Despite Competition, All Big 4 Ambient Company CEOs Believe They Will Succeed

They are the CEOs of the most well-known ambient AI companies, who have raised millions of dollars over the years in their quest to transform patient encounters with physicians and reduce clinician burnout. Abridge, Ambience Healthcare, Nabla and Suki are the most prominent names in a field that everyone knows will shrink in the next 12-18 months.

“Compared to these four, the little guys are going to fizzle away or get swallowed up by these guys as well, who knows,” declared Samir Batra, a venture capitalist and managing partner of HIP (Health Innovation Pitch) in the November episode of Debunked. “I think there’s more chance that they just go away because there’s just a lot of competition out there.”

This graphic lists nearly 30 players in the ambient AI space, including Microsoft, but excluding the three ambient AI companies that the Washington technology company acquired. The Peterson Health Technology Institute puts the number at even higher: it lists 60 separate solutions.

That competition only got more intense when in late summer, EHR company Epic announced that it had selected Microsoft to launch its own AI scribing tool and to help with clinical documentation and charting as well. So what does it mean for Abridge, Ambience Healthcare, Nabla and Suki?

Recently, I had a chance to connect with the CEOs of these four companies. None of them seemed too perturbed — or at least not perturbed enough to divulge to a reporter — about the consolidation ahead.

Abridge’s CEO Shiv Rao

It’s important to note, however, that none of the four companies are pure standalone AI scribing solutions providers even though that is precisely where they started. Here’s how Abridge’s CEO Shiv Rao described the company in a recent Zoom interview.

“I don’t know, looking back, that I’ve ever used the term AI scribe in the last eight years of being a company, but journalists have,” Rao said. “I think the industry largely has moved to a different term, which is ambient AI, and I think that’s a better term, because at least it’s higher level.”

So what can we get at this level?

“Now … beyond burnout, there’s revenue cycle. Now this is one of the secrets that was hiding in plain sight for five or six years, and so we didn’t talk about it that much because we loved that we were sitting on something that nobody else could see. But now we say very openly, which is that these notes are bills, right?” he added.

In other words, the basis for reimbursement is the doctor’s note and if that note can be made pristine from the perspective of coding, compliance and what the payer is going to look for, then the net result will be less hassle for providers in collecting payment. And as an adjacency there’s also prior authorization, which has become the bane of existence for physicians across the board.

In fact, Rao wants Abridge to solve the prior authorization conundrum at the point of the physician conversation with the patient and did a quick demo where I was the patient in need of an MRI because I needed a revision knee surgery.

“The agent behind the scenes who is invisible … went to that payer and looked at the guidelines to get an approval for knee revision and heard that I asked five out of the six questions required to get the knee revision approval. And it’s telling me that there’s one more question left to ask — and I can even trust but verify where this information comes from and [ask] ‘Show me in the guidelines from the payer where this is documented?’ It shows me all the evidence,” Rao explained.

As a layman, this looked pretty powerful to me, but of course to have material impact, Rao and Abridge would have to go payer by payer since guidelines are likely not all uniform across different payers.

Ultimately, for Rao, who is a cardiologist at the University of Pittsburgh Medical Center (UPMC), it’s all about bringing value to physicians.

“You can build this platform of value on top of the conversation, because you can think of Abridge as an agent who’s listening in and helping the clinician be near omniscient, omnipresent detectives and caregivers who are basically able to deliver care like a superhero,” he explained.

Okay, but how does the conversation around value to a clinician change when a trusted partner like Epic becomes a competitor within the EHR? Rao was very careful in stressing that he takes inspiration from Epic. For instance, he didn’t directly respond as to why Epic chose Microsoft’s solution and not Abridge’s.

“We have an incredible relationship [with Epic] because we’ve been able to demonstrate what differentiates Abridge over these last several years. We’ve been able to demonstrate how we can check off boxes in terms of not only being clinically useful across all the different specialties but in all the different care settings,” he said.

And what about consolidation in the marketplace? He thinks for “some people” consolidation may happen, but he didn’t say who. As for Abridge being part of any future consolidation, he was, not surprisingly, flatly dismissive.

“It’s not even something that I’m thinking about necessarily,” Rao said.

Suki’s CEO Punit Soni

Whereas Rao comes squarely from the world of healthcare, Suki CEO Punit Soni’s background is in e-commerce and technology. Suki is an AI scribe company that has recently stepped up efforts in revenue cycle management. In fact, right before HLTH, where I met Soni, the company made an announcement that its AI-enabled coding solution can automatically generate ICD-10, HCC, CPT, and E/M codes.

When asked how Epic’s entry into ambient AI and AI charting affects the broader ambient AI market, Soni responded like this:

“It just matters a lot less to us than somebody whose only revenue source is Epic,” Soni declared, but wouldn’t name who those others were. “I would say some of the other players that we have in the market, they basically are just in Epic.”

So, where else is Suki playing?

Soni explained that Suki’s footprint is found in the big and small EHR companies, the latter including vendors like Meditech and athenahealth. From a health system perspective, the company plays within various sub-sectors, he added. And of course there is the partnership/investment from Zoom where the virtual communications company uses the Suki platform to power clinical notes for telehealth sessions.

He added that other telehealth companies are also building their platforms using the Suki assistant. Finally, Suki also plays in the medical hardware world with certain entities and Stryker, the medical device maker that owns Vocera, a communications company that promotes digital care coordination. Soni explained that Vocera is building next-generation nursing badges that will be powered by ambient AI.

Soni did agree that market consolidation is bound to happen and, in fact, declared that only two or three companies will be left standing after that wave of consolidation is over. But he also painted a slightly different picture, where the make or break for new technologies will not be so EHR-dependent.

