Health Catalyst - Earnings Call - Q4 2019

Transcript

Speaker 0

Ladies and gentlemen, thank you for standing by, and welcome to Health Catalyst Fourth Quarter twenty nineteen Earnings Call. At this time, all participants are in a listen only mode. After the speaker presentation, there will be a question and answer session. Please be advised that today's conference is being recorded. I would now like to hand the conference over to your host, Senior Vice President, Investor Relations, Adam Brown.

Sir, please go ahead.

Speaker 1

Good afternoon, and welcome to Health Catalyst's earnings conference call for the fourth quarter of twenty nineteen, which ended on December 3139. My name is Adam Brown. I'm the Senior Vice President of Investor Relations for Health Catalyst. And with me on the call is Dan Burton, Health Catalyst's Chief Executive Officer and Patrick Nelly, Health Catalyst's Chief Financial Officer. A complete disclosure of our results can be found in our press release issued today as well as in our related Form eight ks furnished to the SEC, both of which are available on the Investor Relations section of our website at ir.healthcatalyst.com.

As a reminder, today's call is being recorded and a replay will be available following the conclusion of the call. During the call, we will make forward looking statements pursuant to the Safe Harbor provisions of the Private Securities Litigation Reform Act of 1995 regarding trends, strategies and anticipated performance of the business. These forward looking statements are based on management's current views and expectations as of today and should not be relied upon as representing our views of any subsequent date. We disclaim any obligation to update any forward looking statements or outlook. Actual results may differ materially.

Please refer to the risk factors in our Form 10 Q for Q3 filed with the SEC on November 1339 and our Form 10 ks for the full year 2019 that will be filed with the SEC. We will also refer to certain non GAAP financial measures to provide additional information to investors. A reconciliation of these non GAAP measures to their most comparable GAAP measures is provided in our press release. During the call, we may offer incremental metrics to provide greater insights into the dynamics of our business. These details may be one time in nature and we may or may not provide updates in the future.

With that, let me turn the call over to Dan for his prepared remarks and then Patrick will provide his prepared remarks as well as provide our outlook for Q1 and the full year 2020. Dan and Patrick will then take your questions. Dan? Thank you, Adam. And thank you to everyone who has joined us this afternoon.

We are excited to share our fourth quarter and full year twenty nineteen financial performance along with the other highlights from the quarter.

Speaker 2

First, on our fourth quarter and full year twenty nineteen financial results, I'm pleased with our performance across the board. To start, I am happy to report that our total revenue for 2019 was $43,500,000 This represents an outperformance relative to the midpoint of our guidance and results in 21% growth relative to the fourth quarter twenty eighteen. Total adjusted gross margin in the fourth quarter was 51.2%, which compares favorably to 48.6% in the fourth quarter of twenty eighteen. And our Q4 twenty nineteen adjusted EBITDA was a loss of $6,500,000 which represents an outperformance relative to the midpoint of our guidance and shows meaningful improvement from a loss of $9,400,000 for the same period in the prior year. Translating this to full year 2019 results, total revenue was $154,900,000 representing 38% annual growth.

Total adjusted gross margin for 2019 was 52.2%, an increase of roughly four thirty basis points compared to 2018. And full year 2019 adjusted EBITDA was a loss of $27,400,000 a meaningful improvement from a loss of 38,100,000 in 2018. Now let me transition to some of the highlights from the quarter. You'll recall from our last earnings call that we measure our company's performance in three primary strategic objective categories of improvement, growth and scale. And we'll discuss our fourth quarter results with you in each of these three categories.

The first category improvement is focused on evaluating our ability to enable massive measurable improvements for our customers while sustaining industry leading satisfaction and engagement. First, I'm pleased to report that the number of documented improvements achieved with our customers accelerated meaningfully in 2019. For the full year 2019, we achieved nearly 700 customer verified documented improvements. This total is more than 2.5 times greater than the total number of improvements achieved in 2018. In our view, this significant growth in customer verified improvements is evidence of the Health Catalyst flywheel accelerating throughout our customer base.

