Quick Summary
Middleware and CC&C, which play a crucial role in the hospital enterprise, have evolved from bridging systems like nurse call and telemetry to enabling clinical workflow on smartphones and other devices.
“Accidental architecture”—which comes from the lack of a comprehensive design and planning process—has resulted in complex and unmanageable integrated systems in healthcare organizations.
Patient engagement technologies are becoming increasingly important, both inside and outside the hospital, and may impact the future of CC&C and nurse call systems.
There continues to be a need for a comprehensive platform that combines messaging, patient engagement, and all forms of communication in healthcare.
The progress in managing medical device alarms and alerts has been limited due to manufacturers' reluctance to cede control of workflow and integration.
The future of nurse call systems in an EHR-centric universe depends on regulatory changes and the ability to integrate with IP-based patient engagement systems.
Once upon a time—as far back as, say, 2010—the purpose of alarm middleware in the healthcare enterprise was simple: to create a bridge between nurse call systems and telemetry, and provide a method for sending alarms and alerts to pagers and proprietary wireless phones.
But as succeeding generations of medical communications devices grew more sophisticated—accompanied by a shift towards clinical workflow using smartphones and purpose-built, Android-based devices by Zebra, Spectralink, and others—clinical communication and collaboration (CC&C) systems arose to provide secure text-messaging between physicians and hospitals. Additional features like voice calling were soon added, eventually giving rise to a full communications platform that included scheduling, additional connected devices, improved routing and escalation, and even patient engagement.
The resulting free-for-all between standalone middleware vendors, many on proprietary platforms, and EMR-centric systems like Epic and Oracle/Cerner, gave rise to a competitive marketplace where the final winners and losers are still being determined—and where the survivors must navigate between customer demand, a strict regulatory environment, and the possibility of a single comprehensive communications platform that would benefit some more than others.
Such a platform, which to many seems inevitable, would result in a healthcare communications marketplace that looks very different from today’s. In the meantime, what can current CC&C and middleware platforms offer customers to remain competitive in an increasingly Epic-centric universe?
Untangling Accidental Architecture
According to Brian McAlpine, a digital health consultant for Cirkel Consulting Group with thirty years of industry experience, one of the major benefits of middleware and CC&C within the healthcare enterprise is its ability to address a problem that arises when institutions must upgrade their legacy clinical systems. As they add new layers of technological solutions and integrations over existing workflows, they can end up with what McAlpine refers to as “an unmanageable mess of integrated systems.”
“Many organizations,” he says, “wake up one day and realize they've accidentally created a complex infrastructure that they never originally intended.”
This “accidental architecture,” as it’s come be known, may begin life as a simple nurse call system that sends alerts to pagers. But with the gradual accumulation of new technology, the need to connect and integrate more things to support more workflows increases, with no overarching vision of how everything fits into the existing environment.
“Most organizations didn't have a vision for what the end state would be,” McAlpine says, “so they simply charged ahead, adding more integrations to support more of the workflows.”
The end result can leave clinicians stuck carrying multiple devices—pagers, phones, and any other devices used for communicating and receiving alarms. And because many of these come from different vendors, they don’t always work well together. This can lead to no prioritization or control over which, or how often, messages and alarms are received, compounding alarm fatigue and endangering patients.
CC&C vendors, says McAlpine, can help clean up accidental architecture by providing a platform to help control and manage the alarms. Some organizations have figured this out, mostly by implementing a full CC&C solution that’s closely integrated with the EHR, which can reduce complexity and costs while eliminating excess vendors.
But these organizations represent a small percentage of the market, and most hospitals today continue to use multiple vendors to manage their diverse set of messaging and alarms. And yet, as McAlpine points out, the more organizations who see the benefits of viewing EHR as a centralized platform, the larger the threat to standalone CC&C vendors.
Middleware in an Epic-centric World
Epic Systems, with over 36% of EHR market share in the U.S., remains perhaps the largest of those threats. The company continues to push forward in these markets, and its outsize influence—along with the industry’s inevitable convergence—poses a major risk to standalone CC&C and middleware vendors.
McAlpine recognizes that increasing numbers of customers are looking to leverage Epic’s mobile applications, such as Rover, wherever they can. But in today’s multi-vendor environment, he also sees this as an opportunity.
As long as Epic—due less to technological than regulatory reasons—is unable to integrate directly with devices like patient monitors to manage alarms, many CC&C vendors are positioned to fill this gap by providing validated alarm management integration into Epic’s mobile apps. In addressing a prevailing customer desire to manage all alerts and alarms within a single platform, standalone alarm management platforms can remain relevant.
Likewise, since every customer has a different starting point, and not every hospital requires a comprehensive platform—sometimes basic nurse call integration is sufficient—there remains a place for CC&C, alarm middleware and Epic to all work together. As long as the customer makes clear what its needs are, vendors will be forced to find a way to make that happen.
Does “good enough” supplant best-of-breed?
According to John Elms, a strategic adviser who is a former Chief Product Officer of TigerConnect and co-founded Connexall USA, Epic’s reluctance to avoid entering the FDA-regulated medical device space is both practical and strategic. But when, or if, that changes, the whole landscape will change with it—making a huge impact on the marketplace.