“I am just pointing to a world, a different world than [health systems] are in today,” he said. “I do believe that AI is a massive inflection point and finally, and this will be hard to extrapolate because we’re in the last 20 years in the world of the reign of the EHR.”

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What is the fate of Abridge, Ambience, Nabla and Suki according to Samir Batra, a venture capitalist and managing director of HIP (Health Innovation Pitch)?

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Ambience Healthcare’s CEO Nikhil Buduma

I didn’t get to meet Buduma in person or through Zoom. Our calendars just wouldn’t align. But he did answer questions about whether Ambience will remain standing after an expected consolidation through email, via a public relations professional.

“We’re building a multigenerational company—one designed to outlast the hype cycles,” Buduma declared. “As the only ambient AI platform with independently verified, third-party ROI and multi-year partnerships with some of the largest academic medical centers in the country, Ambience isn’t here for a quick exit.”

He went on to explain at some length that it made complete sense for Epic to be entering the ambient AI world, given that they work closely with health systems and that capability is a “must have” for health systems today. Still, entering the space doesn’t necessarily mean that the Microsoft-Epic solution will be something that health systems will be racing to implement.

“… building great ambient AI technology is much harder than most people think,” Buduma wrote. “Even hyperscalers with infinite budgets and established companies with hundreds of millions of dollars have struggled to get it right. The question now isn’t ‘who’s building it?’ — it’s ‘who’s actually solved it?’”

And well, no prizes for guessing who has solved it.

“At the most complex AMCs [academic medical centers] across the country like Cleveland Clinic, Ambience is used by 80% of clinicians for 76% of visits. Our numbers blow past baselines for most AI scribes, and we see this because Ambience’s technology deeply understands the context of a clinical encounter.”

And then Buduma addressed the idea of ROI, which all ambient companies talk about and tout, but perhaps not in this way. After all, bringing joy back to physicians’ lives is wonderful and something that health systems should strive for, but reducing burnout and pajama time doesn’t automatically translate to more patients seen, which means more revenue and possible ROI.

“All of our focus on coding and CDI [clinical documentation improvement] also means that we aren’t just a cost center for CFOs; we actually deliver concrete ROI. That’s why we are confident with our unique place in the market.”

Like Rao of Abridge, Buduma clearly communicated that AI scribing was just the first solution. Now, the effort is broader and deeper.

“Ambience is building a platform that automates the entire administrative layer of healthcare, starting in the outpatient setting and now expanding into inpatient care, where the complexity and burden are even greater,” he said. “For example, our recently announced Conditions Advisor analyzes the complete patient record to surface clinical evidence at the point of care, enabling clinicians to identify, evaluate, and document the full spectrum of a patient’s conditions — leading to better care quality, clinical decision-making, and care coordination.”

Nabla’s CEO Alex LeBrun

Like the other CEOs, Nabla’s LeBrun was not surprised that Epic announced its intent to build an ambient AI tool. But the announcement did contain something that caught LeBrun offguard.

“The big surprise for everyone is that they’re not doing that by themselves but with Microsoft,” he said in a Zoom interview. “I think this was the one piece that was very unexpected.”

He added that the announcement somewhat leveled the playing field among ambient AI companies. Abridge was a more core partner of Epic. but since the announcement, that status has changed. He explained that Abridge was previously a Workshop partner of Epic. Now they are a Toolbox partner, same as Nabla and the other ambient AI players.

“The relationship between Epic and Abridge is very interesting,” LeBrun said, smiling broadly. “Someone should write a book one day on that because I’d love to know.”

The level playing field still doesn’t take away from the fact that the ambient AI players need to move fast as Epic gets going.

“It means we need to be much better and it’s a speed game where we must continue to innovate quickly so that there is a good reason for customers to use us or other vendors instead of Epic,” he said.

And Nabla is innovating not only in the world of coding but in what LeBrun described as “nudges.”

“[We are trying to] be proactive with the condition to help [physicians] document in the right way so that coding won’t be an issue,” he explained. “We can, in real time, nudge the clinician to maybe adjust things before it’s too late. So this is really unique.”

He added that Nabla is now bundling ambient AI with dictation. Sometimes physicians/clinicians want to dictate notes, sometimes they want ambient AI to be listening in. Having the dual capability would be valued by providers, he believes. Another area Nabla expects to explore is patient engagement.

“We have a lot of information we can leverage maybe two weeks after the encounter to engage with the patient to make sure something has been done, for instance, [something] that the clinician recommended,” he noted.

Nabla’s CEO also expects consolidation in the marketplace as he predicted that “simple scribing” companies will get absorbed or shutter.

“I never use the word scribing for Nabla. I hate this word because I think it doesn’t represent what we do already. But definitely in order to justify your existence next to the EHR, instead of being replaced by the EHR, you need to — have to — provide a lot of value to the clinician or to the organization. And this is not something most scribing companies do today,” LeBrun concluded.

In that respect, LeBrun and Abridge’s Rao are alike: both hate the term AI scribe. But are these four companies truly that differentiated?

“When you frame it based on how the companies are actually putting forth their solutions [and not as AI scribes], you start to see, well, actually, these are all totally different companies trying to solve different problems,” Rao declared.

I see less differentiation. All of them seem to be trying to graduate from AI scribing to leverage the perfect clinical note for revenue cycle management, prior authorization, patient engagement and other adjacencies. Their futures will largely depend on only one thing: how well they do it and how much better they do it than Epic.

Meanwhile, well-capitalized private equity firms, IT vendors will watch the space — closely.