See Ezra Klein's companion article "The most predictable disaster in the history of the human race."
Recall the movie "Contagion"?
More to come...
Medicine in the Fourth DimensionYeah. But, imagine the difficulties in sorting out temporal efficacy for Rx's administered outside of controlled clinical trials or inpatient settings.
In light of circadian research, prescriptions like “Take Once Daily” are terrifyingly vague.
...Set to rival the personalized medicine “revolution” in the breadth of its implications, the incorporation of circadian rhythms into our health care systems will require re-orientation on a paradigmatic scale.
The idea is that biological rhythms, daily oscillations in physiological processes, make the morning body a functionally different creature from the same body at night. There are peak times of day for each organ’s cell division and metabolism, as well as core temperature and gene expression. Moreover, our illnesses are rhythmic, and our pathogens have body clocks. It makes for a major strategic advantage over disease, and the current resistance in the medical field—a misconception that timing effects are somehow minor—is no longer tenable.
Oncology is forever chasing ways to separate the enemy within from its surrounding tissue and reduce ghastly treatment side effects. Just as each of our cells has a circadian cycle, tumor growth is rhythmic. Some lymphomas see a peak in cell division late in the evening, whereas gut lining divides 23 times as much in the early morning as it does at night. In this case, chemotherapy in the evening targets the tumor while doing away with excruciating effects on healthy tissue. The point is that distance between healthy and diseased tissue does not have to be spatial if you can separate them in time...
Messaging is going to be every bit as important as evidence in coming days. Because it’s not just cancer treatment that would have to be adjusted to get out of our static, 3-D mentality. The dosage of any drug is wildly approximate without a prescribed hour of administration, because all drugs undergo absorption, metabolism and elimination. And all of these processes are controlled by the circadian system—at the cellular level, the organ level, and in the body as a whole.OK, "is there an App for that?"
Even Paracetomol (Tylenol) is profoundly rhythmic in its bioactivity, and its liver toxicity. The practical limitation comes in identifying the optimal time for each patient, which may not be feasible for acute treatment but becomes critical in chronic diseases. In this light, the common prescription “Take Once Daily” becomes terrifyingly vague...
Text messaging helps people to remember their medication. So why don’t we do it?See also Dr. Carroll's post
Aaron Carroll, MD
...Researchers looked at all RCTs examining a mobile text messaging system to improve medication adherence in adults with chronic disorders. The main outcomes of interest were odds ratios of adherence.
They identified 16 RCTs. Five of them involved personalized messages. Half of them used two-way communication, and half sent a text message every day. Half of the interventions were 12 weeks of more.
The pooled analysis found that text messaging significantly improved medication adherence (aOR 2.1). The effect wasn’t different based on study characteristics or text messaging characteristics. Even after an adjustment for potential publication bias, the results were still statistically significant (aOR 1.7).
These are relative improvements, of course. But the authors cite literature that finds that baseline adherence rates in developing countries of people with chronic disease are about 50%. Using the odds ratio found in this study means that text messaging could be expected to increase this adherence rate to about 67.8%, or an absolute rate increase of 17.8%. That’s stunning.
There are still “short term” results. Many of them rely on self-reported adherence measures. But still… this is pretty impressive.
In the 11 studies that reported on text message acceptability, most showed moderate to high levels of satisfaction with programs. The study that used twice-daily text messaging found that only 6% of participants said the messages were intrusive and inconvenient.
This stuff works. It’s not expensive. People like it. Why aren’t we trying this more often in systems-level studies?
Texting people actually gets them to improve their modifiable risk factors
...Researchers looked at patients with coronary heart disease being treated at a tertiary care center in Australia. They had to be older than 18 years and have one of the following: a prior myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, or at least 50% stenosis in at least 1 major epicardial vessel. They were randomized to two groups. The first got “usual care” The second got usual care, but also received semi-personalized test messages which were tailored to provide advice, motivation, and information that aimed to help them change their diet, be more active, or stop smoking (if they were)...
100 Days of Swift
Learning Apple’s new programming language
Since Apple announced Swift as the new modern language for their products, I’ve been wanting to learn it. Even though my background isn’t programming, I decided to give it a shot. A little more than a month ago, I finished my 100 Days of Swift Project...
What are some good resources to learn Swift?My Health IT BFF Jerome Carter, MD is now using Swift.
I studied and read everything I could find on Swift. I also read plenty of material on programming concepts like Object-Oriented Programming and MVC Architecture. I think it’s more important to learn programming than it is to learn Swift syntax. I’ll speak more about that in the next section. In no particular order, here are some good places to start learning Swift:
- The Swift Programming Language by Apple: This book covers the Swift syntax. It’s also available online for people who prefer using their Web Browser. (Free)
- Developing iOS 8 Apps with Swift by Stanford: This is an iTunes U course taught by Paul Hegarty, he worked at NeXT with Steve Jobs. He teaches you how to build a few apps with Swift. (Free)
- Ray Wenderlich: This site has a huge team of talented people who make tutorials for a range of programmer levels. The free tutorials are more than enough to get started with. There’s also books and subscription only tutorials. (Free / Paid / Subscription)
- Design+Code by Meng To: He packs a considerable amount of material in his book. Meng teaches how to build an app from scratch using Xcode, Sketch, Swift, Spring Animation Library and more. He regularly updates the book with new material without charging previous purchasers. (Paid)
- Swift By Example by Brett Bukowski: This site helps you learn Swift Syntax by providing explanations for code in a simple side by side view. (Free)...
You Had Me at “Swift”Go to EHRscience.com, keyword search on "Swift." Bring a Snickers, you're gonna be a while.
by JEROME CARTER on AUGUST 18, 2014
Some things are simply destined to happen. I have written a few times about my multi-year journey in modern software development. Over the last few years, I have studied software architecture, object-oriented analysis and design, discrete mathematics and workflow analysis and had a lot of fun. Netbeans and Xcode are on my MacBook Pro, and I have discovered that I like PHP, Python, and C#. I am also happy to report that the web application I have been working on for what seems like forever is still on schedule.
