Medical Connectivity

July-28-2014

9:00

Developing and launching a competitive product, and getting initial traction in the market are not inconsiderable milestones. And yet for the entrepreneur and their investors, this is just the beginning. What was record setting last quarter is barely acceptable this quarter, and next quarter had better be back on track.

Developing a solid plan for growth depends on two things: a good understanding of the basic means to drive growth, and a deep understanding of the market. This post seeks to combine both of these in a brief survey of the key factors to drive messaging middleware revenue growth in health care. We’re going to consider three basic growth strategies: organic growth, product line extension, and the roll-up strategy.

Organic Growth

For start ups, organic growth can be realized first by targeting a market segment that has broad appeal and large numbers of early and late adopters. Going back to Moore’s market adoption model, it’s relatively easy to identify a market need and generate initial sales to innovators and early adopters. These early buyers want technology and performance, something new the buyer can leverage to gain a competitive advantage of their own.

These early buyers tend to be large institutions with a corporate culture of innovation and the internal resources to support such endeavors. Accounts like the Cleveland Clinic, Mayo Clinic, Partners Healthcare, come immediately to mind. Kaiser Permamente would also fall into this group, except they are held back by their need to have solutions that can scale to considerable extremes, a requirement that is not applied to these other health care provider titans. There is even a cadre of smaller nimble early buyers: Overlake Hospital, Bellevue, Washington, and El Camino in Mountain View spring to mind. Spend enough time in this industry and the early buyers tend to make themselves known. The problem is that this population of early buyers is quite limited; early buyers will only take a company so far.

Once most of these early buyers in a market segment have bought, the market adoption chasm arises because the next group of buyers to adopt – the much larger early majority – don’t want technology and performance, they want complete, proven, easy to adopt solutions. This shift gives rise to the conventional wisdom that, “hospitals want solutions to problems, not tools they can use to solve their own problems.” For vendors, the importance of this is self evident when considering how to maintain or even increase their growth rate over time. For providers, it’s important to recognize from which side of the chasm your organization is operating and proceeding accordingly.

To cross the chasm, vendors must add to the original innovative technology the required features and services to create a whole product solution that is laser focused on a recognizable problem. Figuring out exactly what it is that’s required to transform an innovation worthy of inspiring early buyers into the safe and reliable solution required by the early majority is a challenge. Recognizing the gaps and knowing how best to fill them is not easy, although there are processes that can be used to identify those requirements and confirm that they’re met.

Moore calls the process of creating and going to market with the whole product solution being in the bowling alley. The bowling alley let’s you shift your growth from the early market, which may be nearing penetration, to the much larger early  majority portion of the market. Crossing the chasm is an essential objective for new companies. In a crowded market like messaging middleware, numerous companies will be struggling with crossing the chasm.

Achieving strong organic growth is an excellent indicator that, beyond a solid whole product solution, sales and market are also top notch. Sales and marketing are especially important because health care is not a field of dreams market, where “if you build it, they will come.” Brand awareness, demand generation and market education are key marketing tasks. Sales requires effective sales tools and proofs in support of a sales strategy or process that leads first time buyers to the right decision in an efficient and reliable manner.

Product Line Extension

A main characteristic of the messaging middleware market is the variety of different problems that can be solved by the same basic technology. These different problems are reflected as market segments. Each of the different market segments listed in the previous blog post can potentially support a start up, or represents a potential product line extension. Moore frames these other market segments as additional bowling alleys that leverage the same foundation of product and services that make up the original whole product solution. Some product line extensions may require changes to the whole product solution to gain early majority market adoption.

Much like selecting the initial target market for a start up, the key is to identify new bowling alleys with sufficient market demand (of course, competition is also a factor). Synergy with preexisting whole product solutions is also desired. It’s also helpful if the new bowling alleys under consideration target the same markets (e.g., physician practices or hospitals) so that existing sales and marketing resources can be easily leveraged to take advantage of cross-sell and up-sell opportunities that emerge. If different bowling alleys target different markets – say, physician practices for one and hospitals for another – each target market will require major investments in marketing and sales; potential synergy from a targeting a common market are lost.

Sometimes a product line extension includes product changes that add substantive new features to the platform. For example, a secure messaging solution that is designed to support a single enterprise might add the capability to support users across multiple enterprises, or the addition of a scheduling module to support a more complete secure messaging solution for on-call physicians.

Roll-up Strategy

A roll-up strategy entails a series of acquisitions used to construct a bigger company made up of complementary products or solutions. A relevant example of this strategy can be found in Amcom Software. After their merger with Xtend Communications, Amcom came to dominate the hospital operator console market (due to their HL7 integration capability) and related telephony applications. Subsequent acquisitions extended Amcom’s reach with various communications solutions for health care, government and other vertical markets.

  • 2007, Xtend Communications operator console, PBX, paging gateway and related telephony solutions
  • 2008, Telident 911 Solutions mass notification and emergency management solution
  • 2008, Comtech Wireless hospital messaging middleware solution
  • 2009, SDC Solutions operator console and call center technologies
  • 2012, IMCO Technologies critical test results management

Amcom Software was acquired by USA Mobility in 2011 for $176,800,000. The combined company is now called Spok (pronounced spoke with a long “o”). Starting with the merger with Xtend, the Amcom Software strategy was to build a company through acquisitions and then sell the company. With a 2010 revenue of $60 million, things appear to have worked out well for Amcom’s investors.

Because of the nature of this market, a roll-up strategy can be challenging. Unlike the product line extension strategy, where a company’s existing technology is reconfigured or enhanced to target new market segments, the roll-up strategy entails the acquisition of other companies. How those acquired products, employees and customers are optimized is the challenge.

Mergers and acquisitions occur frequently in the health care industry. The goals of these transactions include:

  • Capturing the target company’s revenue or cash flow
  • Capturing the target company’s installed base or market share
  • Gaining access to the company’s technology
  • Acquiring the company’s patents
  • Capturing the human resources employed by the target company
  • Eliminating a competitor

The first two bullets are obviously related, however the degree and ways they’re related depends on the specific companies and their business models. A company that goes to market selling mostly capital goods (hardware and licensed software) is quite different from a company selling their solution as a cloud based service.

