What does it take to create a decision rule? In this episode of Radiology Firing Line podcast Saurabh Jha (@RogueRad) has a discussion with Robert W. Yeh MD MBA about the deep thought and complex statistics involved in creating a decision rule to guide therapy which have narrow risk-benefit calculus, specifically a rule for how long patients should continue dual anti-platelet therapy after percutaneous coronary intervention. They also discuss the motivation behind the legendary, and satirical, parachute RCT published in the recent Christmas edition of the BMJ, which delighted satirists all over the world.
Our Experience
on Facebook Offers Important Insight Into Mark Zuckerberg’s Future Vision For
Meaningful Groups
By ANDREA DOWNING
Seven years ago, I was utterly alone and seeking support as I navigated a scary health experience. I had a secret: I was struggling with the prospect of making life-changing decisions after testing positive for a BRCA mutation. I am a Previvor. This was an isolating and difficult experience, but it turned out that I wasn’t alone. I searched online for others like me, and was incredibly thankful that I found a caring community of women who could help me through the painful decisions that I faced.
As I found these women through a Closed Facebook Group, I began to understand that we had a shared identity. I began to find a voice, and understand how my own story fit into a bigger picture in health care and research. Over time, this incredible support group became an important part of my own healing process.
This group was founded by my friends Karen and Teri, and has a truly incredible story. With support from my friends in this group of other cancer previvors and survivors I have found ways to face the decisions and fear that I needed to work through.
Our Support Group is
a Lifeline. And We’re Not Alone.
As group of cancer previvors and survivors we’re not alone. Millions of people go online every day to connect with others who share the same health challenges and to receive and provide information and support. Most of this happens on Facebook. This act of sharing stories and information with others who have the same health condition is called peer support. For many years there has been a growing body of evidence that peers seeking information from each other can and do improve the way they care for themselves and others. Today many of these peer support groups exist on Facebook.
I know what anyone reading this might be thinking if you have experienced a peer support group. After all the terrible news about Facebook and privacy, why would ANYONE share sensitive or private health information on Facebook?!
The truth is: we really have no choice. We’re trapped. Many of these health communities formed back before we understood the deeper privacy problems inherent in digital platforms like Facebook. Our own group formed back in 2009 when Facebook was the “privacy aware” alternative to MySpace. And because they grew so big the network effect becomes very strong; patients must go where the network of their peers live. We started out as a small collection that organically grew over time to become bigger and more organized. This dilemma of the network effect is illustrated beautifully in an Op-Ed by Kathleen O’Brian, the mother of a child with autism who relies on her own peer support group and who wishes that she could jump ship but cannot leave.
People turn towards peer support groups when
wefall through the medical cracks of the healthcare system.
When facing the trauma of a new cancer diagnosis and/or genetic test results,
the last thing on your mind is whether you should be reading 30 page privacy
policies that tech platforms require. Rather, patients need access to
information. Patients need it fast. We need it from people who have been down
the same path and who can speak from personal experience. And that information
exists within these peer support groups on Facebook. We need to be protected
when we are vulnerable to those who can use information about out health
against us.
Our awakening to
deep cybersecurity problems.
My own experience with peer support groups
took a terrifying turn last April. After the news of Cambridge Analytica broke
in headlines, I asked myself a simple question: what are the privacy implications
of having our cancer support group on Facebook?
As a geek with a professional background in tech, I thought it might be fun to do some research after looking at the technical details of what happened with Cambridge Analytica. As I looked at the developer tools on Facebook’s platform, I began to get concerned. Not long after this initial research, I was lucky enough to meet Fred Trotter, a leading expert in health data and cybersecurity. I shared this research with Fred. What followed next for me was a crash course in cybersecurity, threat modeling, coordinated disclosure, and learning about the laws that affected our group. Fred and I soon realized that we had found a dangerous security flaw that scaled to all closed groups on Facebook.
Since discovering these problems and
navigating submission of this vulnerability to Facebook’s security team, our
group has been desperately seeking a feasible path forward to find a safer
space. We have awakened to the deeper issues that created breach after breach
of data on Facebook. It seems like every day we hear about a new data breach and
a new apology from Facebook.
Our trust is gone. But we’re still trapped.
The lasting impact
of peer support group privacy breaches
When health data breaches occur, members of vulnerable support groups like ours are at risk of discrimination and harm. Women in our own support group can lose jobs and healthcare when health information generated on social media is used to make decisions about us without our knowledge or consent. For example, health insurers are buying information about my health — and potentially can use this to raise my rates or deny coverage. And 70% of employers are using social media to screen job candidates.
For me, these security problems raise
questions about the lasting impact on our group when data is shared without our
knowledge or consent. Without transparency and accountability from these tech
companies on their data-sharing practices, how will we ever know what decisions
are being made about us? If the data generated in the very support groups these
patients need to navigate the trauma of a health condition is used against
group members who is being held accountable?
