Effective and entrepreneurial CEO
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Thoughts about the journey to grow new ventures...

Lessons Learned ...                  November 6, 2013

During my time as a CEO of two healthcare IT (HIT) companies, I learned a few lessons the hard way.

While there is the obvious list of strategic tasks any CEO should know and understand, there are a few high-priority things that can make all the difference.

So, here are my top 12 take-aways for any HIT executive.

  1. Rock solid product and user experience – this is more intuitive, efficient workflow than it is "look and feel".
  2. Compelling ROI promised and delivered as well as shown to clients – in the product every day.
  3. Customer satisfaction greater than 75% very satisfied  measured in the product with surveys and anonymous feedback and ratings.
  4. Involve customers and designers early in the process to validate the product, market and create the user experience.
  5. Use agile software development process from the start with experienced agilist.
  6. Product quality is both expected valued functionality and no bugs.
  7. Deliver an integrated solution with modules and no data re-entry.
  8. Clear vision around the use case, yes the "V" word, with the ability to pivot that vision based on learning.
  9. Be more aggressive about getting the right people on / off the bus and in the right seats

10      10. Focus - while we have to wear many hats, there were times where we were focused on too many things

11       11. Acquisitions - have a clear, timeboxed plan for effective integration.

12.     12. Make sure messaging is consistent and aligned to the value proposition.  Build the brand!


As you can see, this list is both product and customer-focused. These things are not easy to do, but you may not have to do all of them. I think the first 4 are probably the most important.I believe that success is built on an outstanding product and user experience and maintained with a relentless drive to better understand the customer and what they are trying to do.

Home Health Care Trends      September 6, 2013

Both my parents are no longer alive, but I recall their desire to live as long as possible independently in their home, and then when that no longer became feasible to end their days in hospice care. My father was diagnosed with prostate cancer in his early 60s but with radioactive seed therapy lived fairly happily at home in a thatched house in the English countryside with my mother until he was 81. My mother was an unapologetic smoker and both my parents assumed the lung cancer would get her before the prostate cancer got him! Just before his 82nd birthday, he was in considerable pain and admitted to hospital. A few weeks later, after aggressive radiation treatment to combat the now aggressively spreading cancer, he died in the same hospital.


My mother was then 78. In less than six months, her health and will to live had sharply deteriorated. She did not want to eat and despite care from my sister and neighbors, she was also admitted to hospital after a serious fall at home. After some recovery there was a period of debate whether she was sufficiently sick and near end of life to transfer to hospice care. Then she had a resurgence of lung cancer and was determined too sick to leave the oncology ward. Unfortunately, she never left it alive.


According to the Dartmouth Atlas of Healthcare website, More than 80% of patients say that they wish to avoid hospitalization and intensive care during the terminal phase of illness. In the past, most people died at home; but now, just like my parents, most Americans are in hospitals or nursing homes at the end of their lives.


On top of this, health costs and outcomes are among the poorest in the developed world – and clearly not sustainable. Today, we spend 18% of our $16 trillion economy on healthcare (compared to 5.5% of $3.5 trillion in 1963, for example). Yet, a report from the IOM in January 2013 commissioned by the NIH, confirmed our global health disadvantage: “For many years, Americans have been dying at younger ages than people in almost all other high-income countries.” And this disadvantage has also been getting worse, especially among women and infants. Much of the high cost has come from highly intensive medical interventions during the last six months of life. In 2012, Medicare spending on 50 million elderly (65+) and disabled Americans totaled $536 billion, 16% of the federal budget and 21% of total healthcare spending. Despite the need only 4% of Medicare spending is for home health and minimal preventive services are covered, beyond periodic screenings.


However, going forward under Health Reform, new Accountable Care Organizations (ACOs), for both Medicare and commercial payers, are emerging with population health goals and capitated payment models. So, in order to manage health risks across ACO populations, care will need to be coordinated into the community and the home.



