ConsultingMD

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.

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Careticker

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

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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InQuicker

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

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, Sen.se) 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.

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Tonic Health

There is no denying that the usability of current EHRs sucks. More pointedly, the data entry is really excruciating. Blogs have been devoted to the rants, articles have been written. In fact, the problem is so real that entrenched luddites have spawned a cottage industry of ‘Medical Scribes‘ – hired hands who do nothing but take physician’s narrative and punch the keys on the keyboard to get it in the dang EHR. Regrettably, industry behemoth AMA‘s position seems to be that of fascinated enthusiasm, as noted in this article. So instead of either training clinicians better or mounting pressure on vendors to create better user interface, we are contributing to the mindless expansion of peripheral careers that add cost to the overall system.

Perhaps the solution is, as noted in this THCB post, “..to sprinkle some kind of pixie dust on the EHR” to make the data entry work.  Tonic Health is a data collection management platform that can created user-friendly screens that are easy to interact with. The collection templates or forms can be customized, and made intelligent based on rules. Note that the offering is tailored for patient engagement only, not for clinician’s data entry. The screenshots look like it may have an element of gaming at some places.

Like everywhere else in healthcare IT, there is competition in data entry solutions. Most of it focuses on physician data entry woes, and has some speech recognition and NLP technology at it’s core. Prominent examples are Health Fidelity (based on Columbia’s MedLEE engine), Medicomp, MD-IT, etc. Another interesting overlap is with proprietary patient engagement tablet maker Phreesia. Seems like Tonic Health on iPad is going to eat into Phreesia’s value proposition.

Patient data entry or clinician’s, the Achilles heel is whether data gets back into the local incumbent- the ugly EHR. What matters is the back-end integration with EHR vendors, without which the data is trapped in yet another silo, non-actionable. I’d be a much bigger fan (and believer) if Tonic Health had info on EHR Partners front and center on their website. Also, if/once those inroads are made, why not move into solving data entry grievances for clinicians… that may be a more viable business model.

 

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Phrazer

The last mile problem exists everywhere. Systems may get digitized, products and services may evolve to perfection, but the last link to individual is key. Whether it is the local cable provider laying the actual copper wire to your doorstep or the company that makes a better mouse/keyboard to control any given software, the constraint brings a dose of reality to digital value propositions.

Overcoming language barrier in a healthcare interaction seems like a last mile problem too. Hyper-specialization is getting to be the norm in all domains so it may not surprise you to know that ‘Medical Interpretation’ is a formal career. It comes with training, certification, professional organization and above-average growth prospects. Phrazer may change the need for a human medical interpreter – it is an interactive device that allows collection and communication of clinical information between patient and provider regardless of language differences.

Phrazer content seems to include disease protocols, best practices, patient health education. It can be integrated with local workflow EMR and be used to collect information and consent from the patient. See video below for a demo.

The idea is neat, but ahead of it’s time. Especially given that a human workaround (albeit expensive and scarce) exists in the form of a medical interpreter. I can see it being applied in large primary care setting where patients have the time and ability to hold a device and interact with it. Not so much for emergency or acute care environments. If time is short, clinicians are trained to follow protocols and dont have luxury of waiting for interpretation most of the times.

It’d be interesting if they can partner with patient tablet vendors like Phreesia to create a combined offering. But since this is a last-mile type value proposition, integration with other end systems like pharmacy, scheduling, registration etc. is going to be critical. Not any easy feat, given the myriad combination of systems and vendors for all those other systems. If Phrazer lands a major partnership with a large EHR vendor or IDS, that would give them enough runway towards market adoption.

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Simplee

Consumer tools that help deal with healthcare system complexity are unquestionably needed. A recent niche has focused on dealing with healthcare bills.

Simplee helps it’s users track medical expenses in an friendly online dashboard. The aggregated data and management tools can help manage health care costs and perhaps be used for finding the right medical plan and services for an individual or family. The service can also be used to pay medical bills since it has an integrated payment platform.

Obvious comparisons can (and have) been made to personal finance management websites like Mint. No surprises there since managing health and wealth are equally daunting tasks, riddled with complicated verbiage and stressful decision-making for most. The need is obvious and there is competition (CakeHealth, HealthExpense and Quicken Health for example). Payer coverage is key ground to cover quickly- I couldn’t find my insurer in Simplee, for example.

Regardless, the real utility of a service like this is in its integration with existing channels that push healthcare billing information to patient. A white-labeled Simplee would be fantastic for Payers so they can evolve the annoying EOB letters sent to patients. PHR or Patient Portals (whether provided by the insurer or provider’s EHR) would be another channel for using Simplee’s service to explain the bills. Without channels partnerships like these, I’m less optimistic about Simplee’s uptake in the real world. Another perplexing topic is business model. Providing free management tools can only get a user base, and to monetize that Simplee will need to add more services – perhaps become a shopping engine for health services, provide comparisons and ratings, etc. That can’t be a viable option for short-term since building a value proposition like that would need significant traction in a given healthcare market.

