Despite ending 2018 with a slow Q4, the outlook for technology services in healthcare remains strong, with opportunities in the provider space, robust M&A activity, newly introduced U.S. operations by India heritage firms, and more. The WITCH Report is a comprehensive review of the financial and market performance of global technology firms in healthcare and transaction insight of the sector’s biggest consulting firms.
Damo Consulting announces the annual review of major global technology consulting firms in healthcare. Titled “The WITCH Report” the report includes a comprehensive review of the financial and market performance of 11 global technology consulting firms in healthcare. The report provides a detailed review of market performance metrics, insights and dealings of major global technology firms, including Wipro, Infosys, TCS, Cognizant Technology Solutions and HCL (WITCH).
Aspects covered in the WITCH Report include financial performance, mergers and acquisitions, customer wins, strategic partnerships, new product initiatives and leadership announcements.
“The HLS business of all companies covered in this report contains a mixture of offerings, from infrastructure and applications services to business process services and in a couple of cases, IP and platform-based services. While the provider segment has long been a challenge for global IT consulting firms for a variety of reasons, we believe there are emerging opportunities in the provider space from digital transformation initiatives and cost reduction pressures, leading to IT operations outsourcing.”
The WITCH Report also provides additional insight on each featured company’s growth strategy. M & A activity continues to be robust. DXC, Cognizant and HCL have been the most active in the space. Many India-heritage firms have also set up operations centers and innovation hubs across the U.S. to be closer to customers with local talent and the need to tap into scarce skills such as design thinking which are important for digital transformation programs.
“The demand outlook for healthcare remains strong and broad-based. Most firms in this report are deriving their revenues currently from the payer and pharma segments, leaving a huge untapped opportunity in the provider space. As providers start to embrace outsourcing and invest more in digital transformation, global IT consulting firms will see a significant growth opportunity,” says Paddy Padmanabhan.
The cornucopia that is the annual HIMSS conference and tradeshow – healthcare technology’s biggest event – is behind us, but what’s left in the wake is wonderful, inspiring even, if not a bit overwhelming. The reactions to this year’s event have been overwhelmingly positive. Interoperability in the form of data sharing and a ban on patient health information blocking by CMS (through proposed rules released the first day of HIMSS) set the tone.
This was followed by CMS administrator Seema Verma taking a strong tone in all of her presentations at HIMSS, with the media and during her keynote speech. The federal body made it clear that data generated from patient care is, unequivocally, their data. While these themes heavily influenced the show, there were other takeaways.
There are many other diverse opinions about what came out at HIMSS19 and the themes that will affect healthcare in the year ahead. For some additional perspective, I turned to healthcare’s thought leaders; people who are a lot smarter than I. Their responses follow. That said, did we miss anything in the following?
Dr. Geeta Nayyar, Femwell Group Health and TopLine MD
After spending a week surrounded by some of the most intellectual and innovative minds globally in healthcare at HIMSS19, I’m even more confident that the shift toward patient engagement mass adoption is well underway and ON FHIR. The new CMS/ONC proposed law around interoperability and penalties for “information blocking,” are both touchdowns for the quarterback, which remains to be patient engagement. The robust discussions during the pre-conference HIMSS patient engagement program, reflected a move to a consumer-centric approach evidenced by the presence of Amazon, Google and Microsoft at the show. The keynote by Premier’s CEO Susan Devore shared a consumer-centered, provider led vision, “with data flowing seamlessly and being analyzed and effectively leveraged to guide decision making at the point of care.” Collaboration in healthcare is the key to everyone’s success. I was inspired to see her and so many women coming together to support each other in HIT, as Dr. Mom remains the healthcare decision maker in the households, we are all ultimately trying to reach.
Andrew Schall, Modernizing Medicine
Physician burnout continues to be a hot topic coming out of HIMSS19 and many feel that EHR platforms may be a part of the burnout epidemic. There were several sessions that focused on user-centered design at HIMSS this year including one that focused on the iterative approach to software development and user experience. First, I think that the industry is recognizing that one-size-fits doesn’t work for EHRs. Additionally, I believe that improvements will come in large part from the greater involvement of practicing physicians in designing specialty-specific EHR workflows and interfaces. A combination of powerful technology like AI and augmented intelligence, as well as well-designed EHR solutions with an intuitive user interface and user experience, will help ease the physician burden and automate time-consuming and administrative tasks like coding and billing – ultimately reducing burnout.
