Multiplyd Meta-analyzing Innovations in Health Tech Sun, 04 Mar 2018 00:39:40 +0000 en-US hourly 1 Multiplyd 32 32 Docent Health Wed, 05 Apr 2017 22:52:20 +0000 Service industries like consulting, hospitality, restaurants or the local car mechanic, are judged on experience. Healthcare folks would like to think that it’s all about outcomes but no one would argue that experience is just as important. And most healthcare experiences suck from a patient’s point of view.

Docent Health caught my attention last year in July when they raised a healthy $15M Series A round from big names like NEA and BVP. Their ‘Docent Program’ is an intriguing service approach, to say the least. They offer docents -people who are familiar with the healthcare system, like ex-nurses- to act as a liaison between the patient and caregivers. These virtual and/or onsite docents integrate with the clinical staff to act as a representative of the patient’s anxieties and preferences.

Fair enough. Can’t argue with the benefits of having a personal concierge throughout hospital journey. Building a personal relationship with the patient allows the hospital to create a better brand impression. That kind of word-of-mouth marketing is priceless and spreads fast. Additionally, the learning from one patient’s preferences may be transferable to the next, creating a patient experience-related ‘best practices knowledge base’ that has never existed in traditional health organizations.

But it’s not a panacea. Revitalizing service experience shouldn’t necessarily be about adding more humans into the mix or creating one more layer of touch points. I understand that the current environment doesn’t allow clinicians to have the ideal 1-on-1 time with patients, but adding a new resource into the mix increases the human interfaces through which information has to travel. A new team member gets added to the physician/nursing rounds and the incumbent care team may not like dealing with someone else on their turf. The overall cost goes up too, since someone is ultimately paying for the added cost of docents. Needless to say this added cost will ultimately be handed-off the patient.

If healthcare service experience sucks, the solution should be to fix the fundamental issues (for example overworked caregivers and unhelpful EHRs). It’s the same argument I make against scribe services: fix the EHR user interfaces rather than adding another minion to the mix.

Criticize someone else’s solution is like shooting fish in a barrel. I realize that the current system is straining while waiting for salvation. Docents may be a good-but-temporary fix but tech-enabled services are here to stay. Omada, Livongo, Virta are good examples of how this trend can transform condition-specific care experience and outcomes.

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Virta Health Fri, 31 Mar 2017 05:48:46 +0000 Virta burst on to the digital health scene recently boasting a $37M funding round and a tech-heavyweight CEO Sami Inkinen who previously co-founded Trulia, the online real-estate platform.

Virta is the latest digital health star to follow the trend of what I’m now beginning to identify as tech-enabled care management. Think of it as a healthcare service delivery model where traditional care providers’ interaction with patient is enhanced (in terms of quality and quantity) using modern technology infrastructure like sensors, mobile, machine-learning.

Virta focuses on Type II diabetes management. They offer a dedicated health coach (someone who can help mentor and guide the patient through the health choices they need to make), a personalized nutrition plan and an overall physician supervision of care. All these service experiences are supported by technology that definitely includes a mobile app; and probably includes the needed wearable sensors (for weight, BP, etc. monitoring) along with relevant biomarker tests (like HbA1c).

Diabetes is a complicated multifactorial lifestyle condition that is often made worse with neglect of one/more aspects like exercise, weight, nutrition, mental health, medications, stress, BP, etc. So a comprehensive, closely-monitored program can surely make a difference. And technology is key for scaling services while keeping them personalized. So this kind of solution approach makes sense.

Omada (for diabetes) was an early player in the tech-enabled care management space. Livongo (also diabetes), Lantern (mental health), Hinge Health (musculoskeletal disorders) are some other examples. It’s a good sign to see standardizable niches of healthcare service delivery being scaled up with clever technology use. Of course all this still needs to pass the muster of traditional third-party payment machinery in our healthcare system. Given the accountable care trend I’m optimistic about the viability of such companies as long as they show real outcome improvements.

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MindMaze Mon, 27 Mar 2017 22:32:10 +0000 Switzerland-based MindMaze created news early 2016 when it raised a $100 million round of funding at a pre-money valuation of a Billion dollars. It is creating virtual reality products related to neural recovery.

The medical-grade product (!imaginatively called MindMotionPRO) embodies the usual inpatient medical device: a set of CPUs and monitors attached to a metal framework on wheels. It has optical motion sensors (like Microsoft Kinect) that recognize patient movements, along with sensors to record physiological signals like EEG.

The application is amazing: using immersive virtual reality on half-paralyzed (hemiparetic) patients to trick their brains into jumpstarting control of the paralyzed half. This ‘mirror therapy’ was proposed in 1990s, and modern VR tech is a perfect match for it.

MindMaze has been approved by regulators (CE Mark) in Europe, which is a big deal. Whether that justifies a unicorn status is no longer a question in my mind, mostly because the reality-distortion of unabashed venture capital investment is now a given in most new corners of tech. Who knows what the actual $ business potential is. Looking at the immense spread of what VR can do in healthcare (surgeon training, mental health, patient education, etc.), a solid-start means a good chance of survival.

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Amino Thu, 23 Mar 2017 20:13:23 +0000 The service transaction between a patient and physician has always been looked at closely from a billing perspective. Relatively few attempts have been made to enhance the match-making aspect of it: like which physician is best suited for the given patient? Tweaking this may have cascading effects downstream in the service experience and actual outcome.

Years ago, Zocdoc impressed me with their simple solution in this space. It was making it easier to get an appointment with retail physician of your choice. It’s hard to scale the retail small/medium clinics, so they dabbled in employee wellness for a bit and finally settled its focus on hospitals and health system customers.

