Messaging is all about getting things done. Whether you call it Secure Texting, Secure Messaging, Clinical Communications and Collaboration, Messaging and Orchestration, Workflow Automation or something else, we're talking about the ability to message users to accomplish a specific task who are mobile or at a desk using a conversational user interface.
In this post we'll look at how health care messaging and orchestration solutions are changing for 2019. We'll look at vendor and provider trends, provide some analysis and prognostication.
Remember when everyone was talking about Secure Messaging? SMS texting was not HIPAA compliant and all the market could think about was replacing texting on personal smartphones. Studies show there's still a lot of verboten texting going on, but progress has been made. (This 2018 PatientSafe Solutions/HIMSS Analytics report found that 59% of informaticists report use of unsecure messaging across all clinical roles.) Now you hear a lot about Clinical Communications and Collaboration; the next big thing will be Workflow Orchestration.
Are these changes any wonder? Phone tag and overhead pages, or (the worst) faxes are intrusive, noisy and inefficient. And why stop with person-to-person initiated communications? Why not include workflow automation and orchestration for common functions like alarm notification, patient flow, patient transport, discharge, care coordination and other common tasks?
An example of the power and potential of messaging and orchestration is PagerDuty. Targeting the commercial enterprise market with messaging and orchestration, this startup just went public on April 11, 2019 and a day later is valued at $2.4 billion.
Often traditional enterprise applications require workers to move information from one application to another manually, aggregating information in their minds to get things done. We're starting to see messaging and orchestration solutions overlay those same enterprise applications to improve the efficiency and reliability of the manual tasks workers do in their daily jobs. While messaging and orchestration with PagerDuty is an enterprise app, in health care it is an inter-enterprise app — this is the special challenge and opportunity in health care.
Findings & Analysis
The messaging and orchestration market is maturing. Market leading vendors are making big investments in their platforms to drive growth and it seems we're on the edge of early-majority market adoption.
Various studies have pegged hospital messaging adoption at between 40 to 50 percent (Spok 2018 reference). Another 30 to 40 percent of the hospital market is currently evaluating messaging solutions. Some of these evaluators are looking for their second (and hopefully better) messaging system.
Another portion of those evaluators have been evaluating for multiple years, often due to challenges facilitating an internal consensus on stakeholders, what a messaging system should do, and educating themselves on this new product category.
Conversational User Interfaces
There is growing demand for conversational user interfaces (CUI) in many enterprise applications, especially for users who can't or aren't trained on the software or are mobile. Patients are an obvious target for CUIs as are health care trading partners and those within the enterprise who are mobile or occasional users of a particular app.
Here's a brief explanation of a CUI:
Unlike a command line user interface or GUI, conversational user interfaces require little or no user training. Conversations can be implemented using text or voice (using natural language processing, speech recognition and text-to-voice technologies). Applications using conversational user interfaces are often referred to as "bots" or "chatbots." Chatbots can be separate applications, add-ons to enterprise applications, or a feature in a messaging and orchestration solutions.Health Care Messaging and Orchestration - Systems of Action
Messaging and orchestration apps are the quintessential conversational user interface application. Person to person messaging is obviously a conversation. System or application to person messaging can also be a conversation. The Vocera hands-free badge was probably the first widely deployed conversational user interface in health care. A key question is whether or how one leverages a messaging app to provide a CUI to an existing enterprise application like the EMR, clinical decision support systems or operational applications automating ancillary departments.
The many advantages of CUIs come with some limitations. First, there must be an application on a smartphone, tablet or computer to facilitate the conversation. An uncontrolled proliferation of messaging and chatbot CUIs on users devices could easily impact usability and adoption should there be any confusion about which CUI is generating a conversation or message, or which CUI is needed for initiating a certain type of message or interaction. This proliferation could easily challenge users with a cognitive burden that will be too high for many users. Eventually buyer preferences for single vendor solutions will become more insistent, partly driven by proliferation issues like this.
Recent acquisitions are indicators of the market heating up. Amcom, acquired by USA Mobility (now Spok) was the first messaging market roll-up, created in the mid to late noughties. Since private equity firm K1 invested in PerfectServe in 2018, PerfectServe has gone on to acquire CareWire, Lightning Bolt and TelmedIQ, and a new roll-up appears to be building before our eyes. This year Vatica Health acquired messaging vendor CareSync. Like with PerfectServe, Vatica is backed by a private equity firm.