I would now like to highlight two examples of documented improvements from recently published case studies. First, UnityPoint Health leveraged our solution to integrate the necessary data and subsequently monitor and analyze the utilization of its blood products, including the development of a predictive model to risk adjust blood utilization specific to patient case mix. This resulted in more than 17,000,000 in direct cost savings over six years as a result of decreasing unnecessary transfusions. Next, Billings Clinic leveraged our solution to integrate its data across numerous source systems and enable its users to dynamically author, manage, view and publish more than 400 populations for regular reporting, regulatory reporting and improvement initiatives. Data quality and timeliness and self-service analytics have improved dramatically as demonstrated by a 27% reduction in analytics service requests.

We'd encourage you to please visit our website to view hundreds of documented customer case studies. Next, within the improvement category, I'd like to highlight our team member engagement. Every six months, we utilize the Gallup organization to measure our team members' engagement levels. In our most recent results, we achieved well into the ninety ninth percentile. While we have consistently ranked between the ninety fifth and ninety ninth percentile in overall employee satisfaction scores, this past period score was the highest in the history of our company.

I am particularly pleased with these results as our team members had expressed concerns that as Health Catalyst became a public company, we as a leadership team might reduce our focus on team member engagement. We as a leadership team took specific steps to ensure that team member engagement remained our highest priority through the company's public market transition as it enables us to recruit and retain the best talent in the world and ultimately those team members enable our customers to drive massive measurable data informed improvements. Lastly, under the category of improvement, I'd share that we are happy to see accelerated adoption and utilization of our analytics applications as they have continued to mature. As a reminder, our analytics applications are the newest part of our technology stack with their development occurring within the last few years. As these applications have continued to mature, we are pleased with the resultant adoption rates.

To highlight one example, one of our longest tenured customers who is one of the heaviest users of our data platform nearly doubled their number of users of our analytics applications from 2018 to 2019, both from deepening its use cases with existing applications and adopting new applications. Our next performance measurement category is growth, which we define as adding new customers while also deepening existing customer relationships. Within this category, I'd first like to share our performance on our annual growth key metrics. On DOS subscription customers, we ended 2018 with 50 and we saw the addition of 15 net new customers in 2019, bringing our 2019 ending total to 65 DOS subscription customers. These results are slightly better than what we had anticipated.

As some additional color, approximately 70% of our DOS subscription customer base continues to utilize our all access contracting model. Additionally, the 2019 total is inclusive of three Medicity customers who became DOS subscription customers. It is important to note, however, that two of those three cross sell customers were already in the Health Catalyst pipeline. On our other annual growth key metric, I am pleased to report that we achieved 109% dollar based retention in 2019. This compares to a dollar based retention of 107% in 2018.

As a reminder, this metric excludes our Medicity customer base. Related to this metric, I would also share that we were pleased with the growth across our customer base. I also want to highlight that we achieved an expansion to greater than $10,000,000 of annual recurring revenue during 2019 with one of our customers for the first time in the company's history. We view this achievement as a sign of the pathway we have with our customers to meaningfully deepen and expand our relationships with them over time. Under the category of growth, I'd share two other themes that we saw emerge in 2019.

First, we continued to see evidence that we are in the early stages of digital transformation within healthcare. We partially measure this through the framework of our healthcare analytics adoption model. Our Chief Technology Officer, Dale Sanders, in association with HIMSS developed this model a number of years ago, which measures the analytics maturity of a healthcare organization. The lower levels of the healthcare analytics adoption model focus on more basic data infrastructure and administrative and operational efficiencies, while the later stages focus more on predictive and prescriptive analytics supplemented by artificial intelligence. In 2019, we continue to see that most healthcare organizations reside in the lower levels of analytics adoption and are seeking the help of a partner who can enable the automation of many basic data infrastructure, administrative and operational tasks, which have been largely manual processes to date.