Amino focuses on figuring out the right physician first and then help with cost-estimation and scheduling. It claims to have analyzed a trove of insurance claims data to figure out the attributes of past interactions of care providers. Using the information that patient’s type in to Amino website (health problem, insurance, zip code, etc.) it can align it with the best physician profile in its database.

The approach has merits since most patients are inherently biased (“my sister says this doctor is great”), lazy (“I’ve always gone to this nearby clinic”) or arbitrary (“I just googled it”, “His name was on the first page of my insurance directory”) in the way they select physicians. Having a good partner in healthcare can make a difference. My curiosity is about their business model – who pays for this ultimately? For now, Amino has enough runway to not worry about it ($20M in three rounds so far).

PS: Kyruus does similar stuff, but for enterprise.


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Limbix Fri, 17 Mar 2017 22:11:38 +0000 The idea is certainly not new. Using VR immersion as a part of mental health treatment has been a subject of academic research and debate for a couple of decades. What usually makes news are opinion articles and university research projects.

I’ve seen commercially-oriented companies (like VirtuallyBetter) but none that gave me the impression of a true ‘VR platform for Psychiatrists’. Limbix seems to be the (?)first silicon valley outfit to tackle the workflow, documentation and content needs involved in integrating immersive VR therapy to mental health. Their website is terse, as usual for a startup, so most of this is my gut feel.

Using VR (or AR) to help patients overcome anxiety, phobias and other mental health conditions is in care delivery future. Reminds me of the optimism in late 90s when PACS technology was washing up on the shores of film-based radiology field. Limbix is to be filed away as a representative attempt at a viable digital health niche.

Update: Right after I wrote this, my network pointed to PsiusAppliedVR which look similar.


Cover My Meds Wed, 01 Feb 2017 20:02:12 +0000 CoverMyMeds_Logo CoverMyMeds is a company in a brilliant niche. ePA – Electronic Prior Authorizations.

Usually a doctor’s prescription reaches pharmacy, which informs patient when to pick it up. If the drug needs the insurance company’s authorization, it’s up to the Pharmacist to notice that and get authorization process started (includes paperwork, calls, faxes). Patient may not even find out till they arrive to pick up medication.

This messy cycle happens 200 million times a year in US, costing $20-30 Billions dollars annually. Cover My Meds offer APIs and widgets to digitize this workflow with all stakeholders.

For example, on payer side it can enable automated routing to staff queues acc. to rules, auto-determination for some, electronic notifications to prescribers, reporting, etc. For pharmacies it can alert pharmacists about PA need, kick off approval workflow digitally, etc. For patients it means less prescription abandonment.

Most fascinating aspect of Cover My Meds is its business model. It’s free for everyone who uses it. They make money by charging drug companies to pay for the service. Drug companies fund that from the revenue of what otherwise would have been unfilled prescriptions. That is a win-win all around… minimal barrier to adoption.

Cover My Meds started with a $250K seed in 2008. They were acquired by McKesson Corp. for $1.1B last month. A well-deserved unicorn exit in Health IT.

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Nuna Wed, 25 Jan 2017 02:15:07 +0000 Nunanuna has the right mix of all the tailwinds a startup can ask for: talented team, big funding cushion, valuable data and huge market.

Founder Jini Kim was one of the Google PMs who was poached to rescue That inroad, plus personal experience taking care of her autistic brother led to Nuna’s current shape.

Nuna has the enviable access to Medicaid’s records of 74 million beneficiaries. The cloud-based data warehouse that Nuna is building would be able to generate deep insights that probably have never been surfaced before.

Nuna just announced $90M funding round right out of the gate with the legendary KPCB name backing them. That should give enough runway to make a big dent in a stolid, opaque space.

Adding it to the 10 Year Watchlist. Should be interesting.

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Amion Thu, 31 Oct 2013 21:53:23 +0000 AmionLogo Amion stands for the question every physician asks at one point or other in their residency – “Am I on?”. As I’ve pointed out before, scheduling is one of the prime candidates for being done externalized – done right by a handful of players, and utilized by everyone else.

Unlike the recent upstarts though, Amion has been around for 15 years. You can read the full story here. And unlike vanity metrics thrown around by other start-ups, Amion probably is used by over 100,000 users, as the company claims. They have products aimed at three user categories -residents, attendings, and organizations. Individuals can schedule their blocks, clinics, shifts synchronized with their personal calendars on external services (like Google Calendar or iCloud). Nuances like shift swaps , didactic pairings are probably what makes it highly relevant product for physician scheduling. Organizations probably value features like the vacation request management, policy-based rules checks, vacation/duty-hour reports, managing last-minute coverage changes etc. Plus there are some logical overlays likes auto-scheduler and template-based scheduling. Last year, Amion announced that they were launching a mobile app in partnership with Doximity. It does make sense that Amion user profiles be powered by Doximity, but the tone of press release seems to suggest more intimacy (scope of which I can’t understand).

For those who dismiss scheduling as a calendering feature, not a product by itself, think again. Here is the rough categories of solutions aimed at the scheduling puzzle in healthcare:

Chances of consolidation? Sure. But more likely are acquisitions by incumbent EHR technology players. Either way, it’s fascinating to see the breed of solutions as evidence for the inherent complexity of delivering timely, coordinated care.



November 2013 Update: Stuart Karon from Amion was kind enough to reach out and explain the Doximity-Amion relationship. Seems like it started with Doximity pulling schedule data for it’s users from Amion. They ended up spinning that part off into an independent app (for Amion). That way Amion got a professional mobile app with minimal investment and Doximity got a channel for getting new users onto the network. Symbiotic…

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AmplifyHealth Sat, 22 Jun 2013 19:10:12 +0000 AmplifyHealthLogoMost of the time, Health IT spawns artificial concepts – born as a result of relentless media hype, each reaches a precocious peak of publicity and then quickly fades away. Buzzwords like RHIO, NHIN, PHR, Chronic Disease Management, etc. were all touted as game changing at one point or other in the past. Now it’s more about patient engagement, HIE, Analytics, Care Collaboration. One stands out in my mind though – Population Health Management (PHM). I think that even though it may be riding the hype cycle like all others, it has signs of legitimacy.