There is a stark contrast between Facebook’s rhetoric about “meaningful groups” and our current reality. We are trapped. Who is protecting these vulnerable groups? Who is being held accountable if and when the privacy and data generated by these groups are breached and used against their members? What are the solutions that give us the ability to trust again?
Does Our Support
Group Have Any Rights?
Over this past year we have done a lot to try
and understand what are rights are. Digital rights for groups like my own
really do not exist. I have been reflecting on how when someone is arrested a
police officer will read someone their Miranda rights.
“You have the right to remain silent. Anything you say
can and will be used against you.”
This is really our only right at the moment.
These words keep repeating in my mind as I think about our group’s current
predicament of what to say and not to say about health on social media. From
the perspective of a cancer support group, it seems we’ve reached a point where
anything we share on Facebook can be used against us… by third parties without
our knowledge or consent. As we lose our trust, we stop engaging. We stop
trusting that it is safe to share things with each other in our group. We
become silent. Moreover, our group cannot simply pick up and leave. Where would
we go? What happens to the 10 years of work and resources that we created on
Facebook, which we would lose? How do we keep the same cycle from repeating on
a new platform?
At the root of this problem there are gaping holes in consumer privacy rights that might protect our group. While there are rules about health data breaches from the FTC there has been no enforcement to date. We are watching and waiting to see what the FTC might do. And while health information shared in hospitals, clinics, and doctors’ offices is protected by HIPAA, no such protection applies to the enormous amount of personal health information provided to social networks every day. The millions of people who convene through support groups are in a highly vulnerable position, and are currently powerless to change the dynamic to one in which they have protections and rights.
Congress and the FTC have held numerous hearings about a path forward to protect consumer data privacy, and a central theme for these dialogues is what to do about Facebook. There have been hearings upon hearings held by the FTC on consumer privacy in the 21st century. Recent hearings in Congress include those at the Senate Commerce Committee. While these hearings show a generalized desire to enact meaningful change, and some recognition of the urgency of the problem, I cannot help but notice the lack of representation in these dialogues from actual consumers who are affected by these privacy problems. I have held onto hope that there would be meaningful policy discussion about how to protect these vital peer support communities, but realize that we must help ourselves.
“We Take Your
Group’s Privacy Very Seriously.”
Last year, we started a dialogue with Facebook’s teams after submitting our security vulnerability via the white hat portal. I heard over and over again from people at Facebook: “we take your privacy very seriously.” But Facebook never publicly acknowledged or fully fixed the security problems created within their group product. In fact, Facebook directly denied that there was ever a privacy and security problem for our groups.
Given this experience, you can imagine my surprise this week when Mark Zuckerberg announced his big new plans for Facebook. After a heartwarming commercial of a twenty-something finding her people in meaningful groups, Zuck walks onto the stage and declares: “The future is private.”
Our support
group had reasonably expected the present and past to be private too.
Watching the F8 Summit my heart sank. It seems we must all submit to this future that Facebook imagines for us. A future where problems and abuse in Silicon Valley are swept under the carpet. Where no one is accountable. A future where exploitation of our data lurks just underneath the surface of all the heart-warming rhetoric and beautiful design for meaningful groups. Currently Facebook Groups have one billion users per month. Our trapped group is just one example of so many that are at the heart of Facebook’s future as a company.
These groups go beyond health to others seeking support for a shared identity. Active duty military. Survivors who have lost a loved one. Moms needing support from other moms. Cybersecurity professionals. In extreme cases the information in vulnerable groups can be weaponized. For example there were groups for the Rohingya in Myanmar and groups to support sexual assault survivors that are now quiet or have been deleted.
Facebook unveils that Groups is at the heart of Facebook’s future.
It seems that the data that has made this
company so wealthy is still a priority over our security and safety. I quietly
watch the reactions to the latest Facebook event, and the lack of any responsibility
to the people in groups like my cancer support group.
We Cannot Remain
Silent
When I think about my support group of cancer
previvors and survivors, I feel strong and brave. I fear retaliation writing
this because we are truly vulnerable on the platform where we reside. Yet, we
can’t remain silent. We don’t want any more empty promises from the technology
platforms where we reside. We would rather not be appeased with shiny new
features and rhetoric about privacy.
Rather,
we seek autonomy. We seek a way to take our own power
back as a group. We seek to protect our shared identity as a group and make
decisions collectively. We seek to protect any data that is shared. There is
something truly unique about the shared identity of our support group: we have
always done things on our own terms. We are ten thousand women who have faced
really hard realities about our future.
Facebook did not create our incredible groups.