As a patient do I want a new, independent, smaller company to access, analyze and archive my healthcare bills? How comfortable am I want to give them my credit card info? The answer would probably be no for a significant part of conventional patient population, unless this useful ‘billing translation service’ was embedded in my usual interaction channel with the healthcare system. I’m looking forward to the partnerships that Simplee can muster going forward.

 

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MotherKnows

A startup that helps you access and retain your medical records (to which you are entitled) from providers. Another proof of how impenetrable and complex our healthcare system is.

It’s a brilliant niche. MotherKnows will interact with the healthcare system (your physician, hospital, insurer, etc.) on your behalf to procure a copy of the medical record, store it, analyze it and make the information available to you on-demand. Anyone who has tried getting their child’s immunization record will agree that the conventional interaction is a sub-optimal customer service experience at best. So having someone else do it for you is worth paying for.

Once collected, the information is available in a PHR manner – view meds, problems, allergies, immunizations, growth charts in one place; create emergency cards; get reminders; mobile access, etc. But the key to MotherKnows’ viability, in my view, is being the authorized agent for painful extraction of medical records. As long as the pricing is right (which, at $19-$98/year, is in the right range) it will gain traction.

It’s a prudent strategy to market it initially to parents as a way to keep the records straight for their precious progeny. But I don’t see why it can’t be extended to adult healthcare consumers themselves. I’d like to be able to get my medical data all in one place, hopefully showing me trends found in my quasi-annual physical exams and labs. Today in the patient population, the motivated few try to save copies of records; and the enlightened few go one step further and manually key the data into an online PHR like Healthvault. In either case manual labor and discipline is required. Perhaps having a real-world service (of paper record collection) is what really can make a difference to PHR uptake by consumers. Hopefully, MotherKnows will reach beyond just child medical records in future.

The overall idea of patients paying an agency to wrest to their medical records from providers point to the underlying systemic inefficiencies. Theoretically, there are solutions on the horizon. An enterprise EHR used by care providers could pass the relevant info into a PHR accessible by patients. And if they change providers, a community-wide Health Information Exchange (HIE) could still enable patients to be the custodian of thier own information in another system. But we are not there yet.

The unmet need for electronic systems (like PHRs) to interface with the physical world (i.e. bricks and mortar organizations and paper processes) is very real. Till every end-point in healthcare delivery is digitized and interoperability is no longer a pipe dream, we’ll need services that handle real-world complexities. Take companies like eHGT who are already in this ‘record retrieval services‘ niche. By actually having real account managers who can get imaging records from facilities, they elevate the value proposition of an “Image Exchange” to new level. The phenomenon exists outside of healthcare too. The now defunct Random Acts of Genealogical Kindness (RAOGK) site was a volunteer effort to bridge the gap between virtual demand and physical supply of genealogy records.

 

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Glooko

In March 2009, Apple hosted an event to introduce the iPhone OS 3.0 software. What I really found interesting back then was a prototype showcased with Lifescan (a J&J company), where they demonstrated how a user could manage her diabetes using an iPhone-accessory glucometer. It was a much needed evolutionary conceptual leap for a widely-used consumer medical device category.

Turns out that Lifescan apparently did nothing with that concept. Anita Mathew (who gave the demo on Lifescan’s behalf in 2009) decided to take it forward on her own and founded Glooko. The company currently sells MeterSync, a cable that connects your iPhone to five popular glucometers in the market. Users can download the ‘LogBook’ app from iTunes store to document, analyze and share their data.

I’m not an investor (yet), but if I was, I’d put my money in Glooko. This is exactly what the future should start to look like for conventional consumer health devices. Instead of being isolated products that store a limit amount of quarantined information, they need to provide a service that enables longitudinal disease management. For a patient with long-standing diabetes, he/she needs to know how much insulin to inject for covering the meal they are about to have, not what their blood glucose number is. It reminds me of Theodore Levitt’s famous MBA quote “People don’t want to buy a quarter-inch drill. They want a quarter-inch hole.”

For Glooko, the long-term sustainability is directly proportional to how useful and sticky it’s users find the logbook iPhone app. The hardware (Metersync) may be critical at first, but end user experience and market differentiation will come from the software. There is competition, of course. Agamatrix  has been in the market with it’s iPhone compatible glucometer, and last year they announced partnership with Sanofi-Aventis that gives them the much-needed commercialization ability. Instead of augmenting diagnosis, another company Cellnovo takes a similar approach with therapeutic insulin pumps. Perhaps we’ll see a synchronized gluocometer-insulin pump offering or an intelligent, symbiotic ecosystem for diabetes devices in future.

I’ve talked about the ‘last-mile’ of remote patient monitoring in the past. Conventional medical devices produce digital manifestations of physiological parameters, but the information collected hardly goes beyond the device itself.  We need consumer-oriented medical devices to become monitoring services that automate/transform the last mile for consumers. The future is arriving piecemeal, and sadly enough, it’s not being delivered by the incumbent behemoths of the medical device industry. Withings BP Monitor (which I can personally validate since I use it) enhances the value proposition of a regular BP Monitor for hypertensives. Zeo does the same for people with sleep disorders. Granted these offerings are perfect yet, but all vectors are aligned in the right direction. As for Glooko, look out J&J.

 

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