Shane Whitlatch, FairWarning
HIMSS 2019 showcased the ongoing digital transformation to make healthcare responsive to patients across a continuum of care. Enabling patients to be able to access, use and own their personal health data, while ensuring privacy and security was the central takeaway of this year’s HIMSS. Notable, critical moves to support this goal included: the Department of Health and Human Services announced proposed rules to enhance interoperability and data access with payor data; ongoing security and privacy efforts to ensure appropriate patient access to their data while mitigating emerging risks from items including medical devices to nation-state attackers; and artificial intelligence and machine learning initiatives to effectively manage the tsunami of data in healthcare while promoting optimal healthcare.
Tripp Peake, LRVHealth
The best part of HIMSS this year was we seemed to get away from a single buzzword. Healthcare is hard, there’s no silver bullet. The Precision Medicine Summit got into the weeds about how to really roll out a program in a provider system. The AI companies stopped talking about AI for AI sake and were more focused on ROI. Everyone seemed more balanced about VBC: yes, inevitable, but also gradual. Consumerism was probably as close to a central theme as existed. And I continue to be excited about the energy, creativity, and commitment of the entrepreneurs in this market.
Don Woodlock, InterSystems
Anytime you bring 43,000 healthcare professionals together in one location, you will never have a shortage of opinions on the future of the industry. We are at the cusp of a revolution in healthcare, driven by technological advancements. Some key trends we saw at HIMSS19 were, no surprise, around artificial intelligence, where people are trying to enhance predictive risk scoring and improve patient engagement. Additionally, there were profound announcements around mandating application programming interface (APIs) to improve the flow of healthcare data across the ecosystem. As interoperability becomes liquid, it will become the critical component of every healthcare system, driving the industry to new heights.
Paddy Padmanabhan, Damo Consulting
On day one of the conference, the HHS sucked the oxygen out of the room by dropping a proposed 800-page rule on data and interoperability. The rule aims to aggressively expand interoperability by making it mandatory for providers and health plans participating in government programs such as Medicare Advantage, CHIP and others to make patient data available to patients as a condition for business. CMS head Seema Verma and ONC Chief Don Rucker drove the message home repeatedly during the conference. Indeed, Seema Verma declared it an epic misunderstanding that patient data can belong to anyone other than the patient. A somewhat sobering counterpoint was voiced by Epic Systems CEO Judy Faulkner in a media interview where she suggested that interoperability challenges go well beyond data sharing by EHR vendors. Regardless of where it may fall, interoperability will continue to dominate healthcare IT agenda for some time to come. Related issues around new and emerging data sources, especially social determinants of health, will gain prominence in the coming months.
Erin Benson, LexisNexis Health Care
The proposed rule on interoperability of health information influenced most conversations at HIMSS. In the context of cybersecurity, the rule served as a reminder that it’s just as important to let “good guys” in quickly and seamlessly as it is to prevent unauthorized access. We want to enable value-based care and give patients the ability to manage their own health by having access to their records. We also want to keep costs low and efficiency high by enabling interoperability and giving partners, vendors and employees necessary access to systems. Therefore, a cybersecurity strategy needs to strike a balance between user engagement and data security.
Mike Morgan, Updox
The power of consumerism is really impacting healthcare and the need for patient engagement is alive and well. Providers across the board must look at new technologies and ways to redefine patient engagement to better communicate with patients and partners but do it via channels that are easy for staff and customers to use. New applications, such as telehealth and secure text messaging, have changed how healthcare communicates and consumers are demanding that immediate, convenient engagement.
Vince Vickers, KPMG
HIMSS19 seemed to have the most decision makers at the conference in five-plus years when a lot of healthcare organizations were still looking at implementing electronic health records. We might be ready for another wave of healthcare IT investment after healthcare organizations digested those investments made in electronic health records. The key is now around optimizing EHRs – interoperability, improving ease of use, enhancing analytics — or dedicating resources to enterprise resource planning (ERP) systems to make themselves more efficient in the back office. We’re also seeing healthcare organizations position themselves to be more consumer-oriented, partly to address new entries from some of the tech companies, such as Google, Amazon, Microsoft, and a multitude of others, that wanted to make a big splash at HIMSS.
Damo Consulting, a healthcare growth and digital transformation advisory firm based in Chicago, recently released its third annual Healthcare IT Demand Survey report. The report indicates technology vendors will continue to struggle with long sales cycles as they aggressively market digital and AI. For the second year in a row, the rise of non-traditional players, such as Amazon and Google, will have a strong impact on the competitive environment among technology vendors while EHR vendors grow in dominance.