As discussed in a previous post, most messaging middleware solutions are built using a similar architecture that is often made up of software engines. These engines can be licensed from commercial vendors or from open source projects. The resulting solutions can be built relatively quickly and for modest sums. Consequently, the value in purchasing a messaging middleware vendor for their technology may be limited.

Creating interfaces between multiple messaging middleware acquisitions can be problematic. To date, messaging middleware systems have been designed to operate alone; manufacturers do not intend for their messaging middleware system to be one of a constellation of messaging solutions serving the same user base. Some manufacturers have added to existing designs by implementing APIs and other integration points to facilitate the incorporation of other messaging middleware apps – often to fill feature gaps demanded by prospective buyers. Implementing multiple messaging middleware solutions via acquisitions raises questions about message routing, escalation and the existence of more than one rules engine impacting message flow. A system of systems made up of messaging middleware solutions gets very complicated very quickly, increasing configuration and verification and validation test complexity.

An acquiring company with older software technology may see value in the acquired software platform, or in the intellectual property and expertise behind the development of that software. Further, the acquired company may have software capabilities that are extensions to messaging middleware solutions – such as the staff scheduling for on-call physician messaging example used earlier.

The acquisition of mVisum by Vocera is worth a closer look. It should be noted that Vocera does not appear to be executing a classic roll-up strategy but the rationale that may have driven this acquisition is of interest. mVisum was a start up with an attractive messaging middleware product. Unlike many other messaging middleware solutions, mVisum was FDA cleared for alarm notification, conveyed snippets of medical device waveforms with medical device alarms (important for screening non-actionable false/positive alarms), and also included remote medical device surveillance features. The company subsequently ran into some patent infringement issues with AirStrip Technologies. mVisum was  acquired by Vocera for $3.5 million less than a year later.

There is considerable overlap between Vocera and mVisum solutions. Potential areas of value for Vocera include mVisum’s FDA clearance for alarm notification, one of the strongest messaging middleware market segments. mVisum also filed a number of patent applications that may be of value to Vocera. Vocera was founded in 2000, so there may be some value in mVisum’s software architecture – if not the actual software, then the requirements and design may be leveraged in future versions of Vocera’s software.

To summarize the roll-up strategy applied to messaging middleware, there is likely not a lot of value in acquiring other messaging middleware companies when compared to the product line extension strategy. The main reason is because most software architectures will be similar. There are exceptions to this, some of which are alluded to in the Vocera/mVisum discussion above. Because the messaging middleware market is relatively undeveloped – we’re far short of a penetrated market – there’s little opportunity to buy cash flow or market share through acquisitions. Nor is the market so developed that human resources are a likely justification for acquisition.

The roll-up strategy does make more sense when one looks beyond messaging middleware. Just as Amcom Software took a broader view of vertical market messaging and communications solutions that included messaging middleware as a portion of the whole, one could frame a roll-up strategy from a similar, higher level. For example, a roll-up targeting health care could encompass point of care solutions, rolling-up messaging middleware with nurse call, medical device data systems (MDDS), data aggregation and patient flow with enabling technologies like real time location systems (RTLS) and unified communications (enterprise phone systems). The resulting entity could define a new enterprise software category: point of care workflow automation.

Another practical application of the roll-up strategy is the secure messaging market targeting physicians. There is little apparent differentiation between solutions and vendors with good adoption in a particular geographic market will be difficult to dislodge. Here a classic roll-up, where the acquiring company offers broader economies of scale superior to those of regional players has a lot of potential. Such a strategy would be complex to implement, due to the technical product integration issues noted above. Provided they could dedicate sufficient cash flow, this could be an attractive strategy for Spok, although any company with access to several tens of millions could pull this off.

With 100+ competitors, the messaging middleware market is remarkably crowded. Over time, many of these firms will fade away as they fail to gain initial market traction, cross the chasm or get acquired. There will certainly be mergers and acquisitions. There will be some who plan and execute well, and grow their companies to tens and hundreds of millions in annual revenue. Some degree of luck with be a factor. But regardless of the strategy or outcome, the imperative shared by them all will be the drive for growth.

Other Posts on Messaging Middleware

You can find a post Messaging Middleware Defined here and the post on Messaging Middleware Market Segmentation & Adoption here. In the coming week a post on HIPAA will be published. Be sure to check back!

Pictured is the new Motorola MC40-HC Android smartphone running the Extension Healthcare Engage software client.

Tim Gee is Principal of Medical Connectivity Consulting. He is a master connectologist, technologist and strategist working for medical device and IT companies and various provider organizations. You can learn more about Tim here.

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July-16-2014

9:00

I was listening today to the CE-IT Webinar on CE and HIT from the 2014 AAMI conference in Philadelphia. Much of the session reviewed what has happened over the last five years and it got me thinking about my experiences and what I’ve seen over the last ten years in medical device connectivity and remote monitoring. It’s been an interesting ride and yet I realize there are a few basic ideas that have resonated over the years. These basic ideas are:

  1. Specifying those requirements that are unique to my situation are where I have the most control in acquisition;
  2. There are other players in the market who may change the landscape of what is available to me; and,
  3. The government may require something which can constrain my options.

Ten years ago, I was working for a very large integrated healthcare system as a clinical engineer. One of my projects was to choose and implement the medical device integration system for integrating patient monitoring and ventilator data into the ICU charting portion of our EMR system. There were three main vendors at the time which weren’t part of the large medical device companies and eventually we chose one of the major ones for the system. My responsibility was to ensure the device data went from the device at bedside to the device integration server and out to the interface broker to the EMR application.

While choosing the device integration product, I had to keep in mind my healthcare enterprise infrastructure. I had thirteen hospitals that needed to connect to the two separate instances of the EMR application. Being able to standardize on the device integration system implementation design and management became one of my paramount concerns as I needed to be able to scale the solution over the infrastructure. Additionally, I knew that if I was successful in that particular region, the solution would need to scale over to other regions and nationally.