Over the last decade, we've acted as a trusted and experienced partner bringing to bear the data infrastructure and applications technology along with the services expertise needed to enable greater efficiency. Ultimately, this partnership results in increasingly meaningful clinical, financial and operational improvements for our customers. In this vein, we've seen an emerging trend of greater demand for outsourced technology enabled services where a customer will choose to utilize Health Catalyst to take over an entire function within their organization, usually at the lower levels of the analytics adoption model. The size and scope of these relationships makes them extremely sticky as we bring to bear our technology and our services expertise to more efficiently run that customer's outsourced function. The other growth theme we saw emerge in 2019 was our increased ability to help our customers achieve financial and operational improvements.

As healthcare organizations continue to see margin pressures, we focused much of our R and D over the last few years on developing technology and services to better help our customers achieve financial and operational improvements. In 2019, we saw our solution further resonating with CFOs and CIOs as they look for a partner to help them operate in an increasingly more challenging financial environment. In particular, we were pleased to see increased adoption of our activity based costing solution, Corus, within our existing customer base as well as the driver of new sales opportunities. Likewise, we view the signing of Steward Healthcare, the largest private for profit physician led healthcare network in The United States as a meaningful data point that our technology and services offering is resonating with CFOs and CIOs. Lastly, I'd like to share a few comments on our recent acquisition of Able Health, which we are happy to announce is officially closed.

Able Health is a leading SaaS provider of quality and regulatory measurement tracking and reporting to healthcare providers and risk bearing entities. This acquisition will enhance Health Catalyst's quality and regulatory measures capabilities and we believe it will further demonstrate Health Catalyst's ability to integrate and scale software applications. Of particular importance and excitement is the strong mission and cultural alignment with the Able Health team. We are thrilled to have Rachel Katz, Steve Daniels and the remainder of their talented and diverse team join Health Catalyst in continuing our mission to be the catalyst for massive measurable data informed healthcare improvement. Now I'll turn the call over to Patrick, who will review our performance in the category of scale, including providing a detailed view of our fourth quarter and full year 2019 financial results and our outlook for Q1 and the full year 2020.

Patrick?

Speaker 3

Thank you, Dan. As Dan mentioned, I will be discussing our company's performance in the strategic objective category of scale. This category focuses on enabling greater contribution to our mission by sustainably scaling our organization. Before diving into our fourth quarter financial results, I want to echo Dan's sentiment and say that I'm pleased with our fourth quarter results and the momentum we are seeing across our business. For the fourth quarter twenty nineteen, we generated $43,500,000 in total revenue.

As Dan mentioned, this represents an outperformance relative to the midpoint of our guidance and it represents an increase of 21% year over year. The outperformance relative to the midpoint of our guidance was driven primarily by new customers and expansion contracts signing earlier in the quarter than expected, increasing the revenue we were able to recognize within the quarter. Technology revenue was $22,600,000 an increase of 20% compared to the same period last year. And professional services revenue was $20,900,000 an increase of 21% year over year. Total year over year organic growth was driven primarily by recurring revenue from new customer additions, from existing customers paying higher technology access fees from contractual built in escalators and from existing customers expanding their relationship with us.

In line with what we communicated previously, I'd share that the Modisti business was a headwind on our technology revenue growth rate in the fourth quarter. Additionally, as a reminder of what we shared in our last earnings release, our revenue in the 2018 included certain performance based revenue arrangements, where performance was measured and achieved in that quarter. Moving forward, performance based revenue arrangements will be a much smaller portion of our overall revenue base, and thus they posed a headwind to our Q4 twenty nineteen year over year professional services revenue growth rate. For the full year 2019, we achieved total revenue of $154,900,000 representing an annual growth rate of 38%. As a reminder, we acquired Medicity at the end of Q2 twenty eighteen and thus a portion of the 2019 annual growth rate results were from that acquisition.

