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Getting ahead of myself, but if the UK change government that could have implications to the NHS.
So i'm now watching:
Alcidion are an acquisition hungry company, they don’t really develop their products - they acquire them. We’ve seen this over the last few years with Silverlink and ExtraMed - if you scan back through their news stories on their own website you almost never see product announcements.
I think the last update I saw was some time (years) ago with them upgrading Miya.
The acquisitions are a mix of bolting on capabilities and buying their way in the door to relationships, their lack of new contracts makes me think this part of healthcare tech is extremely sticky in general, and maybe Alcidion’s products aren’t any more sticky than anyone else's. It also means they have to take a lot of calculated risk on acquisitions that might not work out.
Alcidion dilutes like it’s free money. It hurts shareholders. Their most recent dilution was the most puzzling of all to me - a historically lumpy business blindsided by its own lumpiness. It feels like poor planning. They seem allergic to taking on debt - maybe that's a good thing? but raising at 7 ish cents when they've been sold at 33 cents in the past? ouch.
As others have mentioned based on my update on their last year's hiring - this is both a positive and a negative in my mind. It’s great they still have the growth focus, but they don’t have the momentum to back it up. They had this amazing year in 2022, then essentially fell off a cliff in 23.
Lastly, Alcidion’s geographic focus is incredibly UK dependent (yeah I know Leidos is in there, but look at the amounts in the UK), getting in with Alcidion means you’re strapping yourself to the clusterfuck rocket going on in the UK to do with the NHS - I’ve posted in the past there’s a couple of podcasts you can listen to, to get the general vibe of the state of things up there and it ain’t pretty.
Now you could argue that junior doctors in the NHS getting paid the equivalent of a supermarket checkout person up there is an opportunity for digital healthcare to smooth things over, or you could potentially look at it as there not being enough money to go around - despite the massive TAM being bandied about.
Disc: I hold IRL and in SM
Notes from contracts/renewals
Note:
Dates on this aren't exact, they're the month of the announcement.
*EDIT* I've updated the date formats to be DD-MM-YYYY as the default format was American and misleading.
One pattern i've seen in tech companies that don't want to let employees go (first hand) is they stop replacing people that leave, and they cease or severely restrict hiring.
I was curious if I could spot anything on the wayback machine with careers at Alcidion that might hint at something that might have surfaced the trouble they were having late last year.
There are a bunch of snaps dating back to 2020. Keep in mind that these snaps are not the exact point in time when the change occurs in the website, but just a coincidental point at which wayback machine chooses to index the page. At Alcidion's peak of hiring in 2021-2022 they had something close to 16 job ads open at one point. At their lowest point, September 28th 2023 they had 0 job openings.
So let's look at LinkedIn and see what we can find out about recent hiring at Alcidion in the last year
First of all, LinkedIn thinks you're a bot if you open 149 profiles quickly.
Since January 2023 Alcidion has hired:
At my last count before LinkedIn decided get in my way, there were 18 new hires in the last 12 months.
So what did I learn?
From the SPP doc:
And the results / closure:
I was going through stuff from their presentation for potential questions for todays meeting and I realized something about staff costs in this screenshot. If the impact of silverlink staff was just 2 weeks contribution, what's the full contribution in a half? Does this mean the staff cost increase we're seeing is not the full picture and they're actually much higher? or am I reading this wrong.
Just got off the call.
Opportunities:
Risks:
A note I made about their strategy:
If you're wondering about their acquisitions - The ExtraMed acquisition has value at 'Phase1,' Silverlink at 'Phase 3'. I find that interesting because they've said that having PAS capability was how they'd land customers - but this looks like more in the expand part.
About increased costs
It was said on the call that it was a combination of wage inflation, and the Silverlink staff being on for more than 6 months. They said they don't intend to hire like they have in the past - but are looking to fill certain positions. So according to them we shouldn't see the staffing costs increase as drastically as it has.
It was framed as a percentage of revenue, and in that framing it doesn't look as bad, but it's worth noting the increase in marketing costs that was also there.
Just putting this here now. My initial thoughts is it's pretty meh, and I feel like they're really trying to focus you on the revenue while glossing over the increased costs.
Some of my notes:
One thing I noted from the 4C was they said -4.5 mil operating cashflow due to receipts not coming through at the right time. When someone asked a question in the update - they said they expected half of the 5m outstanding in receipts was expected to go through - so they still would've been negative. Weird to write that on the presentation and either way it would've been negative operating cashflow.
Another thing mentioned on the call, not particularly new info was the importance of Silverlink in them winning the contrast for the exemplar University hospital South Hampton, and the number of modules chosen at this location. Having a presence at one of the digital exemplars is a big deal due to this being a proving ground of success and the potential of it being used as a template for the rest of the roll out in the UK. There was also a bit of expansion in existing customers and extension of contracts.
