Some of the biggest electronic health record developers are signing new agreements with tech giants as their clients look to shift workloads to the cloud.
Cerner Corp., Allscripts Healthcare Solutions and Meditech have announced new or expanded agreements in the past year with the cloud arms of Amazon, Microsoft Corp. and Google, respectively. It's part of an interest in offering new capabilities that draw insights from patient data, experts say.
"I think they're just trying to take advantage of the same thing the rest of us are," said Chuck Christian, vice president of technology and chief technology officer at Franciscan Health in Indiana.
Health systems, once hesitant to move applications to the cloud, have warmed to the idea in recent years. A cloud migration takes a hospital out of the business of operating and managing their own data center equipment, since they're moving data and applications to a network of remote servers owned and operated by another company.
More than a quarter of community and critical-access hospitals are actively assessing replacing their health information technologies with cloud-based systems, according to a survey released by Black Book Market Research in February.
"It's very client-driven," said Paddy Padmanabhan, founder and CEO of Damo Consulting, of EHR vendors' recent decisions to enter cloud partnerships. His firm works with healthcare organizations and health technology vendors. "Clients are asking for cloud-based solutions."
By contracting with a cloud provider, EHR vendors can migrate their software applications to the company's infrastructure and sell cloud-based systems directly to the customer, rather than having a hospital strike an agreement with a third-party cloud services provider who manages the EHR system in their cloud.
EHR vendors have also been enticed by a vision of using the cloud environment to build and test new capabilities. Cloud providers tend to offer advanced tools for analytics and artificial intelligence, as well as a pricing model that allows organizations to add or cut server space as needed, making them a promising environment for experimentation.
Allscripts on Monday revealed a five-year extension of an existing agreement with Microsoft, under which Allscripts will create a cloud-based version of its Sunrise EHR on Azure, Microsoft's cloud computing service.
Allscripts already hosts many of its applications that sit outside of the EHR, such as the FollowMyHealth patient engagement tool, in Azure, but the new agreement represents "more of an all-in bet" on cloud than the company had taken previously, said Paul Black, Allscripts' CEO.
It grew out of a conversation that executives at Allscripts and Microsoft had about a year and a half ago, when Allscripts realized it was "time to make a bolder move and make more of an all-in decision to get busy with truly going native on the cloud," Black said, rather than "having multiple different (database) servers being hosted by the cloud."
Allscripts officials expect the cloud-based EHR to be more cost-efficient for customers.
However, some major players are staying out of the new cloud strategy. Epic Systems Corp. has not struck exclusive or preferred partnerships with any cloud companies.
"We provide guidance to help our customers choose the best option to meet their needs—whether it's a public cloud offering or on-premises servers and storage—based on scalability, reliability and security," Seth Hain, Epic's senior vice president of research and development, said via email.
"The same considerations apply when determining cloud technologies that Epic uses for developing and running our software, including our cognitive computing platform and integrated video visits, which were both developed for and deployed directly to the public cloud," he said.
When purchasing a cloud-based EHR system, a hospital will typically pay with a subscription model. That's likely less expensive than purchasing a traditional on-premises EHR system, where a hospital would pay to license software it hosts on-site in the hospital's own data centers that it needs to maintain.
Paying for an EHR with a subscription model often comes from a customer's operational budget, rather than as a costly capital expenditure.
Meditech in October 2019 announced a similar partnership—an agreement for Google Cloud to host a cloud-based version of its Expanse EHR.
Meditech is in the midst of bringing the first customer to deploy an Expanse EHR hosted in Google's cloud live, said Scott Radner, vice president of advanced technology at Meditech. He said not all customers that purchase a cloud-based EHR will be hosted in Google Cloud; critical-access hospitals are generally still hosted in Meditech's existing private cloud.
Larger community hospitals, which tend to vary more in the amount of server space they need, will be hosted in Google Cloud.
That could change as "we get fully comfortable with the public (cloud) space," Radner said.
Meditech's and Allscripts' agreements both involves plans to develop cloud-based applications. Allscripts has said its cloud-based EHR will include additional analytics capabilities operated in the Azure cloud, as well as an avenue for third-party apps to integrate with the system.
Allscripts said its customers will begin to see those updates by year-end.
"It's making the application smarter," said Lisa Khorey, chief client delivery officer at Allscripts, of the company's cloud partnership. "It's not just about collecting data and creating a medical record, but actually using that medical record actively as a value to clinicians who are taking care of patients."
While healthcare organizations and companies have begun to embrace the cloud in recent years, the shift hasn't been without controversy.
A partnership between Ascension and Google has been plagued by privacy concerns since details first emerged about their agreement last year, despite the fact the organizations have said their work—which includes a contract to move the St. Louis-based hospital giant's patient data to Google Cloud—complies with HIPAA, as Google signed a business associate agreement.
That's in large part because Google, like other tech giants running cloud infrastructure, has been embroiled in controversies over data privacy in the consumer world.
Generally, it helps to think about storing data in the cloud like storing boxes in a storage unit, said Dr. John Halamka, president of Mayo Clinic Platform, a digital health initiative at the Rochester, Minn.-based health system. Mayo Clinic has an agreement to store data with Google Cloud, but the health system controls and authorizes who can view the data.
If you drop off moving boxes in a storage unit, "did you give (your stuff) to that company?" he asked. "No, they were just offering you a lockable storage space."
"Google, or Amazon, or Microsoft is very similar," he said. "They're offering you a lockable storage space in a building. You use it as you wish, and they provide the heat, power and lights."
Skepticism over big tech's involvement in medicine could wane over time, particularly if the companies begin to see successes and are able to point to some concrete outcomes, said Adam Seyb, a director in the healthcare practice at West Monroe.
"Quite frankly I think that's going to change over time, where people are going to be less concerned about the Amazons and the Googles having access to this data," he said, since they hold so much potential to help draw insights from data.
If an EHR vendor partners with a cloud company to develop new tools with their analytics and AI capabilities, the companies could eventually deploy shared services that help the software vendor differentiate itself in the market.
That's been a core part of the cloud strategy for Cerner, one of the most popular EHR vendors and the company contracted to build the Veterans Affairs Department's new EHR.
Cerner last July named Amazon Web Services its preferred cloud provider as part of an agreement to build out its software with new features.
When announcing the partnership last year, Cerner CEO Brent Shafer said the company's "work with Amazon and AWS is a key component for the next chapter at Cerner."
So far, Cerner has worked on projects like using a medical transcription service from AWS to develop a virtual scribe, which can "listen" in the background during a patient's visit and automatically transcribe physician-patient conversations into text. It's also running a command center dashboard on AWS that hospitals can use to predict resource needs, like bed and equipment utilization, which has proved useful amid the COVID-19 crisis.
Overall, the partnership focuses on adding new capabilities and migrating specific programs, such as Cerner's population health and device integration platforms, to the cloud. Moving the company's core EHR, Millennium, to AWS is a longer-term project that requires more engineering and development work, said Dan Devers, Cerner's senior vice president of cloud strategy.
"We're focusing on some specific use cases," Devers said. "We aren't yet at the point where the core Millennium EHR is running in the public cloud. That's a longer journey."
EHR vendors' interest in developing cloud-native tools speaks to the healthcare industry's realization that, to get the most value out of digitizing patient records, EHRs have to move beyond just keeping records, creating either a broader array of the vendors' own expanded capabilities or an avenue to more easily hook up to other applications in the market.
"I can't imagine the notion of an EHR vendor going forward into 2021 without a cloud strategy," Halamka said.