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., ConnexAll, Extension 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!