When first announced, Apple’s Swift programming language struck me as interesting, but I did not give any serious thought to using it for anything, being already occupied with the web application. I played with it, but only in a summer romance kind of way. Well…things change.
Swift has a few things that make it really attractive for me. It is compiled, but acts like a scripting language. Syntax-wise it seems very familiar, and thinking in Swift is coming easier than expected. Going from Python and PHP to Swift is not the least bit jarring. Even better, all of the OOP that I learned–patterns, interfaces, closures—is readily usable with Swift...
Swift is a new programming language for iOS, OS X, watchOS, and tvOS apps that builds on the best of C and Objective-C, without the constraints of C compatibility. Swift adopts safe programming patterns and adds modern features to make programming easier, more flexible, and more fun. Swift’s clean slate, backed by the mature and much-loved Cocoa and Cocoa Touch frameworks, is an opportunity to reimagine how software development works.
Swift has been years in the making. Apple laid the foundation for Swift by advancing our existing compiler, debugger, and framework infrastructure. We simplified memory management with Automatic Reference Counting (ARC). Our framework stack, built on the solid base of Foundation and Cocoa, has been modernized and standardized throughout. Objective-C itself has evolved to support blocks, collection literals, and modules, enabling framework adoption of modern language technologies without disruption. Thanks to this groundwork, we can now introduce a new language for the future of Apple software development...
Swift is friendly to new programmers. It is the first industrial-quality systems programming language that is as expressive and enjoyable as a scripting language. It supports playgrounds, an innovative feature that allows programmers to experiment with Swift code and see the results immediately, without the overhead of building and running an app...Note that it supports OS X, the Apple desktop/laptop OS (which is my platform), so it wouldn't be just limited to "mHealth" apps.
Big Pharma’s big push to get patients to take their meds___________
Drug companies around the globe are spending big to push patients to take their pills.
The pharma industry loses tens of billions in worldwide sales each year when patients don’t fill, or refill, their prescriptions.
So drug makers from London to Tokyo to Cambridge, Mass., are pouring money into programs aimed at cajoling — or nagging — patients to take every last pill their doctors prescribe. The companies are investing in smart pills that will send alerts when they haven’t been swallowed at the prescribed time. They’re subsidizing gift cards to thank patients who remember to refill. They’re paying patients to go on talk circuits to tout the virtues of taking medication properly.
They’re even lobbying the federal government for permission to pay third parties, such as pharmacists, to encourage patients to take their pills.
Drug companies say these investments are focused on improving patients’ health. “We’re not pushing pills here, we’re pushing adherence,” said Joel White, president of the Council for Affordable Health Coverage, an advocacy group that works with the industry.
But Matt Lamkin, an assistant professor at the University of Tulsa College of Law who’s studied the issue, sees another motive.
Pharma companies have the sense “that they are leaving billions on the table” when medicine isn’t taken and prescriptions aren’t filled, Lamkin said. The push to improve adherence, he said, “reframes the goal of boosting sales as a goal of public service”...
Updated: Experts argue the benefits, pitfalls of a unique patient identifierI follow Dr. Gropper a lot, and have seen him at various conferences I cover.
Your medical records probably bear different numbers — one for your primary care physician and his or her medical group, one for each hospital you’ve been treated in, different ones for different specialists. This can make it difficult to retrieve your medical information.A common way to match and collect health records is by using a person’s name and birthdate. But consider this: In a health database of 3.5 million Houston-area residents, about 70,000 share the same first name, last name, and birthdate.
When the Health Insurance Portability and Accountability Act was signed into law in 1996, it called for creating “a standard unique health identifier for each individual” to make it easier to link a person with all of his or her health information, no matter where it was stored. In 1998, Congress eliminated that requirement and even prohibited the use of federal funds to develop a unique identifier.Twenty years later, the issue is still very much alive. STAT asked experts to offer their perspectives on why the United States should, or should not, create a unique health identifier for each of us.Tommy G. Thompson: Test identifier to fight medical fraud
Michael D. Greenberg: Unique identifier could protect privacy
Adrian Gropper: Identifier adds nothing beyond “coercive surveillance”
Douglas Fridsma: Make the conversation about patient benefits
Twila Brase: Block the identifier, block national health care
Stephen Smith: Unique identifiers work in the UK...
By Adrian Gropper: Implementing a unique patient identifier would add nothing to our health care system beyond coercive surveillance. It would collect information about us without our consent or even our knowledge, much as the National Security Agency has been doing with telephone records.I've been hip to Dr. Latanya Sweeney for years, I cited her on this blog back in 2011.
Patients are just people. Why bother with a number when scanning the iris of the eye is arguably a perfect way to identify each of us. The technology for doing this is becoming almost as inexpensive as that needed to read a credit card. It’s not a stretch to imagine iris scanners appearing in doctors’ offices, hospitals, ambulances, and the like to match individuals with their health records.
That might be efficient, but it isn’t voluntary and offers us no say about what information is matched and who has access to it, nor does it offer any transparency into the process.
There are other ways to accurately match individuals with information about them. The Internal Revenue Service, for example, is quite good at matching people with their financial information by asking for their name, date of birth, and Social Security number the first time they register at a bank or employer. For health, we could ask individuals to supply their name and an email address, cellphone number, or other familiar unique identifier. Then, whenever an entity wants to access an individual’s data, be it a physician, lab, pharmacy, insurer, or someone else, a notification would automatically be sent to the person by email or text asking if that’s what they intended. This kind of familiar opt-in system gives the individual control over his or her data and the ability to see who is looking at it.