For Q4 twenty nineteen, we achieved total adjusted gross margin of 51.2%, an improvement of approximately two sixty basis points year over year. On the technology side, our adjusted gross margin was 68.2%, an increase of approximately three forty basis points year over year. This year over year increase was mainly driven by existing customers paying higher technology access fees from contractual built in escalators without the corresponding increase in hosting costs, partially offset by the headwinds due to the continued costs associated with transitioning a portion of our customer base to third party cloud hosted data centers in Microsoft Azure. And on the professional services side, our adjusted gross margin was 33%, in line with our expectations. This represents an increase of approximately 170 basis points year over year and a decrease of roughly three seventy basis points relative to Q3 twenty nineteen.

As mentioned on our Q3 twenty nineteen earnings call, our professional services are comprised of data and analytics services, domain expertise services, outsourcing services and implementation services. And depending on the mix of services delivered in a given quarter, we would expect to see some fluctuation in our quarterly adjusted professional services gross margin. For the full year 2019, we achieved a gross margin of 52%, an improvement of approximately four thirty basis points compared to 2018. Moving forward to full year 2020, we anticipate adjusted gross margins will be roughly flat with 2019 performance. In regards to adjusted technology gross margins, we expect a similar trend of existing customers paying higher technology access fees from contractual built in escalators without the corresponding increase in hosting costs that will be offset by headwinds due to the continued costs associated with transitioning a portion of our customer base to third party cloud hosted data centers in Microsoft Azure.

And in regards to adjusted professional services gross margins, we anticipate we will continue to see quarterly fluctuations depending on the mix of services provided and hiring patterns. Specifically, in the first half of twenty twenty, we anticipate that the mix of services provided coupled with annual Health Catalyst team member pay increases will likely result in lower adjusted professional services gross margins in that period. In Q4 twenty nineteen, adjusted operating expenses totaled $28,800,000 As a percentage of revenue, adjusted total operating expenses were 66%, which compares favorably to 75% in Q4 twenty eighteen. Adjusted EBITDA in Q4 twenty nineteen was a loss of $6,500,000 which compares favorably to an adjusted EBITDA loss of $9,400,000 in the fourth quarter of twenty eighteen. As Dan mentioned earlier, we are pleased to report that we outperformed the midpoint of our guidance.

The adjusted EBITDA performance was mainly driven by the revenue outperformance mentioned previously. Full year 2019 adjusted EBITDA was a loss of $27,400,000 an improvement of $10,700,000 compared to full year 2018. Our pro form a adjusted net loss per share in Q4 twenty nineteen was $0.21 The pro form a as adjusted weighted average number of shares used in calculating adjusted net loss per share in Q4 was 36,500,000.0 shares. For the full year 2019, our adjusted net loss per share was $0.93 Turning to the balance sheet. We ended the fourth quarter with $228,300,000 of cash and short term investments compared to $33,200,000 at year end twenty eighteen.

As of December 3139, we had $48,200,000 in total debt, an increase of $28,000,000 over the end of twenty eighteen. The increase in our cash balance and debt are the result of financing events in Q1 twenty nineteen and our IPO that took place in Q3 twenty nineteen. Before I move on to guidance, I will share a few additional thoughts related to adjusted EBITDA and our balance sheet strength. First, I'd mention that consistent with what we've shared previously, we anticipate we will begin 2022 on an adjusted EBITDA run rate breakeven basis. Next, given the size of our current cash position of over $225,000,000 we anticipate we have plenty of coverage to reach cash flow breakeven.