During that time, I also was involved in some of the organizations promulgating the use of standards at the medical device integration system/interface broker interface. The standards organizations wanted me to include the standards as requirements in my procurement documents. And yet, I resisted because I did not see the standards as either being mature enough or being overly burdensome requiring adherence through all layers of the OSI 7 layer model.

In retrospect, I believe I should have insisted on the use of at least the data standards from the devices embedded in the messaging standards (HL7). We were using HL7 at the output of the device integration server, but the EMR application separately mapped each data item to a data base element and had to use the device vendors’ HL7 implementation guide to figure out what the data items meant. If we had specified IEEE 11073 device data standards (perhaps even later on as we evolved), we would have been able to more easily change medical device vendors in the future, if desired, and not have to worry about ‘breaking’ the interface to the EMR interface broker.

With regard to the other standards, physical, networking, etc., I’ve found that the IT industry does a good job of defining standards and then converging to an interoperable solution. Those standards are required across various vertical markets, so there is more demand for the convergence of the standards and products with those standards. What is unique to healthcare is the data and messaging information. And, that is what is most important to the clinicians and patients – consumers of the data. All of the other standards are mostly mechanisms for transmitting the data from where it is generated to where it is acted upon in some fashion.

I see the same thing happening in remote monitoring and mHealth. Buyers are too focused on short term and immediate issues and not realizing that specifying data standards can help them be interoperable in the long run. Again, not having to worry about the data format of another vendor’s sensor data being integrated into the EMR can save time and money as well as allow quicker scaling across your organization.

However, there are other players on the scene now, which may make the buyer’s job a bit easier. With ACA in the USA, the term meaningful use (MU) has led to the establishment of standards which EHR applications must use in order to be certified to allow the US government to reimburse some of the costs of EHR implementation. In fact, the first MU stage was going to include remote monitoring standards to include certain medical devices data (HITSP IS77), however, it was eliminated for that stage. It is anticipated that the last MU stage will require medical device interoperability. The original date for that was projected as 2015, however, the MU stage 3 has been postponed, so, that will most probably postpone the medical device standards identification for MU. Nevertheless, medical device interoperability requirements for MU which will specify medical device data standards will be coming in the near future to the USA.

In other countries, they are also using government to select and mandate data and messaging standards for remote monitoring. The Danes have issued a reference architecture which specifies Continua guidelines for remote monitoring solutions to interact with their national health network and EHR. Norway, Sweden and Finland may follow Denmark. The EU has many projects it has funded which have recommended the use of interoperability standards for remote monitoring. These recommendations usually have been using products that adhere to the Continua Guidelines and/or specific IHE profile conformance. It is no secret that the underlying standards in those guidelines and profiles are very similar. For medical device data it is IEEE 11073 and for messaging it is HL7.

Industries outside the normal healthcare market are responding as well. The mobile operators are very keen to be involved in the healthcare market and ‘disrupt’ it. They have a unique proposition in that they have a one-to-one relationship with their customers and have developed back-end business infrastructures and processes which facilitate that relationship. Moreover, they have managed to build their customer base from ~1 million to ~7 billion worldwide by identifying and enforcing standards adherence beginning with the 3G/PP initiative (which started in 1998, the same year HL7 was started!).

Examples of required standards for 3G/PP include transmission protocols, security requirements (encryption), and user identification (uniqueness). Basically the mobile operators do not allow a handset that does not adhere to the standards to connect to their transmission network. In another example, mobile operators wanted to be able to sell services for images and required that all handsets have cameras and adhere to specific image data standards. It is nigh on impossible now for someone to purchase a handset without a camera and the proliferation of products and services that have sprung up for the management and sharing of these photos is phenomenal. This is due to the mobile operators insisting on data standards for a specific use. Because the standards were specified and enforced, interoperability soared and market penetration and size soared as well.

With that in mind, it is also interesting to note that the most recent handsets have integrated sensors in them which lend them to being used in mHealth applications. The Samsung Galaxy has a 10 sensors built in; a gyro, barometer, fingerprint, hall, accelerometer, heart rate, proximity, RGB ambient light, gesture and compass. Each of these can be used individually or in a combination to measure or provide remote monitoring in a healthcare sense.

In addition, with the use of short range networking (BTLE, ANT, NFC, etc), other sensors can use the mobile handset as a ‘ramp’ to the network. The ‘wearable sensor’ market depends heavily on mobile handsets for data display, computation and network transmission. As before, the mobile operators could require that medical device sensors adhere to certain standards or they will not allow the handset to use the transmission infrastructure.

Other developments have occurred with the handset manufacturers and other technology companies. All of them have announced some type of health data aggregation product with development kits for entrepreneurs (Apple Healthkit, Samsung Digital Health Initiative, Google Fit and the ongoing Microsoft HealthVault). While several initiatives by some of the same companies have failed in the past, many believe now is the tipping point for involvement in mHealth. There is recognition that leveraging the now ubiquitous mobile telecommunications infrastructure to solve some of more pressing healthcare issues is a ‘no-brainer.’

Therefore, medical device connectivity (or medical sensor connectivity) is becoming more prolific and will most likely end up being more extensive outside the currently controlled healthcare enterprise infrastructure. It is imperative that at least data standards be specified and enforced at the different interfaces to ensure true healthcare data interoperability across all of the disparate infrastructures. Healthcare providers currently have a lot of control over this market, however, there are forces outside that will in the future define large parts of the market and may make it easier for the standards to be identified and enforced.

Pictured is the Vital Connect healthpatch patient worn sensor. The Vital Connect business model is based on the assumption that their product will be interoperable with a variety of gateway devices such as smartphones.

Bridget A. Moorman, CCE, is president of BMoorman Consulting, LLC, providing consulting to healthcare providers, standards promulgation organizations and medical device and information technology companies regarding their medical device integration strategies.  She can be reached via email  or at her website.

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July-14-2014

9:00

A while back I had the opportunity to chat with Todd Dunsirn, the CEO of True Process. True Process provides products and services to both hospitals and various manufacturers. The company is focused on the point of care market offering a medication administration solution and a medical device data system.

What was the genesis for starting True Process?