Access to our health information is a first-order privacy issue. Most of the matching and access is done for purposes that don’t benefit the patient. Some access is done for risk adjustment, some for marketing services, and some for setting prices while effectively keeping cost and quality in medicine a secret. Take a look at TheDataMap, developed by Latanya Sweeney of Harvard University’s Data Privacy Lab, to see the types of organizations that routinely tap into our health information.
Americans need a health care system that encourages trust in our doctors, labs, pharmacies, hospitals, and more. You don’t build trust in a system by introducing involuntary and coercive practices like a unique patient identifier just because they are efficient.
Adrian Gropper, MD, is chief technology officer for Patient Privacy Rights.
Tell me about it.
Who Is The Real Customer In Healthcare?Almost none of the buy or pricing decisions involve people "playing" with their own money and their own health. The buying decisions are mostly made by the medical practitioners themselves, and the pricing decisions are mostly made in negotiations between each medical organization and the insurance companies, or between the whole industry and the government, for Medicare and Medicaid.
A real customer is the person who gets the benefit of the product, who can choose it, who pays enough of the cost for it to make a difference in their choice—and who can walk away from the deal, shop elsewhere, buy an alternative way to solve the problem, or even buy nothing. None of that is true of the patient in the traditional healthcare setup...
How has meaningful use really affected healthcare providers?Well, HITECH was the source of my REC job. Not that I didn't take my own shots at it. Now, with the bulk of the MU money all essentially out the door (~$32 billion), it should be a relatively easy kill -- though, with this being an election year, we may not see a lot done on The Hill across a breadth of legislative areas (with the likely exception of several more Quixotic bills declaring ObamaCare repealed for the umptie-dozenth time).
We praised the inclusion of HITECH in the American Recovery and Reinvestment Act of 2009 as a stimulus to expand EHR adoption and improve the quality and effectiveness of patient care for all time. Today, many respected healthcare leaders argue that it is time to declare victory and move on.
Those leaders were recently encouraged by CMS leader Andy Slavitt’s announcement that Meaningful Use would end soon and be replaced by something better. Unfortunately, “April Fools” was declared only two days later, when CMS administrators, including Karen DeSalvo, MD, National Coordinator for Health Information Technology, said the program was going to be with us for the foreseeable future. Now, we can look forward to more good ideas from our government.
It is time to consider the impact of Meaningful Use. How has it affected the provider community? How has it accelerated, or retarded, the innovation of healthcare practice? How has it influenced the economics of healthcare? What has it done for the most important stakeholder, the patient? If it has not achieved the full potential ascribed to HITECH, what are the causes and what are the best next steps?...
Is Theranos done?Good piece. Read all of it.
The Silicon Valley upstart wowed the medical world with a whopping $9 billion valuation, a supremely media-savvy CEO and the promise that it could revolutionize health care by using just a few drops of blood to run scores of lab tests at a fraction of the current cost.
But these days, Theranos is sinking deeper and deeper into a quagmire. Regulators keep issuing sharp warnings about its lab practices. Pharmacies keep pulling back from its partnerships. The Wall Street Journal keeps raising questions about its technology.
Does Theranos have a chance to regain the confidence of potential investors, partners, and patients — or is it on an irreversible decline? For clues, keep an eye in the coming months on these five bellwethers...
Theranos Sounded Too Good to Be True—and It Is___________
...“Is Theranos Finished?” asked health and medicine outlet STAT, which noted that the company “didn’t respond to questions about how it’s doing financially.” Between the government regulation and the rocky business deals, those are reasonable questions to ponder....
...For those of you who haven’t heard of it yet, the Flint water crisis refers to the ongoing contamination of the tap water in Flint, MI with unacceptably high levels of lead that resulted from change in its water supply nearly two years ago to Flint River water. Because river water is more corrosive than the previous supply that came from Lake Huron (why I’ll explain later) and Flint river water was not properly treated to decrease that corrosiveness, the new water leached lead from old pipes. This resulted in the contamination of the drinking water with dangerous levels of lead in many homes in the city. In addition, there has been a marked increase in the number of cases of Legionnaires’ disease thought to be linked to the new water supply...A lengthy, thorough piece on an egregious episode of criminal negligence and utter moral indifference perpetrated by Michigan government officials -- starting with Michigan Governor Rick Snyder.
Flint children never had a fair shot, even before lead poisoning
On one level, the Flint lead poisoning scandal is about a state mismanaging a city under financial duress and moving the city to a water supply that turned out to be unsafe.
But on another level, it's also about something deeper: the vulnerabilities kids face when they grow up in poverty. They are more likely to have lower test scores, become teen mothers, and experience violent crime. And it's not just a lack of opportunity: A recent study found that the stresses of poverty actually stunt brain development.
Add to that lead poisoning — which also stunts growing brains — and that's what you have in Flint, Michigan...
Could What Happened in Flint Happen Anywhere?
Other U.S. cities, particularly in the Northeast and Midwest, could face the same water crisis because millions of utility lines contain lead, a potent poison.
Flint’s crisis with drinking water contamination has been cast as a unique series of fumbles and cover-ups. But the Michigan city’s plight also illustrates a much wider concern: Millions of Americans drink water that flows through lead pipes, fittings, and solder, most installed before the 1970s.
Lead pipes can be found in much of the U.S., but surveys show they are concentrated in the Northeast and Midwest. Nobody really knows how extensive they are today: A 1990 study estimated that 3.3 million utility service lines contain lead—plus twice as many connecting pipes, and countless amounts of lead solder. In addition, many homes have plumbing that contains the hazardous metal.
If utilities don’t carefully balance water chemistry and treatment methods, and if regulators don’t enforce the rules, lead can leach from utility pipes and household plumbing systems and wind up in people’s water. That’s what happened in Flint. A decade ago, it happened in Washington, D.C., too. About 640,000 District of Columbia residents were exposed to lead when changes in disinfection chemicals allowed lead to leach from pipelines.
And health experts warn that the same crisis could happen again elsewhere, especially as local and state public health budgets shrink...