Who else will emerge with a roll-up strategy? What key capabilities will be targeted for a roll-up? How will roll-ups differentiate and seek sustainable competitive advantages?
With more than 100 messaging vendors, there's plenty of raw material for several roll-ups. On the acquisition front, Vocera acquired Extension in 2016, and Voalte was snapped up by Hill-Rom this year. In an example of a customer acquiring a vendor/supplier, HCA acquired Mobile Heartbeat in 2016. Some level of consolidation is likely to continue in 2019 and beyond.
Along with market consolidation, some messaging vendors are running out of runway, unable to finance their current burn-rate. Cash strapped vendors who can't find a buyer, will provide some great software assets available to vendors looking to round out their product offerings.
There has been just as much or more consolidation occuring on the ambulatory and patient engagement ends of the messaging and orchestration market.
There are many go-to-market and product strategies adopted by vendors. Vendors are always looking for sustainable competitive advantages that are often reflected in the different approaches described below. For buyers, it is important to understand a prospective supplier's strategy to ensure that their objectives align with yours.
Here are some of the strategies currently used by various messaging vendors:
- Provider organization: Many vendors target a specific type or group of provider organizations such as acute care, assisted living, ambulatory, physician practice and other easily identified groups with common requirements.
- Users: With this approach vendor solutions target groups of users within one or more types of provider organizations. Nurses, physicians, patients or some other selection of users are common targets.
- Use case: Both person-to-person messaging and workflow automation or orchestration claim specific use case support. Person-to-person messaging solutions tend to provide an appropriate environment in which user can engage in a type of conversation necessary for a use case. Workflow automation and orchestration provides specific logic to automate all or part of a specific use case. Common examples include secure texting, mass notification, clinical communications and collaboration, alarm notification, critical test results management, patient engagement, care coordination are many more. (See all the use cases and the vendors that support them here.)
- Product architecture: Another useful way to look at prospective solutions (or competitors) is their product architecture, which can have many implications regarding integration with other systems and certain key features. For example, some messaging systems are completely standalone, but they can be based on, or tightly integrated with a nurse call system (e.g., Ascom), or telcom features (1Call, Spok), or the EMR (Epic, Cerner). Features like scalability and availability are also highly dependent on product architecture. Some vendors talk about being cloud based as a way to enable certain features.
- Texting centric: Messaging used to be just about person-to-person text messages. Now many solutions also integrate voice (VoIP) for phone calls in the app. Vendors who remain text-only tend to target horizontal markets in addition to health care or are market laggards (e.g., OnPage, xMatters, Epic).
- Orchestration centric: Some vendors are moving beyond person-to-person messaging to include workflow automation, these are solutions with rules engines to automate workflow (e.g., Extension/Vocera, ConnexAll, Conversa, HealthFinch, PatientSafe Solutions, Qventus, Spok, Tagnos).
Vendors can also be profiled:
- Messaging as core business (e.g., Mobile Heartbeat, PatientSafe Solutions, patientping, PerfectServe, TigerConnect)
- Messaging as an opportunistic upsell to a different core product (e.g., Cerner, Epic, Imprivata)
- Vendors leveraging messaging as strategic differentiator to related core business (e.g., Ascom, Vocera)
- Vendors leveraging market segments: leveraging penetration in one market to gain entry into another one (Halo Communications, PerfectServe).
Most buyers are buying their first, and a few, their second messaging solution. With new markets, buyers seldom know what questions to ask to assess their own needs or to critically evaluate potential solutions. This results in longer and more chaotic than usual buying cycles. Sometimes the right solution is chosen, some times not. The complexity and number of stakeholders can make the process lengthy. And not including stakeholders can result in missed requirements and/or challenges driving adoption.
The health care market is learning that adopting messaging solutions is challenging. Social interaction and communications among colleagues is a very personal thing for users. Most all the leading messaging vendors have had a customer abandon their product for another due to challenges with user adoption.
Getting users to fundamentally change how they communicate is a multifaceted challenge that has sometimes resulted in failure or marginal success. There can be many contributors to these unsatisfactory outcomes: poorly understood needs, missing important stakeholders, and underestimating the effort required to drive broad adoption.
