– Shields Health Solutions and Excelera announce a major
specialty pharmacy merger that will form a combined company that consults with
700+ hospitals in 43 states, including Mass General Brigham, Yale New Haven,
Intermountain Healthcare and Henry Ford.
– The network of hospitals is designed to improve patient
care through an infrastructure that helps with things like acquiring prior
authorization for specialty drugs and staying adherent to them. It can also
lower costs for patients by negotiating lower rates from manufacturers with the
leverage of insights from 1 million+ patients in those hospitals.
Shields Health Solutions (Shields), the leading health
system specialty pharmacy integrator, has joined
forces with ExceleraRx
Corp. (Excelera), a healthcare company that empowers integrated delivery
networks, health systems, and academic medical centers to provide personalized,
integrated care for patients with complex and chronic conditions focused on
improving patient care.
Merger Reflects Growing Need for On-Site, Integrated
Serving 60+ health systems and academic medical centers, the
combined organization addresses 700+ hospitals that account for the opportunity
of $30B in specialty pharmacy revenue. The use of specialty medications to
treat complex patients – those with multiple, chronic illnesses or rare, hard
to treat diseases that require close monitoring and support – is increasing an
average of 17 percent per year, and health systems across the U.S. have been
building on-site, integrated specialty pharmacies to provide comprehensive,
streamlined care for this growing population to improve outcomes. Since 2015,
the prevalence of health system-owned specialty pharmacies in large hospitals has doubled, with nearly 90 percent of large
hospitals operating a specialty pharmacy in 2019.
“On-site, integrated specialty pharmacy is the future
of complex patient care and we look forward to combining forces with Excelera
to make our impact even greater. As we have shown, this model materially
improves clinical outcomes for patients and reduces total medical expenses for
covered patients,” said Lee Cooper, CEO, Shields. “Together, our
network of more than 60 of the country’s top health systems, representing
nearly 30% of non-profit healthcare systems based on net patient service revenues,
creates an unparalleled industry-first that will enable unprecedented best
practice sharing and ultimately lead to improved outcomes for complex
Benefits of On-Site, Integrated Specialty Pharmacies for
Shields and Excelera offer programs for health systems to
build, operationalize and optimize integrated specialty pharmacies, as well as
help manufacturers and payors access critical patient and drug performance
insights. With a more personalized, high-touch approach to patient care,
Shields and Excelera have found that hospital-owned specialty pharmacies
dramatically simplify medication and care management for patients and can:
– Reduce medication co-payments from hundreds, sometimes
thousands of dollars, to an average co-pay of $10
– Streamline time-to-therapy, typically from several weeks
to an average of two days
– Decrease physician administrative paperwork by thousands
– Improve medication adherence rates to over 90 percent, on
Financial details of the acquisition were not disclosed.
– Cityblock Health, a transformative, value-based healthcare provider focused on improving healthcare outcomes for marginalized communities, today announced a $160M Series C round, bringing its total raised to $300M.
– Cityblock is a care delivery trailblazer working to right the injustices of a healthcare system that cycles vulnerable communities through frequent ER visits and hospital stays. Its tech-enabled model delivers primary care, behavioral care, and social services, virtually and in-person, to the Medicaid and lower-income Medicare beneficiary communities.
– Cityblock provides social services that address core
aspects of poverty in order to improve health outcomes, including access to
nutritious food and support to safely care for oneself.
Health, a Brooklyn, NY-based healthcare provider for lower-income
communities, announced today the completion of a $160 million Series C funding
round and a valuation of over $1 billion. New Cityblock investor General Catalyst
led the round, with participation from crossover investor Wellington Management
and support from major existing investors, including Kinnevik AB, Maverick
Ventures, Thrive Capital, Redpoint Ventures, and more. The investment round
brings Cityblock’s total equity funding to $300 million, as they look to grow
their footprint to democratize access to community-based integrated care in a
more than $1.3 trillion market.
Care That Meets You Where You Are
Spun out of Sidewalk Labs, an Alphabet Company in 2017 and anchored in a first partnership with EmblemHealth, Cityblock is a transformative, value-based healthcare provider focused on improving outcomes for Medicaid and lower-income Medicare beneficiaries. The company provides medical care (both primary care and complex specialty services), behavioral health, and social services to its members virtually, in their homes, in the community, and in its neighborhood hubs. Their model reflects an underlying philosophy that improving health outcomes and minimizing systemic healthcare inequities requires fundamentals that address the root effects of poverty, like having access to nutritious food or the ability to safely care for yourself and others.
Value-Based Care Model
Cityblock leverages a value-based model, instead of a
fee-for-service basis, like most healthcare providers. Cityblock splits the
cost savings that come from better outcomes with the healthcare payer. Cityblock’s
financial structure squarely aligns the health needs of its members to continuously
deliver patient-centric care.
