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.


The phase of digitizing medical records is passing by, giving way to the next set of tasks. The three most prominent challenges now are:

  1. Exchange – how to break the silos of isolated EHRs, and enable sharing based on geography (think HIEs) or affiliation (think ACOs)
  2. Consumer Engagement – If the official record is electronic, how to make it accessible to patients and open to contribution of self-reported data from increasingly commodity health monitoring devices and tools.
  3. Analytics – how to derive actionable insights (for all stakeholders – patients, providers, payers) from the avalanche of incoming electronic health data due to #1 and #2 above.

MyHealthDirect aims to tackle #1 in a specific way. Founded in 2006, the Wisconsin-based company raised $4M series A in 2009 and claimed a customer base of 104 back in mid-2011. They provide a subscription-based system for facilitating exchange of scheduling information across care delivery organizations in a community. The value proposition is for overburdened ERs that can triage away non-emergent cases with a confirmed outpatient clinic appointment. Call centers, disease managers and inpatient discharge planners can also use it to schedule follow-up PCP or specialist visits.

The alternative would be for the ER staff or case worker to call other clinics and manually confirm appointments – a predictably slow and inefficient process. By giving a confirmed appointment with someone that speaks the patient’s native language at a convenient location, the no-show rates are bound to decrease as well.

Referrals are key transition points in care delivery, and scheduling is a critical part of referral management. A number of Healthcare IT players are trying to make the process better. Big EHR players like Epic are pervasive enough in certain areas that they can provide de facto centralized scheduling. If a community has a functional HIE, doing scheduling may be possible through HL7. There are some new kids on the block, like Par8o and Kyruus, trying to enhance other aspects of the referral process. And with respect to healthcare scheduling, no review is complete without mention of ZocDoc, the startup with most-impressive backers and a mind-numbing $95M in funding.

Note that MyHealthDirect solves only a part of the referral puzzle. You still need functionality like messaging and clinical document exchange to enable complete referral workflow. Nevertheless, I think there is more fundamental insight here. Mammoth system offerings like EHR (handling all local clinical workflows) and HIE (connecting all healthcare organizations in a community) perhaps are reaching a point where they are too complex to deliver satisfactorily on everything. Maybe that is why the vendors in these categories have broad functional parity, rather than excellence in narrow niches. So it makes sense that a company that has a laser focus on doing one or two aspects right may end up creating a superior offering. Which is why I’m hopeful for the prospects of what MyHealthDirect brings to the table. If they branch out into letting patients self-service an appointment across community, that would be almost revolutionary.

Clinical Messaging (esp. Direct-based) between providers or provider-patient is another potential area that is prime for some startup’s laser focus. It can theoretically be done (and claimed to be done) by incumbent EHRs/HIEs, but they all suck at it. If done right, it can be the foundation for some great care collaboration or care transition offerings. Maybe it’s time the pendulum started swinging away from systems that do everything averagely, to systems that do few things exceptionally.

Nov 2012 Update: Just read a NEJM article by Kenneth D. Mandl and Isaac S. Kohane that makes a similar point about EHRs being bloatware (much more eloquently though). Succinct and upfront analysis… a must read.


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.


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.


Curbside.MD is a search engine for finding evidence based clinical information. The idea is to type in the search need as a natural language question that a clinician would normally ask his/her colleague, and get relevant answers from the literature (articles, images, guidelines, etc.)

I took it for a test drive with a moderately complex question (‘what is the indication for platelet transfusion in an 80 year old female with dengue fever?’) and got relevant results in terms of review articles and clinical trial outcomes. Pretty cool.

The logic behind Curbside.MD is semantic indexing using a controlled medical terminology (they call it “semantic fingerprinting“) with a bit natural language processing. They provide a bunch of tools (search box, news, spellchecker etc.) for partners and a browser search toolbar for users. The technology is also available as an API service from an alternate website called Fingerprint.MD.

Praxeon is the company that started Curbside.MD and MyDailyApple in 2006. Both websites are currently free for users, but the company admits to a future ad-based business model.