I'll conclude my commentary with our guidance for the first quarter and the full year 2020. For the first quarter twenty twenty, our guidance for total revenue is between $42,000,000 and $45,000,000 For the full year 2020, our guidance for total revenue is between $185,000,000 and $188,000,000 For the first quarter twenty twenty, our guidance for adjusted EBITDA loss is between $8,500,000 and $6,500,000 And for the full year 2020, our guidance for adjusted EBITDA loss is between $23,500,000 and $20,500,000 A couple of comments on this guidance. First, I'd share that this full year guidance assumes net new DOS subscription customer additions that are consistent with the expectations we've shared in the past of being in the mid teens. As a reminder, our net new DOS subscription adds were 12 in 2017, 16 in 2018 and fifteen in 2019. Lastly, I'd share that this guidance assumes dollar based retention in line with our historical performance over the last few years.

As a reminder, our dollar based retention was 108% in 2017, 107% in 2018 and one hundred and nine percent in 2019. I'd finish by saying that our fourth quarter capped off a strong year of performance in 2019, and we think we are in a good position to continue that momentum heading into 2020. That concludes my review of our financial results. I'd now like to turn the call back to Dan for his closing remarks. Dan?

Speaker 2

Thanks, Patrick. In summary, we are pleased with the performance of the company. We could not have made this progress without all of the hard work, commitment and dedication of our Health Catalyst team members who work hard each day to enable our customers to realize improvements. We're looking forward to keeping you updated on our progress throughout 2020. And with that, let's open it up for questions.

Speaker 0

Thank you. Our first question comes from the line of Robert Jones of Goldman Sachs. Your question please.

Speaker 4

Great. Thanks so much for the questions. I guess maybe just to start off on the new adds in 2019 for this year. Any more you guys could share just around the composition of adds in the year versus your base? Anything more on risk bearing entities versus hospitals?

And then just related to that, Patrick, mentioned kind of a mid teens expectation again for new adds in 2020. Wondering if you'd be willing to share any expectations around Medicity cross sells in that expectation?

Speaker 2

Absolutely. So Bob, this is Dan. I'll start out and then Patrick, if you have additional thoughts, please share them. So as it relates to your first question, the composition of the 15 net new DOS subscription clients looked very much like what we have seen in the past several years. A mix of a majority of customers that are in the provider space, health systems, but also inclusive of some risk bearing entities and others as we've described in the past.

And then as it relates to the second question, as we mentioned in our prepared remarks, in 2019, we saw three Medicity customers who became Health Catalyst DOS subscription customers, which was encouraging to us. But as we noted, two of those three cross sells were already within our Health Catalyst core pipeline. And so we would think of that similarly as we think forward to 2020 that we may continue to see an acceleration within our core Health Catalyst pipeline of overlapping clients of Medicity that may also decide to become Health Catalyst DOS subscription clients. And then we would expect and hope that similar to 2019, there may be some incremental benefit as well. Anything you'd add, Patrick?

Speaker 3

The only item I would add is if we cross sell more mid-fifty customers in 2020 than we did in 2019, that would be incremental to that mid teens expectation that we shared.

Speaker 4

Okay. That's helpful. Thanks.

Speaker 0

Thank you. Our next question comes from Anne Samuel of JPMorgan. Your question please.

Speaker 5

Hi, guys. Thanks for taking the question. I was wondering if you could maybe provide a little bit of color of how to think about cadence of growth and new subscription customer additions throughout the year. I know you talked previously about maybe the second half being a little bit more of a modest opportunity just given you started the cross sell conversations kind of midway through last year. So how should we be thinking about that cadence?

Speaker 2

Thanks, Annie. I think that's a reasonable way of thinking about the Medicity component that as we've mentioned in the past, we do experience around a one year sales cycle in general for the discussions that we have with health systems. And our experience to date has been that that is the right way to think about the sales cycle for the cross sell as well. And as we mentioned in the past, we really began those cross sell discussions in earnest in the summer of last year. And so we would expect to see some of those results coming towards the latter part of this year.

Anything you'd add Patrick?

