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Health Catalyst Inc (NASDAQ:HCAT)
Q4 2019 Earnings Call
Feb 27, 2020, 5:00 p.m. ET

Contents:

  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:


Operator

Ladies and gentlemen, thank you for standing by, and welcome to Health Catalyst fourth-quarter 2019 earnings call. [Operator instructions] Please be advised that today's conference is being recorded. [Operator instructions] I would now like to hand the conference over to your host, senior vice president, investor relations, Adam Brown. Sir, please go ahead.

Adam Brown -- Senior Vice President, Investor Relations

Good afternoon, and welcome to Health Catalyst's earnings conference call for the fourth quarter of 2019, which ended on December 31, 2019. 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 Nelli, 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 8-K 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 13, 2019, and our Form 10-K 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 onetime 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?

Dan Burton -- Chief Executive Officer

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 2019 financial performance along with the other highlights from the quarter. First, on our fourth-quarter and full-year 2019 financial results, I'm pleased with our performance across the board. To start, I am happy to report that our total revenue for Q4 of 2019 was $43.5 million.

This represents an outperformance relative to the midpoint of our guidance and results in 21% growth relative to the fourth quarter 2018. Total adjusted gross margin in the fourth quarter was 51.2%, which compares favorably to 48.6% in the fourth quarter 2018. And our Q4 2019 adjusted EBITDA was a loss of $6.5 million, which represents an outperformance relative to the midpoint of our guidance and shows meaningful improvement from a loss of $9.4 million for the same period in the prior year. Translating this to full-year 2019 results.

Total revenue was $154.9 million, representing 38% annual growth. Total adjusted gross margin for 2019 was 52.2%, an increase of roughly 430 basis points compared to 2018. And full-year 2019 adjusted EBITDA was a loss of $27.4 million, a meaningful improvement from a loss of $38.1 million 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 two and a half 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 million 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 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 99th percentile.

While we have consistently ranked between the 95th and 99th 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 million 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 continued 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&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 Health Care, 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?

Patrick Nelli -- Chief Financial Officer

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 of 2019, we generated $43.5 million 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 $22.6 million, an increase of 20% compared to the same period last year.

And professional services revenue was $20.9 million, 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've communicated previously, I'd share that the Medicity 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 fourth quarter of 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 2019 year-over-year professional services revenue growth rate. For the full year 2019, we achieved total revenue of $154.9 million, representing an annual growth rate of 38%. As a reminder, we acquired Medicity at the end of Q2 2018, and thus, a portion of the 2019 annual growth rate results were from that acquisition. For Q4 2019, we achieved total adjusted gross margin of 51.2%, an improvement of approximately 260 basis points year over year.

On the technology side, our adjusted gross margin was 68.2%, an increase of approximately 340 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 cost 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 370 basis points relative to Q3 2019.

As mentioned on our Q3 2019 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 430 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 cost 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 2020, 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 2019, adjusted operating expenses totaled $28.8 million.

As a percentage of revenue, adjusted total operating expenses were 66%, which compares favorably to 75% in Q4 2018. Adjusted EBITDA in Q4 2019 was a loss of $6.5 million, which compares favorably to an adjusted EBITDA loss of $9.4 million in the fourth quarter of 2018. 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 $27.4 million, an improvement of $10.7 million compared to full year 2018. Our pro forma adjusted net loss per share in Q4 2019 was $0.21. The pro forma, as adjusted, weighted average number of shares used in calculating adjusted net loss per share in Q4 was 36.5 million 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 $228.3 million of cash and short-term investments compared to $33.2 million at year-end 2018. As of December 31, 2019, we had $48.2 million in total debt, an increase of $28 million over the end of 2018. The increase in our cash balance and debt are the result of financing events in Q1 2019 and our IPO that took place in Q3 2019.

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 million, 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 of 2020, our guidance for total revenue is between $42 million and $45 million. For the full year 2020, our guidance for total revenue is between $185 million and $188 million. For the first quarter 2020, our guidance for adjusted EBITDA loss is between $8.5 million and $6.5 million. And for the full year 2020, our guidance for adjusted EBITDA loss is between $23.5 million and $20.5 million.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 15 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 109% 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 and now like to turn the call back to Dan for his closing remarks. Dan?

Dan Burton -- Chief Executive Officer

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.

Questions & Answers:


Operator

Thank you. [Operator instructions] Our first question comes from the line of Robert Jones of Goldman Sachs. Your question, please.

Robert Jones -- Goldman Sachs -- Analyst

Great. Thanks so much for the questions. I guess, maybe just to start off on the new adds in '19 for this year, any more you guys could share just around the composition of adds, you know, in the year versus your base? Anything more on, you know, risk-bearing entities versus hospitals? And then just related to that, Patrick, you 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?

Dan Burton -- Chief Executive Officer

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, Bob, 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 with 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?

Patrick Nelli -- Chief Financial Officer

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

Robert Jones -- Goldman Sachs -- Analyst

OK. That's helpful. Thanks.

Operator

Our next question comes from Anne Samuel of JP Morgan. Your question, please.

