16 April 2019

Secure messaging’s existential crisis


Best Practice (BP), our largest primary care patient management system vendor, and Medical Objects (MO) , one of our top three secure messaging system vendors, have a few important things in common. Both were founded by doctors with a technical bent, and a desire to make things easier, safer and more efficient for their colleagues. Both founders retain firm control of their company’s destiny after more than two decades, despite many offers to sell out to major corporates (BP is owned 30% by Sonic). And  both have (or have had) head offices in very strange locations – BP in Bundaberg (their HQ is now Brisbane, but they maintain their Bundaberg office), and MO is atop a Chemist Warehouse in a suburban shopping mall in Maroochydore.

What comes with that, apart from the travel time you have to put in to get a face to face interview, is a certain coal-face practicality, and honesty, about what they are doing and hope to achieve.

I hired a car and travelled the one hour and 28 minutes from Brisbane’s CBD to sunny Maroochydore, with the hope of getting a coal face and frank view of what might be happening in Australia’s secure messaging ecosystem. After months of talking to and researching the work of various stakeholders, I wasn’t getting close to an understanding why we still find ourselves with so little progress, over something which most stakeholders will tell you is one of the key pieces of our digital health future. And which, even as it stands today, is a major fulcrum in the system for patient safety, and system efficiency.

If you ask this question to MO’s founder, Dr Andrew McIntyre, whose full time job is as a Sunshine Coast gastroenterologist, but whose passion seems to lie with his medical software business, you can almost feel the oxygen sucking out of the air. He comes across immediately as highly intelligent, patient and calm, but his frustration is palpable.

As is that of his technical team, who, unusually for an interview like this, he has brought to boardroom with him, to help with my understanding of the sector. They are all focussed, and passionate. They are also all technologists first, which might explain some of their frustration.

On paper, McIntyre explains, it shouldn’t be difficult. In simple terms, we have appropriate messaging standards we can all use and “we  should all use them”, he says. The key standard he points to is HL7v2, which is recognised as the most versatile and appropriate for complex and atomised clinical data.

By “we”, McIntyre doesn’t just mean his competitors in messaging, but the various software vendors who are at one end or the other of messaging services. Key clients include the major patient management system (PMS) vendors; Genie, Best Practice and Medical Director, and the major pathology providers.

But from this starting point – let’s all just work to a common and compliant standard – things start to unravel fairly rapidly into a long, and somewhat tortuous history of commercial jockeying among the various software vendors and major pathology providers, and an inability or, potentially, an unwillingness, on the part of government to bring any order to the proceedings.

McIntyre, who has been involved deeply in the messaging game for upwards of 25 years now, says that we are at a stage where we might even be going backwards. He cites a serious diminution of technical expertise in sector, partly as a result of the corporatisation of major players, including the pathology companies.

He says that most of the large pathology groups, which once had a lot of deep expertise in their ranks, have very little now, as they have focussed their attention on other priorities in the last decade, like scaling their labs, and integrating their various acquisitions.

“Standards and data quality just wasn’t important enough to them to take much notice in this period, it went off their radar amid all the consolidation and growth” he told Wild Health.

MO’s two major competitors in messaging, Argus and Healthlink, during the same period got acquired by far larger corporate groups, and lost their founders, both who had deep insight into the sector. McIntyre thinks the process or corporatisation results in companies developing different priorities and drivers from founder driven groups. He doesn’t say that these are necessarily bad businesses as a result. But he does say that their focus on coal face technical issues becomes significantly diluted as they move into other concerns such as directed shareholder growth targets and return.

“There just aren’t many people who now understand how to do a lot of the stuff we are doing from a technical perspective,” he said

“From a business perspective, I guess you could say we might suffer as a business as result as there are some things our competitors do better than we do. We aren’t particularly good at deal making, we don’t play politics much, and we don’t spend our time thinking of how we can maximise shareholder profitability. We spend most of our time trying to develop an optimal product.”

Part of that process according to McIntyre, is having a product that is strictly compliant to the most appropriate standards of messaging. Foremost in his mind is HL7v2.

But it also includes a technology stack that he believes is now quite superior to the other vendors. One which allows point to point messaging in seconds, rather than up to an hour in the case of his competitors products, which run a different architecture using ‘store and send’ protocols.

MO messaging can take an hour, but only if they have to connect to one of their competitor products.

You would think that with that sort of product advantage MO might be flying up the messaging vendor market share chart. Anecdotally, they are probably gaining share, but they aren’t flying. Not yet anyway. Their competitors have form in terms of client commercial offerings other than the technology.

Healthlink, for instance, has gained significant share of GP messaging, by offering their service to GPs for free.  And they offer commercially attractive terms to retain PMS software business in certain circumstances.

