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.

Zweena Health


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.


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.

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, “ 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.



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.