Top spending priorities for healthcare executives are digital, advanced analytics and AI. However, spending on EHR systems will dominate technology spending budget in 2019. Healthcare executives continue to be confused by the buzz around AI and digital and struggle to make sense of the changing landscape of who is playing what role and the blurred lines of capabilities and competition.
“Digital and AI are emerging as critical areas for technology spend among healthcare enterprises in 2019. However, healthcare executives are realistic around their technology needs vs. their need to improve care delivery. They find the currently available digital health solutions in the market are not very mature,” says Paddy Padmanabhan, CEO Damo Consulting. “However, they are also more upbeat about the overall IT spend growth than their technology vendors.”
The top spending priorities for healthcare executives are digital, advanced analytics, and AI. EHR systems will dominate technology spending budgets, even as the focus turns to digital analytics.
IT budgets are expected to grow by 20% or more. Healthcare executives are more upbeat about IT spend growth than vendors.
Healthcare executives say they are confused by the buzz around AI and digital. They are also struggling to make sense of the changing landscape of who is playing what role and the blurred lines of capabilities and competition.
Cybersecurity issues are a challenge for 2019 in the healthcare sector, but not the biggest driver of technology spending or the top area of focus for health systems in 2019.
The CIO remains the most important buyer for technology vendors, however IT budgets are now sitting with multiple stakeholders.
The biggest challenge for technology vendors is long cycles, along with product/service differentiation and brand visibility.
The rise of non-traditional players, such as Amazon, Apple, and Google will have a strong impact on the competitive healthcare technology environment. Deeply entrenched EHR vendors such as Epic and Cerner will grow in dominance.
Global IT consulting firms, especially those with an India heritage, have had a long run at high growth rates, fueled by one idea: Outsourcing information technology (IT) operations to countries with low labor costs and a skilled engineering talent pool with a strong English language proficiency offered a huge arbitrage opportunity. The Indian IT services industry monetized this idea with a single-minded focus over the past 25 years and is now estimated to be more than $150 billion. Over the past decade or so, many western multi-national firms, including end-user clients for these companies, have jumped on the labor arbitrage model.
My firm has been focusing on how global technology consulting firms have been doing in the healthcare markets, and reviewing their financial and operating performance since 2015. Our latest mid-year review of 11 publicly held global technology consulting firms indicates that organic growth from the healthcare vertical is trailing overall company growth for most consulting firms, and is slowing down relative to previous quarters. Three of the 11 firms we cover in our report have seen leadership exits for the healthcare business, and the Board of Directors of one high-profile firm is looking to replace its CEO. No major contract signing in healthcare has been reported by any of the firms.
Where is the whole sector headed next? No one knows for sure, but the labor arbitrage model is now surely past its sell-by date. The question therefore is: what’s the next killer app for global IT consulting firms ?
If one were to go by the term most-often used by these firms in earnings calls, annual reports, and marketing messages, it would seem that the new killer app goes by the all-encompassing name of “digital.”
However, unlike a clear concept like low cost labor, digital is much harder to understand. In much the same way as that other overused term – artificial intelligence or AI — the technology vendor market has whipped itself up into a frenzy of “digital” offerings, with each firm defining “digital” in its own way.
However, the global IT consulting firms, and in particular the India heritage firms, seem to discuss a common theme when referring to digital. They are mostly referring to automation when they say digital. These firms are betting on intelligent automation (IA) as the killer app for the future of their business model.
Consulting firm KPMG has released a report declaring that IA is fueling the next generation of outsourcing. As IT operations move to the cloud, automation targets the same IT operations that substituted high-cost labor pools a generation ago, and is eliminating the low-cost pools with even lower cost robots a.k.a robotic process automation or RPA. The implications are like a double-edged sword: Automation is a new revenue opportunity, but it is one that necessarily cannibalizes a current revenue opportunity. The implications reach far beyond the board rooms of multi-billion dollar tech firms, and raise questions about a low-cost labor-pool based model of IT services.
In other words, the killer app of tomorrow is killing the jobs of yesterday, a fact that the KPMG report delicately refers to as a “negative though not significant (at least in the near term) impact on the use of traditional outsourcing and shared services.” However, the Schumpeterian principle of creative destruction may be at play here, with an entirely new class of jobs and entirely new revenue opportunities on the horizon arising from the increasing savings and efficiencies brought about by automation.