I started the company in 2004. I have an engineering background, and had several other companies doing IT consulting and then web development, and application development. Then I had a friend contact me to develop a bar-code point-of-care simulation so that sales reps that were selling infusion pumps could demonstrate the five rights process with the pump. So, of course he said, “Hey can you do this? It’s gotta be done in three months.” And keep in mind, I had never heard of bar-code point-of-care [chuckle] prior to this, so I’d really never thought about infusion pumps.

So I was on the road for weeks learning the technology, spent time in hospitals seeing how it’s used and developed this application. When it was complete, the client was just about to release their wireless suite of products and they said, “Hey, you’ve done all this research, why don’t you do the first installation because over the last three months you became the expert at doing this?” So I became the installation department and there was one site, then another site and it quickly grew from there.

It was apparent to me that, okay, there’s a need here. These medical device companies didn’t have the resources or core competencies on the IT side of things, in their companies right now, and that’s how it started. So we scaled up, and we had created a business out of this single opportunity. We made a conscious decision to just stay focused in healthcare, because it’s a unique industry and a unique space with regards to IT, and I didn’t want be bouncing around across vertical markets.

We’ve branched out in recent years with other companies and other technologies that are in healthcare. Right now we’re doing a lot of work in the RTLS (real time location system) space, with asset management and workflow studies based on the actual location of people and things. We’ve seen a lot of growth in that area, a lot of interest for what we do. So, it’s starting to be an interesting blend of technology now with medical devices and other things like RTLS.

Are these RTLS projects for RTLS manufacturers or are they for medical device companies that want their products tracked? Or are they for hospitals?

Right now we are working primarily with the RTLS hardware manufacturers and system integrators of these types of platforms. The systems integrators have a vendor neutral platform that can use RTLS hardware and provide a variety of tracking and workflow automation applications. Then they have a rules engine so they can trigger things based on location or how long a device or a patient has been in a certain location; they also provide analytics. These systems can do some really interesting workflow optimization and awareness things. So we’re working with a lot of companies like that.

True Process is pretty unique in that you work for both manufacturers and hospitals.  Based on that perspective, what industry trends jump out at you?

The biggest that that sticks out in my mind is that it always feels like health care behind the times. It feels like it’s the last industry to try and catch up. Sometimes it feels like things are made more complicated than they need to be. A lot of medical device manufacturers look at wireless as this high-end premium feature when really in every other industry it’s a given that you have that. It’s not something that really should set you apart anymore. It should be assumed that every device is connected as wireless and can communicate. Another thing that jumps out is that there hasn’t been a lot of movement from the device manufacturer’s side, and there hasn’t been a lot of pressure from the buyer’s side to work towards some level of standardization with respect to how devices communicate.

We have all these standards going on with the EHR and health exchanges and all that, and that’s great. But when you look at the medical device side, everybody’s doing it differently. The messages are different. How they connect is different. The security is different. It’s baffling that in an industry where you can have devices that are recalled and unavailable, the vast majority of products are tied to proprietary messaging and wireless infrastructure.

Take the infusion pump manufacturers for example, and the recent product recalls. If you’re a hospital and you have this gateway and these devices and there’s a recall, you’re done. You’re not communicating or you can’t just get another manufacturer’s pump and put it in there because the messaging is all different, the platform’s all different. It’s like if you had to replace your cable modem or router in your house and you had to replace all your devices accessing the Internet. Nobody would ever do that. But hospitals and healthcare, they currently do that.

I think device manufacturers in general would benefit from some sort of standardization, because they’re all really trying to do the same thing. And I think what it would allow them to do is really just follow some best practices for connectivity and really put their focus on the functionality of the product itself and what it’s supposed to do, and how it’s supposed to deliver a medication or monitor a vital or whatever it is.

I don’t know how that’s going to change. I would think some of the large purchasing organizations would be able to really drive that. I’ve seen different initiatives to try to standardize the buying process of connectivity and say, “Hey, this is how we want to do things and it’s got to meet these requirements, and if it doesn’t, we’re not buying it.” They just haven’t taken that to the next step, and I don’t know where it falls in the priority list of things that hospitals are doing with the recent last few years of EMR integrations and changes, but I think as connectivity moves forward we’ll see that happen.

Tell us about your MDDS platform, ViNES. What is it and what are its capabilities? And do you sell it to medical device manufacturers, or do you sell it to hospitals?

Today in hospitals they have these 10 to 15 different device gateways that they have to manage for all these different medical devices devices, and the data’s all scattered into these separate gateways – or just streamed into the bit bucket. We saw this and thought about this for years. And we saw the need to develop a platform that is vendor neutral, where anything can connect to it, and it stores the data in a common format on a common platform. We use the standards that are out there, whether they’re ones from IHE or Continua Alliance or IEEE. We try to use those standards when we develop our database so that all data is stored the same way, so it can be accessed the same way.

As we got started, it became apparent that what we were developing was more then just a device gateway. It really developed more into an integration platform that included medical devices and other HIT systems. Take for instance, getting an ADT feed, getting vitals data. It doesn’t matter what the data source is, we can take that data and we can accept it and we can organize it based on the structure that we created. And then we wanted to make that data accessible through an interface that really allows hospitals or even a device manufacturer to access that data however they want, whenever they want in a known format that they can control. So that was really how we got started with ViNES, we looked at this vendor neutral device gateway platform.

What about ViNES sets it apart from other connectivity solutions and what do you see as important differences between connectivity solutions.

First, ViNES actually stores and organizes the data. So it’s not just routing data, it’s not just a serial-to-serial connection that’s getting data from the device and sending it to the EMR. We’re actually storing the data, so we have this whole data warehouse structure. The goal was to collect everything from every device, store it in a patient-centric way, and then be able to organize it by unit, or hospital or however you want. So that’s one of the unique things, it’s not just a connectivity engine, it’s a connectivity and data warehousing engine.

Everybody talks about big data and analytics, but this is mostly applied to data in the EMR and claims data – all abstracted and summarized data. If you look at how much data is generated at the point of care in a hospital just from devices, it’s staggering. It’s this full resolution physiological and therapeutic data that, when combined with the HIT data we have now, will really transform big data into a took with a transformational impact on health care delivery. And that’s why we created ViNES to collect all that data and organize it intelligently. Even if it’s not being used today that data in another year or two – just having access to it, you’re going to be able to do some very interesting things with it.