Does The EPA Bear Responsibility For Flint?
A blame game has erupted over the lead-ridden drinking water in Flint, Michigan. For weeks, residents, politicians, and observers across the country have been asking: Who is responsible for this public health catastrophe?
Politically, blame is polarized. Progressives have taken aim at Michigan’s Republican governor, Rick Snyder, who they say failed to recognize through his state environmental agency that Flint’s water was unsafe. Meanwhile, some conservatives have targeted the Democratic emergency manager of Flint, who they say was ultimately responsible for switching the city’s water supply to the highly suspect Flint River.
The most controversial culprit, however, is the federal Environmental Protection Agency. Long before the crisis erupted, an EPA employee sounded the alarm about a serious lead problem in Flint’s drinking water system. But his higher-ups declined to make that information public, and instead tried behind the scenes to get the Michigan Department of Environmental Quality to take action to solve the problem.
Now, many insist the the EPA should have gone public with what it knew. “With a clear mission to protect human health and the environment, the EPA must be held to the same standard of accountability as state agencies,” the Detroit News wrote in a scathing editorial last week. Indeed, it seemed perplexing that the EPA would sit on troubling information about a potentially poisoned water system in a city of nearly 100,000 people. Why on earth would the EPA do that?...
[T]he nightmare in Flint reflects the resurgence in American politics of exactly the same attitudes that led to London’s Great Stink more than a century and a half ago. - Paul Krugman, Michigan's Great Stink
Flint, Michigan's water crisis: what the national media got wrongTHURSDAY UPDATE
...Who's really responsible for the Flint water crisis
Many national media reports would have you believe that the crisis began in April 2014, when the city started drawing its water from the Flint River. They'd also have you believe that the crisis was the fault of the locally elected officials who made a catastrophic decision, not to mention city residents who did not hold their leaders accountable.
The stage was set on March 16, 2011, when Michigan Gov. Rick Snyder signed Public Act 4. This measure broadened an earlier law that provided an "emergency financial manager" for financially distressed cities and school districts. Under the new law, "emergency financial managers" became "emergency managers" with the power to cancel or renegotiate city contracts, liquidate assets, suspend local government, unilaterally draft policy, and even disincorporate. (It is worth noting that Michigan emergency managers have done all of these things except disincorporate, which was entertained by a manager in the city of Pontiac.)
The need for an emergency manager was determined by a series of highly subjective criteria. Almost every city that got one was a poor, African-American-majority city devastated by a shrinking industrial sector: Flint, Pontiac, Detroit, Highland Park, Benton Harbor, and so on.
Flint was one of the first cities to be assigned an emergency manager in 2011, and over the course of four years had four such managers. One of the first manager's first acts was to suspend local government, and this remained essentially in force until the departure of the last emergency manager in 2015. Even today, Flint is under the scrutiny of a "transition advisory board" that has veto power over any local decision, and that has frequently overstepped its professed limited mandate to assure fiscal restraint.
Many Michiganders found Public Act 4 to be a violation of a strong state tradition of "home rule," and so overturned it by referendum in the 2012 election. But that didn't last long: the Republican-dominated state legislature immediately passed Public Act 436, which was almost identical, although it included a provision to pay the emergency managers from state coffers rather than local. Under Michigan law, a bill that includes an appropriation like this cannot be voided through referendum.
Some emergency managers, true, delegated limited responsibilities to the mayor or to members of the city council, but they always retained (and used) their powers to void any decision with which they disagreed. This is the key point that early coverage by flagship newspapers like the New York Times and the Washington Post neglected to mention: From 2011 to 2015, Flint officials had no real control over municipal policy...
The Next FlintWhat a mess.
The communities most susceptible to calamitous infrastructure failures are marginalized places inhabited by marginalized people. And many of them are suburbs.
hen Rohan Hepkins, the mayor of Yeadon, Pennsylvania, heard about the water crisis in Flint, Michigan, he sensed a pang he’s known for a while. “I just felt like, here we go again. That’s what happens to the disenfranchised.”
It’s also what could happen to older communities with aging infrastructure and declining tax revenues. No community can avoid the fact that America’s water infrastructure could require an investment of $1 trillion or more over the next 25 years. Some places, however, are more susceptible to crisis than others. An unholy brew of circumstances created the tragedy in Michigan—in which a money-saving decision to switch water supplies corroded the coating in Flint’s aging pipes, contaminating the supply with lead—yet similar circumstances afflict marginalized municipalities populated by marginalized people across the nation. Some of the most vulnerable communities are small post-industrial cities, like Flint. But the next infrastructure crisis is just as likely to occur in an aging, inner-ring, mostly black or Latino suburb.
“The post–World War II suburbs are starting to sag, because they were not meant to last this long,” says Myron Orfield, director of the Institute on Metropolitan Opportunity at the University of Minnesota Law School. “The housing is rotten, the infrastructure is rotten. But it is the nonwhite suburbs that are the poorest places in metro America, with the smallest tax bases. There are thousands of them, and they are all going to have Flint problems all over the country”...
There are roughly 7.3 million lead service lines in the U.S., according to an estimate by the Environmental Protection Agency, down from 10.5 million in 1988. Service lines are the pipes connecting water mains to people's houses. They're mostly found in the Midwest and Northeast.Link.
Despite the life-altering consequences of lead poisoning, there is no national plan to get rid of those pipes. A top reason for continuing to use lead service lines instead of immediately digging them up is that utilities can treat water so it forms a coating on the interior of the pipes -- a corrosion barrier that helps prevent lead particles from dislodging and traveling to your faucet. But if the water chemistry changes, the corrosion controls can fail.
Amid denials, state workers in Flint got clean waterOops.
LANSING -- In January of 2015, when state officials were telling worried Flint residents their water was safe to drink, they also were arranging for coolers of purified water in Flint's State Office Building so employees wouldn't have to drink from the taps, according to state government e-mails released Thursday by the liberal group Progress Michigan.