History shows that it’s difficult to expect CC&C and middleware to thrive as standalone applications when competing against EHRs. Citing such once-dominant applications as Pyxis and the original Netscape web browser, Elms doesn’t believe the long-term prognosis is good for standalone providers, especially of physiological monitors and nurse call.
“‘Good enough’ features,” he maintains, “always supplant best-of-breed applications when they're tightly integrated with an enterprise platform.”
If that makes the long-term seem grim, there are gaps in the midterm that could be filled between what’s available now and what’s likely to be available with CC&C in the near future. For example, ancillary augmentative technologies like building automation systems could be integrated with access control, lighting, temperature, sanitation, security, safety, and other things—which may be particular to healthcare, but not to the EHR and its related applications.
Engaging with Patients
Patient engagement, which intersects with CC&C and nurse call, is another area that might offer a lifeline. Whether inside the hospital or out in the broader healthcare enterprise, communications are something McAlpine believes have plenty of room for fundamental improvement.
Accordingly, he points to the overlaps between nurse call and interactive patient care, and CC&C and patient engagement. And he agrees with many industry analysts who believe “a combination of CC&C and interactive patient care can essentially replace the functionality provided by a traditional nurse call system.”
He also takes encouragement from the fact that, over the last five years, CC&C vendors have expanded in the area of clinician-to-patient communication.
“Up to that point,” he explains, “the CC&C vendors' messaging was strictly designed to be between members of the care team and hospital employees. But healthcare organizations know they need to change and adapt in order to survive. And it's recognized that patient engagement will play a role in that.”
A single, Comprehensive Platform?
Back in 2010, when Elms was still at Connexall, his company envisioned a sophisticated, automated air traffic control system “that would manage the delivery and prioritization of medical device alerts and alarms, making sure they got to the right person on the right device at the right time.”
But that dream of middleware, smart alarms and universal connectivity has been far from realized.
“When you look at the numbers of connections in a healthcare system connected to a mobile communication platform,” Elms says, “it's still predominantly about nurse call.”
As further evidence he cites the continual presence of alarm fatigue on ECRI’s Top 10 list of preventable medical errors in healthcare. This is in spite of the 2014 Joint Commission mandate calling for accredited hospitals to better manage their medical device alarms to reduce alarm fatigue and the potential for patient injury.
The lack of progress, in Elms’ estimation, is due to manufacturers not wanting to give up control—of workflow, routing, escalation, and notification—to a proposed centralized ecosystem, even as medical devices grow ever more sophisticated.
Nurse call companies are known to be highly territorial about tying their infrastructures to third parties, he affirms, and are not only afraid of losing control over their workflow, but of the resulting decrease in their perceived value. This leaves the customer caught in the middle, between uncooperative manufacturers and their own specific integration needs.
Which is why, at the end of the day, customers need to speak up.
“When the customer demands a certain capability or feature, by and large, those manufacturers will respond to the customer,” Elms say. “And the customer needs to be loud. They need to be demanding.” They also need to be educated to be smarter about what they ask for.
Ideally the industry will continue to converge toward a single platform that handles all communications. So many hospitals would like to be able to deploy a new nurse call system as easily as they deploy telephony systems. But with companies continuing to add features that are more proprietary, not less, it’s anyone’s guess how soon that might happen.
The cost of Convergence
Is there a long-term future for standalone CC&C companies?
McAlpine believes that healthcare organizations will continue looking to save costs, consolidate, and simplify their environment by cleaning up accidental architecture. One way or another, this will lead to a single comprehensive platform that combines messaging, patient engagement, and all other forms of communication, including contact centers.
Whether that convergence happens in two years, five years or longer, it will start across the broader healthcare enterprise—which today extends as far as the home—before it happens within the hospital itself.
Elms agrees that a single platform handling all communications “is really where we'd like to see the industry get to.” But he thinks the future of nurse call ultimately comes down to one thing: the fate of UL 1069, the regulation that requires an uninterrupted, fully reliable system for activating tones and lights when patients need attention. It’s a regulation he considers rooted in the past—one that prevents engineers from launching innovative, IP-based nurse call systems that use “tablets instead of pillow speakers and all those other things that we might imagine for a nurse call system.”
“We’re either going to get more intelligent and less wedded to the standard that guides nurse call today,” he explains, “or we'll hold onto UL 1069, and nurse call systems will get dumber, not smarter.”
Or, as Epic and Oracle already begin to incorporate new generative AI capabilities into their platforms, there’s a third possibility—nurse call systems that are both dumber and smarter.
Co-founder of Connexall USA and the former Chief Product Officer at TigerConnect, John Elms is an accomplished executive with over 25 years of leadership experience in the high tech industry. His career spans various roles, including CEO positions at public and privately held companies, venture backed startups, and his own entrepreneurial ventures.
Brian McAlpine has spent most of his 30-year career assisting innovative startups with developing and taking to market solutions focused on the provider side, primarily in acute care. His career has been focused on developing new markets in healthcare IT including device data integration, connectivity workflows, alarm management, clinical surveillance, clinical communications, patient engagement, and medical devices segments.
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