We did. We’ve worked hard for ten years cultivating this online group for a
simple reason: we wanted our group to
feel less afraid and alone than we felt in the beginning. Facebook does not
have a monopoly on any vision for our future. The data generated within these
groups is not an abstraction to us. It represents generations of suffering. Our
own suffering. Our families’ suffering. We have an urgent need to develop a new
way forward that protects our identity, and the future of our groups. We will
create the future we choose for this community. That future exists with or
without Facebook.
If you are in the same boat, please reach out to us here.
Andrea Downing. Previvor | Community Data Organizer | Accidental Security Researcher. This post originally appeared on Tincture here.
With the application deadline for Bayer’s G4A Partnerships program coming up on Friday, I thought I’d throw out a little inspiration to would-be applicants by featuring an interview I did with one of last year’s program participants at the grand-finale Launch Event.
Not only was this a great party, but a microcosm of the G4A program experience itself: a way to meet Bayer execs en-masse, an opportunity to sell directly to key decision-makers across Bayer’s various global business units, and a chance to feed off the energy of like-minded innovators eager to see ‘big health care’ change for the better.
While the G4A program itself has changed a bit this year to be more streamlined and to allow for bespoke deal-making that may or may not involve giving up equity (my favorite new feature), startups questioning whether or not they have what it takes should take a look at some alums.
There’s a playlist with nearly two dozen interviews waiting for you here if you’re REALLY up for some procrastinating, or you can click through and just check out my chat with Joe Curcio, CEO of KinAptic. A healthtech startup taking wearables to the bleeding edge, Joe shows us a mock-up of the KinAptic ‘smart shirt’ which features their real innovation: printed ink electronics that look and feel like screenprinting ink, but work bi-directionally to both collect data from the body AND apply signals back to it. Is it AI-enabled? Did you have to ask? Listen in for a mindblowing chat about how this tech can change diagnostic analysis and treatment and completely redefine our current limitations when it comes to healthcare wearables.Once you’re inspired, don’t forget to head over to www.g4a.health and fill out your own application for this year’s partnership program.
Jessica DaMassa is the host of the WTF Health show & stars in Health in 2 Point 00 with Matthew Holt
Nearly a decade has passed since Healthy People 2020positioned social determinants of health (SDoH) at the forefront of healthcare reform. As defined by the report, SDoH are the “conditions in the environment in which people are born, live, learn, work, play, worship, and age, that affect a wide range of health, functioning, and quality of life outcomes.” Examples of social determinants include:
Resources to meet daily needs (e.g., safe housing and local food markets)
Educational, economic, and job opportunities
Community-based resources in support of community living and opportunities for recreational and leisure-time activities
Transportation
The ability to influence
social determinants largely falls outside of the health care system’s reach.
Therefore, a key to address opportunities for health involves collaboration between
health care and different industries such as education, housing, and
transportation. Both the public and private sectors have made significant
efforts to bridge the gap between physical, mental, and social care by
experimenting with non-traditional partnerships.
The Center for Disease Control and Prevention (CDC) has spearheaded multiple programs with government agencies and community partners to achieve the goals outlined in Healthy People 2020. One of the most notable successes is the Childhood Lead Poisoning Prevention Program, an initiative by the CDC with the Department of Housing & Urban Development and the U.S. Environmental Protection Agency. Through housing rehabilitation, enforcement of housing and health codes, and partnerships with healthcare experts, the program helped Healthy People 2020 exceed their target of reducing blood lead level in children.
Other programs such as the “National Program to Eliminate Diabetes Related Disparities in Vulnerable Populations,” leveraged community partners and resources to increase food security, health literacy, and physical spaces for active living. In one of their projects, the program partnered with community health workers (promotoras) who spoke Spanish to engage with Hispanic/Latino communities where participation to Diabetes Self-Management Education (DSME) was low. The community health workers provided linguistically and culturally-sensitive materials that effectively increased participation in DSME among the targeted population. The outcomes from such initiatives have inspired more health and community organizations to work together to reduce health disparities.
Private health insurers have also joined the movement to influence SDoH as the shift towards value-based care incentivizes them to keep their beneficiaries healthy beyond clinical settings. Kaiser Permanente, which prides itself on helping their beneficiaries achieve total health, will launch their social care network Thrive Local to connect healthcare and social services providers. Thrive Local will be powered by Unite Us, a startup that helps providers refer social services, track outcomes, and collaborate care with community partners. Meanwhile, Blue Cross Blue Shield has invested nearly $40M into Solera Healthto integrate social determinants data and resources into healthcare. Solera Health will use the funding to build out a network of digital health and social services providers and reimagine how health plans will pay social service providers. Both insurers are hopeful that the partnerships will promote better health outcomes and create a new care delivery model that effectively address social needs.
