Alarm Management Middleware and the Enterprise

Posted by: Kenny Schiff on May 3, 2009

Consultant, “Connectologist,” and industry observer Tim Gee’s Medical Connectivity site is one of the rare places on the internet that covers the healthcare alarm management middleware space. Recently he published a series of  posts tracking activities at Globestar’s Annual User group meeting in Lisbon, where he served as the keynote speaker where he brings to life some real life examples of middleware applications in acute care.

In his 05/01/09 post Tim reports on case studies shared by three Canadian hospitals who are using Globestar’s ConnexALL® to meet their respective workflow and alarm management requirements. And while these case studies will be of great interest to hospitals attacking similar requirements, Tim’s posts from Portugal makes some important commentary regarding the “middleware” space as a whole that go beyond ConnexALL.

In his closing comments, Tim notes that “automating workflow through improved messaging is a need that spans the enterprise. Consequently, manufacturers in this market segment have enhanced their products and repositioned them as enterprise wide solutions.” He goes on to say that, “an enterprise architecture is more cost effective and is easier to manage than a series of disparate messaging products.”

These are very well taken points, and there is no doubt that a coordinated organizational effort that adheres to enterprise standards will yield the most impacting results. And in as much as the stories told at WorldConnex are wonderful representations of what can be done by creative folks working across departmental lines, the actual state of the products on the ground often tells a different story.

Let me explore this a bit here…

Middleware Politics
Because of the specific “point” needs that have driven organizations to adopt middleware implementation (e.g. nursecall or patient monitoring), middleware applications have quietly crept into hospitals for over 10 years, often with very little visibility. In many cases, the players involved with fulfilling the immediate need didn’t even think to consider larger organizational collaboration or standards at all (e.g. a nursecall middleware project may have been bundled into a construction budget).

In the last few years, this has started to change, especially since the middleware applications increasingly require IP network connectivity that requires IT involvement. But while this connectivity is a welcome move forward, it has quickly changed what was once a much simpler “acceptance” dynamic.

Today, when one of these solutions becomes necessary for a project, middleware can become a battleground between BioMed, Clinical Engineering, IT, Telecom, and various other enterprise stakeholders. Throw in middleware vendors hungry to keep their competitors out, and those on the input/output side (devices and end points) not especially eager to cooperate for their own selfish reasons, and nasty turf wars can beak out that can grind these projects to an absolute halt, the enterprise be damned.

As an example of how this can play out, I was recently involved with a project where the nursecall integrator simply refused to allow connectivity to their system in spite of the fact that the customer had already purchased the middleware application. And having been involved in this space for 6 years, I can assure you that this is not an isolated incident.

Enterprise Positioning Yes. Enterprise Implementation, Not Ready for Prime Time
But it’s not just organizational and vendor politics that make the enterprise middleware vision a difficult goal to achieve. As I’ve observed (and worked with) the key players in this space (Emergin, Globestar and Ascom), enterprise thinking has absolutely crept into the feature set and marketing materials, but there are still large gaps here in respect to enterprise-readiness when it comes to product and system implementation.

Despite the fact that these solutions are becoming more common, this is such a small niche that you won’t see technical reviews or evaluations that explore these issues. Customers are truly left in the dark for lack of available information.

Without going into a deep technical comparison regarding enterprise features, let me share some examples of of enterprise weakeness that maybe useful to an organization working through alarm managment middleware adoption:

  • Many customers are forced to employ more than one middleware application (from different vendors) to achieve their desired results, often because of technical reasons, but sometimes because of inter-vendor issues. This can lead to crafty (and potentially shaky) workarounds by customers or their integrators looking for messaging to traverse systems
  • These systems maintain their own directories and security models that live outside the enterprise
  • Middleware application often prefer their own local databases (sometimes proprietary or sealed to the outside world). Yes there are options for other type of connectivity,  but may systems in production weren’t built from the ground up for enterprise database management or connectivity
  • Redundancy and high availability are an after thought. Like the database limitations, there are methods for providing some resiliency, but these are not natural parts of the application
  • The listener components that evaluate incoming messages prior to delivery to output devices may exist as discrete applications, rather than system services, creating unnecessary failure points and security vulnerabilities. (Note: We have several situations, where the restarting the application because of a system change, literally requires a human being to relogin to get the application going again.)
  • The user experience is a low priority. When these applications lived primarily in data closets, the UI was a reasonable place to cut corners. As these applications grow to have visibility at the nursing unit level, there is need for cleaner more contemporary UI standards

Once You Open the Alarm Floodgate, it’s hard to control
To be fair to the middleware vendors, keeping pace with rapid changes in the input and output devices is a dizzying effort. The demands on their respective engines for the delivery of an increasing amount of traffic has forced attention on bolstering a core framework that was never built to anticipate the current demands. Throw the likely tide of regulatory attention into the mix, and you can understand why we haven’t seen entirely new platforms built to contemporary specifications.

In as much as I may be poking holes in the current state middleware applications, the promise of applications of this technology that cross departmental boundaries outweighs whatever weaknesses I point out. The technology is far improved and the potential for an enterprise future state is within reach. Indeed, as was pointed out to me by an insider close to Globestar, the soon to released ConnexALL® V4 will have a high availability and database connectivity features not seen in earlier versions of the product.

Some Potential Solutions
As we talk to customers regarding alarm management initiatives, we advise to not rush to conclusions or assume that any one product can magically bring devices, users, and alarms together in a cohesive fashion. Great gains can be had here; however, one needs to start first with the business issues that are driving adoption, rather than the technology platform.

Not only will this require process engineering, but change management that’s difficult to manage within healthcare. It’s easy to quickly assume that “enterprise” is a hard technology concept, where we would argue that it’s a systems principle whereby the components (not just technical) are intended to serve the larger organization. The manufacturers have struggled with participating with this process from a distance, and this is a place where systems integrators like TPC Healthcare can help (shameless plug). It’s not easy to fly in a swat team to work through the type of complex re-engineering that’s likely to be required.

The manufacturers need to get closer to customer requirements (especially the end-users) to understand what they need to do with alarms, escalations, notifications, and the resulting data trail left behind. If they observe closely, they will see that interfaces need to be simpler, and that changes to workflow and reporting shouldn’t always require deep technical intervention (especially from the manufacturer’s HQ).  I would also argue to that there needs to an openness at the application level that we’ve yet to see. Today this is all way too hard to prone to error because of lack of standardization.

Closing Thoughts
As the Globestar global user conference case studies clearly show, compelling business issues (that involved alarm notification and workflow) can be solved by smart folks with good enabling technologies. Globestar, Emergin, Ascom, Amcom/Commtech (and others like Radianta) have a great opportunity to step up and see past their own platforms and create better tools that are truly aligned with customer’s enterprise needs.

Kenny Schiff ( is founder and President of TPC Healthcare, a specialty provider of point-of-care communication technologies, such as wireless voice, alarm notification, and workflow automation, to hospitals and healthcare organizations.

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