Cityblock is powered by Commons a groundbreaking care delivery platform that brings together distributed community-based care teams, care delivery workflows, data feeds, and multimodal member interactions. It allows social workers, pharmacists, doctors, paramedics, and our virtual care teams to all come together on the same page in real-time. With each new market we enter, our technology reinforces our care model, allowing us to serve more members while ensuring consistently high quality, empathetic, and effective care.
Integrated Care Team
Cityblock’s integrated care teams include doctors, nurses,
advanced practice clinicians, behavioral health specialists, licensed clinical
social workers, and community health partners, and leverage close partnerships
with existing healthcare providers and community-based social services
Today, Cityblock provides care to 70,000 members in Connecticut,
New York, Massachusetts, and Washington D.C., with high member engagement and
NPS scores of high 80s to 90s across its markets. Over the past year, Cityblock
members have seen reductions in in-patient hospital admission rates and
improvements in quality outcomes, keeping people healthier and driving down
costs across the board, while more than doubling membership and revenue,
The Impact of COVID Has Magnified Health Disparities
According to Cityblock, the COVID-19 pandemic has
significantly magnified health disparities highlighting three fundamental
– Inequity of
America’s social infrastructure, including the legacy of systemic racism, has
created unacceptably disparate health outcomes
– Healthcare’s volume-based, fee-for-service payment model contributes
poor outcomes, especially for marginalized communities
– The models that
have to-date addressed key components of these challenges have not successfully
Story of Cityblock Member Sonia
The story of Sonia, a Cityblock member, is featured in the blog post announcing the raise. Counted out and considered
a ‘nuisance’ by the healthcare system, Sonia was visiting the emergency room
several times a week for care and services, resulting in poor outcomes for the
health system and for herself. Cityblock enrolled Sonia in their high-risk
short-term housing program, placing her into a hotel during the peak of her
community’s Covid-19’s outbreak. As her trust in Cityblock grew, Sonia worked
with Cityblock and its community partners to secure permanent housing. Over the
course of two years, Sonia saw a 21% reduction in hospital use and a 24%
reduction in monthly costs, and has had zero ER visits since April 2020.
“The devastating impact of COVID-19 has been a painful
reminder of the vulnerability of lower-income communities and communities of
color,” said Iyah Romm, Cityblock Health co-founder and CEO. “We cannot turn a
blind eye to a healthcare system that cycles vulnerable communities through
frequent ER visits and hospital stays. We believe that new models of care
delivery, rooted in preventative care and augmented with social services, are
one major path forward to righting the injustices of our healthcare system.
This starts with listening to our members, extends through changing payment
models to create sustainability for primary care providers and building
technology to democratize access to the care models that we are building.”
Senior isolation is a health risk that affects at least a quarter of seniors over 65. It has become recognized over the past decade as a risk factor for poor aging outcomes including cognitive decline, depression, anxiety, Alzheimer’s disease, obesity, hypertension, heart disease, impaired immune function, and even death.
Physical limitations, lack of transportation, and inadequate health literacy, among other social determinants of health (SDOH), further impair access to medical and mental health treatment and preventive care for older adults. These factors combine to increase the impact of chronic comorbidities and acute issues in our nation’s senior population.
COVID-19 exacerbates the negative impacts of social isolation. The consequent need for social distancing and reduced use of the healthcare system due to the risk of potential SARS-CoV-2 exposure are both important factors for seniors. Without timely medical attention, a minor illness or injury quickly deteriorates into a life-threatening situation. And without case management, chronic medical conditions worsen.
Among Medicare beneficiaries alone, social isolation is the source of $6.7 billion in additional healthcare costs annually. Preventing and addressing loneliness and social isolation are critically important goals for healthcare systems, communities, and national policy.
Organizations across the healthcare spectrum are taking a more holistic view of patients and the approaches used to connect the most vulnerable populations to the healthcare and community resources they need. To support that effort, technology is now available to facilitate analysis of the socioeconomic and environmental circumstances that adversely affect patient health and mitigate the negative impacts of social isolation.
Addressing Chronic Health Issues and SDOH
When we think about addressing chronic health issues and SDOH in older adults, it is usually after the fact, not focused on prevention. By the time a person has reached 65 years of age, they may already be suffering from the long-term effects of chronic diseases such as diabetes, hypertension or heart disease. Access points to healthcare for older adults are often in the setting of post-acute care with limited attention to SDOH. The focus is almost wholly limited to the treatment and management of complications versus preventive measures.
Preventive outreach for older adults begins by focusing on health disparities and targeting patients at the highest risk. Attention must shift to care quality, utilization, and health outcomes through better care coordination and stronger data analytics. Population health management technology is the vehicle to drive this change.