Developers and innovators are encouraged to create technology that can support the integration of SDoH collaborations into healthcare. Those who are interested in this space and have a digital solution should apply to the “Robert Wood Johnson Foundation Social Determinants of Health Innovation Challenge,” which seeks novel technology that helps providers and/or patients connect to health services related to SDoH.
Examples
include but are not limited to:
Digital tools that pull data from
non-profit services to assist health systems in serving diverse patient
populations on an ongoing basis
Apps for consumers that provide health
information based on their community/location
Technology that harnesses governmental
or open source data to create insights for healthcare providers to evaluate
SDoH data and improve population health
In this multi-phase
challenge, innovators are asked to submit tech-enabled solutions that account
for SDoH. Subject matter experts will evaluate the entries and select the top
five teams who will move onto Phase II. The five semi-finalists will be awarded
$5,000 each to further develop their application or tool. Then, three finalists
will be chosen at the end of Phase II to compete at a live pitch event! They
will demo their technology in front of a captivated audience of investors,
provider organizations, and members of the media at a prominent health
conference. Judges will select the first, second, and third place winners live.
Winners will be awarded $40,000 for first place, $25,000 for second place, and
$10,000 for third place.
The challenge is open to innovators and companies at any stage of development. If you are interested in applying, the competition is now accepting Phase I applications and the deadline to submit is June 7th, 2019 11:59 PM EDT.
To learn more about the challenge, please visit the website. To sign up for updates on the challenge, please click here.
Catalyst @ Health 2.0 (“Catalyst”) is the industry leader in digital health strategic partnering, hosting competitive innovation “challenge” events, as well as developing and implementing programs for piloting and commercializing novel healthcare technologies.
How long does it take to diagnose guttate psoriasis versus pityriasis rosea? Swimmers ear versus a ruptured eardrum? A kidney stone? A urinary tract infection? An ankle sprain?
So why is the typical “cycle time”, the time it takes for a patient to get through a clinic such as mine for these kinds of problems, close to an hour?
Answer: Mandated screening activities that could actually be done in different ways and not even necessarily in person or in real time!
Guess how many emergency room or urgent care center visits could be avoided and handled in the primary care office if we were able to provide only the services patients thought they needed? Well over 50% and probably more like 75%.
Primary Care clinics like mine are penalized if a patient with an ankle sprain comes in late in the year and has a high blood pressure because they are in pain and that becomes the final blood pressure recording for the year. (One more uncontrolled hypertensive patient.)
We also get penalized if we see an infrequent visitor only once in a given year and don’t screen and provide interventions for depression, alcohol use, smoking and a host of other conditions unrelated to what the patient came to us for.
So we can’t afford to have quick visits since anything less than comprehensive makes us look bad.
Imagine if you pull up to an ATM for $40 in cash and the machine insists on going over your annual budget with you. That’s what primary care feels like sometimes.
Of course I will look one or two steps beyond the chief complaint. If a smoker has bronchitis, I’ll talk about smoking. And if an alcoholic falls down his front steps, I will take the opportunity…
But I can’t do everything for everybody in every visit. I can be comprehensive, over time, if I am not penalized for squeezing In patients with simple problems for quick visits. I think that is more comprehensive than declining to provide rapid access and thereby forcing patients to fragment their care between multiple unrelated providers.
Here is my simple prayer:
Dear Overlords of CMS and all you other Healthcare Policymakers and Deities,
Let us judge how to best meet our patients’ needs when they come to our clinics. Admit that sometimes a sore throat is just a sore throat.
Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.
Today the notion that health is a preferred state of being, rather than a set of disconnected functions or services, is increasingly being embraced. A recent JAMA article promoted a health measurement system called the “flourishing index” focused on 6 key domains: happiness and life satisfaction, physical and mental health, meaning and purpose, character and virtue, close social relationships, and financial and material security.
Dr.
Gro Brundtland, former director-general of the World Health Organization, wrote
in the World Health Report 2000 that
“The objective of good health is twofold – goodness and fairness;
goodness being the best attainable average level; and fairness, the smallest
feasible differences among individuals and groups.”
In
the age of Trump, with forced separation of immigrant mothers and children,
criminalization of abortion, and purposeful obstruction of enhanced access to
health care for vulnerable populations, it becomes impossible to ignore a
significant modern-day truism. Health is profoundly political.
Health is a collection of resources unequally distributed in society. Health’s “social determinants” such as housing, income, and employment, are critical to the accomplishment of individual, family, and community well being and are themselves politically determined.
Health
is recognized by many throughout the world as a fundamental right; yet it is
irreparably intertwined with our economic, social, and political systems. And
growth in health, health care, and health systems requires political debate and
political consensus.