Also, we’re really tried to create something that is developed around current technology. We use a lot of open source technologies to keep current and to keep the cost down. Consequently, we’re able to approach the market with a very scalable and flexible licensing agreement. Take for instance, low census devices like intra-aortic balloon pumps, dialysis machines or, somebody that has five scales that wants to integrate them. Our approach to licensing can scale down to these small deployments to price ViNES so that it can be affordable in most situations.

In the future, ViNES is designed to be cloud based so we can host customer data on an Amazon cloud, and provide connectivity for somebody that didn’t want to have manage the infrastructure. The goal is to enable a hospital had ViNES, to be able to go onto a screen, select whatever device they wanted to connect, configure it, and be up and running without really any intervention from us. We’re also moving to modularize software as plug-ins and provide the ability to send data to a data warehouse where we really don’t have to be involved. And that goes back to the standards.

We’re not looking to create some sort of system where they have to pay a lot of money to get the data out of their platform. It’s their data, they should have access to it, and we think there are opportunities and growth in other aspects of developing the product other than charging them data access usage fees and things like that.

Unlike some medical device manufacturers I can think of.

That’s how the industry is, and we’re just trying to be different. We’re trying to shake things up, and the more we talk to hospitals, CIOs and people that are in charge of these efforts, you see the movement and the frustration. It’s like when are we going wake up and do things the right way and take control of this and demand solutions that meet our business needs, meet our cost structure, and are technologically done the right way.

That’s a great segue to my last question. What are the trends that you’re seeing in the connectivity market? Is growth increasing? Are we starting to peak because of the meaningful use roadmap? Are buyers getting better informed? Are they asking harder questions, or are they still just buying whatever their favorite vendor wants to sell?

I think medical device manufacturers are starting to really look at the value of a prospective connectivity solution. We’re working on several opportunities right now, two opportunities in the last week, where companies that are with a current provider had said the cost is just unsustainable. What I’m hearing it like, “This is great, but I’m not going pay all this money to do it just because I can. It’s got to mean something. And it’s got to fit into our strategy.” So that’s a trend that we’re seeing. You look at how much some of these connectivity systems cost, and that’s being driven by what they’re doing and also how the work is done. It seems like nothing’s really turnkey, and there’s a lot of time and a lot of effort to get things done. And I don’t know if that’s because of the technology itself or their design approach.

Take the core cost of a system – the software licenses and hardware costs – and now add on all this consulting and development time to get things working, and it can easily become a black hole of cost. With ViNES, we’re really trying to change that paradigm and to make it more efficient.

The final trend we’re seeing is a glimmer of recognition regarding the value of medical device data beyond clinical documentation in the EMR. Not everybody understands right now the value of this data. Everybody talks about big data, but few people know what they’re really talking about or what it really means or how it applies to them. This is true for both medical device manufacturers and the data their devices produce, and hospitals and the data generated from their patients. A lot of data now is used really in the short term. It’s used right away, but it’s not mined or analyzed to learn what really happened here, and what were the events that happened, and how this lines up to what was actually done, and the ultimate patient outcome. That’s just not happening now.

The photo above is from the True Process booth at HIMSS14.

Tim Gee is Principal of Medical Connectivity Consulting. He is a master connectologist, technologist and strategist working for medical device and IT companies and various provider organizations. You can learn more about Tim here.

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July-9-2014

22:59

The previous post in this series suggested a set of characteristics to define the messaging middleware market and described the typical product architecture for these systems. In this post, we’ll look at ways the market may be segmented and how the market is adopting these systems.

Market Segmentation

Market segmentation is the dividing of a broader market into subsets of potential buyers who have common market requirements who then become the target for your product, sales and marketing. Using my favorite market adoption model, Geoffrey Moore’s Crossing the Chasm, this is the bowling alley strategy. Software developers in the messaging middleware market are currently pursuing a variety of market segments or bowling alleys.

One high level way to segment the market is to draw a distinction between those messaging apps that target users within an enterprise, usually a hospital, and those messaging apps that target users outside of a single enterprise, typically physicians and/or patients and associated staff at various hospitals, pharmacies, labs and physician practices within a health care community.

Secure messaging, alarm notification and certain workflow automation solutions (routine tasks like bed turns, patient discharge, room turnover and patient flow, patient transport, on-call physician scheduling, etc.) are inherently enterprise-centric applications. For example, there is little demand to notify a user in one hospital of a patient alarming in another hospital. This contrasts with solutions intended for use by people that work across multiple enterprises.

Messaging solutions where physicians are the primary intended users are often characterized by workflows that span more than one enterprise. For example, physicians with admitting privileges at one or more hospitals who also see patients in ambulatory settings, e.g., physician offices or clinics, engage in communications that span multiple enterprises. In this ambulatory messaging environment the population of potential users – either who want to communicate with others or to whom physicians might want to send messages – is defined by the health care community.

Defining Health Care Communities

We’re going to define health care communities in detail here because this impacts the kinds of messaging that may occur and because the community circumscribes the network effect (which we’ll talk about later). The health care community is made up of all the people and entities that deliver and pay for care within a specific geographical area. These people and entities start with physician groups, hospitals and their staff where the physicians have admitting privileges, local pharmacies, ancillary providers like physical therapy groups, diagnostic services like regional clinical labs, and payors.

The geographical boundaries of these health care communities are variable. Generally, the size of a health care community is defined by the distance a patient is willing to drive to see a doctor, receive treatment at a hospital or fill a prescription. Rural communities are, by necessity, geographically larger than suburban or urban communities. The practical distances for receiving service also varies by the type of health care community member; payors are state wide, regional labs and compounding pharmacies may also serve geographical areas that are larger than the typical patient is willing to drive for service.

By defining the health care community, we define the universe of potential actors engaged in communications, workflow automation and care coordination. This defined universe becomes the foundation for vendor’s market requirements and the features supported by their messaging solutions. Currently, most messaging solutions target a narrow portion of the health care community, either a subset of entities and users, or entities and users engaged in specific workflows like prescription refills, hospital bed management, or alarm notification. Prospective buyers and messaging product developers should define their needs and plans based on a thorough understanding of both their immediate objectives and how they fit into the broader health care community – eventually all of these separate tasks and products will be connected in some fashion.