Think of it this way. For decades, we have endured and participated in a healthcare system that is geared towards encounter-based medicine. Patient comes in with complaint X, gets treated and billed for complaint X. Now with changing payment models though, it is important for the payers and providers to broaden their perspective. They need to keep track of patient (member) over a period of time, and keep them out of hospitals/ERs. As a result they need a “Longitudinal Health Record” that spans across encounters. This is what HIEs promise to provide and interoperability standards promise to enable.

From a Health IT vendor perspective, PHM means tools that help user do two things:

This is done by analyzing a population in a given care context. Like HbA1c tests for diabetics. PHM construct is based on the premise of looking beyond those who need immediate care (i.e. are having an encounter) and provide insights on the entire cohort under care.
This is where the analytics graduates into what it should be – Actionable Analytics. The ideal PHM tool will not only help find at-risk individuals, but also make it easy to do something about it. So if the PCP user has found the 50 at-risk diabetics in his/her 1000 patient panel, they now need to send reminder letters or queue them up for some kind of outreach. This workflow integration is what really legitimizes the emerging niche of PHM. Just analytics on it’s own doesn’t cut it.

But the devil is in the details, of course. One can argue why EHRs, the perennial stolid incumbents of health IT world, don’t have this as native capability. The answer is clear if you’ve ever used an EHR. They were (and are) built as transactional systems that focus on the current visit billing and documentation. Doing a parallel meta-analysis of how this patient fits into a population profile and what they need outside the context of this visit is a humungous leap for almost all EHRs. And that is why a new crop of startups have started to focus on this niche.



AmplifyHealth says all the right things on it’s website. They point out the need for finding patients that are going off-track. Like most startups, it avoids putting a live demo video on the site (so frustrating) so I’m going off of what the webpages claim as capabilities. The three areas they speak of:

  1. Patient Management: Seems like this provides ability to create custom lists, akin to registries. That is a valid value-add, aligned with actionable analytics as described above. But the website description veers off into “engage new patients, influence productive behavior, establish relationship” which is confusing. All those belong to the foundational practice management and EHR system.
  2. Measuring Outcomes: This would be the ‘meta-analysis’ that doesn’t come native with EHRs. Tracking outcomes based on measures is just starting to get engrained into the EHR DNA, thanks to the bullying by Meaningful Use regulation. But even that is a very regimented approach to this meta-analysis, and may not suffice for an ideal user. Hence the value-add opportunity.
  3. Client-Sales Support: Very interesting. This seems to be an administrative dashboard for provider groups, self-insured employer groups to analyze of potential savings for a population. So it goes beyond just the clinical aspect of Population Health Management. I can see that as a separate sell to administrative, non-clinical users.

Buoyed by the hype that usually accompanies anything new Health IT, PHM is ready to bask in media limelight. But this may be one of the rare occurrences where there is actual substance underlying the claim to fame. Of course, only time will tell. One thing is for sure – you will see this term splattered across a lot of vendor booths in HIMSS 2014.

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ConsultingMD Thu, 30 May 2013 21:59:25 +0000 One the joys of working in an opaque system is that there are endless opportunities for curators. “Handpicked“, “Invite-only“, “Top 0.x%” slogans carry emotional value because the perennially ill-informed consumer is guaranteed to be frustrated with the complexity and impersonal nature of the given opaque system. The national prize for opaque system has been consistently won by healthcare ever since Medicare was signed into law in 1965. And after a few decades of helter-skelter with managed care acronyms, the age of healthcare service curators has arrived it seems. Thanks to the ubiquity of internet and communication infrastructure that connects everyone, there are a number of startups looking at how to match the demand for medical opinion with an …ahem… ‘hand-picked’ supply of experts.

ConsultingMD made news recently with it’s $10M series A round. They are in the very legitimate second-opinion niche of healthcare startups. There is a clear need for facilitating a marketplace between patient and doctors. But as I read more about what they do, two issues surfaced.

First is price. ConsultingMD’s opinions are priced at $3750 a pop for individuals. For an industry with a culture of third-party payment, that is huge! Which means that sadly, their usage will skew to high net worth individuals who already have a lot of healthcare options at their disposal. <soapbox>Which brings me to the philosophical argument of how should we solve the ‘second opinions’ need in healthcare? I think it’s by giving patients *all* their data back in an understandable way and make them informed consumers. Not by giving expensive access to an elite club of medical experts. If we do the former, the right options will automatically become popular (because of good outcomes), and hence easily discoverable. Just like it happens in retail.</soapbox>. I’m sure a significant part of that hefty sum goes towards collecting the myriad medical records on behalf of the patient and putting them in one digital place (silo alert). That manual aggregation service is probably a real value… I made the same point about MotherKnows previously.

Second  is the referrals part of ConsultingMD. The website says $200 per referral for an individual. Wait…What?? The patient pays the lead generation service to connect to doctors? That doesn’t make sense to me. Referrals are a visceral  process in the care ecosystem, part of the intrinsic flow that physicians generate as part of care continuity. I find the notion of patient-requesting-paid-referrals-directly (without a Primary doc in loop) as the wrong type of consumerism. Par8o has a better approach to referrals. We need Patient Centered Medical Home based solutions, where primary care team guides care.

However, both the issues fade away when one considered ConsultingMD as an added benefit from an employer to it’s workforce. That’s where the sweet spot is. Employers (good ones, at least) try to elbow each other out in providing fantastic benefits around health. So ConsultingMD services are meant to be sold to employers. That’s how the current system works anyways. You prevail by getting someone else to pay.

