Earlier this month Oracle closed its $28.3B acquisition of Cerner and shortly after Oracle founder and CTO, Larry Ellison, outlined Oracle’s vision for Healthcare IT post-acquisition. The key elements of this vision included:
– Developing a solution for a national EHR database.
– Leveraging this solution, and similar smaller-scale connected EHR initiatives, to provide life science, pharma and other users with a rich environment for research, clinical trials and drug development.
– Leveraging the combined company’s provider customer base across ERP (legacy Oracle) and EHR (legacy Cerner) to drive new products and synergies.
– Expansion of Millennium functionality in telemedicine, disease-specific management tools, RCM, HCM and diagnostics.
The element of the vision that has captured most of the headlines since has been the national EHR plans, with most commentators correctly highlighting the challenges that would be faced with any such initiative. The last 20 years represent a graveyard of examples of similar projects with similar lofty ambitions that were announced with fanfare but were followed years later by failure. I’m from the UK and the catastrophe that was the National Program for IT (known here as “the biggest IT failure ever seen” and which had similar ambitions) is ingrained into the UK health industry’s long-term memory as a warning to all.
That said, the key thrust of Ellison’s arguments rings true. For the most part, the US is a web of siloed EHRs that are hospital/provider-centric in terms of the patient record, not patient-centric, and they do not provide the population and clinicians with a longitudinal patient health history. The same is true for most other countries and the time-honored argument that “if other industries can connect data better, why can’t healthcare?” still resonates.
A key question is, has anything changed in terms of healthcare structures and healthcare IT in recent years that make the viability of a national EHR overlay any more likely?
To some extent, yes, there have been several developments over recent years that have chipped away at some of the barriers.
The Affordable Care Act (ACA), while itself now more than a decade old, has changed healthcare structures and the technology deployed significantly. There is already more integration in the provision of healthcare and the associated IT across the US. The rapid rise of IDNs, ACOs and consolidation of healthcare providers has spurred greater IT integration, particularly in relation to patient records at a health system level. While the journey is far from complete, e.g. a huge proportion of EHR installations are still siloed, some of the barriers have come down with HIE, PHM and data integration tools being offered by companies like Health Catalyst, Innovaccer, InterSystems, Lyniate, AWS, Google, Redox, Epic and Oracle Cerner itself. These already connect EHRs and other associated health care IT at regional/health system levels, providing a summary EHR overlay.
The ACA, and earlier initiatives, also spurred the rollout of regional HIEs across parts of the US over the last decade. These are, in essence, watered-down versions of regional EHRs, and depending on the sophistication of the technology deployed and ambitions of the HIE scope, do serve to some extent in supporting shared access to patient data across organizations.
However, issues relating to interoperability, ability to integrate HIE data back into a provider-specific EHR, depth of information exchange, level of provider participation and information latency have limited the usefulness of these HIEs resulting in them failing to really take hold in large parts of the US. Further, health system participation in HIEs has also been patchy with some choosing to only participate in HIEs where other participants are using the same vendor for their EHR or only participating in systems with allied groups.
However, they do offer at least a starting blueprint for greater data sharing, and with next-generation HIE deployment on the horizon, this could offer a conduit for Oracle Cerner and its national EHR ambitions.
Internationally there are pockets of success in terms of countries adopting a national EHR database whilst still using local instances of an EHR for provider operational use. Examples tend to be in small- or mid-size economies, with notable success in the Nordics (e.g. Kanta in Finland). However, for every successful model, there are usually two or more failed or stalled models where the system has not succeeded, or fallen significantly short of the original vision (e.g. Australia, New Zealand, and the UK attempt mentioned above).
Why Oracle Cerner?
Even if the barriers to creating a national EHR overlay from a technology, demand, privacy, logistics and integration perspective can be overcome, Oracle Cerner is not the only company that could support deployment from a technology perspective. Many other vendors offer solutions for aggregating multi-vendor, cross-setting EHR data into a longitudinal record such as those listed earlier.
InterSystems already has some experience doing this at a national level in the US to some extent via its contract to provide the underlying technology (HealthShare) for the eHealth Exchange (effectively a national network of regional HIEs covering 77% of state/regional HIEs, and 75% of hospitals). This is less of a national EHR and more of a national system for exchanging patient data, but nonetheless offers a real-world example of a solution aimed at addressing the siloed nature of EHRs and patient data at a national level.
That said, Oracle Cerner is in a strong position in terms of credentials given its large installed base of US hospital customers already using its EHR (second only to Epic) and its installed base of ambulatory and primary care EHR customers (although its share is much smaller here compared to the hospital market).
Further, it has experience in deploying solutions to connect providers’ individual EHR instances having deployed HealtheIntent (its current solution to support system-wide summary care records) to more than 200 customers across the US. Here in the UK, HealtheIntent has been used to support connecting approximately a quarter of regional Integrated Care Systems (ICSs) and their associated providers, providing summary patient care records of the type Ellison envisions, but at a regional rather than a national level.
However, Oracle Cerner did not share, and cannot yet confirm, whether HealtheIntent will be the foundation technology for any national EHR database. It is still not yet clear whether the strategy will be to develop HealtheIntent for this purpose, develop a new solution or look to extend the connectivity functionality of Millennium.
HealtheIntent would seem the obvious foundation, given its current main use-case is integrating data from disparate EHRs, vendors, and settings; exactly what the company says it wants to do at a national level. However, scaling to this extent would be a significant step beyond its original design.
Headline Grabbing Opportunity Versus Real Revenue Opportunity?
At the start of this insight, I stated that Larry Ellison had outlined several elements of Oracle’s vision for Healthcare IT post the Cerner acquisition.
The national EHR database was one, but Ellison also highlighted using the national EHR, or similar, smaller-scale connected EHR initiatives, and the data that resides in the underlying systems to provide life science, pharma, and other users with a rich environment for research, clinical trials, and drug development.
Is this the real story and the real focus for Oracle Cerner in terms of new revenue-generating business?
It’s less headline-grabbing than the national EHR database, so understandable why Oracle Cerner led with that, but the obstacles for success are significantly lower and potential revenue higher and more immediate.
A national EHR may be the ultimate vision for Oracle Cerner, but the more immediate value and the more achievable short-term goal would be from the aggregation of Cerner’s (anonymized) in-house patient data to support this business opportunity. Cerner had started to head down this route already before the Oracle deal, as had many of its competitors.
This would not require the database to be national, indeed this could be something offered using Oracle Cerner’s existing connections and data, with the value incrementally increasing as the network broadened and potentially one day reached a national level.
The national EHR announcement may have worked best to grab headlines and prompt analysis such as this insight, but an increased emphasis on connecting and commercializing Cerner’s repository of patient data to support life science, pharma and research, is likely to ultimately prove the “real announcement”.
About Alex Green
Alex Green is the Director and Principal Analyst at Signify Research, a UK-based market research firm focusing on health IT, digital health, and medical imaging. Alex is responsible for leading Signify Research’s Digital Health market intelligence portfolio, initially developing its coverage of the patient engagement platforms and portals market.