That was the subject line of the message from Lantern, a behavioral health startup whose app and coaching services I had used for a while. Lantern’s letter stated it is shuttering its business on August 1, helpfully offering to continue the coaching services for a limited period and pointing to other resources for those who relied on its services for six years since it started. News reports say Lantern is laying off 25 employees after failing to find a buyer for the company.
Firstly, I want to say this to the folks at Lantern: I’m sad we have to say goodbye. Although I had ceased to use the app a while back, I had developed a relationship with my personal behavioral coach who checked in with me regularly to see how I was doing with my meditation practice, often prodding me with a gentle nudge when I missed reporting on my sessions. I had the benefit of several conversations with my coach who was helpful, understanding and skilled at her work. Despite my short relationship with Lantern, I felt a positive impact on my well-being through regular meditation and mindfulness.
I came to know about Lantern back in December 2016 when I shared a stage as a speaker at an industry event with one of their executives. Back then, behavioral health was getting recognized as a $280 billion problem, which I wrote about after the Senate Health Committee announced the Mental Health Reform Act. Behavioral health is a complicated and expensive issue in U.S healthcare, which consulting firm McKinsey estimated affected 20 percent of the U.S population and was significantly underfunded in terms of treatment infrastructure.
In late 2016, there were more than 200 behavioral health startups, all of whom were responding to a brewing mental health crisis, and a favorable legislative and funding environment. Lantern was one of the highly visible ones, raising $17 million in series A money from marquee names, such as UPMC, Stanford University and Mayfield Ventures. The opioid epidemic and the exacerbation of related mental health issues was about to explode into public consciousness. Health insurance companies, faced with increasing costs for mental health and substance abuse, had started taking an interest in these startups. High profile partnerships were announced, such as the one between Highmark BCBS and Quartet. For a while, behavioral health seemed like a sure shot.
So what went wrong?
I’m sure the folks at Lantern and their VCs are pondering the question hard. However, back when I wrote about it, the signs of trouble were already visible. The Lantern executive I met at the time indicated that the lack of a reimbursement model for behavioral health was a huge challenge for growth. In healthcare, as we know, following the money is a prerequisite for success. The Department of Health and Human Services (HHS) had thrown $44.5 million at the problem, a drop in the ocean relative to the size of the problem.
Even for those who had access to funding, finding and recruiting trained clinicians with experience in behavioral health was a massive challenge.
Many startups, looking to stay outside the purview of regulation, tried to sidestep the FDA and go straight to employers and consumers (an expensive mistake that many failed digital health startups have learned the hard way).
Eventually, these problems had to come to a head. Lantern’s sad demise, brought about by a lack of ability to scale, and a lack of interest from the same insurance companies who were bullish on the sector two years ago, tells us that a business model with no revenue model has limited chances of success.
Is behavioral health dead then? Perhaps not. Many new telehealth companies, such as Teladoc, now offer behavioral health services. The CMS’s new rule to boost telehealth payments could be a shot in the arm that revives the fortunes of struggling behavioral health startups.
The digitization of healthcare records across the nation over the past several years has created an electronic backbone for patient data that is in the early stages of getting unlocked for value. However, as we have seen in the past couple of years, technology-led change is slow to take hold in healthcare, and the policy uncertainty of the previous year has meant that healthcare enterprises have been cautious with technology investments.
In my latest book “The Big Unlock,” I discuss the competitive forces within the healthcare technology provider landscape, which I have classified into four major categories: The custodians are the dominant electronic health record (EHR) vendors who have the data and the workflow. The enablers have built platforms that they hope will be used by the enterprises as well as other technology providers to develop new digital health experiences. The arbitrageurs are solutions and services firms that rely on global labor pools, and increased automation, to deliver technology-enabled services at lower costs. The innovators are developing new ways to provide healthcare experiences, and are often venture capital funded startups.
These categories are not watertight compartments, but indicate a dominant business model for a particular type of solution provider. Vendors in each of these groups face challenges related to organic growth within their space and competitive pressures from other incumbents as well as new entrants. In response, technology providers in a specific category are also trying to expand into different categories, examples being EHR vendors who are building out advanced analytics and digital capabilities. All incumbents face threats from emerging non-traditional sources of competition: Amazon, with its blockbuster Amazon Web Services (AWS) business, is reportedly considering an entry into the pharmaceuticals distribution space, while Apple is getting deeper into digital health space, leveraging its vast consumer base of iPhone and Apple Watch users. Large healthcare enterprises, such as UPMC and Quest Diagnostics, are getting into the technology solutions space, either by leveraging proprietary data or by investing in startups through innovation programs. Health plan major Cigna’s recent acquisition of digital health firm Brighter is an example of the lines blurring between technology providers and enterprises.
