Sunday, July 12, 2015

Advice to Healthcare Startups

Like many in my role, I am constantly pounded by young entrepreneurs with the "next great innovative idea for healthcare".  I appreciate their energy and enthusiasm, and in some cases they really do have something cool and special.  However, I do find myself repeating many of the same thoughts and "rules" - so I thought that I would put some down on paper to prepare them ahead of time.

This is in part inspired by an GREAT blog by Todd Dunn (Director of Innovation, Intermountain Healthcare Transformation Lab):  The Seven Deadly Healthcare Startup Sins (and his follow up advice).  The summary:
Sin 1: Healthcare startups assume hospitals will let them host patient data in “their portal.”
Sin 2: Startups assume that clinicians will be willing to access yet another portal for their data.
Sin 3: That one doctor or hospital lends enough credibility for other organizations to simply accept a startup’s solution.
Sin 4: Believing that ONE key leader inside a hospital is the decision-maker, influencer, etc. all in one role….
Sin 5: Thinking that conducting a “proof of concept” and/or pilot is a simple endeavor.
Sin 6: There isn’t anyone else out there solving the problem.
Sin 7: Believing that startups need to have more answers than questions.

His Advice:

  • Use the Lean Startup tools! Regardless of where you start, it comes down to your value proposition as a starter or non-starter. 
  • This often tries the patience of entrepreneurs. I cannot overemphasize the need to use the learning loop in every single part of the Value Proposition and Business Model canvases. The only way to do that is to GET OUT OF THE OFFICE!
  • Be curious about workflow  - Be empathetic to your user.
  • Study the industry more deeply. While you may have a great value proposition for one or two hospitals, how does your solution fit into the regulatory landscape, workflow, etc. of multiple hospitals?
  • Listen! Assume you don’t have enough evidence to scale your business yet. Act like you don’t know enough. While an entepreneur’s “go get ’em” attitude is appreciated, it isn’t appreciated when the entrepreneur isn’t open to feedback, seems to have all the answers, and has a condescending attitude toward the way “jobs” get done today. Test your assumptions! Come loaded with questions that are related to your assumptions.
  • Last but not least, structure a learning plan. Embrace the Lean Startup tools and methods. Following this structure will cause you to write a learning plan. A foundational question to guide your learning plan in every part of your business model is “What do we need to learn before we invest more time and money?”

Some thoughts and Rules I would add to enhance the above

  • There are basically no new ideas... a successful startup understands it is about execution.  So please don't tell me that you have a brand new idea and want an NDA because the idea is so priceless and if anyone else finds out about it they will copy it.  If it's that easy to replicate, then you really don't have a business.  I remember years ago when I was being mentored by the great informaticist Dr. Bob Greenes.  He took me into his office and showed my his PhD thesis from around 1966.  This was the dawn of the age of computers, and in his thesis was basically every idea we are now hearing from "startup" companies daily - computer guided interviews and diagnosis, telemedicine, artificial intelligence to read notes, etc...   The key is rarely the idea, but how you combine the right people with the right technology and the right timing to make it all work.  Bill Gross had a nice Ted Talk on the topic of "The Single Biggest Reason Startups Succeed".  So convince me you really understand a problem and solution well and that you can be THE company that executes on it better, faster, cheaper than anyone else!
  • Truly understand and be able to explain your "Value Proposition" - specifically, clarify (1) Who Pays for your tool, (2) Who Uses your tool, and (3) Who Benefits from your tool.  In healthcare, the incentives are often not aligned - and the smart startup will fully understand and have a business plan that makes sense.  Nothing turns me off quicker than a company that expects a doctor to pay for and use a tool, when all the financial benefit then accrues to another party.  
  • Bring me a solution, not just a tool.  A lot of startups are talking about how they use "big data" to identify problems and opportunities for improvement.  That is nice, but the truth is we have a lot of low hanging fruit in healthcare- I don't need to find more problems as much as I need solutions.  So if all you are selling is a way to find more problems, that will not resonate as well as a packaged solution that also "fixes" them.   For example, the analytics vendor  HealthCatalyst is soaring because they realized that they need to use analytics to identify both the problem and the potential solutions to be successful.  Another interesting company, Transfuse Solutions, combines analytics and process improvement techniques to focus on the specific issue of identifying when a hospital is doing too many transfusions and then offering solutions on how to improve on those metrics. 
  • Be committed... healthcare is not for the faint of heart.  This is a big business, with long sales times, difficult implementations and hard change management.  When something works and can improve efficiency, quality and financials at the same time - and can scale well... then you will have a winner, but nothing happens overnight like in so many other industries.  So don't tell me how you have a part-time CEO, and you are out-sourcing all your IT work so some guys who have other jobs.  That is not going to build a company which has the DNA needed to succeed in this industry - show me executives and staff that wake up every day obsessed with fixing a specific problem, and an IT team that understands the nuances of healthcare and can react quickly to solve issues. 
  • Make it easy to do the right thing, especially if this is doctor facing.  I often say that the best healthcare IT can make life easier for doctors and better for patients at the same time.  Do not try and tell me how "this system only asks the doctor to spend one more minute for each patient" - we don't have one extra minute!   We want you to tell us how you save us time from mundane tasks so we can have more face to face time with patients - that is what will win our hearts and minds!   This post from last year explains this thinking further:
So yes, please keep innovating and trying to make things better.  Our current healthcare system is clearly not sustainable as it stands, making for a "target rich environment".  But when pitching to busy providers and healthcare organizations, remember that their plate if often very full - so have your value high, your proponents lined up, your story straight, and your team ready to truly make a difference in the lives of both providers and patients.