Speaker 3

And as far as standard net new subscription customers go, we usually see those weighted towards Q2 and Q4. Rough numbers would be that approximately 40% of the full year net new DOS subscription customers come in Q2 and approximately 40% in Q4, similar to what we've seen over the past several years, although there can be some variation on that exact timing.

Speaker 5

Very helpful. And then maybe just one on Able Health. How many other opportunities like that in terms of tuck ins to the apps layer are there? And how should we be thinking about your criteria as you evaluate buy versus build?

Speaker 2

Yes. Thank you for that question, Annie. Great question. So we are very excited, as we mentioned in our prepared remarks to welcome our teammates from Able Health to join Health Catalyst. And they're a great example of a company that operates within the apps layer of the three layers of what we provide to customers.

So the first layer is the platform. The second layer is the apps layer. And the third layer is the wraparound expertise and services that we provide. Importantly, we see by far the most opportunity for acquisition activity in the apps layer where there are literally hundreds of companies, many of which are startups that have developed some very innovative capabilities, technology capabilities, where as we evaluate moving forward, we believe there will be a number of other cases where the acquisition path will be the most effective path for us to meet the needs of our clients across the application suite area. So I would anticipate that we will continue to be active and we have a very robust and meaningful pipeline of potential companies where we are in discussions and we will continue to do that in the months and years ahead.

Speaker 5

Great. Thanks guys.

Speaker 6

Thank you.

Speaker 0

Thank you. Next question comes from Ryan Daniels of William Blair. Your line is open.

Speaker 7

Yes. Thank you for taking the question. One on the upsell opportunity to an existing customer. I believe you mentioned one, it was $10,000,000 and I'm curious if that's annual opportunity or kind of the contract value. And number two, it seems like a novel data point in quite a strong opportunity.

So maybe a little bit more color on what drove that and the potential for similar opportunities going forward?

Speaker 2

Great. Thank you for the question, Ryan. As it relates to that upsell opportunity, to your first question, that does represent an annual recurring number. So that greater than $10,000,000 is annual recurring revenue, which is inclusive of both technology and services. And as it relates to some of the specifics that we feel are perhaps repeatable at other health system clients, we do see as we mentioned in the prepared remarks, a trend towards more and more of our clients looking for greater support and help at the lower levels of the analytics adoption model where through the use of our technology and through the use of our expertise and our scale, we are in a position to provide those lower levels, some of those lower levels of activities better, faster and cheaper than any of our clients could achieve on their own.

And that does involve us taking over processes that were often manual processes and automating them through the use of our technology. And then also benefiting from process improvements on the expertise side that when coupled together provide us with real differentiation relative to what our health system clients could achieve in terms of both efficiency and in terms of accuracy and effectiveness. And we do believe this will be a pattern that will repeat itself for many of our clients. We would anticipate that within our TAM, there are likely hundreds of clients that could grow to a similar size as what we just experienced in 2019.

Speaker 7

Okay. That's great color. And then if we think about visibility at this point of the year, I know most of the 15 new contracts will drive the bulk of revenue growth, provide the ramp throughout the year. But how much visibility do you really have at this point? Is it extremely high as we look towards the revenue line?

Speaker 2

Good question, Ryan. It is extremely high. As we've discussed in the past, over 90% of our revenue is recurring in nature. And related to that, we have over 90% visibility to our projected 2020 revenue, which is very helpful in terms of our forecasting and planning process.

Speaker 7

Just one more if I could on the Able acquisition. I'm curious if you could talk about the potential revenue opportunity. I know it's not material in your guidance, but is that really to drive more all in purchases? Does it help you support pricing improvements over time? Or is it really something that you see as a client acquisition vehicle that you now have an even broader value proposition versus really a separate revenue generation line for the company?

Speaker 2

Yes, very good question. I think we see some elements of each of those categories that you mentioned, but I might emphasize just a couple of things. And first, let me broaden to the general M and A topic that as we acquire a company, particularly at the apps layer, in general, the acquisition of that new technology would fall outside of the current technology subscription that our clients have with us. So there is an upsell technology opportunity through these acquisitions generally. We do expect a small incremental upsell opportunity within our existing client base, specifically related to the Able Health acquisition.

