In the last episode of the Pristine Story, I mentioned that we'd be travelling all over the country visiting with medical centers. I'm happy to report that the last six weeks have been fruitful. We're going into 2014 with a strong pipeline. We're targeting first revenue in January. We are going to begin rolling out Pristine EyeSight to hospitals and outpatient centers on a regular basis starting in just a few weeks.
We are finally graduating from an R&D lab to a real company. I would like to thank everyone who's helped us get this far so quickly - employees, their families, advisors, investors, and beta users.
In 2013, we devoted most of our hiring efforts towards engineering. In 2014, we're going to devote the majority of our hiring efforts towards client success. We are, and will be, hiring project managers, trainers, support staff, and salesmen on a regular basis for the foreseeable future. We are seeking individuals with experience deploying and selling health IT solutions in hospitals. We're also looking for a product marketing manager. If you or anyone you know might be interested, please apply.
We are gearing up for our Series A round of financing, though we have a bit of room left in our seed round. We have been fortunate to find a great investor base that's been supporting us. I can't thank them enough.
I'll be attending the annual JP Morgan Healthcare Investors Conference in San Fransisco in a few weeks. Buzz and I will be at the annual HIMSS Conference in Orlando February 23 - 27. We're going to have fun running gamified live demos in the exhibit hall.
I kicked off 2013 by committing to write three blog posts per week. I put my money where my mouth was: I bet $10 / week using stickk.com. I haven't missed a single week. Having accomplished my New Year's resolution and as Pristine grows, I'm probably going to slow down to one or two posts per week. I've established five new years' resolutions for 2014, two of which will be enforced through stickk.com at $100 / month each. I highly encourage everyone to set New Year's resolutions and enforce them through stickk.com. I can say that blogging was among the top five decisions I made in my life; Pristine probably would've already failed had I not blogged.
2013 has been the craziest year of my life, and it's been hectic for all of Pristine's stakeholders. So I decided to recap the year into a blog post. I hope you enjoy it. It's one of my favorite blog posts of the year.
What Makes us Tick: Curiosity
Pristine is an organization built on the yin and yang of freedom and responsibility. Many organizations struggle to manage that delicate balance. We haven't figured it out, but we work towards it.
We've identified eight values that detail what freedom and responsibility mean.
Curiosity
Passion
Simplicity
Excellence
Selflessness
Communication
Respect
Accountability
This is the first in a series of posts that will explore what each value means at Pristine.
The first and most important value is curiosity. It's also my favorite.
Pristine was founded out of a passion for the novel, the new, and the exciting. We live at the cutting edge. We are an engineering driven organization. Engineers are king.
We are at the cusp of the eyeware computing revolution. Eyeware computers will vary significantly more than PCs, smartphones, and tablets because 1" changes in hardware will completely change the use cases and user experience of the device. 3", 4", and 5" smartphones are used to accomplish the same things. 8" and 10" tablets are used to accomplish the same tasks. 13" and 17" laptops accomplish the same tasks. But increasing the screen size of an eyeware computer from 1" to 3" completely changes how the device should be used. Glass will not be used to accomplish the same tasks as the Meta SpaceGlasses or the Atheer One.
It's our job to make sense of the incoming flood of eyeware hardware, build incredible user experiences for each, and determine where and how each hardware device should be deployed throughout the medical enterprise. We have awesomely fun challenges ahead. Our curiosity will drive the future of eyeware computing in medicine.
Eyeware computers break fundamental assumptions that have predicated human computer interaction for the past 30 years. Healthcare delivery was designed with last year's communication technologies in mind. It will be our job to help our clients redefine the future of healthcare delivery with the latest and great tools at their disposal.
Curiosity is not limited to engineering and product teams. We foster curiosity throughout the client success, marketing, and sales teams as well (not accounting though).
In sales and marketing, we face an enormous education challenge. We must overcome copious volumes of public misinformation about Glass. We must convince people that Glass isn't a silly toy. We must convince them Glass presents incredible new opportunities. Traditional marketing channels simply will not work. We must pioneer new means to marketing success.
And in client success, we have to change behaviors. Medical professionals (MPs) aren't wearing eyeware computers today. Many are scared of eyeware devices. The vast majority of MPs don't know what eyeware computers can do or how they work. We must open their eyes to the incredible opportunities that eyeware computers present.
We face a host of challenges that have never been faced before. We smile. We explore. We have fun. And we figure it out.
New Year's Resolutions 2014
I set two New Year's resolutions in 2013:
Learn to cook
Blog 3x weekly
I accomplished both.
Although I haven't been cooking as much as I'd like to, I learned the basics. I cooked dinner for close to a dozen girls. I cooked for my colleagues. I cooked for myself. Success.