Addendum: List of Other Relevant Blogs and Advice for Startup Entrepreneurs

Monday, May 18, 2015

Six Lessons in Health IT Innovation

I speak frequently on the intersection of HIT and Innovation.. especially around how can we be more innovative in using the HIT we already have in place via human centered design thinking ("ask, observe, think and feel" about what the end user has to deal with).  At a recent healthcare conference, I spoke about this topic based on a combination of my own professional experiences as well as learnings from the book I wrote about the intersection of HIT and Innovation (see this post and check out  I didn't realize that a reporter was in the room, but was pleasantly surprised a few days later when a nice article came out summarizing my "Top 6 Lessons in HIT Innovation".   A listing of these lessons is below, along with some expanded thoughts and examples: 

1. Identify the minimal viable innovation. Don't be afraid to borrow ideas from other people. "Fail early, Fail fast, Fail often and Fail cheap."  I often give the story of three organizations in the book all talking about the same issue (how to use their EMR to automate and delegate some routine preventive maintenance and disease management care).  Each organization had a different EMR and a different workflow, but the end result was similar- they figured out how to use the EMR to empower their staff to do more, resulting in a more efficient system with better quality.  The idea thus is not to exactly copy what any one of them did, but to understand the essence, and figure out how you can make it work at your organizations. 
2. People and processes are more important than the IT. Do not except technology to be a silver bullet. The people and processes behind the technology will be the forces that drive innovation.  So many of my best "innovations" are the result of creating some content and workflows to take advantage of having a single communication tool (the EMR) that links everyone in an organization and allows for creation of consistent templates and routing... which allowed us to set up a care coordination system all the way back in 2008 which resulted in better experiences for patients and providers along with better, faster and cheaper care (we even published on this data).  In the book, we hear other examples, such as how Children's National used their EMR to identify signals that indicated an "adverse events" had happened the night before (e.g. a low glucose, use of Narcan)... that was the easy part.  The more important solution was having a dedicated nurse reviewing that data every day, tracking down what happened, and working with a team to minimize it from every happening again... with spectacular results.  Another story involves the use of a ubiquitous technology Skype) to enable multiple hospitals across California to enable the concept of "virtual translators" across their disparate systems.  So even though these were all separately owned, the hospitals could "borrow" translators from each other and thus all ensure they had enough of the right language.  The innovation was less in the technology, and more in the idea- as well as the business agreement they had to set up.
3. You can start small. Innovation in health IT does not have to mean something big and radical from day one; In other words, little bets make for big wins. For example, we used a pilot of 5 iPads on the inpatient oncology floor to explore what happens if we offer free use of them while patients are "confined".  We immediately learned about workflow (how to distribute and track and clean the devices), as well as network issues we had to address as the top use of the iPads was to use FaceTime or Skype with friends and relatives... a use case we did not realize would be so popular.  The result immediate patient satisfaction as well as a much better understanding of what it will take to roll out a bigger effort in the future. 
4. Apply new innovations to old problems. This is about using some established innovation methodologies to really rethink how we practice healthcare.  I said "We are cutting the cost curve, but not as much as we need... and we must innovate or we will lose." An example I gave was use of "Video Ethnography" to better understand poorly controlled diabetics.  Working with gravitytank, a local innovation consultancy, we spent 2 hours with 8 separate patients and were able to understand this population in a whole new way.  We condensed their videos into a 20 minute summary which was used as a kick off for a half-day brainstorming session that created a slew of ideas that resulted in new ways to educate both patients and providers about diabetes (we moved away from trying to scare them and towards simplifying the message). 