There is competition for ConsultingMD, of course. Second opinion companies (like BestDoctors, 2nd.MD, WorldCare), academic medical centers (like Johns Hopkins, Cleveland Clinic)  and even generic expert-request sites (like JustAnswer) are in the fray. Not to mention the free, yelp-like review sites (like Vitals) that have existed for a long time. So while I’m excited at the continuous movement in Healthcare IT startups, the central thrust of it still feels a bit misguided. Its like the big silicon valley echo chamber sucks in the few glitzy healthcare ideas that it inherently likes/understands; while ignoring the ugly hairy ones that roam outside praying for salvation.

Mar 2017 Update: ConsultingMD changed name to and has since then raised about $106M dollars. Let the good times roll!

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Box Mon, 13 May 2013 05:38:43 +0000 BoxLogo It’s not often that non-healthcare startups make it to the review list at Multiplyd. But the recent news about cloud storage mega-startup Box moving into healthcare is too tempting to ignore. Let’s first talk about what Box does, and then dissect it’s applicability to healthcare.

Box is a cloud storage, file-share-and-sync company. It claims more than 8 million users and has taken about $284M in funding so far (yeah, that’s right.. >quarter of a billion). With that kind of hormonal surge, it wants to grow up. Fast. And become an enterprise storage company, beating some of its rivals to the punch.

Last month Box announced that they are embracing healthcare, HIPAA and all. “That’s gutsy..” was my first thought. It’s about time we created some of the fundamental building blocks for modernizing healthcare IT – storage, communication, mobility, scheduling, collaboration, pricing, discovery, to name a few on my wishlist. No doubt we need broad disruptions like this in healthcare. If companies like Box solve a fundamental infrastructure problem like storing PHI in a device-agnostic secure platform, it’ll take away some of the complexity of developing for healthcare. More innovation will certainly ensue. The healthcare partnerships Box kicked off with are already some of the young disruptive startups in the field.


To make this a balanced analysis, let’s see the if there are other points to consider. And to do that I’ll put on my traditional health IT hat, deformed and stained as it may be from having worked with EHRs and HIEs for more than a decade.

1. Workflows – Storage is fine. But what about the darn workflows that get/put things in that storage? The ER visit that needs access to your cloud-stored Medication will also need to reconcile them somewhere. And once that is done…. ahem…. in the EHR, it’ll probably need to be updated back in the cloud storage (perhaps Blue Button can help, but it’s not quite there yet in terms of adoption). My point is that without workflows, it’s a bit like taking your hard disk to work/vacation instead of laptop. And whether we like it or not, 95% workflows in healthcare today are done on incumbent EHRs. I’d like to see Box become vendor of choice for some of the multimillion enterprise EHR systems. Then we’ll really be making a dent.

2. Content ownership – Storage may assume clear ownership of what’s being stored. We wish, but it’s not that simple in healthcare. Some first-hand experiences at IDS like Kaiser have proved to me that DURSA is a synonym for chaos in healthcare. Is everything owned by the patient? Yes? Then why don’t all patients carry home their entire medical records? Perhaps it’s the hospital that owns it? Maybe the insurance company? The answer is anything you want it to be. What complicates it further are nuances like consent (which is a conundrum by itself) and state jurisdictions (Exhibit A – if the patient has Anthrax, which is state notifiable disease and a public health risk, the state owns the information regardless. Exhibit B – how to give break-the-glass type access during an emergency). My point is not that this is insurmountable. Only that the number of dials and knobs needed in a healthcare content dashboard and administration is an order of magnitude higher that any other industry.

3. Mobile access – This is where Box’s vision may shine. The inherent complexities and convolutions of healthcare may start to fade when tempted with the mobility value proposition. Your neighborhood endocrinologist values family dinners and golf outings as much as you. So anything that lets him/her easily get to the information he needs, will get traction. A platform that centralizes information and makes it available on-demand, in device-independent way will be appreciated. Incumbent systems like EHRs can have their own flavors (Exhibit A: Haiku) but we may still need a neutral party to do the data arbitrage with smart features like device pinning.

4. Collaboration – Sharing links not files, version control, discussion threads, tasks, etc. are worth doing in a consistent way across applications. So Box can bring value here too. But this featureset is less about technical prowess and more about business development. The more applications Box can bring to it’s platform, more sticky it becomes. Interoperability is undoubtedly the next frontier in healthcare IT, and everyone in the traditional industry is solving it using byzantine standards like IHE, HL7. Maybe there is a simpler way.

Ah, ‘Simple’. It’s uncanny how that word keeps coming up when talking about Box. Not all of it can be credited to its elegant offering though. I think the technology world around us has grown like foliage in an amazonian rainforest. Continuous barrage of super-specialized, hyper-ambitious offerings takes its cognitive toll. Try to browse the startup listings on AngelList, for example. Hybrid taglines (“ meets Groupon” is one) sound cool but I still have to repeat it few times to understand what the company does.

My point is that simple visions are starting to stand out. Maybe that’s why Box is such a media darling. It’s almost like we subconsciously want to believe that a simple approach to storage and content management makes sense. And may be it does. But it’s certainly not a panacea. I’d like celebrate Box’s move into healthcare, but not necessarily as a savior. Smart startups taking aim at healthcare bodes well in general.

Like in the 80’s Sun Microsystems made a splash with it’s prophetic tagline “Network is the computer“, I believe the next transformational wave in healthcare IT thinking is going to be about the network (read exchange, analytics, population). Time will tell if the cloud storage value proposition survives on it’s own in healthcare.

PS: Interestingly enough, it seems like Sun was considering “Network is the disk drive” as the slogan first, according to this article. Apparently that didn’t capture the intent. Not then, not now.