Bimodal Outreach: Prevention and Follow-Up Interventions
Preventive care includes the identification of high-risk individuals. Once identified, essential steps of contact, outreach, assessment, determination, referral, and follow-up must occur. Actions are performed seamlessly within an organization’s workflows, with automated interventions and triggered alerts. And to establish a true community health record, available healthcare and community resources must be integrated to support these actions.
Social Support and Outreach through Technology
Though older adults are moving toward more digitally connected lives, many still face unique barriers to using and adopting new technologies. So how can we use technology to address the issues?
Provide education and trainingto improve health literacy and access, knowledge of care resources, and access points. Many hospitals and health systems offer day programs that teach seniors how to use a smartphone or tablet to access information and engage in preventive services. For example, connecting home monitoring devices such as digital blood pressure reading helps to keep people out of the ED.
Use population health and data analyticsto identify high-risk patients. Determining which patients are at higher risk requires stratification at specific levels. According to the Centers for Disease Control and Prevention, COVID-19 hospitalizations rise with age, from approximately 12 per 100,000 people among those 65 to 74 years old, to 17 per 100,000 for those over 85. And those who recover often have difficulty returning to the same level of physical and mental ability. Predictive analytics tools can target various risk factors including:
– Recent ED visits or hospitalizations
– Presence of multiple chronic conditions
– Food insecurity, housing instability, lack of transportation, and other SDOH
– Frailty indices such as fall risk
With the capability to identify the top 10% or the top 1% of patients at highest risk, care management becomes more efficient and effective using integrated care coordination platforms to assist staff in conducting outreach and assessments. Efforts to support care coordination workflows are essential, especially with staffing cutbacks, COVID restrictions, and related factors.
Optimal Use of Care Coordination Tools
Training and education of the healthcare workforce is necessary to maximize the utility of care coordination tools. Users must understand all the capabilities and how to make the most of them. Care coordination technology simplifies workflows, allowing care managers to:
– Risk-stratify patient populations, identify gaps in care, and develop customized care coordination strategies by taking a holistic view of patient care.
– Target high-cost, high-risk patients for intervention and ensure that each patient receives the right level of care, at the right time and in the right setting.
– Emphasize prevention, patient self-management, continuity of care and communication between primary care providers, specialists and patients.
This approach helps to identify the resources needed to create community connections that older adults require. Data alone is insufficient. The most effective solution requires a combination of data analytics to identify patients at highest risk, business intelligence to generate interventions and alerts, and care management workflows to support outreach and interventions.
About Dr. Jenifer Leaf Jaeger
Dr. Jenifer Leaf Jaeger serves as the Senior Medical Director for HealthEC, a Best in KLAS population health and data analytics company. Jenifer provides clinical oversight to HealthEC’s population health management programs, now with a major focus on COVID-19. She functions at the intersection of healthcare policy, clinical care, and data analytics, translating knowledge into actionable insights for healthcare organizations to improve patient care and health outcomes at a reduced cost.
Prior to HealthEC, Jenifer served as Director, Infectious Disease Bureau and Population Health for the Boston Public Health Commission. She has previously held executive-level and advisory positions at the Massachusetts Department of Public Health, New York City Department of Health and Mental Hygiene, Centers for Disease Control and Prevention, as well as academic positions at Harvard Medical School, Boston University School of Medicine, and the Warren Alpert Medical School of Brown University.
– GigCapital2 Inc has agreed to merge with UpHealth Holdings Inc and Cloudbreak Health LLC to create a public digital healthcare company valued at $1.35 billion, including debt, the blankcheck acquisition company said on Monday.
– The combined company will be named UpHealth, Inc. and
will continue to be listed on the NYSE under the new ticker symbol “UPH”.
Blank check acquisition
company GigCapital2 agreed to merge
with Cloudbreak Health, LLC, a unified telemedicine and video medical
interpretation solutions provider and UpHealth
Holdings, Inc., one of the largest national and international digital
healthcare providers to form a combined digital health company. The deal is valued
at $1.35 billion, including debt. the combined company will be named UpHealth, Inc. and will continue to be
listed on the NYSE under the new ticker symbol “UPH”.
Following the merger, UpHealth will be a leading global
digital healthcare company serving an entire spectrum of healthcare needs and
will be established in fast growing sectors of the digital health industry.
With its combinations, UpHealth is positioned to reshape healthcare across the
continuum of care by providing a single, integrated platform of best-in-class
technologies and tech-enabled services essential to personalized, affordable,
and effective care. UpHealth’s multifaceted and integrated platform provides
health systems, payors, and patients with a frictionless digital front door
that connects evidence-based care, workflows, and services.