A Jan. 7, 2015, notice from the state Department of Technology, Management and Budget, which oversees state office buildings, references a notice about a violation of drinking water standards that had recently been sent out by the City of Flint...
State officials could not immediately answer e-mailed questions about the water purchases, including how long the state continued to buy bottled water for state employees in Flint while telling Flint residents the water was safe to drink. An official said the administration was "looking into these issues."
Lonnie Scott, executive director of Progress Michigan, said it appears the state was not as slow as initially thought in responding to the Flint drinking water crisis.
“Sadly, the only response was to protect the Snyder administration from future liability and not to protect the children of Flint,” Scott said. “While residents were being told to relax and not worry about the water, the Snyder administration was taking steps to limit exposure in its own building”...
Health IT Entrepreneur’s Guide to the UniverseAnd so on. You can rather easily register/login and fill out "your dance card."
March 1, 2016 — 11:30AM - 12:30PM, PT Sands Expo Convention Center, Delfino 4001, Session ID: 35
New ideas in healthcare are driving novel technologies and improving focus, quality, efficiency and effectiveness of care delivery. Innovators require the support of an entrepreneurial structure and capital to move from design to prototype, alpha to beta test, and pilot to commercialization. We will provide an overview of healthcare innovation process, and strategies for identifying collaborators, strategic partners, customers and capital.
Howard Burde, JD, FHIMSS
Eric Toone, PhD
Filter: Entrepreneurship and Venture Investment
- Outline and illustrate the process of developing a health IT idea into entrepreneurial reality
- Discuss considerations for collaborators, advisors and strategic partners, as well as allied solutions
- Evaluate appropriate methods of protecting intellectual property, assessing markets and determining how to reach customers
- Identify sources of capital and what each type of investor offers to, and demands from the innovator
IntroductionThat's enough for now. I get the general idea.
For years, this question has played in our minds: why do some startups defy all odds and become multibillion-dollar successes while many others fail? Is this purely a stroke of luck or is there a science behind the success? If so, what are the common characteristics among successful startups and entrepreneurs? To find answers to these questions, we went straight to the source and asked the venture capital investors who are part of some of the most notable successes of our time.
In this book you will hear leading startup investment practitioners discuss, in their own words, how they got identified promising ideas, markets, products and entrepreneurs, and how they helped build a game changing companies. We explored with them the lessons learned from not only the successes, but also their failures, to identify the factors that separate the two groups and also to draw the common patterns. Finally we asked them what advice they would give to entrepreneurs aspiring to build the next Google, Facebook, grew upon, or twitter.
To provide you with a 360° view of how to build successful startups, we have included interviews with several nominal entrepreneurs and exceptional startup operators. We explored with them the end to end journey from formation to exit and discuss the most common operating challenges along the way, and how they tackled them...
One of the most surprising revelations was that many successful companies arose out of non-consensus, unconventional, and in fact contrary and ideas. Most people didn't think those ideas was succeed at all, let alone become multibillion-dollar companies. In each of these cases, the entrepreneurs had very strong intuition and access to asymmetric information based on their predisposition toward, and early exposure to, potentially huge untapped or emerging market opportunity. Groupon, Twitter, and Facebook are great examples of that. Given the general market disbelief, these companies enjoyed very little competition until they broke off the chart. On the other hand, the riskiest startup ideas tend to be those most people can see are great ideas. Hence, there is so much competition that it negatively impacts everything from gross margin to valuation.
Surprisingly, most successful startups were not started with the goal to build a billion-dollar company. They rather started with a desire to solve a meaningful "pain point" — a VC term for a problem that causes people a lot of frustration. this is usually something that affects the entrepreneur personally and directly. Then the entrepreneur does a wonderful job of solving the problem for a small group of customers. Eventually the entrepreneur, with the help of venture investors, finds a way to expand the solution to a very large group of customers. This doesn't necessarily put management before market, but rather it emphasizes the fact that the best companies are created when great teams intersect with large market opportunities.
Whereas entrepreneurs focus on identifying and solving these burning pain points, venture investors trying to find those extraordinary entrepreneurs who are trying to solve potentially huge problems in a meaningful way. Venture investors tap into their tremendous network of contacts and "pattern recognition" — the art of leveraging lessons drawn from past successes and failures to identify a combination of factors and behaviors that may point to promising markets, entrepreneurs, products, business models, and so forth. Together, these build a "prepared mind" or "gut feel" about the emerging market opportunities created by the tectonic shifts in customer behavior and the enabling technologies that can be successfully applied to those shifts. Entrepreneurs are true visionaries, and venture investors are great pattern recognizers with an experienced toolkit of how to build companies — and how not to build them. Successful startups are created when a trusted relationship and line of communication is established between the visionary (entrepreneur) and the pattern recognizer (investor) for two way knowledge transfer.
In discussing the characteristics of the successful founders, the words are repeated most often are extraordinary passion, intelligence, authenticity, intellectual honesty, dogged persistence, risk taking, and integrity. Many of these entrepreneurs were scarred by past failures, or hungry to win big, or came from humble backgrounds. They also had this fact in common: they were hardly known to the world before starting companies that made them successful and famous. Most of these successful founders also paired with one or more cofounders rather than going solo. The cofounders they partnered with had not only complementary skills, but more importantly, a long history of working together. They had built a great chemistry with each other well before they became cofounders.
It's also clear from the interviews that most successful startups have an "A" team of 30 to 40 people stroking together in harmony towards a common mission. This gives them 10 times the productivity advantage over their competitors. These teams come together when the passion, intelligence, and charisma of the founders serve as a talent magnet to attract some of the best people in the industry to solve the toughest and most challenging problems for their customers. The first 10 to 12 hires in the startup team are extremely important, as they determine the DNA and culture of the company and, in turn, it's successful trajectory...