A number of tenders are up and not entirely just for EPR, but many of the other offerings that Alcidion has, another thing to watch with Alcidion over the year.
Lastly, Kate mentioned that the NHS digitisation strategy had some delays due to various political issues in the UK - but the deadlines are still the same - so it will be interesting to see how this plays out.
Through a family contact I had the opportunity to speak to someone who is a part of a team managing IT systems at a hospital that uses Alcidion. I mentioned that it sounds like they have some interesting systems at the hospital and if they’ve worked with something called Miya. While this person was not a health professional - it turned out they were part of the team that worked with Alcidion on the hospital side and said Alcidion were a really pleasant vendor to work with, who took the time to sit down ask questions and listen, as opposed to vendors like Oracle, and as a result they’re going to see something going live in the next few weeks (I’ll be keen to hear how that goes!)
While this doesn’t really change a whole lot for me regarding Alcidion, it’s good to hear that they’re taking the time to manage their relationships with the teams they need to work with where it sounds like other bigger players just throw their weight around.
Takeaways from the Investor presentation
Latest digital health project to enhance decision making across Australian hospitals - October 28 2021
I found this article googling around the internet about Miya precision. Not sure if this is old news for others following Alcidion.
The summary: The Digital Health Cooperative Research Centre is doing research to evaluate and improve clinical decision tools across Australia, it's a 3 year collaboration between Sydney LHD, eHealth NSW, Queensland University of Technology, and Alcidion.
"Their project will make use of Alcidion's Miya Precision system to identify priority areas where decision support tools will add value. The platform, which consolidates data from various systems such as EMRs, is currently being used by the Royal Prince Alfred Hospital and Wagga Base Hospital. "
I think it could potentially be a big deal for winning government contracts, my partner deals a lot with government as part of a not for profit, and having peer reviewed studies behind you helps a lot. Of course, it depends on whether this research ends up finding decision support tools like Miya adding value.
Given around 50% of Alcidion's revenue comes from the UK and recent macroeconomic happenings - I've been trying to learn a bit about their foothold in the UK.
I noticed that Alcidion had landed some NHS Foundation trusts, South Tees was a recent one, as was East Lancashire.
I had the question: How does a NHS foundation trust differ from other NHS trusts?
I found this old Guardian UK article to explain: https://www.theguardian.com/society/2002/nov/13/health.theissuesexplained
They are described as "sort of halfway house between the public and private sectors," where they do get some level of financial and managerial autonomy. An NHS foundation trust is typically one considered to be held to a higher standard and larger than other NHS trusts.
Next question was: How many NHS foundation trusts are there in the UK?
There are 145 authorised foundation trusts in the UK, 99 of those are acute. So of the 138 acute NHS trusts that Alcidion are targeting, 99 of them are foundation trusts.
Which are considered the best NHS trusts?
There's a site that ranks them: https://top100hospitals.co.uk/
South tees is in there at number 87. East Lancashire was 37.
Why do I care about this? well, if Alcidion are helping the best ones - this might help them win more contracts.
For those that aren't ranked highly, if Alcidion meaningfully changes their ranking here over time - then that might also be a positive sign.
The NHS Acute global digital examplars
There is no date on this NHS page - but there are a number of NHS trusts selected to be considered the most 'digitally mature,' In 2020, Alcidion won their first digital examplar contract with Taunton and Somerset NHS Foundation Trust, 6 of these use Cerner, 1 uses Epic with 1 'fast follower' using Epic. Still looking into who has contracts with the others.
Why are these important contracts? "Each Global Digital Exemplar has selected one (or occasionally two) trusts to partner with to accelerate their digital maturity. In some cases, this will be sharing software or a common IT team. Others will adopt standard methodologies and processes. Fast followers are supported by NHS England funding and will enable Global Digital Exemplars to establish proven models that can be rolled out across the NHS more broadly."
Meaning a contract here has the potential for a two in one.
A little tidbit on the financial well-being of NHS trusts
I also found some recent coverage from the HSJ, a UK based publication and podcast on health, a few of their recent reports speak of the threat to the NHS given economic factors. One interesting one was: The NHS’s £18bn rainy day fund. The TLDL of this report is that essentially they threw buckets of money at the NHS during the start of the pandemic, but many trusts didn't actually spend said money - so were encouraged to do some 'creative' accounting to hold onto the money, so the economic conditions in the UK may not hit those NHS trusts for a while.
I guess we'll get a good look in Alcidion's next half.
I found this article on Nature that gives an overview of CDSS's, pitfalls and opportunities. I found it useful to help understand the positioning of the Miya platform a bit better without the bias that comes with a company's own statement.
https://www.nature.com/articles/s41746-020-0221-y
@Marsdrix that would be amazing.