Anne Samuel -- J.P. Morgan -- Analyst

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 DOS subscription customer additions throughout the year. I know you talked previously about maybe the second half being a little bit more of a Medicity opportunity, just given you started the cross-sell conversations kind of midway through last year.

So how should we be thinking about that cadence? Thanks.

Dan Burton -- Chief Executive Officer

Thanks, Anne. 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've 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 toward the latter part of this year. Anything you'd add, Patrick?

Patrick Nelli -- Chief Financial Officer

And as far as standard net new DOS subscription customers go, we usually see those weighted toward 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.

Anne Samuel -- J.P. Morgan -- Analyst

Very helpful. And then maybe just one on Able Health. You know, 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?

Dan Burton -- Chief Executive Officer

Yeah. Thank you for that question, Anne, 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 app 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 start-ups 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.

Anne Samuel -- J.P. Morgan -- Analyst

Great. Thanks, guys.

Dan Burton -- Chief Executive Officer

Thank you.

Operator

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

Ryan Daniels -- William Blair and Company -- Analyst

Yeah. Thank you for taking the question. One on the upsell opportunity to an existing customer. I believe you mentioned, one, it was $10 million.

And I'm curious if that's an annual opportunity, or kind of the contract value? And number two, it seems like a novel data point and quite a strong opportunity. So maybe a little bit more color on what drove that and the potential for similar opportunities going forward.

Dan Burton -- Chief Executive Officer

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 million 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 toward 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 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.

Ryan Daniels -- William Blair and Company -- Analyst

OK. That's great, that 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 toward the revenue line?

Dan Burton -- Chief Executive Officer

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.

Ryan Daniels -- William Blair and Company -- Analyst

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 know, have an even broader value proposition versus really a separate revenue generation line for the company?

Dan Burton -- Chief Executive Officer

Yeah, 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&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?

Patrick Nelli -- Chief Financial Officer

Just to emphasize that we felt 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.

Ryan Daniels -- William Blair and Company -- Analyst

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

Dan Burton -- Chief Executive Officer

Thanks, Ryan.

Patrick Nelli -- Chief Financial Officer

Thanks, Ryan.

Operator

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

Sean Wieland -- Piper Jaffray -- Analyst

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?

Dan Burton -- Chief Executive Officer

Absolutely. Great questions, 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 road map, 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 road map 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?

Patrick Nelli -- Chief Financial Officer

The only item I'd add is, we shared in the 8-K 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.

Sean Wieland -- Piper Jaffray -- Analyst

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

Patrick Nelli -- Chief Financial Officer

Of course. So, when we look at our deferred revenues, they are -- 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 million 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.

Sean Wieland -- Piper Jaffray -- Analyst

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?

Patrick Nelli -- Chief Financial Officer

So, we've shared that starting approximately 4 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.

Sean Wieland -- Piper Jaffray -- Analyst

OK. Thank you.OperatorThank you. Our next question comes from Michael Newshel of Evercore ISI. Please go ahead.

Michael Newshel -- Evercore ISI -- Analyst

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 continuing transition to Microsoft Azure. But is there any just update on time line for completing that transition? And can we see more gross margin improvement in 2021?

Patrick Nelli -- Chief Financial Officer

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 doing our best to try 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.

Michael Newshel -- Evercore ISI -- Analyst

Got it. And so similar size headwind in 2021?

Patrick Nelli -- Chief Financial Officer

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.

Michael Newshel -- Evercore ISI -- Analyst

Got it. And maybe separately, I 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, is it possible preparations and uncertainty, just the competition for attention could have any delays on contracting decisions? Or is kind of like the process and people involved separate enough and the process is visible enough that you don't really foresee any impact?

Dan Burton -- Chief Executive Officer

Good question. Thank you for the 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.

Michael Newshel -- Evercore ISI -- Analyst

Great. Thank you very much.

Dan Burton -- Chief Executive Officer

You bet.

Operator

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

Stan Berenshteyn -- SunTrust Robinson Humphrey -- Analyst

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?

Dan Burton -- Chief Executive Officer

Yeah, good question. What we have found is that as we have shared in the past, we continue to not see a material impact from the 2020 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.

Stan Berenshteyn -- SunTrust Robinson Humphrey -- Analyst

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?

Patrick Nelli -- Chief Financial Officer

Of course. Thanks, Stan. 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 were in our pipeline at the time of acquisition that are Medicity customers.

Stan Berenshteyn -- SunTrust Robinson Humphrey -- Analyst

Got it. Thank you.

Operator

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

Dan Burton -- Chief Executive Officer

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.Operator[Operator signoff]

Duration: 50 minutes

Call participants:

Adam Brown -- Senior Vice President, Investor Relations

Dan Burton -- Chief Executive Officer

Patrick Nelli -- Chief Financial Officer

Robert Jones -- Goldman Sachs -- Analyst

Anne Samuel -- J.P. Morgan -- Analyst

Ryan Daniels -- William Blair and Company -- Analyst

Sean Wieland -- Piper Jaffray -- Analyst

Michael Newshel -- Evercore ISI -- Analyst

Stan Berenshteyn -- SunTrust Robinson Humphrey -- Analyst

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