Incumbent share is a valuable asset in medicine as doctors, and their practice managers, are not creatures who adapt well to change. Changing messaging vendors and messaging infrastructure, if they understood the implications, should be a topic of concern to them. But amid their day to day concerns, it’s not what you’d call an easy topic to create engagement. Like many key players in this ecosystem, it’s just not on their radar. It’s out of sight and out of mind.

It’s a pattern that starts to explain a lot about the engagement of many of the major stakeholders in messaging in Australia.

Like Healthlink and MO, Argus has a large established client base. It also has Telstra Health as its parent, with lots of potential messaging business to be had through this group’s other healthcare businesses such as FRED IT (which virtually owns the pharmacy desktop management market), and  it’s various aged care and hospital based products that need to talk to external points  of the system, such as specialists and pathology labs.

So to significant extent, there are commercial reasons which likely mean that we will see all three major vendors, and a few smaller ones, continuing to jockey for a messaging market, well into the future. Especially given that this market can only get much bigger as digital health takes hold and the key nodes between specialists, GPs, hospitals and laboratories, start to be more fully utilised.

One possible disruptor to such a scenario is potential of is new paradigm interoperability technology like Fast Healthcare Information Resource (FHIR).  This is a technology which in theory would mean that a lot of the work the secure messaging vendors do now, will become redundant, as distributed software system data bases are enabled to talk to each other via API protocols over the web.

Some think this may happen over the next 5 to 10 years, but even if it does, it is difficult to see the messaging vendors with their existing client footprints and relationships, and value adding to their services (MO is developing expert systems that assist a doctor to assess their messages), going away.

That means that for the near term at least we are stuck with multiple vendors:

  • each with their own versions of translation of the client medical software vendor messages;
  • each with their own architecture for sending;
  • each with varying degrees and interpretations of the use of existing messaging formats like PDF and CDA, but probably most importantly, HL7v2, which is the key standard for messaging complex pathology data;
  • each with a large section of client base glued tightly to their system by a combination of history, loyalty and a reluctance to change anything;
  • each with their own directory of providers (with the secret sauce a wad of technical information of what systems they are using to receive and send), which they, for obvious reasons, see as part of their valuable IP as commercial entities.

A lot of little differences add up to a lot complexity.

An underlying issue has always been, and still is, that the messaging vendors have no commercial upside in sharing much of anything, including settling on a set of common messaging formats and standards.

Multiple players in such a complex technical sector is always going to present “change” issues. In New Zealand messaging works much better because there is really only one vendor. That has the upside of the simplicity that results from common formats and standards, as there is only one player, but it has the downside that messaging in that country is significantly more expensive.

Enter government and its many failed attempts to get the vendors to ‘burn their boats’ for the greater good of Australian patients and healthcare. It’s a sordid history, littered with quite a few attempts by the government to bully the messaging vendors into submission by threats of “we’ll do it without you, if you don’t do it!”.

On each occasion, not surprisingly, the government (once in the form of NEHTA, and more recently as the ADHA) has found itself in very deep water quickly from a technical standpoint in their attempts to bypass the vendors.

NEHTA famously made the threat not long into its existence, and as a result alienated the entire messaging sector. This slowed progress in opening up messaging to a near halt for many years.

It turned out to be commercially and technically naïve for that agency to think they could bypass the vendors. For starters, they had all the client relationships. With that they were in a very strong negotiating and influencing position, no matter what the government tried.  They had lots of ammunition to fight the government if they were forced to do something that was commercially too difficult.

But the vendors real trump card was IP. On paper, it seemed easy to come up with a ‘phone book’ of providers, and develop a centrally run system. In practice, as McIntyre points out, there is a lot of IP in the messaging companies that no one is even aware of and possibly still doesn’t appreciate. The government soon found out they couldn’t do it for anything near the cost that the vendors were already doing it.

It was therefore with cap in hand and no doubt, some charisma and sales mojo, that Tim Kelsey, the newly appointed CEO of NEHTA reincarnated as the Australian Digital Health Agency (ADHA) , broke bread with the vendors soon after he joined. He was smart enough to assess very quickly how much they actually needed the vendors to get things sorted out.  Reasonably soon after starting Kelsey got all the vendors back to the table to discuss and formulate a solution with other key stakeholders such as the RACGP and the Medical Software Industry Association (MSIA).

That was nearly two years ago.

Many in the industry love to bellyache about the ADHA (we do) and its bureaucracy and politically driven agendas. But the Agency tried very hard and with some intelligence to kick start a path to much better messaging solutions. They got the major messaging and client medical software vendors in the same room, to agree on a roadmap, set a series of principles they could work by and remain commercially viable, and initiated a series of interesting, albeit, very specific trials of how progress might be achieved. This was all done while the agency was trying to get the unpopular and controversial My Health Record (MHR) back on the rails as well. The MHR was clearly the main game for the agency in terms of its political agenda, but it continued trying to get messaging sorted none the less.