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Careticker Tue, 05 Feb 2013 07:25:45 +0000 CaretickerLogoI know nothing more about Careticker than what their spartan website says. But the first time I read it, something clicked. Careticker is a sort of personal (health) productivity app that lets users manage their interaction before, during and after hospital stays. I think that is a great niche.

Except for hypochondriacs, no one likes hospital stays. Most of the anxiety related to a hospital stay can be attributed to the fear of unknown. Patients simply dont know enough about what they need do or what is going to be done to them during that stay. It’s like visiting a foreign country with no map or translation tool. That, is where I think niche context-aware companion apps can help. For common inpatient procedures (like hernia, tonsillectomy, etc.) a focused mobile app that gives patients reminders, education, to-do lists like functionality is  a tremendous value proposition.

Note the word ‘focused’. That’s the key. There are plenty of WebMD, MedlinePlus like generic health information apps that have wide variety of conditions covered. But to make the experience worthwhile the app needs to align all interaction vectors and focus on one intervention (or a group of closely-related conditions/procedures). Take a look at the list of most common procedures performed in US: all of them are candidates for an app. An app to remind patients when to stop eating/drinking for surgery, what to expect during stay, read FAQ posted by surgeon, get a copy of handout/discharge summary, etc. etc.

Back to Careticker. It surprises me that with the fundamentals rooted in an interesting niche, why did they pick a generic, already-crowded-with-apps condition of pregnancy as their first product. To be clear, Ob/Gyn is surely the right subdomain since the majority health-related app user skews to female gender. But a sharper focus (like Caesarean section) may have been smarter. The slightly derogatory name ‘Knocked Up’ doesn’t help either.

There is definitely room for growth in the target market. Especially since outpatient surgeries surpassed inpatient a couple of years ago. For a service like CareTicker, the gamut should run all types of procedures, regardless of care setting. Watch out for more entrants in this space.

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Zweena Health Sat, 26 Jan 2013 04:44:41 +0000 ZweenaLogo

Zweena Health provides a service to collect real-world paper medical records, digitize them and enter it into a Healthvault account. That way users can have a Personal Health Record (PHR) created for them, without dealing with multiple bricks-and-mortar medical offices.

I’ve endorsed the validity of services offering such ‘last mile’ value propositions before. Note MotherKnows for getting pediatric medical records, Phrazer in the medical interpretation realm, etc. No doubt there is a need to fulfill here.

Couple of interesting things about Zweena Health. First, they store the digitized information in Microsoft Healthvault, and not in their own proprietary application. That’s smart because it adds a layer of disintermediation that could be a sell for the rare savvy PHR users. Better to store information in a more-recognized brand name platform than in a startup’s coffers. To me it also underscores the need for ubiquitous platforms in the Personal Health Record space. After Google Health’s untimely demise, seems like Healthvault is the de facto choice. Microsoft could definitely use some more competition.

The other interesting aspect is Zweena Health’s pricing model. It has three parts. First, there is a base monthly access fee ($10) which is to be expected in any subscription based service. Second are the copy charges which are no fault of Zweena Health. They are an absurd figment of conventional healthcare system, so still okay to pass on the the user. The third part is about ‘page bundles’ – a set number of pages that a user needs to buy on Zweena Health. I find that to be an archaic way of thinking about digital information. The bloated paper records, when retrieved, should be parsed into discrete information that is in bits and bytes. So why should the payment be modeled on paper units? What if a provider took 3 pages to describe a simple procedure or left one blank intentionally? Sadly, this is the part where a new-age idea seems to be bogged down by antiquated processes. PHRs continue to be a valid need that hasn’t been solved to any shred of viability. Sigh.

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Lightning Bolt Sun, 13 Jan 2013 07:32:26 +0000 LightningBoltLogoScheduling is starting to become a great example when I talk to others about what is wrong with the current mainstream healthcare IT market. In short, the mainstream vendors are trying to do everything, and ending up with sub-optimal solutions across the board. Luckily for them, most clients are either unaware or choose to overlook the grotesque in the IT solutions presented. Which is why, I think the future is niche. Focused solutions that do a fantastic job at a subset of the myriad jumble called healthcare will be the next generation. Scheduling, is one such focus.

Some good examples already exist, albeit with slight variations on how/what they approach in healthcare scheduling. MyHealthDirect, ZocDoc, Zeel, YourNurseIsOn, InQuicker come to mind. Add Lightning Bolt to the lineup (the complete list is here). Founded in 2002 by a scientist working on scheduling supercomputer tasks, Lightning Bolt provides medical staff scheduling solutions to create, manage, request, report and communicate staff schedules.

I’ve not used their solutions, so unable to do a deep examination. But two things stood out for me. First, they position tailored solutions to certain clinical domains like radiology, hospitalist, etc. That is  nice, because I do believe that the challenges and complexities of scheduling in one clinical domain (like anesthesiology) may be different enough from another (say, something like Emergency Medicine) to warrant a different user experience. The underlying technical platform can of course be common. Second, I like the subscription-based pricing model. It’s common in the SaaS world, but most healthcare IT vendor ecosystem is still mired in license mentality.


It’s encouraging to see more entrants in the scheduling arena. What worries me is that niche solutions need to find enough scale to be viable long-term. Like it or not, the checks in enterprise healthcare IT are still written to stolid incumbents. Partly because these incumbents continuously claim to be a one-stop-shop (simpler for the client CIO, CFO)… which brings me to the point I started this post with (that they try to do a lot, and end up sucking at most of it).

So how does a new entrant, which does a singular-but-key workflow, find it’s place in the established ecosystem? I wish I knew. Regardless, an upstart like this will surely claim the crown for healthcare scheduling one day.

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Par8o Mon, 19 Nov 2012 00:30:21 +0000 As I’ve pointed out before, referrals is a complicated workflow in healthcare. But it’s important nevertheless because it affects transition points in a patients care continuum, in turn affecting outcomes and cost.