And we do believe also that there are other meaningful opportunities for us to cross sell within Able's customer base and for us to have a new entry point potentially at a lower cost to begin new client relationships by virtue of this new capability that Able Health brings to us. Anything you'd add, Patrick?

Speaker 3

Just to emphasize that we thought very much about the acquisition enhancing specifically our quality and regulatory measures application suite. And we focused on the product capabilities it could bring us more so than its independent financial characteristics.

Speaker 7

Okay, great. Thank you and congrats on the closing of the transaction.

Speaker 2

Thanks, Ryan. Thanks, Ryan.

Speaker 0

Thank you. Our next question comes from Sean Wieland of Piper Jaffray. Your line is open.

Speaker 8

Hi, thanks. So just digging into Able Health a little bit more, I just want to understand you spoke a little bit about the strategic importance, but what is the their offering versus your existing offering that you had in quality and regulatory reporting? Is there overlap there? Are there shared clients? And can you give us any specifics on revenue and EBITDA contribution or number of employees?

Speaker 2

Absolutely. Great question, Sean. So I'll share a few thoughts and then Patrick, please also share. So as it relates to their offering compared to our existing offering, Importantly, we see meaningful complementarity and a minimal amount of overlap. Our focus on quality and regulatory measures has included in the future roadmap, the desire to offer our clients the specific capabilities that Able Health brings and that is specific to our clients submitting regulatory measures.

But that has not been an area that we had yet developed on our own. We have been more focused on the curation of those metrics in the improvement work that we have done to improve clinically operationally with our clients. So the addition of the Able Health capabilities is very complementary to what we have today and it's very consistent with our desired product roadmap and consistent with feedback from customers that they would like that additional capability as it is a good example of a process that in many cases is very manual when our clients handle all of the steps of submission themselves, whereas with Able, they automate and streamline many of those steps as well. Patrick, what would you add?

Speaker 3

The only item I'd add is we shared in the eight ks that ABLE will have an immaterial impact on our 2020 revenue or EBITDA. I would also share that it is a relatively small team that we're bringing on, a very talented team that we are very excited to bring on, but a relatively small team.

Speaker 8

All right. Thanks. And Patrick, what's can you comment on the trend on deferred revenues on the balance sheet?

Speaker 3

Of course. So when we look at our deferred revenues, there's a little bit of noise there given the acquisition of Medicity and the fact that Medicity has a different deferred revenue profile than Health Catalyst. The other item that can cause a little bit of noise is the deferred revenue profile between technology and services for our core business does vary. And depending on the timing of new client additions or the timing of expansions, it can have fluctuations in our deferred revenue in given quarters. The last item I would note is because our average ARR per customer is approximately $2,000,000 a year, invoices can be fairly large.

So an invoice moving between one quarter or another can also have a fairly material impact on our deferred revenue.

Speaker 8

All right. That's helpful. And then one more quick one. What percentage of clients DOS clients today are on Azure and how many converted in the quarter?

Speaker 3

So we've shared that starting approximately four years ago, all of our new clients went to the Microsoft Azure environment, which means that the majority of our clients are in the Microsoft Azure environment. We do have a minority, but still a material portion of our DOS subscription customers that are in our private cloud data center that we have been converting into the Microsoft Azure environment and expect to continue to convert over the next year plus, one to two years. And then we also have a few on premise clients remaining that we expect to move to the Microsoft Azure environment. And that process we also expect to take over a one to two year time period.

Speaker 8

Okay. Thank you.

Speaker 0

Thank you. Our next question comes from Michael Nutshell of Evercore ISI. Please go ahead.