Blogging was a spectacular success. It is among the best decisions I made in my life.
Based on my success in 2013, I want to set even more ambitious goals for 2014. I've been contemplating my goals for 2014 for a while. To arrive my goals, I adopt a simple framework: where do I want to be at the end of 2014?
I want to be a successful CEO of an amazing company.
There are two components to being a CEO: looking like a CEO, and acting like a CEO. So I've set a few goals that support that framework.
Look Like a CEO
I've gained quite a bit of weight since starting Pristine. I'm going to lean back out. I'm at 24% body fat today. I intend to lose 1% of body fat per month to be at 12% by the end of 2014. I'm going to place $100 / month on the line using stickk.com (I used stickk.com to enforce blogging throughout 2013). I've lost weight and put on muscle before, so I know what to do - record what I eat, join a gym, and stop drinking. I'm going to enforce this goal through stickk.com.
I don't enjoy shaving, so I tend to skip it unless I have a major presentation. But if I'm going to look like a CEO, then I must groom like a CEO. I've never experimented with groomed facial hair, so I'll start with that. If I'm not experimenting, then I'm going to shave completely every couple of days. No more uncontrolled beard.
I shake lots of strangers' hands. I want to put my best hand forward, so I'm going to start getting manicures once a month.
Act like a CEO
I love short form reading. I read an enormous amount of short-form content. But I don't read enough long-form content. So I'm going to read twelve books in 2014 - one every month - and write a blog post about each. I'm going to enforce this goal through stickk.com.
I check my email too much. Email prevents me from achieving ideal productivity. I'm only going to check my email 5x daily - when I wake up, when I get to work, after lunch, before I leave the office, and before sleeping. I intend to break this rule while mobile - driving, at conferences, etc. - because email isn't preventing me from being productive during those moments.
As Pristine grows, I need to get out of the details. My brain naturally tends towards details. So I'm going to make an effort to remove myself. Of all my goals, this is the only goal that I have been unable to come up with measurable success metric.
I asked everyone on our team to come up with one or two New Year's resolutions. We're all going to make them public and hold one another to them.
Making Sense of 2013
My 2013 year in review begins in Q4 of 2012. At the time, I was working at VersaSuite as the product manager for all clinical applications and the project manager for two grueling hospital EMR deployments. We were trying to deliver the impossible in an impossibly short period of time. I was constantly stressed and concerned. I fell into what I retrospectively call depression, though that's probably a bit hyperbolic.
Going into 2013, I decided that I was going to start a business in health IT. I had no clue what I was going to do, but I knew I wanted to start something in health IT. I had no savings. Or ideas. So I set a New Year's resolution to blog 3x weekly. My hope was that potential stakeholders - investors, employees, and clients - would read my blog and come to the conclusion that I knew what I was talking about. In retrospect, I can safely say that Pristine would have probably already failed had I not blogged. Blogging has contributed to at least $200,000 in direct capital investment, Pristine's pilot at UC Irvine, helped convince some of our early employees to join, and has opened several serious opportunities in our sales pipeline.
With a bit of hindsight, this raises an interesting question: was the most important decision I made in my life to start blogging or to start Pristine? The two are so intertwined, it's nearly impossible to discern.
Through the first quarter of 2013, I was actively looking for opportunities. I contemplated dozens of ideas. My favorite was to build an Wikipedia-esque database of open source order sets to compete with FirstDabank, Zinx, and Provation.
Then I saw Glass.
From the moment I saw Glass in February, I knew that's what I wanted to do. The launch of the Glass Explorer Program felt particularly timely since I'd just written three brief essays in January about human computer interaction.
Resurgence of the command line UI
I began frantically learning Android development. I spent almost every night in February pouring through Android material and coding late into the night; I actually built a horrendous RSS reader to learn Android development. By the end of February, I realized that I would never learn Android to the extent I would need to. So I began looking for a technical cofounder.
Thanks to my friend Mike Wilson, I scored free tickets to SXSW Interactive in early March. It was my first SXSW, and I loved it. I wondered SXSW and aimlessly talked to strangers. I met my first potential cofounder there. At the time, we were discussing Glass apps for blind people. After a month or so, we decided that we wouldn't be the best partners for one another.
I'd known that Patrick was a technical genius since we'd first met in high school computer science class. So I floated "Glass for healthcare" by him in April. By the end of April, we were playing with the Mirror API even though we didn't have Glass yet. At the time, we were trying to push EMR data to Glass via the Mirror API.
What a terrible idea.
