Amino

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.

 

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.

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

Par8o

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.

Easy Referrals

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 MedicalReferrals.com after 2012 and eventually got acquired by The Advisory Board, which seems to have lost interest in it.

Doximity

Doximity is a mobile-based social network for physicians. It brings back memories of Sermo, which was my first review, written more than two years ago. Doximity  was started by Jeff Tangney who was also one of the co-founders of Epocrates- an extremely popular physician information tools vendor that recently filed for an IPO in July 2010.

The free app is currently only available for iPhone platform. It offers a staple of standard social networking functionality- creating profile pages, looking up colleagues based on certain criteria, finding med-school classmates, sharing private contact info, sending messages etc. Being mobile-focused gives it some amount of differentiation from other online physician networking sites, I guess. Users can also look up phone numbers and location maps of healthcare facilities like pharmacies but I dont quite see what is the unique selling point in that. Below is a short video demo of some of the functionality.

On to more important things.

Their about page hints at their possible revenue models – “We have a number of fee-based products in the works, including a service for hospitals and clinics to better manage their scheduling and on-call lists“. In an online interview with iMedicalApps, their CEO gave more details. First, they plan to sell a premium version (base version will always be free) to hospitals as a real-time ‘enhanced communication tool’ for physicians so they can get quick consults, updates etc. from each other. That may work, but only if the hospitals or physician groups foot the complete bill for such an ‘enhancement’ tool. I doubt individuals would pay anything for it- enlightened physicians may already have effective substitutes through enterprise EMR messaging functionality or Linkedin/Twitter.

Second one was honorariums given for occasional survey participation. Hmm…don’t think practicing physicians would find that lucrative enough to join, since the time spent on doing such things is almost never worth the money that can be offered in return.

Third one was mediation fee for physician recruiting. Now that may work, but it depends on how they structure the job-exchange functionality. Because there is a real risk of physician recruiters short-circuiting Doximity and approach the candidate physicians directly if they can identify them for free on the network.

Irrespective of the vague details on the revenue model, I’m a supporter of niche social networks. I think the Facebooks and Linkedins of the world are eventually going to be victims of their own success. Beyond a certain size, generic networks risk imploding under their own weight. Just like MySpace did. Professional networks (especially for highly paid professions like doctors, lawyers) need to serve very specific purpose and be fine-tuned to that. One specific aspect that may be served well by a real-time physician social network is scheduling. Enterprise-wide, rules-based smart scheduling that enables physicians to manage their availability in a group setting is a tough problem to solve. There is some analogy to be found in the nurse scheduling space- a startup called YourNurseIsOn. This page explains what they do. That kind of service, I think, is something that large healthcare establishments can find convincing enough to pay for.

By the way, those who know Joomla (the popular open-source content management system) would notice the uncanny resemblance of Doximity logo to Joomla’s logo. Hopefully they will realize it at some point and get a new logo made.

Dec 2011 Update: Doximity changed their logo..