What You Should Know:
– 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.