I overlooked Epic. Quick look: present in at least 8 NHS trusts. Seems to have organic growth unlike Dedalus (who ill put my research in detail in the next few days as I’ve spent a lot more time looking at them).
So far I feel like Dedalus and Epic are the most likely threats to Alcidion, of the three ALC appears to have the most share of NHS trusts so far, but the other two just have so much money behind them and massive presence in multiple countries. The other competitors seem too far behind to catch up to these 3.
How likely is it for the winner to become a standard? Is this an environment where one becomes the absolute winner or is this an environment where multiple winners are possible?
Some related articles for Epic:
https://www.digitalhealth.net/2021/10/speculation-of-epic-deal-with-nhs-england/
https://www.digitalhealth.net/2022/07/two-nhs-trusts-go-live-with-epic-electronic-patient-records/
I have been trying to get a rough look at the competitive landscape for Alcidion, primarily in the UK.
It seems like Alcidion’s competition are companies that do a single piece of the many pieces Alcidion offer.
A good place to start felt like ALC’s most recent acquisition (Silverlink), they’ve obviously identified a need to focus on an area (EPR) - so it made sense to look at what the landscape in that area looks like.
I found a list of accredited EPR providers here (it’s not the most recent, it’s from 2019 - I noted that Silverlink isn’t present on this list).
https://www.england.nhs.uk/2019/08/nhs-launches-accredited-suppliers-for-electronic-patient-records/
I need to do a deeper dive into each of these when I get the time - so this is only a surface level look and there are probably some of these you could rule out. Some other thoughts I had while quickly checking these companies were whether or not contracts signed with NHS trusts with some of these were necessarily mutually exclusive for Alcidion. Competitors with full service products obviously would, but if these competitors only offered a single piece - would that necessarily rule out Alcidion signing a contract? I’m not sure. Mainly I just wanted to have a brief idea of who the companies were and how many NHS trusts they had signed - since that appears to be the main place of opportunity for Alcidion in the UK.
The list was:
Allscripts, Cerner, DXC, IMS Maxims, Nervecentre, Meditech, TPP, System C
Oracle Cerner - The big dinosaur, Oracle products are usually slow moving beasts, and probably the one all the other Healthcare tech are disrupting. Tangent: if you ever want to see why Xero is so loved, google Oracle Netsuite.
I couldn’t quickly find information on how many NHS trusts use Cerner, however, there’s no shortage of signs of a product with quality problems.
https://spectrum.ieee.org/uk-coroner-fingers-nhs-computer-system-in-toddlers-death
http://pediatrics.aappublications.org/content/116/6/1506
DXC (NYSE:DXC) - 19 NHS trusts - a spinoff of Hewlett Packard Enterprise - Lorenzo patient record systems.
https://investors.dxc.com/investor-relations/default.aspx
Meditech (Private, US Based) - 5 NHS trusts
https://ehr.meditech.com/
IMS Maxims (Private) - 3 NHS Trusts
https://www.imsmaxims.com/about-us
Allscripts (NASDAQ: MDRX)- 3 NHS trusts
https://www.healthcareitnews.com/news/black-book-ranks-top-ehr-vendors-regions-across-globe
Nervecentre software (Private, UK based) - around 3 NHS trusts
TPP - (Private) - around 9 NHS trusts
System C - (Private) - 2 NHS trusts
https://www.systemc.com/about-us/
I’m curious if anyone else has looked into competitors / found a good list of who Alcidion is up against and where?
*edit*: dxc sold off Lorenzo to the Dedalus group. Ill be looking more into them next as they seem like a pretty credible threat to Alcidion
@rh8178 I think it’s more a matter of what it would cost them if they didn’t acquire EPR capability, given the aggressive push toward digitisation in the NHS - not having a key capability that is battle tested could leave the opportunity open to global competitors and this stuff in healthcare appears to move pretty slowly - if someone else gets there first and cements their position it's going to be bloody hard for Alcidion to make up that ground, so to stretch the metaphor a bit further - you wouldn’t want to have a tailwind and no sail to push you forward.
On the surface, it could look like Alcidion were in it to get 12 NHS trusts, and I do think that’s still a small factor at play here, but not key to the strategy. I think the fact that Silverlink had been tried and proven for EPR in multiple NHS trusts is the part that they likely wanted. It’s one thing to have EPR capability, I think the social proof is important for future contract wins.
I think Silverlink is probably too small to make a meaningful impact on its own (there are 12 personnel on LinkedIn and 1-2 specialists in integrating with NHS systems), but if Alcidion manage to integrate them well, it’ll be pretty key to their growth over the next 3 years in the UK.
So to answer your question, purely on numbers it looks expensive - but having proven and tested solutions that tick all the boxes is going to be really important moving forward and I’m not exactly sure what price that is worth.