As
the nation struggles to contain an essentially lawless executive branch, it is
easy to lose sight of the fact that fundamental changes in attitude over the
past two decades have laid the groundwork for today’s majority support for
universal health care as a right for all Americans.
In
health delivery, we have moved away from paternalism toward partnership; from
individual care models to team approaches; and from intervention toward
prevention and health planning.
Many
sites now embrace evidence-based clinical care, while others incorporate
educational and social missions as well. We are moving away from hospitals and
outpatient care sites toward home settings, and away from authority directed by
professional elites toward inclusive power sharing between patients and their
care teams.
But
despite this shifting environment, there is a growing political disconnect
between those in control of our federal government and the people they are
governing.
Are
we as a nation and a people “flourishing”?
Our
president and his protectors reinforce silos and the status quo. But our
people, in majorities, seek broad, fundamental and comprehensive reform.
Such
reform includes expansion of insurance coverage, realignment of financial
incentives toward prevention, increased reimbursement of health professionals for
coordination and continuity, support for early diagnosis and screening, and
expansion of funding for education and social determinants that allow citizens
to flourish.
This is no longer simply a battle over the future health of Obamacare. This is fundamentally a battle over the health of our nation and the future ability of our citizens to flourish in a changing world.
Mike Magee, MD is a Medical Historian and the author of “CODE BLUE: Inside the Medical Industrial Complex” (Grove Atlantic, June 4, 2019).
In this two-part series, we examine several common misconceptions
made by health tech start-up companies in working with Health Systems and
offers advice on how to recognize and address each. From approaching systems
with a solution-first mentality to not understanding the context in which
health systems work, we look to provide constructive criticisms meant to
support more effective partnerships between health systems and digital tech
solutions.
Perspectives
and Reactions from the Industry
Understand the Current System Environment We Are Working In: In some cases,
technology solutions are barricading healthcare systems inside. In other
cases, they are allowing us to seamlessly interact with other systems. Typically, large healthcare systems have a
combination of both. For outside solutions to be effective,
start-ups need to be intimately familiar with the existing (and on-the-horizon)
systems that healthcare organizations are using or contemplating. Rarely
will a solution not have to interact with existing software solutions – and
this goes well beyond just the EMR.
Advice
Have an Integration Plan: A
stand-alone solution, which doesn’t tie to one or more of the healthcare
institutions key systems of record (SoR) or systems of engagement (SoE) is a
useless solution. Your solution should be able to stand alone in the first few
weeks, as users begin to use it and get familiar with its capabilities.
However, as soon as value is realized
(not necessarily achieved), it’s crucial that your solution support either SMART on FHIR, FHIR,
HL7v2.x, or all of the above. If you don’t have a believable integration story
fully worked out, you’re not ready to launch into the health system market. Go
back and do your homework.
Having a Clinician Is Nice, But Not Enough: The physician, nurse, or other clinician on your team helps credibility but we also understand the incentives associated with selling solutions, and this takes away from the altruism you think we will blindly swallow. And they are rarely businessmen or women who understand both the complexities of solving a problem that isn’t theirs and starting, let alone, running a company. Pair an MD with an MBA? Now we’re talking.
Advice
Create a Balanced Team: If you’re selling
clinically facing solutions, you need to ensure clinicians are on the product
development team or senior product management leadership. Beyond the product,
the value of a clinician is limited, unless the clinician on your team has been
a department head with P&L responsibility, or significant budgeting or
procurement experience. When building your “dream team,” combine sales
professionals who understand the sales cycle with business development
professionals who deeply comprehend the health system procurement process, and
product professionals who know the clinicians’ jobs inside and out. The best
product people may be your clinicians, but they need to be trained in design thinking and
product management if they’re in leadership roles. The educational background
and degrees your staff hold are generally not important (because they won’t be
credentialed), but the skills they possess along with real-world experience
across a number of facets is key.
You Probably Won’t Be Around in 3 to 5 years There is a harsh
reality that we need to grapple with if we want to have a mature relationship
with you. You probably won’t be with us for very long. Yes, we recognize that if you partner with us
there is a much greater chance of survival, but our healthcare systems does not
want to be the life support that keeps you breathing. I’ve seen too many
situations where healthcare systems “invest” in start-up solutions,
only to have that solution not succeed elsewhere. The result is a bad relationship where the
two parties have become so reliant on each other that they can’t break up (the
start-up for money, the healthcare system for sunk costs,
not rational, and transition costs, rational). If healthcare systems were an
investment firm (and indeed, some of them are), they would see hundreds of
solutions only to pick a few. Healthcare
systems don’t have time for this, so are picking 1 from a handful at most. This is bound to fail. Because of this reality, start-ups need to
not just show us that they will survive and thrive without us, but that if they
don’t, that there is a logical transition to the next solution, and then the
next.