5. Try different ideas and technologies that have found success in other industries. Thought leaders consistently point out that healthcare is fell behind so many other industries when it comes to technology and innovation. Try ideas from the airline or retail industries; perhaps one of these will spark rapid innovation in your organization.  I'm a big fan of "Innovation Safaris", also called analogous observations, in which we spend time in another industry to understand how they view quality or satisfaction or efficiency... and see what we can learn and bring back to healthcare.  I am fortunate to be part of a group (The Innovation Learning Network) in which we do this together every 6 months.. here is good write up of what it can be like. 
6. Embrace the power of physician happiness. Physicians can be both the source and users of innovation, but without them technology cannot go very far. "There is no quality without use" is a quote I've been using for many years in explaining that creating super-complicated systems might look good on paper, but they will not provide any real benfit if your end users are not using them in everyday practice.  Rather, we need to think about how we can use HIT to "Make life easier for physicians, while also making it better for patients". 

Wednesday, January 14, 2015

Perspectives on the Future of Healthcare and IT.. a Video Interview

I was recently "Video-interviewed" about my thoughts on the future of healthcare and IT.  These types of interviews are usually quick - two questions, five minutes... hopefully some value!  Here are my two questions and a summary of my answers:

Where is the healthcare industry headed?
I believe healthcare is currently a runaway train with an unsustainable model.  But there is hope if we can adapt reimbursement models to incentivize value over volume, and use HIT to simplif, automate and delegate all the care that needs to be done.  With respect to HIT, since over 80% of physicians have an EMR in place, we now an infrastructure or platform on which to build "EMR Extender Tools" which allow for better EMR functionality, efficiency, and effectiveness.  Furthermore, we need to focus HIT efforts on Population Health, Virtual care, and Workflow Efficiency to meet the increasing demands for care that are upon us.  With respect to population health; ACOs and other types of volume-based to value-based reimbursement changes will make it easier and financially viable to really manage the health population well - but we need the right HIT tools to risk stratify the population and then manage them more easily.  Meanwhile, we should see a rapid expansion of virtual care as technologies and demand sync up. Lastly, as physicians (and staff) are burning out quickly, using HIT to create workflow efficiency by simplifying, automating delegating care, is vital to the performance of doctors, as well as the health of patients (which is why I helped found healthfinch to build software solutions that allow medical groups to redesign care more efficiently and effectively). 

What is an HIT Innovation you would like to see happen soon?
I think we are getting closer and closer to “ubiquitous monitoring.” Wearable devices are available, but right now these are often just used by the “healthy and wealthy.” Although this is a good starting point, there is a need to develop patient monitoring tools that are fully ubiquitous - so that collecting biometric data becomes a simple byproduct of everyday life.  These may start as being embedded in smart phones, and now we are seeing them woven into in clothes, but soon we will have watches, patches and even injected nanotechnologies. As these evolve, doctors will be able to receive regular, real-time monitoring of their patients. From there, one can feed data into a rules engine to notify doctors (or even patients themselves) if something is medically wrong. This portends a fantastic future for remote monitoring so that doctors do not have to rely on patients to manually input data all the time and wait for them to come into the office to explain there is a problem.