I got picked up by HIStalk in May, and my first blog post on HIStalk attracted the interest of our first angel investor, who ended up investing $100,000. He is an anesthesiologist who really opened up our eyes to the opportunities around video-based communication in the OR. We would only later discover that what we were onto much broader and more profound applications.
Meanwhile, things were degrading at VersaSuite. I was getting distracted as things started picking up with Pristine. I couldn't focus at VersaSuite. I was scared to quit. I only had a few months of cash. I had never raised money before. But I quit anyway. Quitting VersaSuite was probably the most difficult thing I've ever done. Both Patrick and I finished our obligations with our previous engagements on June 14th.
We received our first $100,000 by the end of June. Just 24 hours after finalizing our first $100,000 investment, I lost what was at the time our only Google Glass unit while drunk at a bar in NYC. After a huge scare, we got a few Glass units and raised our second hundred thousand by the end of July.
In early June, an anesthesiologist from UC Irvine emailed me out of the blue because he saw a blog post I'd written for HIStalk reposted on MedCityNews. At the time I didn't think much of it as we'd already had a handful of surgeons reach out asking to pilot. I flew out to UC Irvine on July 2nd; they wrote a letter of intent that day, and we began ironing out pilot paperwork shortly afterwards.
By mid July, Patrick and I were growing sick of working out of my living room, so we began exploring incubator options. I emailed Gordon Daugherty, one of the directors of Capital Factory, out of the blue, who introduced me to Josh Baer, the Managing Director at Capital Factory. Josh made us an offer to join the incubator program during our first conversation, which I didn't think much of at the time. I actually blew Josh off for a while, but eventually came to my senses and joined Capital Factory. I was utterly stupid for thinking that we could run a legitimate company out of my living room. Our first day at Capital Factory was August 1st.
I could have never imagined how difficult it would be to hire our first non-founding employee. No one wants to be the first non-founding employee in a startup. The first two offers we issued were rejected. In retrospect, that's a good thing, as neither of them were as talented as Mark, who joined as VP of Engineering and has been running our development teams since. Patrick and I met Mark at the Austin Google Glass meetup, which I selfishly organized to find folks who might be willing to sell a Glass unit to us. Instead of finding Glass units for sale, I found Mark. Good compromise.
I spent most of my time through August, September, October, and November traveling around the country to attend conferences and tradeshows to network, demo our software to hospitals, and pitch investors. I learned that that conference educational material is useless, that investors have no respect for my time or capital, and that most importantly, we were onto something. I refined our messaging and investor pitch extensively. I successfully raised quite a bit more capital. And although I was frequently travelling, we were hiring. During that time, we fleshed out our engineering team as Rahul, Aaron, Arik, Derrick, and Devin joined.
Out of dumb luck, I found Buzz, who would become our VP of Sales. A woman from the Central Texas HIE reached out to me in August about developing Glass apps for the Central Texas HIE. I entertained the idea - an idea that would have derailed the entire development path of the company - long enough that she introduced me to her colleague Buzz. A couple of days later, I received an email from Buzz inquiring about the VP of Sales opportunity listed on our website. I have no clue what I would've done if Buzz hadn't joined; it's extremely difficult to find successful health IT salesman that are as talented as Buzz that are willing to join an early-stage startup.
We ran our first live surgical case on October 2nd at UC Irvine. Mark and Patrick coordinated everything to bring our product to life. I was attending the Health 2.0 conference in Santa Clara that day, and was scared beyond literal expression that we would crash and burn. But we didn't. Somehow, the system worked. Mark and Patrick spent a few more weeks at UC Irvine where they identified an enormous number of bugs and UX challenges that we would keep us busy through the end of the year.
Two weeks after our first live surgical case, I launched the company to the public at the DEMO conference in Santa Clara, CA. I cut open a TraumaMan that was squirting a fountain of blood onto the stage in front of 1000 people. It was awesome. We won the DEMOgod award. Check out my DEMO presentation.
Buzz began working full time on November 1st, and began driving deals immediately. We have a very strong sales pipeline ahead of us going into 2014. We're expecting first revenue in January of 2014, 8 months after founding the company. If we can successfully execute on our commitments through Q1 of 2014, the rest of 2014 is going to a story of managing rapid growth.
I could have never imagined how difficult it would be to start a business from nothing. It was an order of magnitude more difficult than I expected. Something would go wrong on a daily basis. And yet, for everything that went wrong, 1.1 things would go right.
I have learned more in the past 8 months than during any 5 year period in my life. I have been kicked around by investors and media, rejected by those whom I asked money of and offered money to, and laughed at by doctors. I have learned more about what it takes to raise money, to hire, to fire, to communicate, to market, and to lead than I could've possibly imagined. Running a startup is without a doubt the most dense learning experience in life. There's nothing quite like it.