Market Segment Proliferation

In the blog post on HIMSS14, I noted that there are a lot of messaging middleware vendors competing for business (I’m presently tracking 100 companies) and yet they each tend to run into a very small number of competitors – a handful or less – on a regular basis. Within a broader market segment, the market can be further divided in subsets of potential buyers based on their pain-points, or the particular problem they want to solve. Hospital examples include:

  • Medical device alarm notification
  • Avoiding a particular hospital acquired condition, e.g., falls, pressure ulcers, ventilator acquired pneumonia
  • Bed management/room turnover
  • Nurse call integration
  • Medications administrations – injections and orally administered meds
  • Discharge planning workflow automation
  • Managing patients at risk for re-admission
  • On-call physician messaging in the ED
  • Critical diagnostic test results messaging
  • Generalized care coordination – messaging between physicians, caregivers, techs and support staff

Each of these needs represents a market segment, and each is currently populated by a small number of messaging solutions. Likewise, a different but similar list can be found in the ambulatory segment:

  • Secure messaging between physicians and patients
  • System generated patient communications for such things as appointment reminders, chronic disease, medication or health and wellness messages, and debt collection
  • Managing patients at risk for re-admission
  • Eligibility and/or referral processing workflow automation
  • Prescription refill workflow automation
  • Generalized care coordination – messaging between physicians, caregivers, techs and support staff

Another reason why messaging solution companies that are otherwise competitors don’t run into each other lies in how they are sold. These different go-to-market strategies result in a kind of de facto market segmentation. Let’s take the broad market segment of physician communications. Some companies sell this solution to individual hospitals and then pull in additional paying users through the contacts of that hospital’s physicians. Other companies start with large physician groups and then seek to pull in additional users in a similar way. A third approach is to go to the state or county medical society that credentials physicians and physician specialty associations. With the above examples competing vendors will likely not compete directly with companies going to market through different channels.

A final way to segment characterize messaging solutions is whether they are broad or deep. Messaging solutions with a broad focus support a very wide variety of users in most if not all of the entities and roles found in a health care community. This approach contrasts with deep solutions that include multiple detailed features that handle the communications and workflow requirements of a specific type of solution. The predominant example of broad messaging solutions is the secure messaging market segment. Companies in this segment are many, and include CellTrust, ConversePoint, Cureatr, Doc Halo, Global Relay, Imprivata Cortex, MD Chat, qlikSoft, TigerText and Zipit Wireless. Common features to these broad solutions include:

  • Data encryption and user authentication required by HIPAA,
  • Closed loop communications with message resend and delivery failure notification,
  • Multimedia attachment support, and
  • Sender notification when a sent message is received and read.

Companies in the deep messaging solutions segment include Amplion Clinical Communications, Ascom, Cardiopulmonary Corp., ConnexAllExtension Healthcare, HealthFinch, Mobile Heartbeat, PatientSafe Solutions,   Spok (was Amcom), Starling Healthcare (acquired by Hill-Rom), and Vocera. A few examples of deep solution features include the broad solution features, plus:

  • Role based messaging extending to dynamic care delivery teams,
  • Message escalation,
  • Contextual data automatically assembled and sent with original message,
  • Critical test results management
  • Specific workflow automation for bed management,
  • Medical device alarm notification, and
  • Forensic database (messaging “black box” recorder)

Almost every task and activity that occurs in the delivery of health care requires coordination between various actors such as physicians, hospitals and payors, pharmacies and their employees. These workflows are often multi-step, require more than one actor, and include interaction with one or more information system or medical device system. Virtually all of these workflows can be automated using a variation of the engine-oriented software architecture described in the previous post. Software developers have only started to scratch the surface.

For buyers market segmentation helps identify a group of potential suppliers based on the characteristics of your organization and what you’re trying to accomplish. A fundamental question for vendors is which market segments are the largest, growing fastest, and which adjacent segments could best be targeted to maintain or increase growth?

Market Adoption

As dynamic and seemingly different many of the aforementioned market segments are, it is important to recognize that ultimately there are basic market needs driving the adoption of messaging middleware solutions. A byproduct of current efforts to increase automation has contributed to the market forces giving rise to messaging solutions. These root causes are manifesting themselves in a multiplicity of ways as buyer pain-points associated with market segments for which buyers seek specific solutions.

I have repeatedly heard from messaging solution providers that EMR adoption is sucking the oxygen out of the health care market for other types of solutions. Regardless of budget availability, people are just too busy implementing EMRs to do much else. Ironically, while many hospitals and physician practices are indeed fully engaged in EMR adoption, a consequence of this increased automation is bringing to light the need for improved communications needed to realize the full potential of EMRs. The following are a number of drivers behind this increasing need to improve communications.

It turns out that the use of EMRs themselves results in an increased need for better communications as various users work to orchestrate activities to successfully complete tasks that are documented via the EMR. Today, the EMR remains a retrospective medical, legal and financial record of the diagnosis and treatment of an episode of care. Over the past several years, the industry has worked to stretch the EMR beyond this evolving role to “automate” ever more of a clinician’s daily activities. As the HIT industry extends their value proposition ever closer to the actual delivery of care, there’s always a learning curve where vendors learn through their customer’s experience. A great example of the current state of this learning curve is CPOE.

A lot of the interaction, collaboration and communications between physicians and the caregivers and staff, who are expected to fulfill the orders generated in CPOE, is either not very well understood, or not addressed in current CPOE systems. The most current iteration of Order Entry, now called CPOE, often includes a clinical decision support system (CDSS). This CDSS is used to not just document and communicate the order, but to bring automation closer to the actual delivery of care – in this case, the thought processes a physician uses to write an order. The inevitable learning curve creates the need for new levels of communications that must be orchestrated and monitored if the tasks “automated” in the EMR are to be completed in a reliable and timely manner. Understand that I’m not bashing EMRs; none of us are omniscient. It’s just that the way things are working out is creating a market opportunity that a growing number of hospitals are spending money to fill.

