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.




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.


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.


Tablet publishing is a nascent domain. Consider that Flipboard, arguably the runaway success story, was in stealth mode mid-2010 and had started getting serious traction a year later. The underlying concept of creating aggregated, curated and organized channels for personalized content consumption in a magazine like format has never been so viable. It hasn’t taken entrepreneurs long to recognize this and start applying it to niche markets.

Docphin leverages that same fundamental paradigm shift for medical content. It is positioned (their own words) as “a free platform that personalizes medical news and research”. It’s been called the ‘Bloomberg for Doctors‘, but I disagree since they don’t create original content like Bloomberg. They re-purpose and re-format it for customized consumption, like Flipboard.

Regardless, its a fact that physicians (clinicians, in general) are drowning in a sea of ever-changing medical knowledge. It’s perhaps more like a tsunami, if you consider the explosive growth of peer-reviewed scientific literature. One way to survive is to stay on land, i.e. be blissfully ignorant and pray to avoid an error and subsequent malpractice suit. Another is to get on board a chartered vessel of some kind – navigate with help of others who curate the content for you or give you the tools to do so.

I’ve not had a chance to use Docphin personally since their beta signup was over by the time I got to it. They claim to help combine multiple information sources, giving various filters to control and customize the final publication. There seem to be pre-configured channels for specialties, social sharing/commenting and instapaper-like personal archiving features. No real info about business model, so I’m curious what direction that will take. Hopefully Docphin team will be creative and go for something more than just ad-based revenue.

Overall, this is a great niche to be in. Analogous applications in other verticals (law? finance? or any significant topic with enough professional or enthusiast population) may be just as interesting. Key to success would be figuring out the right channel partnerships to get in front of enough customers and to be sufficiently sticky that users get addicted. That, sadly enough, is the toughest part in permeating healthcare industry.


VisualDx is healthcare’s answer to the visual search trend led by companies like, etc. VisualDx helps identify dental and medical diseases by letting providers search for diagnosis based on how a disease looks and presents itself.

Rochester, NY based Logical Images is the company behind VisualDx. Understandably enough, it was founded by two dermatologists from University of Rochester in 1999. At its core lies a pretty big repository of clinical images (they claim > 60K) that are tagged with clinical metadata like symptoms, location, history etc. A user can browse through diagnosis domains or input findings to reach a relevant set of images.

There is a 15-day trial for non-enterprise users, and individual subscription pricing ranges from $49.99 (Pediatric) to $99.99 (Adult) for a year. Student discounts brings it down to a very reasonable level ($29.99 and $49.99 respectively) in my view. The company has leveraged their content to create an online consumer health resource called Skinsight. Besides the clever name, I really liked their slick ‘Skin Condition Finder‘ tool. Overall, it’s a smart approach for gaining market recognition and expanding services.

The concept of Diagnostic Decision Support (DDS) often comes with the implicit notion of text-based query, so I really like the ‘visual’ DDS approach. Dermatology, Pathology are obvious choices to implement such an approach and situations like ER, bioterrorism, infectious diseases are prime contexts since there is not enough time to engage a pure text-based knowledge base. Also, some conditions are rare enough that most practicing physicians and non-specialists haven’t actually seen one in real life. Other factors like dark skin, atypical presentation can be confounding. It’s handy to have a this as a medical education tool and as a care delivery aid in facilities where specialists are not available all the time.

I’m bit surprised why it’s not a widely subscribed resource in hospitals, public health entities, medical education and general EMR vendor products. Anyway, it’d be interesting to see this visual content embedded in other consumer tools (like iTriage, FreeMD) and enterprise offerings (Isabel Healthcare, SimulConsult, Curbside.MD etc.). Wonder which firms are competitors for VisualDx today…