Par8o was founded by the same guys who started Sermo (the online physician community that had the distinct honor of being the first review on Multiplyd 🙂 ). It’s a referral management platform for physicians and their staff. Basic participation features like send/receive referrals, adding staff is free. For $80.20/month, the premium account will enable prominent placement in search results, personalization (availability, insurance accepted, etc.).

The recent rise of startups focused on referrals indicates another failure point in the conventional EHR world. Why, one wonders, is this not just a feature of the EHR installed in the PCP and specialists’ office? Or a service provided by the regional Health Information Exchange (HIE)? Having yet another place to log in, figure out, and use is a detriment for the average physician who is time-strapped. Other headwinds exist. ONC‘s push for Direct Project based secure messaging may start creating a genuinely untethered (from EHRs) way for physicians to connect with each other. Competing with the current fax, phone system of referral is not easy either. They may be ugly and inefficient, but they are there. With established workflows and staff familiarity.

The gold at the end of referral management rainbow lies in two pots: Analytics and Provider Directory. The former provides overarching insight that has never truly existed thus far. Local referral patterns can be extremely useful for an organization (or an incoming independent provider) that is trying to grow roots in a given geographical region. Interesting side note: Fred Trotter is trying to figure this out by mining medicare data. Another example can be a referral leakage report that points out which kinds of patients are being referred out of the network and to whom are worth their virtual weight in gold for an aspiring ACO or an existing IDS.

Provider Directory is a comprehensive, up-to-date list of verified providers that includes, amongst other attributes, a secure digital way of reaching them. That may sound as simple as the yellow pages, but it’s not. The ideal Provider Directory that spans geographies is a great monetizable asset since any vendor who wants to sell something to those providers needs a valid, secure digital way to on-board and reach them. Not to mention the benefits to patient care when all providers can communicate with each other, irrespective of their bonding to the default EHR system.

Although referral management natively fits in EHRs functional spectrum, EHR vendors are most probably not going to get there fast enough or do a good enough job once they do. So there is definitely room for a dedicated referral management solution today. Since this is a network play, my money would be on a team that has created large viable physician networks before. Par8o (Sermo DNA) , Doximity (ePocrates DNA) both fit the bill.

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HIPAAT Sat, 13 Oct 2012 22:55:44 +0000 When EHRs started showing up on the mainstream industry radar a couple of decades ago, everyone focused on how they helped get rid of the archaic paper records and digitized care delivery within organizations. How time changes perspective. Now EHRs are somewhat commodity and local, intra-organization workflow digitization is a bit passé.  The buzz now are inter-organization workflows and health information exchange.

Within the conventional realm of EHRs, attention was given to modules that emulated real-world clinical workflows like order entry (as CPOE), medication administration (as eMAR), etc. But with interoperability as the next frontier, we are seeing new solutions that tackle hitherto unrecognized/under-appreciated healthcare information topics. One such topic is consent management.

If you think consent is just a simple boolean flag that needs to get stored in a table somewhere, think again. Consent is a surprisingly complex multifactorial concept that is mired in vague laws that differ from state-to-state, but needs to be implemented accurately as a gatekeeper for critical information. Consider the following examples of what all needs to be factored into consent management:

  • Consent can be of different types: consent to disclose information, consent to access information
  • Consent can be given at different levels: provider, group, region, state, HIE
  • Consent can have different implementations: full opt-in, full opt-out, opt-in with restrictions, opt-out with exceptions
  • There are different workflows that interact and over-ride consent: like ‘break-the-glass’ functionality that lets certain providers access information in case of emergency
  • Consent is governed by different laws vary by state: For example, in NY a minor (<18 years) can receive certain reproductive, mental health services regardless of their parent’s consent. So the consent management software has to not only track the parental consent but also the child’ birth date, procedure/diagnosis and reconcile them constantly
  • Other thorny questions: time range applicable to consent (can/should it be retrospectively applied? what about reports that have been produced before patient chose to opt-out?), public health considerations (does the state own information about critical communicable diseases irrespective of consent?), what to default to if consent is unknown (opt-in? out? restricted?), how to handle conflicts between systems that claim to have consent, etc.

This paper by ONC is a good summary of most of the nuances related to consent. It’s no small feat for a Healthcare IT vendor to manifest nation-wide consent management as software artifacts, esp. if they have to retroactively fit it into legacy offerings. Which brings me to Health Information Protection And Associated Technologies (HIPAAT). They provide consent management and auditing software to enable health information privacy for various healthcare participants. What makes them unique is that they are the only vendor I know of that does nothing but that.

The core HIPAAT product seems to be ‘Privacy eSuite’ (PeS), which is essentially a consent validation and management SaaS offering that can be implemented by EHRs, HIEs and stand-alone care organizations. PeS would help its customers implement consent workflows like break-the-glass functionality in their native applications. Other interesting products are myConsentMinder (a consumer-oriented web application that helps patients self-manage consent) and the IHE-ATNA compliant Universal Audit Repository (stores and implements PHI-related auditing capabilities).

HIPAAT is another example of my previous point about healthcare IT excellence emerging in narrow niches. Traditional market solutions are getting bloated because they are trying to do too many things. Superlative marketing and regulatory anxiety are muddying the field by encouraging cross-dressing. EHRs are trying to claim interoperability features (e.g. Epic’s abysmal failure called Care Elsewhere) and HIEs are trying to do EHR work (e.g. Axolotl’s EMR lite and Medicity‘s ProAccess).

I’m a bit pessimist about the near future being kind to niche solutions. I think most of these one-trick-ponies are going to get acquired by richer incumbents. Specially the incumbents enjoying the cross-subsidy of their parent conglomerates, like Medicity (owned by insurer Aetna), McKesson (main business is drug distribution) or GE (truly diversified). But once the market zeal for inorganic growth slows down, the once remaining will be having a genuine value proposition that is worth paying for. And I bet that will be a more focused set of survivors who do a few things, but do them right.