Mobile messaging is also provided by many EMRs and a cursory look at those capabilities could lead a hasty hospital to conclude that a third party messaging solution is not needed. Enterprise software applications like EMRs are intended to be used by people in front of a display, mouse and keyboard. This is especially true with system generated alerts or messages – the user has to be in front of a client app to be able to receive any system notifications. Because health care delivery is inherently a mobile endeavor, few physicians, nurses or techs spend much time interacting with enterprise software. The mobile messaging or alerting provided by many EMRs only supports EMR generated messages. This alerting does not include the care coordination or orchestration resulting from the use of the EMR or communications requirements that are totally separate from the EMR.

In the ambulatory market, still mired in fax machines and phone tag, basic communications inefficiencies have been around for many years. Here automation trends, EMR and mobile device adoption, are driving the market, but in different ways. The advent of smartphones and texting showed clinicians a better way to communicate, and many took it – to a degree, patient care trumps HIPAA any day. Entrepreneurs saw the market opportunity for secure messaging and many start ups were launched in response (many founded by physicians). As in hospitals, spot solutions are also compelling to ambulatory market buyers as they look for solutions to specific pain-points around patient rounding, admission/discharge, avoiding re-admissions, and various types of patient communications.

Market Evolution

This market is evolving like other markets in health care over the years. The market starts out with no experience buying or using messaging middleware, but recognizing they have specific problems or pain-points they want fixed. Early on, buyers don’t know how to properly define their needs and match those needs with the “best” solution available. They don’t know the questions to ask vendors, and often don’t understand the answers to the questions they do ask. This results in protracted procurement cycles that often seem to veer from non sequitur to non sequitur as buyers attempt to become confident with their purchase decision.

The risk for first and perhaps even second time buyers is investing in the wrong solution. Poorly understood needs, combined with selecting an imperfectly understood solution often results in a poor match between actual needs and the actual capabilities of solution. When this happens, unmet needs are just that and user adoption becomes a struggle, if not an impossible goal. Ultimately, the buyer must replace their initial purchase with a more suitable solution, or look for ways to fill those solution gaps.

Getting into something for the first time is a common experience and there is a body of thought that’s arisen around this common challenge. One’s knowledge deficit in these situations can be divided into a number of areas:

  • Unknown knowns – things we don’t know we know
  • Known unknowns – things we know we don’t know
  • Unknown unknowns – things we don’t know we don’t know
  • Errors – things we think we know but don’t
  • Taboos – dangerous or forbidden knowledge
  • Denials – things too painful to know, so we don’t

Both buyers and sellers can mitigate their risks by finding and using experienced resources who have already learned things the hard way. Without assistance, buyers are left to figuring things out on their own – often trying to finagle their prospective suppliers to educate them. The challenge for vendors is to not only sell their solution, but simultaneously, show the customer how to buy it. The term I’ve heard repeatedly is, “showing the customer the way.” To do this, marketing, sales tools and the sales process itself must be developed to accommodate both these objectives, selling and educating.

As markets become more educated and mature, the characteristics of the market change. Presently, many buyers are becoming aware of their needs to improve communications and automate workflow. Entrepreneurs tend to be highly skilled at identifying emerging market needs, and the existing market segments closely reflect the pain-points prospective buyers are seeking to ameliorate.  As these market segments continue to emerge, disruptions can arise to complicate things for buyers and sellers both.

Market disruptions are factors that cause changes among buyers, sellers or both. Besides taking note of, and compensating for current disruptions in the market, it is important to anticipate and plan for future disruptions. One obvious potential disruption is the proliferation of messaging solutions. Over time within a health care community, individual users who overlap with various entities will be put in a position to install different messaging apps on their smartphone in order to communicate with the rest of their patient care team. The potential impact of having to use two, three, or even more messaging apps is something to consider. Does your message/worklist queue lose effectiveness when you have more than one? Will push messages or alerts appear on your phone regardless of what client is on the screen? How easy will it be to manage and respond to your message flow when it comes from multiple apps? It could be this will be no problem depending on what your role is, your message volumes and how your messaging apps behave. Or it could be that this becomes a big problem, rendering all or some of your messaging apps ineffective.

Another potential disruption might occur in the enterprise or hospital market. In this example, messaging solutions proliferate but the messages are all received and responded to through one smartphone app. This kind of proliferation – a systems of systems proliferation rather than a proliferation of messaging client apps – is occurring now. Currently a number of broad messaging solutions are partnering with deep messaging solution providers to fill in gaps in features desired by some prospective buyers. For example, TigerText partners with Amion (for on-call physician scheduling) and xMatters (for emergency mass notifications) to offer a more complete messaging solution. Another market leader, Imprivata Cortex partners with Amion, HIT Notifi (for critical test results reporting), and Extension and ConnexAll (for medical device alarm notification) for the same reasons. Were these deep market solution providers’ products designed with the intent of relying on an other messaging system for message receipt and response? What degree of verification and validation testing was conducted – using what specific use cases – for these deep market solutions to qualify as technology partners for the broad market solutions? At what point will the market start to demand all of these features from the same vendor? Likewise, when will some of these messaging solution vendors broaden and deepen their solutions eliminate the need for these partners?

Of course this system of system proliferation of messaging solutions isn’t necessarily limited to the hospital market. I’m sure any secure messaging solution targeting the ambulatory market would love to partner with a company like HealthFinch to include managing prescription refills into their overall messaging solution. Other specialized capabilities revolving around managing patients at risk for re-admission, patient engagement for chronic disease management, and providing structure to care team coordination. Whether in the hospital or ambulatory market segments, systems of systems proliferation remains both an opportunity and a potential problem.

Let’s not forget the perennial role of HIT vendors as spoilers for smaller niche solution providers as a future market disruptor. As noted earlier, EMR vendors already provide messaging to mobile devices for EMR generated alerts. Some also provide worklists for caregivers based on patient specific orders. How many sales reps from large HIT vendors whispered into CIO’s ears, “don’t buy that messaging solution from that little company, we’re working on that – it will be out… soon.” And in fact, one of the largest HIT vendors already does have a messaging solution, Cerner’s Alert Link (no link as it appears that Cerner doesn’t has a landing page for this product). The big HIT vendors entering or dominating this market is not a foregone conclusion for a variety of reasons.