Speaker 9

Thanks. I guess I wanted to ask about the trajectory for gross margins. I know the flat gross margins you've guided to for this year is something that you talked about before because of that continued transition to Microsoft Azure. But is there any just update on timeline for completing that transition? And could we see more gross margin improvement in 2021?

Speaker 3

From a financial impact, we would expect to continue to have a headwind from moving clients to the Microsoft Azure environment in both 2020 and 2021. We are obviously working and doing our best to try to, obvious to outperform those expectations. But from an expectation perspective, we would expect it to take both 2020 and 2021. And that's why technology gross margins will be roughly flat over that time period.

Speaker 9

Got it. And so similar size headwind in 2021?

Speaker 3

Yes. And I should note that the natural tailwind is from the fact that our escalators on the technology side are very high margin because they don't come with corresponding costs. That would naturally lead our technology gross margins to expand every year, but the headwind counteracts that and results in overall flat technology gross margins.

Speaker 7

Got it.

Speaker 9

Maybe separately, know this is kind of speculative, but I was just wondering if you had any thoughts about whether hospitals response to coronavirus could have any indirect impact on you. I mean, it possible preparations and uncertainty just the competition for attention could have any delays on contracting decisions or is kind like the process of people involved separate enough and the process is visible enough that you don't really foresee any impact?

Speaker 2

Good question. Thank you for that question, Michael. So let me offer a couple of thoughts there. So first of all, we along with many others share deep concern for the well-being of those who have been impacted by the coronavirus. We're also on behalf of our team members closely monitoring the situation and its impact on the well-being of our team members.

We continue to provide our health system customers with significant data and analytics support for this specific health issue along with all the other health issues that these clients help to address. And we recognize and respect the dedication, commitment and sacrifice of healthcare providers around the world, including our exemplary customers. I would share specifically related to your question that we have not yet seen any impact of the coronavirus as it relates to our pipeline or our and therefore our forecast either.

Speaker 9

Great. Thank you very much.

Speaker 2

You bet.

Speaker 0

Thank you. Our next question comes from the line of Sandy Draper of SunTrust Robinson Humphrey. Your line is open.

Speaker 6

Thanks. This is Stan on for Sandy. Maybe a continuation of the previous question. Just looking at the sales pipeline, is there anything to call out, given that this is also an election year that maybe you're seeing any changes in decision making?

Speaker 2

Yes, question. What we have found is that as we have shared in the past, we continue to not see a material impact from the twenty twenty election cycle. The good news from the perspective of Health Catalyst is that in whatever political or reimbursement landscape we find ourselves within, the market continues to believe in the need for data and analytics. And importantly, our model is not tied to the transition to value based care like some other healthcare IT companies. Fundamentally, our model and our value proposition to clients is to help them manage the complexity of data and the economic model complexity that they have to deal with in working within both a value based and a volume based economic model.

Now all that being said, we have also observed over long periods of time that healthcare providers tend to be more cautious in purchasing situations. So this is something that we'll continue to closely monitor.

Speaker 6

Got it. That's helpful. And maybe just a follow-up. Besides the two wins from Medicity that you called out that were already in your pipeline before the acquisition. Are there any Medicity clients today that you have not yet cross sold but were in your pipeline before the acquisition?

And if so, can you quantify that number for us?

Speaker 3

Of course. Thanks, Dan. Yes, that number would be very low. So since we have approximately a year long sales cycle, and we are more than a year since the time of acquisition. At this point in time, there are very few customers that are in our pipeline that were in our pipeline at the time of acquisition that are Modesty customers.

Speaker 6

Got it. Thank you.

Speaker 0

Thank you. At this time, I'd like to turn the call back over to Dan Burton for closing remarks. Sir?

Speaker 2

Thank you. And thank you to everyone who has dialed in for this earnings call. We appreciate your interest in the company and we look forward to keeping you updated in the months ahead. Thank you very much.

Speaker 0

Ladies and gentlemen, this concludes today's conference call. Thank you for participating. You may now disconnect.