Few buyers of messaging solutions have a mid to long term vision for future communications capabilities, use cases or users. In a rapidly evolving market, this lack of planning is problematic. One result of poor planning is the need to replace an already implemented solution with another one that includes the newly recognized capabilities. Alternatively, multiple messaging solutions will be chosen in an effort to meet different requirements and/or users.
As noted earlier, app proliferation can easily result in confusion and inconvenience for users and a drop-off in adoption. App proliferation can be minimized by proper planning or replacing your current messaging solution with a new one. App proliferation can also result in governance challenges as a wide variety of stakeholders must be accommodated. Driving adoption for a second or third messaging solution is much harder than it is with the first solution (which itself was not easy).
As the market matures, buyer profiles are coming into better focus. Here are some obvious buyer profiles:
- Convenience buyers: These buyers do not see the differences between solutions so much as they want to make a quick and "easy" decision from a "trusted" seller, "We use Epic, so we'll buy their Secure Messaging app," or "We use Imprivata for authentication, so we bought Cortext." The proverb, "act in haste, repent at leisure" comes to mind.
- Solving the immediate problem: buyers who bring some rigor to the buying process, but only consider their immediate needs and users.
- Mid to long term planners: this smallest set of buyers consider both immediate needs along with where the market is trending and future needs they are likely to want to meet with a messaging and orchestration solution to craft a phased adoption plan over a period of years.
- By far the largest profile is the group of buyers "evaluating" solutions. They have yet to really determine their needs, stakeholders or key capabilities they're looking for in a messaging system and are working to learn about this new product category.
There remains a meaningful percentage of buyers who lack even a mobility strategy (43%) — and of those with a mobility strategy, many are incomplete (see this Spok report). PatientSafe Solutions has created a mobile maturity model (download the model here) to help health care providers improve their planning. Use it.
Evolving Product-Market Fit
Product-market fit, and the related term minimal viable product relate to assembling the essential features and capabilities in a product that will drive market adoption. Everyone, both buyers and sellers, are trying to figure out what the magic formula of features is for the "best" messaging solution. With all the different stakeholders and messaging use cases, one ideal product-market fit has yet to emerge. As we consider messaging in 2019, we can see certain approaches to product-market fit emerging among vendors.
Product enhancements generally aim to move solutions up the value chain, offering increasing (and hopefully, desired) capabilities to buyers. (Watch this great interview for Ron Remy's perspective on the messaging value pyramid.)
EMR Vendor Advantage?
Many believe that EMR vendors have a natural advantage should they integrate messaging into their systems. For some use cases this may be true, but for many other use cases EMR vendors have little or no advantage. Currently, Cerner and Epic are offering their own messaging solutions. See more on this topic below under Prognostication.
Tight integration with telcom systems is another approach to product-market fit (e.g., 1Call, Spok). This telcom approach to messaging combines a messaging system with operator consoles and integrations with the EMR and other telecom systems. Several messaging systems replace physician answering services.
Medical Device Strategy
Some medical device vendors have gotten into messaging, both as a necessity for alarm notification and as a strategy to gain competitive advantage. For example, Masimo incorporated alarm notification into Patient SafetyNet years ago. Philips has the biggest footprint in messaging, starting with their 2007 acquisition of Emergin. Hill-Rom may end up being the best example of using messaging to address product-market fit. Besides beds, Hill-Rom has nurse call and middleware for medical device integration. Now with the acquisition of Voalte, they could potentially put together a compelling product strategy with sustainable competitive advantages.
Alarm notification is also a key feature for some messaging vendors targeting acute care (Ascom, Cerner, ConnexAll, Extension/Vocera, Hill-Rom, Philips, Spok). An alarm message is not much different than any other kind of message, except that it must be cleared by the FDA prior to sale. Being an FDA regulated feature has proven to be an effective barrier to entry to most health care IT vendors. And to date, most buyers don't seem to mind buying two systems from different vendors, rather than one.
Some existing health care products are ideally suited to conversational user interfaces. Nurse call systems come to mind, and a number of vendors have rearchitected their messaging and nurse call systems to be fully integrated. This integration is intended to increase the capabilities and usability of both the messaging and nurse call systems. Ascom is one vendor who has taken this approach. Hill-Rom's existing Linq messaging product is tightly integrated with their Navicare nurse call. And Hill-Rom might do the same thing with their Voalte acquisition.