“We are excited to partner with UpHealth and Cloudbreak through our Private-to-Public Equity (PPE)™ platform. The combined UpHealth has all the hallmarks we look for in a successful partnership, including a world-class executive team and an exceptional business model with scale, strong growth, and profitability margins in the digital healthcare industry. We are particularly excited about the opportunity to provide our Mentor-Investor™ discipline in partnership with an exceptional global leadership team, as well as participate in a high-tech integrated platform that comprises a variety of cutting edge disciplines, such as the Artificial Intelligence platform being developed by Global Telehealth in conjunction with the tech-enabled Behavioral Health divisions. We are confident UpHealth is at the inflection point and positioned for accelerated growth.” – Dr. Avi Katz – Founder and Executive Chairman of GigCapital2
Combined Company Offerings
Upon closing the pending mergers and the combination with Cloudbreak, UpHealth will be organized across four capabilities at the intersection of population health management and telehealth:
1. Integrated Care Management: Thrasys Inc. (“Thrasys”) has reinvested $100M of customer revenue to
develop its innovative SyntraNet Integrated Care technology platform. The
platform integrates and organizes information, provides advanced
population-based analytics and predictive models, and automates workflows
across health plans, health systems, government agencies, and community
organizations. The platform plans to add at least 40 million lives to UpHealth
in the next 3 years to support global initiatives to transform healthcare.
2. Global Telehealth: will consist of a U.S. division and an international division
that, together, are anticipated to grow revenues by an additional $47 million
The U.S. division of
Global Telehealth following the combination, Cloudbreak, is a leading unified
telemedicine platform performing more than 100,000 encounters per month on over
14,000 video endpoints at over 1,800 healthcare venues nationwide. The
Cloudbreak Platform offers telepsychiatry, telestroke, tele-urology, and other
specialties, all with integrated language services for Limited English Proficient
and Deaf/Hard-of-Hearing patients. Cloudbreak’s innovative, secure platform
removes both distance and language barriers to improve patient care,
satisfaction, and outcomes.
division of Global Telehealth following the combination, Glocal Healthcare
Systems Pvt. Ltd (“Glocal”), is a global provider of virtual consultations and
local care spanning the care continuum. It has designed proven, affordable and
accessible solutions for the delivery of healthcare services globally. The
platform provides a full suite of primary and acute care services, including an
app-based telemedicine suite, digital dispensaries, and hospital centers. The
platform has signed several country-wide contracts with government ministries
across India, Southeast Asia, and Africa.
3. Digital Pharmacy: MedQuest Pharmacy (“MedQuest”) is a leading full-service manufactured and compounded pharmacy licensed in all 50 states that pre-packages and ships medications direct to patients. The company also offers lab services and testing, nutraceuticals, nutritional supplements, education for medical practitioners, and training for organizations, associations, and groups. MedQuest serves an established network of 13,000 providers. The MedQuest platform is poised for strong growth via targeted product expansion and expansive eCommerce capabilities for the entire provider network. UpHealth and MedQuest have mutually executed a merger agreement, the closing of which is awaiting regulatory approval for the transfer of licenses expected by the end of 2020 or early 2021.
4. Tech-enabled Behavioral Health: TTC Healthcare, Inc. (“TTC Healthcare”) and
Behavioral Health Services LLC (“BHS”) offer comprehensive services
specializing in acute and chronic outpatient behavioral health, rehabilitation
and substance abuse, both onsite and via telehealth. UpHealth’s Behavioral
Health capabilities have dramatically expanded use of telehealth for medical
and clinical services and are leveraging UpHealth’s platform to increase
volumes across its services. UpHealth and TTC Healthcare have mutually executed
a merger agreement, the closing of which is awaiting regulatory approval for
the transfer of licenses expected prior to the end of 2020.
Global Financial Impact and Reach
UpHealth will have agreements
to deliver digital healthcare in more than 10 countries globally. These various
companies are expected to generate approximately $115 million in revenue and
over $13 million of EBITDA in 2020 and following the combination, UpHealth
expects to generate over $190 million in revenue and $24 million in EBITDA in
– How the top US acute EHR vendors, namely Cerner, Epic, Allscripts, and MEDITECH (+85% share of US acute market in terms of revenues), have progressed on international expansion.
As highlighted below, there is a significant variance amongst the big four in terms of revenue and share of business outside the US. Cerner has by far the highest revenue at more than $650M in 2019, representing 12% of its business. Whilst MEDITECH has considerably lower revenue than Cerner, its international revenue is broadly similar to a share of its total revenue.
By contrast, Allscripts and MEDITECH each has international business that is comparable in terms of revenues, but as a share of overall revenues, international is much less important for Allscripts.