Advice
Have Failure Based and Success-Based Objections Health systems have reasonable fears about startups for many good reasons:
questions around whether the solution can handle user requirements, whether the
solution is high enough quality, whether the solution can scale to a high
number of users, whether the solution can be integrated with the EHR, and so
on. Most of the fears are failure-based
– meaning, will the startup fail one
or more of their promises? But, there are also success-based fears: if the solution works, will the company be
around for a while; if the solution works, will the health system maintain the
attention and receive the support
it requires, and in case the solution works and the company disappears how will
get our data out and be able to maintain the solution on our own? As
entrepreneurs we’re often good at handling failure objections but we have to be
great at talking about success-based objections. For example, you could offer
source code in case the company goes out of business; you could offer extended
support plans with third party integrators for attention, and you can offer an
easy way for them get access to their data, rules, and other information
they’ve put into your solution.
Pulling those numbers for you to prove your solution is harder
than it sounds Healthcare systems are obsessed with data, indeed it is
fundamental to research and demonstrating clinical efficacy for clinical
approaches and interventions. And healthcare systems are becoming more
and more proficient at reporting and analyzing traditional metrics such
as mortality rates, infection rates, prevalence of avoidable errors, among
others. But we’ve only recently developed the ability to perform deep
trend analysis on large data sets (don’t think big data, think spreadsheets). Traditional
mechanisms for healthcare
systems have been to rely on “Tracers”, the act of following sample
random encounters through the health system to document whether the course of
care was handled appropriately. The
point is, data analytics is an evolving competency and we are still just
learning to crawl. And data availability and analysis of the impact on
new emerging solutions designed to improve access, efficiencies, and decrease
operational burden is still new, especially when that analysis is on a digital
technology. Start-ups need to understand that the data request they need to
prove their solution sometimes is just not possible. Those data requests can be
guides for long term goals to improve our analytic approaches or solutions.
For now, unless the system has a strong and resource analytics
department, you’ll have to rely on what we have, an answer no one should be
satisfied with*.
Advice
Use OKR Decision Making Frameworks to Negotiate Objectives Health systems are obsessed with data, but sometimes they’re focused on
the wrong kind of data: process
measures instead of outcomes measures. The smartest startups these days
build their products using the Objectives and Key Results (OKR) decision-making
and operational excellence framework. If you build your solution with OKRs in
mind, then you and the health system can negotiate the objectives (“O”) in
general and specific expectations as key results (“KRs”). What’s nice about
OKRs is that they are not subjective plus they require data-driven and
evidence-based approach to understanding whether a solution is worthy of
implementation and further expansion (scaling). Instead of using time-based
roadmaps and implementation schedules you should negotiate objectives- and
accomplishments-based roadmaps and schedules. With strict actionable and
accountable accomplishments described as OKRs for both the health system and
the startup, the solution can be far easier to build consensus around and get
the permissions necessary for deployment.
* we know this answer flies in the face of a system’s need
to see impact on clinical outcomes. this is the elephant in the room when
digital medicine collides with the need for clinical rigor
Conclusion
While it’s important to know how healthcare systems think, and
what might resonate with them, it’s just as important to maintain your
independence in thinking and approach. This is what makes you so
valuable. Indeed, other industries have
already benefited from “fresh” thinking approaches, and it’s well known that Healthcare is in desperate need of this infusion
of “other side” perspective. While just a small step, we hope our perspectives
can help you know how healthcare systems think. But just be careful, we
wouldn’t want you to start thinking like
them.
Brian Van Winkle, MBA works with clinicians and health systems to tackle status quo thinking. He focuses on bringing the most innovative solutions and digital technologies to our hospitals to re-imagine how we provide and consume health.
Shahid Shah, M.Sc. is an award-winning Government 2.0, Health IT, Bio IT & digital Medical Device Inventor & CTO with over 28 years of technology strategy, architecture, engineering, entrepreneurship, speaking, and writing experience.
Start-ups are an increasingly important “node” within the
healthcare ecosystem. They are challenging status quo concepts that have
long been ingrained in the healthcare system, like questioning the value of
traditional EMR systems, or shifting the power of information to patients, or
breaking down cost and quality transparency barriers. They may be the future of
the industry, but startups have a long way to go to truly transform the
system. The reasons are many, from an incredibly convoluted and bureaucratic
review process and rigid risk-controlling regulations and policies, to the
large-scale organizational inertia most of our healthcare systems have.
And while all of these hurdles can and will be overcome if we work
together, there are still several lessons each “node” in the ecosystem can learn to more effectively work with each other.
This article is directed at the emerging digital solutions trying
resiliently to help transform this stubborn industry. It provides some critical
lessons in dealing with healthcare systems and is accompanied by reactions from
a digital solutions expert with serial digital health entrepreneurship
experience. We hope to provide perspective from two people living and
breathing, and surviving, from both sides of the
equation every day.