The granddaddy of all disruptions might be when the market transitions from the current multiplicity of pain-point solutions to enterprise class solutions that are both broad and deep. In a very real sense, messaging is messaging – once you have the plumbing and enabling features like scheduling and rules engines, brand extension becomes an exercise in developing configurations to tackle as yet unmet needs. This disruption will come from both buyers and sellers. At some point buyers will recognize that they’re dealing with proliferation issues and market demand for broader and deeper – more complete – messaging solutions will begin. On the vendor side, there will be a natural tendency to add capabilities to gain competitive advantage. Eventually messaging solution provider’s product roadmaps will lead to enterprise class applications.

Other Posts on Messaging Middleware

You can find a post Messaging Middleware Defined here. In the coming weeks posts on Strategy Implications, and HIPAA will be published. Be sure to check back!

Pictured above is the new SpectraLink Pivot Android-based enterprise smartphone from HIMSS14.

Tim Gee is Principal of Medical Connectivity Consulting. He is a master connectologist, technologist and strategist working for medical device and IT companies and various provider organizations. You can learn more about Tim here.

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July-1-2014

21:56

What do secure communications, care team coordination, patient engagement various workflow automation solutions and alarm notification have in common? They’re all examples of messaging middleware solutions found in health care. Which begs the question, what the heck is messaging middleware? This label is a term of art that was first coined by Emergin in the early to mid 2000s. As the name of a product category, it’s descriptive of the underlying technical functions of the product, but has nothing to with how the products are actually used – which can vary considerably.

All of this said, the term messaging middleware is terrible because it’s too generic and the term middleware usually doesn’t mean anything to people outside of IT. A survey of the market shows that many companies are avoiding messaging middleware and using words that describe their product in terms of their target market segment – secure messaging and alarm notification as two examples. In this series of blog posts, the terms messaging middleware, secure messaging, and messaging applications are used pretty much interchangeably.

What Is Messaging Middleware?

Messaging middleware provides integration with and transport for data or communications between users, applications and medical devices. The data streams between these entities are mediated by software to orchestrate secure message flow, message payload and can even generate new messages based on the content of data streams. These systems also provide closed-loop communications where the transmission, reception, reading and response of a message is tracked, with messages resent or redirected (i.e., escalated) in response to a variety of possible delivery failures. All of this communications is recorded and logged in a database to provide management information and big data analytics opportunities. Messages sent to or from users typically entail some sort of mobile device, a wireless voice over IP handset or smartphone running a client app. Such systems also have web based clients that can be accessed on PCs for users to both send and receive messages. These systems can include a number of common features:

  • Secure communications between message senders and receivers (both messages originated and sent by users, and messages generated by the messaging middleware system itself or other external systems), that can include support for multimedia attachments
  • Systems integration via HL7, Active Directory, LDAP, SIP, TAP, SMPP, SMTP, proprietary medical device interfaces and web services, communications with EHRs, nurse call, medical devices, phone switches, etc.
  • User directories that span multiple enterprises to enable communications across a health care community
  • Role based messaging where messages are sent to a role such as a particular patient’s caregiver or the phlebotomist covering a particular nursing unit rather than a specific individual or device
  • Message escalation resends the message to a predefined user or role in the event of failure of the message to be received or acted upon within a preconfigured time frame
  • The assembly of contextual data that is automatically sent with the message, such as relevant clinical data sent with a medical device alarm or a message sent to a clinician or team of clinicians like a rapid response team
  • Predefined or canned message replies that can be sent with a message to speed replies to a message or automate workflow
  • Rules engine for clinical decision support or to automate workflows

In the IT world, middleware or messaging middleware (messaging-oriented middleware) refers to infrastructure that enables applications; in health care, messaging middleware is the application. How these messaging applications are positioned and sold – and the kind of additional features used to differentiate and provide a competitive advantage – are quite varied. Examples of messaging middleware applications include secure physician-to-physician and physician-to-caregiver communications, physician- or hospital-to-patient communications (appointment reminders, prescription adherence), workflow automation applications (patient transport, bed management, rounding, prescription refills, etc.), alarm notification, and mass notification systems to name just a few.

Product Architecture

All of these seemingly quite different applications can be implemented using the same basic product architecture. This architecture is made up of a number of highly configurable modules that are integrated and configured (via scripting and tables) to accomplish specific tasks. These  modules, or software engines are very powerful, and an integrated constellation of these engines can provide very sophisticated enterprise-class capabilities. Not all of the solutions in this product category include all of the components noted in the diagram, and there are often qualitative differences between the different software engines included in a particular vendor’s solution. There are also key features in some vendor’s systems that are not included in this diagram (e.g., physician or staff scheduling).MMWarchitecture

The reasons for this shift to highly configurable software engines to replace purpose written source code are many. One fundamental shift is the considerable reduction in the scope of source code development and an increase in configuration as the primary means to define software functionality. Now, rather than having software engineers coding specific product features and workflows, engineers work on the basic enabling capabilities of the software engines. The task of implementing features and workflows for users can now be done by application specialists who tend to have direct work experience with those clinical workflows as nurses and techs. And besides having a vastly improved grasp of user requirements than engineers, application specialists are currently a less expensive human resource.

Another important consequence of this new product architecture is a substantially reduced time to market and associated reduced product development costs. A team of a dozen engineers would need 3 to 5 years or more to write source code from scratch to implement a basic messaging middleware system. Using engines, a half dozen engineers and a few clinician application specialists can launch a very competitive product in 18 months.

Other Posts on Messaging Middleware

On a weekly basis, posts on Market Segmentation & Adoption, Strategy Implications, and HIPAA will be published. Be sure to check back!

Pictured above is the Voalte smartphone client on the Apple iPhone.

Tim Gee is Principal of Medical Connectivity Consulting. He is a master connectologist, technologist and strategist working for medical device and IT companies and various provider organizations. You can learn more about Tim here.

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