questions to Ask When Issuing an RFI/RFP—Technical
› What is the vendor’s strategy for hosting vs. on‐premises?
 Is the vendor already cloud‐based, or are they moving to the cloud? How does this impact pricing?
 Does the vendor host the system themselves, or are third‐party vendors used?
› What are the vendor’s hardware and network requirements?
 Which server and database software packages are supported by the vendor?
 Does the vendor support virtualization?
 What other key technologies are supported (e.g., single sign‐on, Citrix)?
 What are the vendor’s storage requirements?
 What are the vendor’s network requirements?
› Which end‐user devices are supported by the vendor?
 Computers/all‐in‐ones/WoWs?
 Mobile devices—tablets, phones?
 Printers—network and label, barcode scanners, other?
› With which of your other vendors has the vendor successfully integrated?
 Third‐party systems (e.g., key applications such as ERP; bolt‐on/niche applications, content providers)?
 Medical equipment (e.g., infusion pumps, point‐of‐care devices, bedside monitoring devices)?
2015 | © Kurt Salmon | 34
17
Questions to Ask When Issuing an RFI/RFP—
Implementation, Training & Support
› What is the vendor’s implementation strategy?
 What method does the vendor recommend (i.e., staged vs. big bang)?
 What is the specific plan for your organization (i.e., duration, multiple facility)?
 What is the vendor’s recommended staffing for the implementation team?
› What is the vendor’s training strategy?  What is the training approach for the project team and end‐users?
 How and where is training conducted? › What is the vendor’s support strategy?  What are the basic included services (availability and location of support resources)?
 What are the costs for additional support?
› What is the vendor’s recommendation for your IT support staff structure?
1. 2015. Partners’ $1.2b patient data system seen as key to future. The Boston Globe. http://www.bostonglobe.com/business/2015/05/31/partners‐launches‐billion‐electronic‐
health‐records‐system/oo4nJJW2rQyfWUWQlvydkK/story.html
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