Perspectives
and Reactions from the Industry
Healthcare Startups Must Understand how Provider
Systems Operate: Most
health systems are increasingly becoming rightfully skeptical about new
solutions because they feel the solutions don’t understand the environment of
their system. To help overcome the challenges of introducing your innovation into a complex business and
clinical environment, startups must understand how health systems operate to
include how they make decisions, contract and evaluate solutions.
Advice
(1)
Recognize that Decisions are Consensus-driven and Permissions-based: Unlike
other industries, where “shadow IT” is rampant and there can be one or two “key
decision makers,” in health systems you’re not likely to get very far without
figuring out how to build consensus among an array of influencers and then
figuring out how to get permissions from a group of key decision makers. You
should seek a “Sherpa” that understands enough about your solution to champion
the idea of change – which is really what you’re seeking when you’re
selling a new solution (the solution is just the means to accomplish the change,
it’s the change that’s hard). The first thing to focus on is to identify the
group of decision makers and how you convince them that the status quo should
be abandoned in favor of any change –
then, once you know how to convince them of some
change you’ll work with the group to get the right permissions to work on the
change management process – which will then influence a purchase of your
solution.
(2) Walk
a Mile in the Systems’ Shoes: If you’re getting into
the healthcare industry and most of your cofounders or senior leaders have
never worked inside a healthcare
system, then do volunteer work at a potential client to truly understand their needs. Find the department(s) that may be
buyers of your system and figure out a way to work in that department to
understand all the nuances of their current (“as
is”) and future (‘to be”, with your solution) workflows. Once you’ve walked a
mile in the systems’ shoes, your solution will be much better, and you’ll find
it easier to build consensus and get the right permissions from multiple
stakeholders across multiple departments.
(3)
Understand the Budgeting, Procurement and Buying Process:
Health systems are often similar to governments in that they have multi-year
budgeting cycles, complex procurement processes, and stringent buying
conditions. Even if you find the right group to build consensus around, and you
can even get permission to buy your product, your solution may not have been
budgeted for the current procurement cycle. Before you get too far in your
sales cycle, check to ensure that budget is available, procurement is possible,
and that the terms of a purchase are something you can live with.
Know the
Difference Between Fixed and Variable Costs: Your claim to reduce cost
dramatically often misses the differences between fixed costs and variable
costs. It’s true in the long run that disrupting the cost equation may include fixed costs
(reducing the big hospital footprint or repurposing) but in the short term,
these hospitals are stuck with the real estate and capital equipment that keeps
fixed costs high despite decreasing readmissions. Claiming to reduce
readmissions to the emergency department, for example, is an admirable and much
needed goal. But claiming the reduction will decrease the operating costs
associated with running that department is just misleading.
Advice
Work with
the Healthcare System to Build a Business Case that Makes Sense for Them: Before
you start giving out-of-context cost reduction figures, offer to work with the
health system to understand their current “as is” process that you’re trying to
improve. If the provider organization doesn’t even have
the staff to work with you to understand the current costs, they either don’t
care enough or won’t have enough capability to work with you and your solution.
To overcome the hurdles, help define some simple business metrics, using the
novel Objectives and Key Results (“OKR”) framework and then put in some basic
metrics data capture capabilities in place that will let you help explain to
the health system what their actual costs are. Once you and they know their
actual costs, then you can start to model what the potential savings might be.
It’s not
just about the clinical outcomes, but the financial and administrative ones: Showing clinical results or
outcomes from studies is a step in the right direction, but unless there are
complimentary financial (increased revenues or decreased costs) and
administrative results (less paperwork or decrease in phone calls), providing clinical
evidence isn’t enough. What good, for example, is it to know a digital
solution can reduce medication errors when we don’t know the financial cost of
those specific errors to our healthcare systems.
Results
have to be easily localized as well. It’s true on-time OR
starts costs the industry millions, but to really resonate, you’ll need data
from our healthcare systems, which can then be converted to opportunity costs
that will be sure to get our attention.
Advice
Co-Create
Balanced OKRs with Decision Makers: Create appropriate OKRs
for each outcome you’re targeting and see if the department heads or senior
leaders buy into those OKRs. Extend the data capture and discovery phase to
properly document and compare OKRs across different shifts. If you cannot get
buy in on the proper OKRs and how the KRs should be improved, you’ll never get
a health system to actually purchase your solution either.
Free is a Trojan Horse: Your free pilot is a Trojan
horse, distorting the economics of scaling your product. And the people you are
selling to, those with the greatest pain are often those without a budget, or
ability to weigh options. You are then competing for a client that is price
agnostic and competition blind. It is hurting both of us. Testing, studies, or
pilots should have costs associated with them, either real or just accounted for. And for those “free pilots”, clear
end points with specific goals in mind should be pre-set to help kick-start
next steps.