Beyond Acute Care
Looking beyond the acute care setting, some messaging vendors are incorporating tele medicine features to extend messaging to delivering patient care. These virtual consults can extend from acute care providers looking to minimize patient readmissions and among community physicians, their patients and sometimes payors. Examples include messaging oriented care by Conversa Health, telehealth centric by CirrusMD and pingmd, virtual patient-doctor visits by Bright.MD, and eConsults whereby primary care providers receive consults from specialists by RubiconMD. All of these solutions utilize messaging and many include workflow automation and orchestration.
In 2017, CMS provided reimbursement to physicians managing patients with chronic diseases. Like all such reimbursement, specific documented activities must be completed to qualify. Two years later, some 20 vendors now claim messaging and orchestration solutions that help physicians meet and document these requirements (e.g., CareMerge, Diagnotes).
Person-to-Person versus Orchestration
Person to person messaging offers more efficient communications, but still relies on people manually coordinating their activities. Workflow automation or orchestration uses software to apply rules to data seen or retrieved by the system. Examples include dynamically altering the severity level of a medical device alarm based on the patient's clinical data, ensuring the receipt of critical test results by clinicians, or sending reminders to team members involved in a complex task like patient flow.
Some messaging vendors have decided to stick to messaging and let other applications like patient flow apps do the workflow logic — they'll just deliver the workflow oriented messages (e.g.,Halo Communications, Mobile Heartbeat, Voalte). Other vendors have incorporated native workflow automation capabilities for those cases where there is no enterprise application sending messages to prompt workflow (Extension/Vocera), or as an outright replacement of conventional enterprise applications (Qventus, Tagnos).
Enterprise scalability is another area of investment for some messaging vendors. The objective is to provide a solution that can span tens or hundreds of hospitals in a system, enabling intra-enterprise messaging on a large scale and aggregating data at the enterprise level. Mobile Heartbeat and Spok are moving in this direction.
A different but related capability to enterprise scalability is inter-enterprise communications. There is a significant amount of communications between those within a provider organization and external health care trading partners that also care for the patient. These different users include hospital clinicians/caregivers, physician practices, sub acute care, patients, and payers. Discharge planning, avoiding readmissions and managing patients in ambulatory settings are some of the use cases where communicating with those outside the enterprise is a necessity.
This capability requires a user directory structure that supports users outside the enterprise. A good example of this is DocbookMD, acquired by Medici in 2018. DocbookMD's go-to-market strategy, and underlying user directory structure, targeted county medical societies to endorse or buy DocbookMD's messaging solutions for all the physician members of that medical society. Halo Communications has a different approach, using national physician ID numbers to find users who are outside of the enterprise. Either way, the need to communicate with health care providers and trading partners outside the enterprise is a growing requirement for messaging systems.
Several messaging vendors are exclusively targeting physician practices where there is currently less competition compared to the acute care market (e.g., OhMD, pMD. Certainly product-market fit drives product and go-to-market strategies in this segment. Telemedicine and virtual care capabilities are represented. Patient engagement is also a frequent complement. Some of these solutions are tightly integrated with the practice management system and focused on basic workflow like appointment reminders and facilitating payments. There are also many messaging vendors targeting this segment that simply offer messaging across health care trading partners.
One of the hallmarks of conversational user interfaces is that they require little or no user training. As messaging solutions become more sophisticated, usability can become a challenge. A number of vendors have recently invested in refreshing their user interfaces to make them easier to use (Mobile Heartbeat, Voalte).
Many messaging solutions require lots of integration. with EMRs, provider's Active Directory, other apps like staff scheduling, nurse call systems, medical devices or third party alarm notification vendors. Many of these integrations are one-off system-to-system integrations that require the integrating vendors to sign agreements and work closely together (unwillingly at times).
There are a couple of alternatives to this common integration issue. A company can acquire and integrate a complementary application into their standard offering, much like Amcom did or PerfectServe is in the process of doing. On-call staff scheduling is a common app that's integrated with some messaging solutions.
Another approach is to publish a set of open APIs that make integrating with your system easier and less expensive than it is to integrate with your competitors. Of course, the key is to get other vendors, who want you to write to their APIs, to insteady write to your APIs. This is easier to pull off for leading vendors with a big installed base. An ideal solution is a set of APIs that are open to everyone to use, so that integrations with an API work for all the other vendors who support that API.
The above are just some of the approaches taken to product-market fit. There are more, all with some vendors getting good market traction.