Even McIntyre was convinced to go back and try to help, something that after years of trial and disappointment, can’t have been easy. MO, as part of one of the conglomerates set up to do some trials, wrote a common format standard, which they believed could be used by all the PMS vendors to standardise messaging.

If you talk to the ADHA, and read their recent press on secure messaging, and interoperability, you might think that this was all going reasonably well still. There is a lot about the success of its trials.

McIntyre begs to differ.

He got so frustrated with the process that he resigned his company and resources from any ongoing process late last year. He told Wild Health that the ADHA lacked enough technical know how to understand how to properly manage the process. He said that participants were given unrealistic deadlines, ones which he guessed were being set by the politicians up stream, and things became rapidly surreal.

“We were being driven by deadlines that didn’t have any relationship to the technical issues we were trying to solve,” he said. “It was being politically driven”.

In some ways such an impasse between the most technically driven of the vendors, and the government might have been forecast based on the past.

As long ago as 2012, under NEHTA, the same alliance of vendors joining forces to create a common exchange was spruiked as a solution. Back then Argus, Healthlink and Global Health joined forces to create a secure messaging exchange. And back then MO identified the problem which ultimately probably put this latest attempt by the ADHA on the rocks. McIntyre said in an interview with PULSE IT back then that he might join such a venture if “infrastructure like NASH and ELS and payload compliance makes this a safe reality”. He also said that he felt there would  be a lot of technical “devil in the detail” of this venture that he felt the vendors may not be able to accept.

It turns out that a lot of those objectives and ideas were a part of the latest ADHA attempt to bring the vendors to the middle and sort things out. It isn’t that surprising the MO didn’t persist that long with this attempt.

The ADHA is driven by politically expedient goals as well as technical and practical ones. The MHR project might be a key example. In two years, and with nothing to work with but a bad record, bad relationships and an MHR program stuck in controversy, you could easily argue that picking this program up and forcing it to some sort of benchmark of political success – opt-out –  was the only option for the ADHA if it was to retain its credibility enough to have the backing to get on with other projects.

The other two vendors kept going with ADHA, possibly because each was more politically sensitive than MO, and late last year and early this year, announcements were made by the Agency, which suggested that the various messaging pilots were successful and the program remained “on track”.

Whether MO pulled out for good reasons or not, it is hard to see how a national program to create a uniform messaging environment, could be on track with one of the three major messaging providers deciding not to play ball. Especially given McIntyre says his decision wasn’t made so much on the grounds that the program was threatening his group commercially, but because he just felt everyone was “again”, wasting their time.

McIntyre’s retreat had some commercial logic of course. But not the normal hard headed IP protection type of logic that you might expect from a software vendor in this situation. He simply felt that the “best way forward was to concentrate solely on building the best product for the entire system”. He didn’t think that this goal and what the Agency were doing in the end, or what the other vendors were doing, was aligned in any way.

He admits that “playing the game” and being a “a little bit more politic”, which his competitors did, was probably a more commercially savvy response to the situation. But he isn’t that type of operator he says.  His strategy is to concentrate on good product and wait on something which he says he is able to do, given the health of his group.

Wait for what though?

He is of the view that after trying so many times over so many years, there exists a fundamental issue that will likely forever prevent the alignment of even the most diligent and committed stakeholders in secure messaging.

“There is too much money swirling around from the government, and it is blurring the fundamentals in this market”, he says. “If and when the money runs out [he points to the possibility of a new version of the GFC], then the fundamentals will be in play. At that time, the most versatile and effective product will be a much more natural choice for providers and software vendors.”

If you believe McIntyre, then the key issue is government money and influence providing the wrong signals to the market. That and a general apathy around messaging from medical software vendors who aren’t being pressed at all on key issues that are emerging because of non action, highest among them, patient safety.

I’ve worked with small and big software teams, albeit as the boss of a local country unit of a big global corporate, and some of those teams have been hugely successful in building complex digital businesses. I never saw one that succeeded that wasn’t tribal in some way, led by someone who knew what they were doing, respected and admired by their staff, and committed wholly to their purpose.

Also underpinning the success of high performing tech development teams often was someone higher in the pecking order running some protection on their at times outlandish behaviour.

Sitting across that boardroom table, upstairs from a Chemist Warehouse, in a regional shopping mall, somewhere a 100kms or so north of Brisbane, with four very passionate and committed technologists (who all knew their stuff inside out), I definitely got the tribal vibe of such a team.

McIntyre doesn’t seem that interested in making a lot of money. If he was he likely would have already accepted one of many offers made to acquire his company’s significant client footprint in national secure messaging. He wants impact where he thinks it really counts – in his medical practice and with his patients.

As to McIntyre and his team having someone upstream in this eco-system that might run a bit of protection on their passion and lateral approach to where we find ourselves, you can only hope that someone in one of the key government agencies sees this group for what it is offering the system into the future.

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