Allscripts’ international revenue was lower than Epic, Cerner, and Meditech in 2018, however, its growth in 2019 enabled it to overtake MEDITECH and become the third largest of the four vendors in 2019.
Cerner’s international revenues fell marginally as a proportion of its total business in 2019 (11.5%, down from 11.9% in 2018), although revenues grew in absolute terms by 3%. This growth was aided by success in Europe, particularly in the UK and Nordics where it won new contracts. Cerner’s overall revenue suffered a 3% decline in 1H 2020 (versus 1H 2019). Despite the impact of COVID-19, its international business witnessed marginal revenue growth (+1%) and rose as a share of its overall business (11.9%) during this period.
Cerner received a significant boost to its international business in 2015 when it acquired Siemens’ EHR business. This provided it with a broad footprint of deployments in DACH (Germany, Austria, Switzerland), Benelux, France, Norway, and Spain. Since this acquisition, the challenge for Cerner had been to migrate the customer base to Millennium. However, this has not happened to date, particularly in Germany and Spain.
Tough market conditions, especially in Germany which already had a highly competitive acute EHR market, was another factor impacting the market growth. The above challenges faced by Cerner were key drivers behind the deal to sell parts of Cerner’s Healthcare IT portfolio in Germany and Spain to CompuGroup Medical (CGM). Cerner will continue to maintain a presence in Spain and German acute markets via its i.s.h.med solution (originally contracted to SAP/Siemens), which was not included in the CGM agreement. i.s.h.med has also provided Cerner a footprint in several other European, African, and Asian countries such as Russia and South Africa.
In other European countries where Cerner has a Millennium footprint it has had more success, and the additional product support and development costs have been less.
Cerner has a substantial UK presence, in part owing to its legacy relationship with BT and the subsequent contracts given out under the largely failed NPfIT program. These customers do use Millennium and the company has grown this business in recent years. To date, Cerner has an installed base of 26 trusts in the UK, up from 22 in 2019, and has had success upscaling these contracts to include products such as HealtheIntent. It has also grown the number of acute trusts served. For example, in 2018 it won contracts with The Countess of Chester Hospital National Health Service Foundation Trust, previously using MEDITECH, and Sandwell and West Birmingham Hospitals. In 1Q 2020, Cerner was selected by two NHS Foundations Trusts (Ashford and St Peter’s Hospital and Royal Surrey) to implement a shared Millennium EHR system, which should support a more coordinated care approach between the two organizations.
Elsewhere in Europe, Cerner expanded its Nordic business recently with large contracts in Region Skäne and Västra Götalandsregionen (both in Sweden) during 2018 and 2019. Cerner was chosen as the preferred EMR supplier for Central Finland (four of 19 sote-areas) and will have the opportunity to expand the contract to other surrounding regions in the mid-long term. However, it lost its Norwegian footprint to Epic when it chose not to bid when the Helse Midt-Norge (Central region) contract was renewed in 2019.
The company has also seen success in the Middle East, particularly in the UAE, Qatar, and Saudi Arabia. However, growth has been more subdued over recent years. In the UAE, it has large contracts with the Ministry of Health and Prevention (MOHAP) and Abu Dhabi department of health (HAAD). Whilst Cerner already has a significant footprint in Saudi, e.g. King Faisal Hospital, the country is still relatively untapped in terms of deployment of digital solutions and offers Cerner a good future growth opportunity.
In Asia Cerner has been successful in Australia, winning state/territory-wide EHR contracts in both Queensland and New South Wales (the only vendor to win two state/territory-wide contracts), and also had success in other states/territories where procurement is decentralized. Cerner was aiming to add a third centralized Australian contract to its customer base, namely ACT Health (Capital Territory), but was unsuccessful in a head-to-head with Epic, which was selected as the chosen partner in July 2020. Cerner aims to push its PHM solution (HealtheIntent) through its existing state-level contracts where it already has a presence with Millennium.
Most of Cerner’s non-US business in the Americas is in Canada where approximately 100 hospitals are estimated to be using its solution. Here it faces competition from the other leading US vendors such as MEDITECH, Epic, Allscripts, and also local vendor Telus.
In summary, Cerner has broadly made a success of its international business. It tops the market share table in several of its international geographies and it has done this while broadly maintaining the margins achieved with its US business. However, Cerner’s divestiture of the legacy Siemens business in Germany/Spain, and withdrawal from Norway (Central region), will reduce the size of its European business. Cerner also faces an increasing threat from EMEA competitor Dedalus, whose recent acquisitions of Agfa Health’s EHR and integrated care business, and DXC’s healthcare provider business (deal to close in March 2021), could impact Cerner’s position as acute EHR market leader in EMEA moving forwards.