As a result of these interesting trends, I see an inevitable and long-overdue imperative to deliver more care and health services in the home, where costs are lower and where people want to live.

HIPAA vs Open HIT Systems      July 11, 2013


In March, as required by the HITECH Act in 2009 as part of ARRA (American Recovery and Reinvestment Act), the DHHS (Department of Health and Human Services finalized the rules for HIPAA (Healthcare Insurance Portability and Accountability Act) Privacy and Security compliance and breach. Covered entities and their business associates now have until September 23, 2013 to comply with all 563 pages of the new HIPAA rules, at an estimated total cost of $110-$225M. The extension of these complex rules (and their direct regulation by the DHHS) to the much wider scope of business associates and their subcontractors has many people worried. How can they possibly comply with all the requirements, the documentation, and the corresponding federal audit liability? Business associate agreements, terms of use, privacy statements and compliance policies are just the first items that will need to be reviewed and updated by anyone involved in HIT (healthcare information technology).  


Many believe that HIPAA has restricted healthcare information sharing, rather than being the promoter of information sharing that it was originally intended to be when it was enacted in 1996. HIPAA standards for security and privacy of healthcare data are defined in the Code of Federal Regulations 45 CFR Parts 160 and 164. The majority of these standards deal with the process for managing the security and privacy infrastructure. This infrastructure includes the full suite of security measures and organizational compliance procedures, beyond merely the encryption of electronic protected health information (PHI). Electronic PHI is defined as individually identifiable health information including demographic information, health conditions, healthcare service delivery and payment for care.


HIPAA compliance is all quite similar to an ISO 9000 certification program. Organizations begin with a risk analysis, then manage the disclosure process as authorized for specific uses under contracts to provide care, with tracking and review of activities (e.g. audit logs, access and tracking/monitoring); finally, security reports and workforce reviews are implemented to ensure compliance with all the Federal requirements, and of course appropriate response to breaches.


In the face of this looming challenge, we have seen an understandable tendency by healthcare CIOs to want to lock down as much disclosure and data sharing as possible. Patients are generally neither interested in owning nor in managing their own healthcare data – especially the most vulnerable such as the elderly and those with multiple chronic conditions. Interestingly, HIPAA bypasses the whole murky issue of who owns the data. The real issue has correctly become the process of disclosure or sharing of PHI data outside the entity that is holding the information.


This tendency is music to the ears of large HIT software providers with expensive, closed integrated solutions. Healthcare data disclosure – or lack of it – can effectively lock patients into payer and provider networks. For many patients, the convenience of selecting an out-of-network provider, even one with potential cost and quality benefits, can be outweighed by the daunting challenge of gaining access to their records and treatment history.


However, there are real issues with these closed platforms. For example, because the complete patient record is not always available, care coordination issues are still widespread. So, despite the difficulty of measuring the ROI (return on investment) of open HIT systems, a significant volume of emerging evidence of the benefits of data sharing is fueling the trend towards open systems, especially under health reform. In fact, interoperability for EHRs (electronic health records) is the theme of Stage 2 Meaningful Use, and the ONC (Office of the National Coordinator for Health IT) has just released the governance framework for HIEs (Healthcare Information Exchanges). Worldwide, a growing number of physicians are using EHRs and HIEs.


Open data is a fundamental enabler of innovation, and examples abound, not just in healthcare. Big data services are helping both commercial and Medicare ACOs with population health management; hospital systems and IDNs are starting to share digestible information with providers in real time at the point of care to improve the health and outcomes of individual patients and reduce errors; patient portals are engaging and empowering patients to share their electronic records with providers and control access to their medical histories; and remote patient monitoring devices in the home are being connected to data platforms being hosted in the cloud.


So, we should be looking for significant developments in healthcare data sharing. A granular, permission-based data sharing capability should form the core of a robust and open HIT system, together with a HIPAA-compliant disclosure infrastructure. HIPAA sets forth a comprehensive framework to facilitate the sharing of healthcare data. Without it, HIT systems will remain closed and insular, either dragging the current burden of double manual entry of data into every new application – or forcing providers to continue their reliance on big vendors and expensive, integrated systems.