Successful startups also end up making drastic changes to their original plans in what's called a "pivot." Only a small percentage of such pivots — one in 10 — are successful, though. The successful pivot is a function of the "authenticity" and "intellectual honesty" of the entrepreneurs, where a deep knowledge of the market space and its fine nuances, combined with their ability to quickly adapt to new market realities, lazy key role in determining the effective degree and direction of the pivot. The journey to a successful pivot as a logical progression without any leaps from one strategy to the next, and the domain knowledge of the founders remains relevant in the new plan.
The interviews also reveal how important market timing is in determining startup success. It's probably the most overlooked concept by the entrepreneurs, and they usually end up being too early or too late to the market. Many companies fail not because they are too early or too late, but because they don't recognize or admit that, and change their plan’s cash burn accordingly…
"Effectuation is a logic of entrepreneurial expertise. What makes great entrepreneurs isn't genetic or personality traits, risk-seeking behavior, money, or unique vision. Effectuation research has found that there is a science to entrepreneurship and that great entrepreneurs across industries, geographies, and time use a common logic, or thinking process, to solve entrepreneurial problems. Effectuation is a logic of entrepreneurial expertise that both novice and experienced entrepreneurs can use in the highly unpredictable start-up phase of a venture to reduce failure costs for the entrepreneur."__
Meaningful Use Is Dead. Long Live Something Better!I've cited Margalit recently here and here. Notwithstanding my perplexity and qualms with respect to some of her recent positions, she deserves to be taken seriously. No one can rationally assail her humanity.
At the J.P. Morgan Healthcare Conference in San Francisco, Mr. Andrew Slavitt, acting administrator at the Centers for Medicare & Medicaid Services (CMS),announced on January 11th that “The meaningful use program as it has existed will now effectively be over, and replaced with something better”, and later clarified onTwitter that “In 2016, MU as it has existed– with MACRA– will now be effectively over and replaced with something better”. Meaningful Use is dead. Just like that. No apologies. No nothing. As someone who’s been lamenting the havoc wreaked by the program on both doctors and patients, I should be elated nevertheless. Well, I am not.
Let’s start with appearances. The J.P. Morgan Healthcare Conference is the “largest and most informative healthcare investment symposium in the industry which brings together global industry leaders, emerging fast-growth companies, innovative technology creators, globally minded service providers, and members of the investment community”. In other words the event is all about money for the millionaire and billionaire class. J.P. Morgan Chase itself is the largest financial institution in the country. It is the embodiment of Wall Street and its death grip on our collective neck. Was this conference really the best place to make such momentous announcement?
Besides, why would these extractors of wealth be interested in the fate of something as obscure as Meaningful Use?...
Meaningful Use is dead. Long live something better! And what is that better something? It is paying physicians for outcomes. It is the use of evidence based medicine. It is interoperability and “user-centered” design. It is Accountable Care Organizations, value, patient centeredness, coordination and such. It is also the making of markets “by leveling the technology playing field for start-ups and new entrants”, because when Epic makes money, nobody on Wall Street or in Silicon Valley gets a piece of the action. It is about engagement and analytics and population health, calculations, penalties, incentives and lots of new technology things. It is “like the second generation iPhone”.
After collectively sinking billions of dollars in Certified EHR Technology over the last five years, hospitals and doctors will now be expected to foot the bill for new software and computer products to support the lifestyles of a new generation of Silicon Valley entrepreneurs and the insatiable greed of the old generation of Silicon Valley investors. Why? Because the next app is sure to fix health care in America. It’s always the next one. There is always “something better” you can buy. Planned obsolescence, which is fueling the obscene fortunes of Silicon Valley and destroying life everywhere else, has finally arrived to the $3 trillion health care sector. It took a bit longer than the folks at J.P. Morgan expected, I’m sure, but we’re in business now. Let the good times roll…
"...the event is all about money for the millionaire and billionaire class. J.P. Morgan Chase itself is the largest financial institution in the country. It is the embodiment of Wall Street and its death grip on our collective neck."Feeling the "Bern," much?
Help Us Build a Hospital In the CloudHe proffered some significant optimism that we will in fact soon see significant true "interoperability" (supplanting what he called the incumbent "intra-operability"), that what I have irascibly called "interoperababble" may soon wane.
...[A]s my company, athenahealth, expands beyond the ambulatory (outpatient) care space and builds out its cloud-based services for hospitals and health systems, we’ve quickly realized that this entrepreneurial spirit is badly needed. If we’re going to disrupt the status quo and truly wow the hospital market with a new way of doing things, we need that innovator’s passion, and we need it now.
Inpatient facilities – from tiny critical access hospitals to leading academic medical centers – are starved for innovation when it comes to IT. They’re running on clunky, monolithic systems that were never built for the internet. Many of them weren’t even designed for a clinical setting. Rather, they were built as general ledgers, tracking financials long before they were tracking diagnoses.
At athenahealth, we refuse to play this old-school enterprise software game of highly-customized solutions, massive upfront implementation fees, and multi-year installation timelines. Instead, we’re ushering in something entirely new. We’re replacing on-premise solutions with the nimbleness of the cloud, and closed systems with an open platform built for partnership. Now, we’re looking for cloud-based partners to join us on that journey.
The entrepreneurs that are tackling the inpatient space already are, for the most part, operating on its fringes. I don’t blame them. The pain of selling into a large health system can take years off your life. Hospital workflows are complex, inconsistent, and puzzling even to their own doctors. But if we want to extend athenahealth’s health information backbone across the continuum of care, we need help. Below are just a handful of the big, hairy problems we’ve observed in the inpatient space. Let this serve as an open call to entrepreneurs (from healthcare, or not!) to step up to the challenge of solving them...