If I had to sum up everything I've learned into a few key themes, they would be:
Focus - I pursued augmented reality hardware, apps for blind people, EMR extensions, and more while still thinking I could pursue video-based communications. It took me at least 4 months to realize how absurd my aspirations were.
(Over) communicate - I type faster than anyone that I know. I speak faster than most. And yet I still find that I communicate less effectively and overall less than I'd like. We've put structures in place to shape communication, but it's something that I continue to struggle with.
Have fun - Until November, I would have good days and bad days. I was high until I was depressed. That's not a sustainable way to run a business. The bad days were particularly difficult. Bad news in any form would create a level of uncomfortable anxiety. I'm learning how to deal with an always-heightened level of anxiety, and how not to overreact to both good and bad news. I still have a long way to go.
Adapt - as companies grow, the most dynamic and changing role is that of the CEO. At the idea stage, the CEO does literally everything other than technology. As the company grows, the CEO must invert the business so that s/he isn't responsible for anything. The ultimate goal is to make the CEO irrelevant.
I won't make myself irrelevant by the end of 2014, but it's a goal I'll continue to strive for.
Speak Freely
I began blogging in January 2013 as a new years resolution. During that first month of blogging, I wrote brief essays on the power of the keyboard and mouse in human computer interaction models:
The resurgence of the command line UI
At the mHealth Summit, I recently had a chance to play with Nuance's and VoiceFirst's (by Honeywell) latest voice solutions. I was thoroughly impressed. The key function that caught my attention was that the Nuance app was parsing a single block of text into multiple functions. An example:
From the patient selection screen I said "order 500mg Levaquin for John Smith."
Nuance would first recognize that John Smith is admitted and in the current patient list. Next, it opened John Smith's chart. Then it displayed a new screen with the order details of the pending order on the top half of the screen and a listing of existing orders and allergies on the bottom half of the screen. Lastly, it prompted the provider to fill in the rest of the required fields - route, frequency, etc.
In a separate demo, the Nuance rep showed me voice-print based authentication, aka logging in with your voice. If you combine the two above, doctors wouldn't have to sign orders so long as they spoke them. The EMR would know who placed the order based on voice, and the order would be authenticated against one's voice. Awesome.
The point of this post isn't to praise Nuance. It's to postulate on the future of voice based interfaces in medicine.
Voice is an interesting beast. Designing UXs that heavily incorporate voice can significantly alter UI design. For example, voice can help solve the 'there's too many buttons on the screen' problem. Just get rid of the buttons. If you don't want tabs for labs, vitals, allergies, meds, immunizations, etc, then get rid of all of them and make them accessible via voice.
That's a powerful concept. With voice, UIs don't have to be exclusively bound by the pixels on the screen. There are still some pixel based limits, but voice can virtually extend pixels. So long as the voice command is contextual and intuitive for the user, buttons can be removed.
Voice also opens incredible new opportunities for the patient to enter data him- or herself without even knowing it. So long as the provider guides the patient and asks the right questions, the patient could fill out the EMR as they speak. See the example below.
In this example, the provider could prompt the patient "So tell me a bit more about your [complaint]. How long have you had it? Where does it hurt? Any associated symptoms?" The NLP could pick up that this is obviously referring to HPI, and then dictate the patient's response into the HPI field. CC and HPI are supposed to be patient reported anyways.
Looking at the two examples above, it's clear that voice will be a highly contextual UI concept. Although this is intrinsically true in visual UIs (keyboard / mouse and touchscreen), it's worth repeating in a voice-driven UX because voice doesn't appear to be bounded by what the user can see. For developers, this means a few things:
Don't try to design voice commands to be generic across the entire application. And don't try to show available voice commands on the screen. Assume users learn to use the voice queues over time. Train them and provide subtle visual cues to encourage them to use voice. Help them explore.
Try to really understand context. Context was previously bounded by screen real estate. It no longer is. For example, while looking at a given patient's labs, the user may want to jump to meds. Don't force the user back up the tree to the dashboard before they can navigate to meds. (Note, most EMRs aren't architected to support this. Many are intrinsically tree-based. In these instances, they'd need to simulate two steps programmatically).
Use voice consistently. Although voice can remove the need for certain buttons / tabs, it should be available for navigational elements that are on screen. If one navigation item can be selected to via voice, all comparable voice items should be.
All voice commands and triggers should be one or two words. Given that voice is 90-95% accurate per word, if 1/10 voice commands fail, that's probably ok. Users won't mind repeating one or two words (but they will be frustrated repeating two sentences).
If your company is doing awesome stuff with voice, please let me know. I want to learn about it.