Allscripts’ international revenues witnessed a substantial rise in real terms (up by 34% versus 2018) and as a share of overall business in 2019. This was partly due to a strong performance in the UK with existing customer sales, and new contract wins in New Zealand, Qatar, Philippines, and Saudi Arabia. The impact of COVID-19 on Allscripts’ total revenues was comparatively significant (versus Cerner and MEDITECH), with declines of 9% and 6% respectively in 2Q 2020 and 1H 2020. It is estimated that these declines predominantly impacted North American revenues, whereas international revenues suffered to a lesser extent.
Canada had historically been its largest market outside the US accounting for just under a third of its non-US business, however, its share fell by six percentage points from 2018 to 23% in 2019, largely owing to the growth of its business in the UK and Australia, which are estimated to now be broadly similar in size to Canada.
In Canada, it is a top-five player, but lagging someway behind MEDITECH, Cerner, and Epic in terms of hospital installations. Allscripts continues to steadily grow its Canadian business with a focus on selling added functionality/upgrades to long-standing customers in three provinces (Manitoba, Saskatchewan, and New Brunswick). It aims to expand its Canadian coverage by securing the contract with Nova Scotia province in 2H 2020.
Success in EMEA was mainly driven by wins in the UK, which included two Sunrise clinical wrap contracts along with several added-value solutions for existing client systems. In May 2019, Gloucestershire Hospitals NHS Foundation Trust selected Allscripts to provide a clinical wrap around InterSystems’ PAS. This was rolled out to the entire Trusts’ inpatient wards in March 2020 and represented the fifth clinical wrap around another vendor’s PAS in the UK. In the UK it serves 18 acute trusts (only Cerner, DXC, and SystemC are estimated to serve more).
Much of the company’s UK footprint was built from its acquisition of Oasis Medical Solutions six years ago. However, it has slowly built on this foundation adding new acute trust customers and upgrading many from the legacy Oasis PAS solution to Sunrise and other Allscripts’ solutions such as dbMotion – although perhaps at a slower rate than hoped. Besides the UK and Italy (where it has one Sunrise contract) Allscripts does not have immediate plans for Sunrise expansion in mainland Europe. However, countries that are attempting to implement integrated data-sharing programs (e.g. France, Germany, and Italy), offer Allscripts potential markets for its dbMotion solution.
Allscripts also achieved growth in the Middle East, fuelled by a contract win in March 2020 with Qatar’s Alfardan Medical / Northwestern Medicine for Sunrise. Allscripts has been working on opportunities across Saudi Arabia, UAE, Oman, Qatar, and Kuwait, with different strategies for each country. For example, Oman has a relatively low level of digital healthcare maturity and is being targeted with EMR solutions, whereas relatively mature health markets (e.g. UAE and Qatar) are being targeted with PHM/dbMotion.
Its entry into the Oceania market was also largely via acquisition (Core Medical Solutions in 2016). Core Medical Solutions was a leading player in the smaller hospital and private hospital markets in Australia. Allscripts has added to this legacy with a state-wide Sunrise EHR contract in South Australia (although deployment has not been without its challenges). Sunrise has been implemented in Royal Adelaide Hospital, South Australia Health and Medical Research Center, University of Adelaide, and the University of South Australia.
In 4Q 2019 Allscripts added South Australia’s largest regional hospital network, Mt Gambier, to its coverage. It also had success selling its Sunrise solution outside of this state-wide contract (e.g. Gippsland Health Alliance in Victoria in 2018) and in 2019 its footprint expanded into New Zealand.
In terms of its broader Asian strategy, the company recently split its Asian business into two sub-businesses, ASEAN and ANZ, indicating it sees opportunities beyond its existing Singapore footprint in South East Asia. This has been supported by 2019 wins in the Philippines. In less digitally mature countries, the BOSSNet EHR solution it obtained via the Core Medical Solutions acquisition offers a potential route to offering a more entry-level EHR solution compared to Sunrise.
At just 4.0% of revenues in 2019, international remains a relatively niche business for Allscripts. To some extent the company needs to decide where it wants to take this business. Relying on organic growth in the regions it currently serves is unlikely to move the dial far from this 4.0% figure over the next five years. A significant change is likely only via acquisition, something the company has not shied from in the past. However, should it focus on cementing its position in existing markets or expansion into new? Given it is not a top-two vendor in any of its current geographies outside the US, acquisition to cement its position in existing markets would make more sense than further expansion into new geographies.
Historically, there have been two major points of entry into new geography for EHR vendors; either through a partnership to gain expertise and ‘localize’ a solution or through the acquisition of a local vendor (as with Cerner and Allscripts earlier). Both have their challenges, with partnerships often being slow to progress and acquisition resulting in the long-term support, and in some instances a significant burden of a legacy solution (e.g. Cerner is still supporting several legacy Siemens EHR solutions nearly six years after announcing its acquisition plans and most of Allscripts’ UK customers are not using Sunrise).