...Aside from issues of life and death, there is no more urgent task for American intellectuals and writers than to think critically about the salience, even the tyranny, of technology in individual and collective life. All revolutions exaggerate, and the digital revolution is no different. We are still in the middle of the great transformation, but it is not too early to begin to expose the exaggerations, and to sort out the continuities from the discontinuities. The burden of proof falls on the revolutionaries, and their success in the marketplace is not sufficient proof. Presumptions of obsolescence, which are often nothing more than the marketing techniques of corporate behemoths, need to be scrupulously examined. By now we are familiar enough with the magnitude of the changes in all the spheres of our existence to move beyond the futuristic rhapsodies that characterize much of the literature on the subject. We can no longer roll over and celebrate and shop. Every phone in every pocket contains a “picture of ourselves,” and we must ascertain what that picture is and whether we should wish to resist it. Here is a humanist proposition for the age of Google: The processing of information is not the highest aim to which the human spirit can aspire, and neither is competitiveness in a global economy. The character of our society cannot be determined by engineers.Wafts of Morozov, absent the sharp elbows. Well, sharp enough:
“Our very mastery seems to escape our mastery,” Michel Serres has anxiously remarked. “How can we dominate our domination; how can we master our own mastery?” Every technology is used before it is completely understood. There is always a lag between an innovation and the apprehension of its consequences. We are living in that lag, and it is a right time to keep our heads and reflect. We have much to gain and much to lose. In the media, for example, the general inebriation about the multiplicity of platforms has distracted many people from the scruple that questions of quality on the new platforms should be no different from questions of quality on the old platforms. Otherwise a quantitative expansion will result in a qualitative contraction. The new devices do not in themselves authorize a revision of the standards of evidence and argument and style that we championed in the old devices. (What a voluptuous device paper is!) Such revisions may be made on other grounds — out of commercial ambition, for example; but there is nothing innovative about pandering for the sake of a profit. The decision to prefer the requirements of commerce to the requirements of culture cannot be exonerated by the thrills of the digital revolution.
And therein lies a consoling irony of our situation. The machines may be more neutral about their uses than the propagandists and the advertisers want us to believe. We can leave aside the ideology of digitality and its aggressions, and regard the devices as simply new means for old ends. Tradition “travels” in many ways. It has already flourished in many technologies — but only when its flourishing has been the objective. I will give an example from the humanities. The day is approaching when the dream of the democratization of knowledge — Borges’s fantasy of “the total library” — will be realized. Soon all the collections in all the libraries and all the archives in the world will be available to everyone with a screen. Who would not welcome such a vast enfranchisement? But universal accessibility is not the end of the story, it is the beginning. The humanistic methods that were practiced before digitalization will be even more urgent after digitalization, because we will need help in navigating the unprecedented welter. Searches for keywords will not provide contexts for keywords. Patterns that are revealed by searches will not identify their own causes and reasons. The new order will not relieve us of the old burdens, and the old pleasures, of erudition and interpretation...
...the discussion of culture is being steadily absorbed into the discussion of business. There are “metrics” for phenomena that cannot be metrically measured. Numerical values are assigned to things that cannot be captured by numbers. Economic concepts go rampaging through noneconomic realms: Economists are our experts on happiness! Where wisdom once was, quantification will now be. Quantification is the most overwhelming influence upon the contemporary American understanding of, well, everything. It is enabled by the idolatry of data, which has itself been enabled by the almost unimaginable data-generating capabilities of the new technology. The distinction between knowledge and information is a thing of the past, and there is no greater disgrace than to be a thing of the past. Beyond its impact upon culture, the new technology penetrates even deeper levels of identity and experience, to cognition and to consciousness. Such transformations embolden certain high priests in the church of tech to espouse the doctrine of “transhumanism” and to suggest, without any recollection of the bankruptcy of utopia, without any consideration of the cost to human dignity, that our computational ability will carry us magnificently beyond our humanity and “allow us to transcend these limitations of our biological bodies and brains. . . . There will be no distinction, post-Singularity, between human and machine.” (The author of that updated mechanistic nonsense is a director of engineering at Google.)Recall Morozov's take-no-prisoners beef with digital "Solutionism"?
...These days, like so many of my 76 million-strong Boomer cohort (~28% of the U.S. population, defined more or less as those born during the period from 1946 through 1964), I keep one suitcase mentally packed at all times. My Dad is now 88 and lingering in a nursing home in central Florida, enfeebled by dementia. My Mom is 82 and still independent, though only marginally mobile. The enervating encroachments of age similarly impinge increasingly on my wife’s parents back in rural northern Alabama.Just an idea. We continued on with easier ways to fleece people. I left a year later anyway to return to health care. Subprime was just too jive.
Consequently, we minimally expect four distressing phone calls at random intervals in the coming years, imploring us to get back home quickly. For us this means at least three short-notice round-trip cross-country airline reservations (along with car rentals)—four times. Twelve last-minute seats (my wife, our son, and me), just to pay respects and help tend to the affairs of the parents when the times come. And, our daughter and her son just moved here to Vegas from Florida, so make that perhaps five round-trip seats each time. I just checked online prices: five immediate family last-minute "lowest fare" round-trip seats, Vegas to/from Orlando, and Vegas to/from Huntsville, Alabama, roughly $13,000 retail covering all four parents. So much for all of my DiscoverCard available credit (and part of another card, or a chunk of my savings).
There are tens of millions of Boomers facing similar circumstances.
Airline bereavement fare policies
Four adjectives become evident after a bit of research: complicated, confusing, contentious, and air carrier-specific. Just what you don't need when you’ve just gotten "The Call." For someone living beyond driving distance from loved ones, what would be extremely beneficial at such a time would be the ability to make one call that gets you on the next available flight at advance reservation discount rates, complete with rental car and lodging at the destination as required.
