BoxLogo┬áIt’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.