Examples where vendors have taken on large regional projects without sufficient ‘localization’, have often resulted in projects not meeting expectations and negatively affecting both vendors and providers alike. To some extent, Epic has suffered from this with several of its non-US deployments, in particular in the UK (e.g. Cambridge University Hospitals in 2015) and more recently in Denmark (regional contracts in the Zealand region and Capital Region) and Finland (regional contract in the Apotti Region).
Epic has not made acquisitions to enter its international markets and in all these examples EHR implementations have not met expectations and have either had to be scaled back, delayed, or required a significant amount of remedial action. The main criticism is often not enough ‘localization’ before deployment. That said Epic has had success elsewhere internationally, with less controversy surrounding its deployments in DACH, Netherlands, Middle East, and Singapore. In Canada, it is estimated to be the market leader in terms of revenues and second only to MEDITECH in terms of hospital deployments.
Epic has increased its focus on international expansion in recent years with incremental increases in revenue. However, it needs to improve on implementation/execution or future opportunities may be limited. The fact it was the only vendor to hit the preselection criteria in Norway for the Helse Midt-Norge contract which it won in 1Q 2019 (replacing Cerner) suggests that progress has perhaps been made on this front.
Historically Epic has struggled to win any Australian state/territory-wide deployments where Cerner, Allscripts, and InterSystems have been successful. However, Epic strengthened its position by winning its first state contract in July 2020 – a $151m deal for the Australian Capital Territory (ACT Health). This was also significant due to it being the first time the Capital Territory had centralized contracting.
At 12% of 2019 revenue, MEDITECH had the highest proportion of non-US sales of all the vendors analyzed in this insight. However, the overwhelming majority of this was from Canada, where it is estimated to be the market leader in terms of the number of hospital installations (although in terms of revenues it is smaller than Epic, Cerner, and Allscripts). Of approximately $60M in non-US sales in 2019, nearly $50M is estimated to have been from Canada. Non-US revenue share was down marginally from 13% in 2018 and in absolute revenues (-7%) due to a fall in Canadian revenues (-8%), whereas revenue from other international markets was marginally up (+1%).
In early 2018 MEDITECH announced the release of its cloud-based EHR, Expanse. MEDITECH has since been rolling out its cloud-based EHR to new customers and replacing its legacy hosted Magic solution for existing customers. This will ease some of the costs and time associated with implementing the solution, which should make it more competitive. In addition, the data hosted on the cloud will make it easier to drive interoperability through a Health Information Exchange, further increasing its attractiveness for provider networks.
Implementation delays caused by COVID-19 contributed toward MEDITECH’s total revenue declining by 3% in 2Q 2020 (versus 2Q 2019). However, a strong international performance in 1Q 2020 (estimated revenue up by c.25%) was driven by new Expanse installations in Canada (including Ontario Mental Health Hospital), leading to 1H 2020 revenues rising by almost 10% (versus 1H 2019).
Approximately 2% of MEDITECH’s business comes from outside North America, a trend that has remained relatively unchanged for several years. As with Epic, Cerner and Allscripts, a significant proportion of its non-American business is in other English-speaking countries, such as the UK/Ireland (22 customers in the UK and 3 in Ireland – mainly public/private sector hospitals), South Africa (24 hospitals) and Australia (72 private hospitals). In the UK it is a second-tier vendor providing EHR solutions to a small number of NHS trusts (low double-digit). Despite a concerted push into the UK, with the acquisition of Centennial (its UK distributor and system integrator) and the official formation of MEDITECH UK in 2018, the number of trusts served decreased with Cerner taking Chester NHS Trust from MEDITECH in 2018.
The company has had considerable success in Africa, selling solutions in 12 countries including Botswana, Namibia, South Africa, Kenya, Nigeria, and Uganda. In September 2019, it partnered with Aga Khan University for a new 2020 deployment of Expanse in South African and Kenya, and subsequent deployment in Pakistan. Contracts in Kuwait and the UAE result in the whole MEA region accounting for a sizable share of its non-North American business.
MEDITECH’s international business mirrors its US business to some extent. It has one of the largest installed bases of hospitals worldwide, but predominantly small hospitals, and often in countries where spend per bed is low; it is also typically not upselling beyond core EHR, meaning that its international revenues, particularly when Canada is excluded, remain small.
In Signify Research’s latest global EHR analysis, it was estimated that the US accounted for nearly two-thirds of global EHR sales in 2019, so for these four vendors it must remain the key priority. However, the US is forecast to be one of the slowest growing EHR markets over the next five years as it approaches saturation, particularly for core-EHR products in the acute market. Further, the acute market in the US has now broadly consolidated around these four vendors meaning opportunities for gains in share through replacement is increasingly rare – the long tail has gone.