Gartner has estimated that some 6.4 billion connected things will be in use by the end of 2016, with some 5.5 million new things getting connected every day. There’s been a clear boom in health and fitness wearables, with healthcare consumers investing in tracking devices – sometimes with their employer’s encouragement – and the MedTech industry has jumped on this in a big way.
Fascinating IoT applications are being developed today, often through unlikely partnerships. For example, medical devices company Medtronic is developing an application that transmits wearables data to the IBM Watson cognitive computing and predictive analytics platform. And Swiss pharma company Novartis is joining hands with Qualcomm to develop an internet-connected inhaler that can send information to a cloud-based big data analytics platform for healthcare providers to use in treating patients. These are exciting examples of how technology and analytics can support personalized medicine.
However, there are a couple of big issues that the IoT movement has to contend with when it comes to the Medical Internet of Things (IoT). These issues concern us as consumers, and they also concern our employers and our healthcare providers equally.
Data security: The medtech industry is widely seen as unprepared for the security risk and vulnerability to hacking that their devices can cause for the rest of the healthcare system. This has immediate repercussions for consumers who may be unaware of the exposure of their personal medical information to cybercriminals. In addition, as healthcare providers start using medical information from these interconnected devices in a cloud-based environment, their enterprise IT, specifically electronic health record (EHR) systems, could be seriously compromised and vulnerable to hackers. And this brings us to the other, emerging issue that is beginning to get some attention in the exchange of IoT data.
Privacy and legal concerns: While there are undisputable benefits for healthcare consumers as physicians gain access to medical information from a range of connected devices, there is a real threat to privacy as well. We start with the question of who owns the data. State law in the U.S varies when it comes to this question, and device makers and other software providers may lay claim to the data which can be used against consumers. At the same time, collecting personal data through devices imposes a set of legal requirements on enterprises, starting with proper disclosures about the collection and use of the information.
After years of underinvestment, CIO’s in healthcare may have something to cheer about this year. The biggest trend seems to be the increased focus and investment in IT in healthcare enterprises. With more than $30 billion invested in electronic health record (EHR) systems, and meaningful use (MU) requirements out of the way, we are seeing enterprises turn toward the more strategic aspects of IT in the ongoing transformation of the healthcare sector.
These investments, however, will follow the money. In other words, funding will focus on initiatives that have the biggest impact in terms of revenues, cost avoidance, and transformative potential. A recent survey by technology provider Healthedge suggests that investments among payers will be targeted at selective enhancements to the most critical systems that support business development, and not a wholesale upgrade of IT. Here are a few of the top investment areas across healthcare:
Population Health Management (PHM): Everybody is on board with the concept of PHM as the defining principle in an outcomes-based business model. However, PHM has eluded a consistent definition, other than that its desired impact is to reduce overall costs of patient populations, and improve clinical outcomes. Analytics has been an important aspect of this discussion, however standalone analytics solutions have struggled to demonstrate value, and progress on advanced analytics involving predictive models and cognitive sciences has been slow. This year may change all of that. Many standalone analytics companies are likely to be acquired, and IBM Watson will gain more traction. M & A in healthcare will drive PHM as well.
Information Security: With healthcare data breaches at over 112 million in 2015, including high-profile breaches at Anthem, Premera, and Excellus, IT security is now a CEO level issue. There is no doubt what this means – investments in data security technologies are going to increase. However, there is no guarantee that data breaches will not increase.
Healthcare Consumerism: Changing demographics and unexpected increases in the costs of health insurance are driving the consumerization of healthcare today. Silicon Valley startups, flush with VC money, are coming up with direct-to-consumer approaches that are making traditional healthcare firms sit up and take notice. At the same time, the newly awakened healthcare consumer is also demanding information and price transparency. New York Presbyterian has launched a patient-first marketing strategy aimed at improving engagement with patients through information sharing, and is revamping its website completely. BCBS of NC has already released the cat among the pigeons by publishing price data (and is facing pushback from its provider network). IT investments will now be focused on maximizing the reach and value of the information to empower consumers to make the right choices.