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InQuicker Sun, 12 Aug 2012 22:31:46 +0000 In the standard healthcare IT media landscape, increasingly all I find are the ruinous signs of bloated, overcomplicated conventional healthcare IT systems struggling to do everything that they claim to do. Alongside that increasingly infertile landscape are green shoots of some startups doing few things, and doing them right.

I’ve harped in the past on scheduling being a ripe area for disruption, perhaps something that we will see being ‘done right’ very soon. Zocdoc is forging ahead, turbo-charged by humungous funding and legendary backers. But it only handles non-emergent situations where both patient and provider have the luxury to find a mutually convenient time.

Nashville, TN based InQuicker takes that value proposition to a new level. Besides facilitating non-urgent outpatient scheduling, it allows patients to ‘hold their place’ online in the urgent care or ER waiting room queues. That way patients with non-life threatening medical conditions can stay at home till it’s their turn to be seen. ER and Urgent Care Centers avoid overcrowding and patient frustration. The operational benefits of having a smooth flow in such round-the-clock care delivery centers is huge from a staffing, customer satisfaction and overall efficiency perspective. Which is why InQuicker has a growing list of participating facilities that underwrite this free service for patients. The conspicuous absence of a mobile InQuicker app is a bit odd though. This is a perfect context for mobile solution.

Enabling just-in-time operational strategy for emergency care operations… it’s a small but important piece of the overall process of delivering healthcare in a efficient and cost-effective manner. If you expect the incumbent EHR, EDI, HIE vendors or payers to get to this, don’t hold your breath. Pragmatic innovation like this will happen faster at the periphery of the perceived center of healthcare IT. InQuicker was founded in 2006, and has never raised a single dollar of venture capital. Their 2012 revenues are expected to be around $4. That, is a sign of a real business.

The need has not gone unnoticed by others. ERExpress, ERTexting are already there as direct competition. iTriage (now a part of Aetna) takes an almost similar approach with their ER wait times and check-in features.  ZocDoc may very well get into it with relative ease. Regardless of the competition, InQuicker is a great example of what laser-sharp focus can do in a nascent, over-regulated industry. Look out for such small and significant success stories in other healthcare IT sub-niches like clinical analytics, consent management, diagnostic decision support, care collaboration, transition of care, PHRs etc.

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Sandalbay Life Sat, 07 Jul 2012 22:28:31 +0000 The personal wearable-sensor devices trickle that started with FitBit around 2008 is now starting to look like a flash flood. For every one offering that has got media love (like Basis), there are perhaps five other being incubated (like Node).

It’s an embryonic market, and one that is tackling complex health problems with commoditized sensor technology. Every smart inventor in a garage seems to be capable of doing something about it. So a few things are bound to start happening now:

  • Event Managers will take notice. Exhibit A: Quantified Self Conference
  • Doubts on where does this lead us or what we learn
  • Hardware and software platforms that unify the myriad devices start sprouting

Sandalbay Life exemplifies the last. It’s is a young startup (started last last year) at LA-based accelerator StartEngine. Not much information out there about details of the offering, but their aim is to provide a single software platform for manufacturers to leverage. Given the device and format proliferation, it makes sense that someone should try to manage the complexities of dealing with application and network security, cross-platform performance and reliability issues, etc.

“Providing the white-labeled consumer software for manufacturers to utilize”, as Sandalbay Life founder Neil Malhotra puts it in an interview, is smart, since so many of these offerings are from small players. But the big guys are noticing it too. Qualcomm’s 2net platform is going to be close competition. It too, is a cloud-based system designed to be universally-interoperable with different medical devices and applications and provide easy access to the aggregated data.

I’m also not sure how to align it with other platform approaches that are already out there. Biggest one being Microsoft Healthvault. Healthvault may not be white-labeled, but does provides a way for device manufacturers to contribute their data to a PHR. They do have API’s that let a developer get to the unified Healthvault data. Plus they have a fast-growing ecosystem of devices and apps that are integrated with it.

There are smaller, but committed players going at the aggregation value proposition from multiple angles: Digifit (cardio), WellDoc (disease management) for example. Open-source grassroots projects (OpenYou, Cosm, LockerProject, are surfacing too.

The play for sensor manufacturers to have a common platform for reducing their development cost is valid. Remaining value propositions (single app for consumers, unifying data from multiple devices, giving providers tools to create workflows and insights, etc.) all come with crushing competition. Plus the whole field of personal wellness tracking is too nascent – we need the devices to take a hold in the mass market before aggregating platforms truly become a viable business themselves.

2017 update: Sometime in the last few years, Sandalbay Life has recalibrated its offering to be more about wellness training programs. More about services than data aggregation.

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Easy Referrals Sat, 02 Jun 2012 22:32:10 +0000 In healthcare, ‘referral’ is used when a provider from one clinical domain directs a patient to a provider in another clinical domain. Most prominent use case is when a primary care physician (PCPs) refers a patient to a specialist or for services  performed outside the PCP’s office (diagnostic tests, outpatient surgery, etc.). If a referral is deemed medically warranted, the PCP decides at minimum:

  • In case of specialist: physician to whom the referral is made
  • In case of services: what service, for how long (how many visits to authorize)

Most referral arrangements are based on mutually agreed referral guidelines between the referring and referred-to parties. These guidelines either developed by the medical groups or insurers themselves (sometimes in cooperation with their specialists) or bought from actuarial companies. In the majority of cases referrals result in a continuous back-and-forth communication between providers. Example: If a patient needs to be referred to a surgeon, what exactly should the PCP authorize as a part of the initial referral? The surgical procedure itself… Or simply authorize the patient’s initial consult and then issue any necessary additional referrals later (based on communication with the surgeon).