The geographic expansion offers a potential avenue to drive growth. However, it is not easy and there are plenty of pitfalls. Localizing solutions, acquiring local vendors, displacing local incumbents, aligning products to match government requirements and projects, and putting in place local implementation, project management, and support teams all require significant time and investment. Because of this, the global market remains highly fragmented and market share change is slow. However, for the big four discussed in this insight, ignoring the international opportunity will significantly limit long-term growth; so despite slow and sometimes painful progress, we expect it to remain a priority.
About Arun Gill, Senior Analyst at Signify View
Arun Gil is a Senior Market Analyst at Signify Research, a UK-based market research firm focusing on health IT, digital health, and medical imaging. Arun joined Signify Research in 2019 as part of the Digital Health team focusing on EHR/EMR, integrated care technology, and telehealth. He brings with him 10 years’ experience as a Senior Market Analyst covering the consumer tech and imaging industry with Futuresource Consulting and NetGrowth Consultants.
– Brightline raises $20 million to bring its virtual behavioral
healthcare platform to kids and families across California and beyond.
– Brightline delivers integrated care through innovative
technology, virtual behavioral health services, and a collaborative care team
focused on supporting children across developmental stages and their families.
Palo Alto, CA-based provider of technology-enabled pediatric behavioral healthcare,
announced it has raised $20M in Series A funding led by Threshold Ventures and
previous investor Oak HC/FT. Leading healthcare organizations Blue Shield of
California, Blue Cross Blue Shield of Massachusetts, and Boston Children’s
Hospital joined the round, as well as SemperVirens VC, Rock Health, and City
Light Capital. In addition, the company announced the expansion of its telehealth
services to children and families across the State of California, with
additional states coming soon.
Founded in 2019, Brightline is reinventing behavioral health
care for children and families. Brightline’s treatment programs are grounded in
proven clinical methods and designed to track progress and move children
forward in their care. Their virtual behavioral health services available now
● Behavior therapy with child and adolescent psychologists
and clinical social workers
● Psychiatry evaluation and medication support, in
combination with therapy
● Speech-language therapy
● Coaching support and training for parents
● Free clinician-led classes for parents
● Digital treatment programs families can use between
● Mobile app to make it all easier
The round follows exciting news earlier this summer about
Brightline’s decision to launch four months ahead of schedule to bring urgently
needed telehealth services (including behavior therapy, psychiatry,
speech-language therapy, coaching support, and more) to families feeling the
overwhelming impact of a global pandemic on their kids. Brightline plans to use
the funds primarily to enhance its technology and innovations, expand
telehealth capabilities and treatment programs, and grow the team to support
children and families across the country.
We need behavioral health and developmental support for kids and their families more than ever,” said Naomi Allen, Brightline CEO and co-founder. “Bringing strong new investors and strategic partners into the Brightline family allows us to continue innovating on our breakthrough model of integrated clinical teams, coaching support for parents, and care through telehealth and our mobile app for families when they need it most. We’re thrilled to have an exceptional Series A investment to continue building a brighter future for families.”
– Innovaccer has recently partnered with CareSignal to
address healthcare’s urgent need amidst the COVID-19 pandemic: to create and
maintain solid, clinically actionable relationships with patients in a new set
of predominantly virtual care.
– CareSignal offers evidence-based end-to-end support services for chronic medical conditions such as asthma, CHF, COPD, diabetes, depression, hypertension, and hospital discharge support, and maternal health monitoring.
Innovaccer, Inc., and CareSignal today announce a partnership to address healthcare’s urgent need amidst the COVID-19 pandemic: to create and maintain solid, clinically actionable relationships with patients in a new setting of predominantly virtual care.
The partnership combines more than two dozen
condition-specific patient monitoring programs with population
health data insights for a more integrated care and improved clinical
outcomes with industry-leading financial returns.
CareSignal offers evidence-based end-to-end support services for chronic medical conditions such as asthma, CHF, COPD, diabetes, depression, hypertension and hospital discharge support, and maternal health monitoring. With a focus on prevention and addressing the social determinants of health, each program offers personalized clinically-validated features to deliver even more value from Innovaccer’s population health, care management, and organization-specific offerings.
“Innovaccer has always stayed on top of delivering on promises to our customers, and our partnerships with leading organizations have been instrumental in achieving 100% client satisfaction,” says Abhinav Shashank, CEO at Innovaccer. “Working with CareSignal supports our mission to help healthcare care as one. With CareSignal as our partner, we will strengthen our approach towards better patient engagement and enable smart deviceless remote patient monitoring.”