I suspect that market penetration for basic messaging systems will be achieved within 5 years, orchestration will take a bit longer. But because this technology is new to health care, the market will retain a moderate level of activity as buyers go enterprise-wide with pilots, or replace their first or second messaging system purchase for one that better meets their newly recognized longer-term needs. Drivers for these changes will be additional use cases to be orchestrated and systems and groups of users as new sources for messages to be integrated.
Disrupting Enterprise Applications
Conversational user interfaces will increasingly disrupt existing enterprise applications. Mobility and the multiplicity of roles and responsibilities of clinicians, caregivers, patients, support staff, etc., is often poorly suited to conventional graphical user interfaces on desktop computers. Health care IT vendors will grapple with increasing pressure to complement their traditional products with conversational user interface capabilities as referred to in the Chatbots and EMR's Role in Messaging sections below. How vendors respond to this pressure will have an impact on their success.
Systems integration and multi vendor solutions; where to draw the line? As the market continues to mature, the tolerance for multi vendor solutions, e.g., one vendor for messaging, one for alarm notification, and perhaps a third for workflow automation, and/or a lot of systems integration will fall. Single vendor solutions will become more appealing. And yet, the product-market fit question remains: which key set of capabilities must be built into the messaging app and which will remain acceptable for systems integration?
Given the distributed cottage industry nature of health care delivery, there may never be a single vendor solution for messaging and orchestration. Where the fault lines will appear between solutions in a broader health care industry context is an interesting question that remains to be answered.
And what can be done to address systems integration overhead? If the industry, that's vendors and providers together, can facilitate a way to make systems integration much quicker and less expensive, market adoption would increase. That's certainly the experience of groups like the WiFi Alliance, USB Implementers Forum and the Bluetooth Special Interest Group.
Person-to-Person vs Orchestration Messaging
Clinical communications and collaboration is the new table stakes for entering the messaging market in health care. Secure texting solutions will eventually be pushed out of most health care markets due to the absence of sophisticated messaging features and workflow automation. Those secure texting vendors that survive will do so targeting horizontal markets. A related market, mass notifications (e.g., EverBridge, xMatters, OnSolve), will also end up as a point solution for health care IT departments and other horizontal markets.
Workflow automation, or orchestration will become increasingly important to buyers as they realize that there is a lot more to messaging than person-to-person communications. A priority for many provider organizations is to improve staff productivity, patient outcomes and patient safety — workflow automation and orchestration can provide that in a myriad of ways. Messaging and orchestration systems could be the essential tool for the growing number of process improvement departments in large provider organizations.
Currently there are only few partners who can provide alarm notification for messaging vendors without it (Bernoulli Health, ConnexAll, Excel Medical, Medical Informatics). Extension used to serve this role while also competing for messaging business, but they've been acquired. The remaining options could easily be reduced to one with another couple acquisitions. Actually, including a clinical decision support system company — that also does alarm notification — in a roll-up strategy could be pretty appealing to the market, and further constrains competitors who lack this essential acute care feature. Exactly what will happen here is unclear, but keep your eyes on this important part of the market.
Chatbots will continue to become more important, with some messaging vendors offering a chatbot capability along with startups focused on chatbot-only offerings. Application vendors will have multiple choices for adding conversational user interfaces to their solutions: third party chatbot tools and white label providers, an acquisition, or partner with vendors selling chatbot solutions (by themselves or as part of a messaging solution) to providers. Each approach has its trade-offs. Expect some contention for space on users' smartphones and tablets.
EMRs Role in Messaging
Expect more EMR vendors to acquire or develop messaging solutions. However, there are several factors that should prove challenging to EMR vendors: for example FDA regulated alarm notification (and perhaps clinical decision support), and figuring out how to address health care trading partners outside the hospital. The last thing most health care IT vendors, including EMR vendors, want is to be regulated by FDA.
EMR vendors are strongest in acute care hospitals, but there's plenty of messaging that occurs in health care outside of hospitals. Other entities could come to dominate messaging outside of the acute care hospital, messaging vendors themselves or perhaps entities like Health Information Exchanges (HIEs).
Well, there you have it, the 2019 health care messaging and orchestration market in all its dynamic glory. We've looked at many of the angles, from use cases, markets, technology and the changing dynamics of this market segment.
If you're looking for some insight into messaging and orchestration, let me know — we've just skimmed the surface in this post!