Advice:
Partner to do As IS Business Modeling and Have Clear Decision
Points: Instead of offering your service or
solution for free or running a pilot, offer to do the “as is” business
modeling, OKR development, and metrics capture for free. Then, as a
deliverable, offer a report that could model and describe what your solution
would be able to do to adjust the OKRs up or down (based on what’s most important to the health
system). Once you have real financial and clinical metrics, you know your OKRs,
and you get consensus on what your solution would offer in terms of a return on
the innovation then you’re ready for a real pilot that could be paid for by the
hospital because they know what they’re getting.
It’s not easy getting innovative products into health systems, but we hope you’ve seen in Part 1 of this post that there a few useful tips to get you well along your way. In Part 2, we’ll cover important questions like whether or not having a clinician on the team is crucial and how to cover objections.
Brian Van Winkle, MBA works with clinicians and health systems to tackle status quo thinking. He focuses on bringing the most innovative solutions and digital technologies to our hospitals to re-imagine how we provide and consume health.
Shahid Shah, M.Sc. is an award-winning Government 2.0, Health IT, Bio IT & digital Medical Device Inventor & CTO with over 28 years of technology strategy, architecture, engineering, entrepreneurship, speaking, and writing experience.
Today on Health in 2 Point 00, we have another takeover! Dr. Jennifer Schneider, president of Livongo, is here to give us her take on health tech news. On Episode 81, Jess asks Jenny about Daye, a startup developing cramp-fighting CBD tampons, which just raised $5.5 million, and LetsGetChecked, which raised $30 million for at-home health testing. Jess also asks about Jenny’s new book, Decoding Health Signals, which offers a blueprint for building a consumer-focused healthcare company.
GuideWell
Innovation, in collaboration with Springboard Enterprises, is hosting an
exciting new 10-week Scale Up Accelerator program for women-founded health tech
companies (or those with at least one female key
executive) located in the Southeastern US (FL, GA,
AL, MS, LA, NC, SC, KY, TN). Because both women-led startups and the
South East are lagging in access and closure of venture capital, this unique
cohort is dedicated to accelerating the growth and financing of companies
within these demographics.
The program will run from Jun 26th – Aug 30th and
includes a kickoff boot camp (June 26th – 28th) at the
GuideWell Innovation Center in Orlando, FL. Most of the program will be conducted virtually other than the 3-day kickoff boot
camp and a innovator/investor matchmaking showcase at the end of August. During
weeks 2-9, the cohort companies will be matched with various advisors and are
expected to connect with advisors every week. In addition, each week will
incorporate a virtual 2-hour workshop/collaboration session led by subject
matter experts on key challenge topics faced by most early-stage health tech
companies.
Required
criteria for the cohort:
Company must be a health, wellness
or medical device technology company that addresses critical gaps in providing
affordable, accessible health care or holistic health/wellness solutions for
diverse populations and communities in the United States
Life sciences companies are NOT
eligible for this cohort
Women founders or key executives
must own a minimum of 25% of the company’s equity
The company must be headquartered
and have a minimum of 50% of its staff located in the Southeastern US (FL, GA,
AL, MS, LA, NC, SC, TN, KY)
Can show proof of “Scale Up”
traction through revenues, capital raised, customer acquisition, and product
development (see below)
Addressing a huge market
opportunity in the U.S. healthcare, holistic health or wellness industry
Scale Up
traction:
Eligible companies must meet GuideWell’s
minimum “Scale Up” requirements. A Scale Up company is a growing technology
startup with verifiable traction in its chosen marketplace. Traction may be
different based on the company’s chosen market, but is typically demonstrated
by one or more of the following:
A minimum of $500,000 in revenues
A minimum of $500,000 in seed
capital raised
Patents in place for unique
digital innovation or medical devices
FDA approval process underway for
products requiring FDA approval
Verifiable (reference required)
customer pilots
Accelerating product adoption
(especially for consumer-focused solutions)
GuideWell is partnering with Springboard Enterprises, a nationally recognized accelerator for women-led, high growth, scalable businesses. Since launching its first program in 2000, Springboard has worked with 735 women who have raised $8.5B in capital and drove companies to 17 IPOs and 185 M&A exits. They bring forward a deep, highly experienced mentor network to help support this cohort and provide incredible industry expertise.
Catalyst @ Health 2.0 (“Catalyst”) is the industry leader in digital health strategic partnering, hosting competitive innovation “challenge” events, as well as developing and implementing programs for piloting and commercializing novel healthcare technologies.
Health Advice and more 