You get the picture. Referrals are not a simple in the real-world. And any software solution for referral management would need capability to effectively enable that back-and-forth workflow. Enter a new sub-species of Healthcare IT startups. EasyReferrals is an online system for facilitating and managing referrals between physicians. It’s not alone. See Trust.MD, DermLink.MD (dermatology-specific referrals). A more complete list is on Multiplyd Wiki.

The need seems to be there. My concern is around how these offerings fit in with the current healthcare IT ecosystem of EHRs and HIEs. If the daily workflow of participating provider is captured mostly by EHRs, isn’t referral management a candidate functionality within the EHR? Of course, EHRs are not good at everything (some would say, anything) so one can argue there is a need for a niche players. But referrals are not just a case of isolated messaging. To do them effectively, one would need to have some serious cross-over into patient information. E.g. sending clinical summaries or results or schedules back and forth between referrer and referee. Or communicating updates, results to the patient’s PHR. All of that requires information that is forte of an EHR. Standards or not, EHRs don’t have incentive to share that with other players.

It’s even more interesting for HIEs, since their whole value proposition is around connecting disparate providers in a geopolitical affinity group to enable such value-added workflows across participants. The whole HIE infrastructure, from Master Patient Index (MPI) to a Community-wide longitudinal health record, is created with the aim to facilitate business cases that are worth paying for. And referral management lends itself beautifully to the core of HIE and ACO viability. HIE vendors know it, and are busy in creating tools and governance that enable exactly that. Case in point – regional provider directories. Referral management is a non-starter without knowing what the end-points are. And HIEs/ACOs will own provider directories going forward. Integrating regional healthcare information is a political game (sadly) and I wouldn’t bet on untethered (with respect to EHR/HIE/ACO/IPA..) technology vendors for making a dent in that on their own.

Since I’m already at risk of being labeled doomsayer by few readers, I’ll bang the last nail in this coffin. DirectProject is enabling forcing all incumbent Healthcare IT systems to have secure,  point-to-point communication functionality that transcends data silos. Referrals are already the first use case being enabled by that uptake of DirectProject standard. So even the regulatory forces are creating headwinds for independent referral management solutions.

2017 Update: Seems like this company changed name to after 2012 and eventually got acquired by The Advisory Board, which seems to have lost interest in it.

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Jiff Thu, 24 May 2012 13:19:19 +0000 Among other things in healthcare, the care transition process is also broken. For example, outpatient care usually ends with the provider summarizing for the patient their medical issue, instructions on next steps, etc. Ideally, the key takeaways are given to the patient as printed handouts, prescription instructions. But as most of us who have been a patient would know that printed medical artifacts are cryptic and conversational details fade away rather quickly. So for a recently diagnosed Crohn’s Disease patient, the label on prescription may inform about corticosteroid treatment details but remembering doctor’s talk about it’s cause, lifestyle changes, treatment options etc. is not easy.

Jiff is a company that is focusing on ‘reinventing healthcare communications’ (their own words). They seem to have two offerings to that effect so far- JiffPad, and Circle of Health. JiffPad is an iPad app that allows annotations and notes to be overlaid on educational content and sent back/forth between provider and patient. Circles of Health allows the creation of niche social health networks around an individual so caregivers can educate and collaborate (like CareFlash). The apps are free for patient, but Jiff plans to make money from  providers through app licenses, storage space (!) and possibly sponsored content.

With that background, the ‘reinventing healthcare communication’ mission of Jiff makes sense. It’s a lofty goal though, since there are multiple incumbent players who own the digital workflow that Jiff is intending to lubricate. Exhibit A – EHR offerings. Where do the physician/nurse documentation (like H&P, Progress Note, Discharge Instructions..) live today? EHR is not only the easy answer, it’s the legal answer. So unless provider annotations on JiffPad are integrated into the EHR workflow and considered part of the medico-legal record, they create yet another silo of information. Beautiful, user-friendly, cool iPad app. But on it’s own isolated digital island.

Exhibit B – PHR offerings. Personal Health Record space may not have a clear winner, but it certainly has a growing number of players in the game. Neutral platforms like Microsoft Healthvault and Indivo along with EHR-tethered or insurer-sponsored offerings are all vying to be the patient’s personal health record. Unless Jiff plans to be yet another PHR platform in the fray, integration is needed at this end too.

Exhibit C – HIE, ACO offerings. One of the reasons for creating complex geo-political health information exchanges is to be able to engage patients in their own care. If ACOs are going to make a buck from bundled payment model, they need to make sure patients are involved in their own care. Other drivers like Direct Project based messaging (the ‘how’) and Meaningful Use (the ‘why’) are emerging as well. All of these are rooted in the clinical information/workflow that is generated by EHRs and other point-of-care tools. Again, Jiff platform needs to find it’s footing in real clinical or administrative workflow to be viable long-term.

I rest my case for high barrier to entry. If Jiff can re-state their mission to be about ‘care coordination’ rather than communication, there is scope for a new entrant. Inpatient discharge, palliative care, oncology services… there are numerous care transition points where better communication is key to better outcomes. A compelling offering across care settings that is well integrated with local workflow systems would fly off the shelves.

I admire all startups. Esp. the ones with the cojones to take on established, orthodox players. But as I read this quasi-cheerleading post about Jiff, I feel that the romance between healthcare and tech entrepreneurs has reached a feverish pitch. Yes, conventional healthcare software artifacts are ugly, inefficient and low-tech. But not because healthcare professionals want them that way. There are legal, political, real-world constraints in care delivery because medicine is an art, not a perfect science. Unless the disruption is from or with the players that own the underlying digital workflow (like EHRs), it’s prognosis is not good.

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