The rapidly growing "stored value" concept
The bank where I work is getting tepidly into the "stored value card" arena, an expanding area of retail financial services. During a recent weekend, as I pondered this nascent offering and our associated hand-wringing over issues such as the chump-change prospects of someone getting auth'ed to pump a buck too much gas at Quik-Mart, the NextFlightHome idea bubbled up in my mind. Essentially a stored value product, also not conceptually distant from "insurance." You know you're going to have to book these trips. Why not avail yourself of a service that will get you the lowest price at the least hassle when the time inevitably comes. Moreover, if your credit rating warrants, you can even spread the payments conveniently -- making it in effect a (competitively priced) credit offering should you choose not to store the value up front.
Mitigating the "I-gotta-get-there-now" hassle factor
What is that worth? Air-carrier bereavement rate policies typically require authentication documentation confirming that you are in fact "immediate family" and that a next-of-kin has indeed passed on. NextFlightHome perhaps doesn't even care. It's your account, your money; you can use it as you wish. You can always reload. The built-in activation waiting period precludes using the service as an end-run around regular retail airfare rates, and, should you have opted for and been approved for the revolving credit payment option, your account must be in good standing to book an itinerary. We've even provided for that, with our credit insurance cross-sell ancillary product, and the fact that we provide shamelessly copied positive incentives such as "payment points" and other non-punitive inducements (e.g., sweepstakes entries) for keeping accounts current...
Digital health firms, say goodbye to easy venture capitalGood article. Nice summation of the day. I was surprised that it was really the only substantive piece out there. Beth wraps up:
By Beth Kutscher | January 13, 2016
Digital health startups have benefited from easy access to capital over the past few years, but the market is about to get a lot tighter.
Analysts and investors watching the space offered a sobering take Wednesday during one of the biggest industry meetings of the year, the J.P. Morgan Healthcare Conference, which is largely considered the event that sets the tone for the next 12 months...
Even digital health companies that are far from being candidates for stock market listings are likely to see a pullback in funds, and could find themselves raising less money from investors than they did in earlier financing rounds.
“There's going to a reset of expectations across the board,” Francis said.
Ruchita Sinha, director of healthcare for GE Ventures, had a similar prediction.
“There will be a correction,” she said. “There's a strong sense of realism coming back into the market.”
A common sentiment at the conference among health systems and their venture capital arms was that technology entrepreneurs don't really understand their business. Many of their new tools try to solve a patient problem but create more work for providers and don't necessarily fit the way they do business...
“There's a growing debate [in the digital health world]: Do I want tech investors or do I want healthcare investors? And the answer is, you want both,” said Jeff Tangney, CEO of Doximity, a networking and recruitment site for physicians. Doximity raised $54 million in 2014 in a Series C round led by DFJ Growth, and through funds managed by T. Rowe Price Associates. “It's the rare breed that does both,” he said.Given the market turmoil and contractions of late (I simply can't bring myself to open my latest IRA statements), I don't doubt that health care space VC dollars may well contract in 2016.
Be Prepared For Callbacks
Memorize your deal facts, know whom you’ve contacted, and be prepared to talk about your deal at a moment’s notice. These are some of the questions you should expect:
- What is the value proposition for the investor?
- What makes your deal different?
- Who are your competitors and why are you better?
- Why are you going to win?
- What is your revenue model and what is your current revenue run rate?
- What events will positively or negatively impact revenue?
- How does the current business/ political environment affect your business?
- Do you benefit, suffer, or is the impact negligible, and why?
- What is the average ROI for your customers?
- How do your customers measure the results of your product?
- What is your sales cycle?
- What is the length of time from identifying identifying customers to receiving a signed contact?
- What is the average cost per unit?
- Where does this funding round get you?
- Breakeven, cash flow positive, and so on?
- What were your sales last year?
- What are this year’s sales?
- How much money has been invested?
- Who are your investors?
- What is your burn rate?
If you cannot provide direct and simple answers (that is, three sentences or less) to each of these simple questions, you still have some homework to do. Beyond rote memorization, you need make sure your answers sound natural, not “canned.”
Don’t Recreate History
Do not waste time showing off your encyclopedic knowledge of the history of technology and communication. Investors have heard about this thing called “the Internet.” They know the history of communication. They know all about the telephone, telegraph, fax machine, electricity, and stirrup. Tell them what they don’t know.
Venture Capitalists Don’t Know Anything About YOUR Deal!
Focus on that fact. Your plan needs to educate the reader as to the how, what, where, why, and when of your company. This is basic college freshman year term paper stuff. On the following page I’ve listed some of the basic questions your plan needs to answer.
Basic Questions Your Plan Needs To Answer
- What do you sell?
- How much have you sold?
- Whom do you sell to?
- How do you sell?
- Where do you sell it?
- How do you price it?
- What market pain do you solve?
- What is the stage of your product development?
- What is the compelling reason the market will buy your widget?
- What is your revenue model?
- How do you make money?
- Why are you going to win?
- Who are your competitors and how are you different from them?
- What are your milestones?
If the reader cannot divine the answers to these questions from a cursory look at your plan, the reader probably will not get these answers from a deeper study of your plan because your plan will not receive a deeper study. You must immediately and explicitly address each of these questions. Failure to do so will likely send your plan to the trash pile.Highly recommended. Great jargon glossary at the end. I loved his advisory acronym GYHOOYA (Get Your Head Out Of Your Ass). Meaning, be realistic and honest when dealing with the VCs if you hope to stand the slimmest chance of success. Early on in the book:
Simply put, entrepreneurs need to be realistic; venture capital is not for everyone; they need to operate in an industry (with a product) that has the chance to become a “billion dollar baby;” they need to seek the right investors at the right time; they need to have a “hook,” that is, give investors and customers a compelling reason to act (invest and buy, respectively); they must have a business that builds real assets on the balance sheet (cash); they must close deals and book sales; they must offer a solution that solves a real pain point (and not offer a solution looking for a problem); they must compile a world-class management team; and they must be imbued with persistence, doggedness, resourcefulness, and creativity.For a comprehensive deep dive, this book below looks excellent (if pricey at $47.19 Kindle), based on my read of the Amazon preview and the comments.