UK Government initiative to add £2 billion of funding to support electronic patient records to be in all NHS trusts (https://www.gov.uk/government/publications/a-plan-for-digital-health-and-social-care/a-plan-for-digital-health-and-social-care)
From the site:
This all lines up pretty bloody well with Alcidion’s offering.
So currently we’re looking at a total of 217 NHS trusts in the UK, and based on the last 2 Annual reports of Alcidion since their acquisition of ExtraMed they had a foothold in 27 NHS trusts, and since then have signed contracts with roughly 18 new NHS trusts - putting them at about 20% of the NHS trusts so far.
Digitising healthcare in the UK seems to have loads of charitable organisations behind it such as the KingsFund and the Health Foundation - I’ve leafed through some of their recommendations and a lot of key themes are repeated around interoperability of systems (something Alcidion claims to do well), and integrated systems (pretty much the Miya offering).
There also appears to be a bit of pressure behind getting the NHS’s digitisation strategy to cut the mustard quickly enough
From my last exploration, I wanted to know more about the people working at ALC and their breakdown of software engineers and designers - the people capable of either running the systems or producing new products. What’s their average tenure so far? Do they have a period of mass hiring anywhere?
Alcidion - 142 employees
CTO (10 years), promoted 1 year and a bit ago after 4 years as the head of data analytics. He had a background with AlfredHealth working as a Corner specialist, Cerner is an electronic medical record database.
Head of engineering (7 years) - has been in the position for 1 year and a bit (similar timeline to the CTO), previously worked for 7 years as Software Development manager for 7 years at Alcidion, background in what looks like consultancies.
Technical architect (15 years) - 3 years as architect, was a devops engineer for 7 years, and software engineer for 8 years before that all at Alcidion.
Previously I was curious about the structure of their teams, people self-title on LinkedIn but it looks like we have a couple of delivery leads/engineering managers, and one product manager. The distribution of these seems reasonable enough for an outsider looking in.
Development and design team:
23 software engineers + 1 devops engineer
1 specialist mobile app developer
1 specialist front end developer
4 QA specialists
2 designers
Tenures
Of the 23 software engineers - 10 have been at Alcidion longer than a year, half of those have been there longer than 2 years. 13 have been hired in the last 12 months. I noticed there was some shift in a lot of jobs around about that time for Alcidion. So many hires in that period could be them ramping up for something, or replacing people that moved on during the pandemic.
Potential for teams
Given the number of production staff, if they were to follow a Spotify model (https://www.atlassian.com/agile/agile-at-scale/spotify) of 6-12 individuals per team - they could probably field about 3-4 teams for developing new software.
Takeaways
So how do I feel about Alcidion’s technical capabilities as an outsider looking in? I think this exploration has increased my confidence in the org. They have a reasonable amount of seniority in their engineering, some really long tenures are in there, however, the last 12 months of engineering hires feels like they could put themselves at risk of growing too fast and incurring technical debt if they don’t have the systems in place to protect against this, and we wouldn’t see signs of that for a few years (but I’ll be on the lookout for those kinds of mentions in glass door).
Given just about every software company (and a wide range of other industries) have issues hiring and retaining people at the moment, I was curious what sort of environment and sentiment there might be amongst the employees, and more specifically the developers at Alcidion - given they're essentially the core engine for growth here. I usually take Glassdoor with a grain of salt - you tend to get the extremes as with any review site and there’s always the chance that someone from the company is boosting the score with false reviews.
In this case there aren’t a huge number of ALC reviews compared to other tech companies, however, from the small sample size we’re looking at around 4.2 star compared to something like Atlassian 4.7, or Microsoft 4.6
One thing that stood out was a few mentions of praise for the tech stack.
I thought hmmm, how can I find out about their tech stack? Usually the careers page is a good start, however there wasn’t enough there for me to get a full picture. So I thought, I can probably use the wayback machine (https://archive.org/web/) to look at snapshots of their career page over the years. https://web.archive.org/web/20220601000000*/https://www.alcidion.com/careers/
My takeaways from their job ads (forgive me I’m trying to piece together a 1000 piece puzzle with about 50 pieces):
Anyway, the picture I painted from the job ads I read was a pretty positive one - on the surface at the very least it sounds like a good mix of technologies. It looks like potentially process wise from glass door reviews they might have some pains.
When you read this one:
The disgruntled developer above makes me wonder what their team structures look like. If I were going for a job there I'd definitely be wanting to ask as many questions as I could to surface this.
Was the big sell off by Kate Quirke ever mentioned anywhere? Did Kate think the stock was overvalued at 0.34?
I was going through their financial report and noticed that in the last year the ownership mix has changed.
Based on the report - it looks like ALC are at about 20-21% insider owned now, a change from last year where they were closer to 28-29% insider owned.
The breakdown of ownership of insiders:
The biggest shareholder is JP Morgan now.
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