Healthcare Challenges and Opportunities June 28, 2012

Even with the recent Supreme Count’s close 5-4 ruling on the legality of the Affordable Care Act (ACA, also known as Obamacare) we seem no closer to resolving the rising cost of healthcare in America (see recent posts at blog histalk.com). Our healthcare system is primarily a capitalist one, with no ceiling and no floor, for the most part. Those that can’t pay get very poor healthcare; those than can pay, can get pretty much anything that is available. We all now know that we spend towards 20% of our GDP on healthcare and the largest component is Medicare. According to the Center for Disease Control (CDC), our largest healthcare challenge is caused by the large proportion of the population with one or more chronic conditions (such as heart disease, cancer and diabetes) which lead 75% of the spending on healthcare and 70% of fatalities.


In response, it would seem that our largest opportunity in healthcare is to manage chronic disease proactively and reduce costs through early and sustainable protocols. One of the less publicized aspects of the ACA is the increased requirement for coverage of preventive services by new insurance plans. For example, it was interesting to see the investor attention paid to Weight Watchers at this year’s annual JP Morgan Healthcare Conference in San Francisco, in January.


So, I am very interested in and excited by innovative solutions like the Collaborative Chronic Care Network to help manage doctor-patient interactions, medication compliance (like e-pill), as well as weight reduction, increased exercise levels and healthy diets (like Team Beachbody, Traineo, and Lance Armstrong’s Livestrong, to name but a few) – especially for at risk kids and adults.

Lean Startup Opportunities   May 22, 2012
When I first attempted to climb Denali via the West Rib in 2007, I was extremely lucky to be tied into a rope when I fell into a deep crevasse. The experience was not unlike a typical product launch or new venture start-up: there are huge pitfalls waiting for you to fall into based on your customer and market assumpti
ons, which can be very time-consuming and expensive to overcome.

Recently, I have become very excited by the Lean Start-Up movement because it offers a proven approach to engineer the fit between new products and intended customers and markets. Now, I am energized to put this methodology to work to create efficient start-up business models with effective product visualization and evidence-based customer development! I wish I'd known about this five years ago - heck, even 2 years ago would have made a difference. I thoroughly recommend the book that started it all, The Lean Startup by Eric Reis as a great way to dive in. The Lean Startup business model actually mirrors the agile approach to software development, with a focus on a minimum viable product (MVP), rapid testing of ideas and concepts early and the ability to pivot if customers do not respond as expected. Another important aspect of this is to treat customer development with the same rigorous attention as we typically do for product development. In another useful resource, Brant Cooper explores methods of finding and approaching prospects and markets in his useful Entrepreneur's Guide to Customer Development.

Going forward, to actually visualize a product, test business hypotheses and get a real service business going, there are now several interesting SaaS solutions to help you out: for example, LeanLaunchLab has a comprehensive business model development tool that is now being used not just for start-ups but for any organization that is looking to drive lean innovation.Similarly, Zuora has what is probably the first decent billing and finance solution for recurring revenue, subscription-based services. Again Lean Canvas has a simpler lean business definition solution to help navigate the challenge of identifying new product/market fit and communicating it in a simple one-page format. In fact, it seems that there is already a new venture out there with every recent idea i've had to capitalize on the lean startup movement! For example, I've long felt that CRM tools only go part of the way to help track customer interactions. Now Kiss Metrics provides the next stage, with the ability to track every interaction between customers and your product: now you really can know if you are driving engagement or if product enhancements will make a difference!

This is the most exciting time I have ever seen to create and grow a new venture. There are more scientific capability and useful solutions out there to use, and relatively inexpensively too, than ever before. As Eric Reis says, the problem is that almost any product that you can conceive of can now be built; so the real question is not if it can be built, but should it be built? And now there is proven methodology to help you answer that question before you invest, or possibly waste, significant capital resources.