One Small Wink For Man, One Giant Head Nod For Mankind

We would love to issue a huge congratulations to our partners at Rhode Island Hospital (RIH). They just went live with Pristine EyeSight on Google Glass in the ER for dermatology consults.

One of the fundamental challenges of delivering care in an ER is that patients can show up at any time of day with any problem. Often times, the ER staff need to call in a specialist. The problem is that those specialists aren't sitting around doing nothing; they're usually busy in their own clinics (which are rarely in the same building), or at home on call. The physicians and nurses at RIH are using EyeSight on Glass to beam in dermatologists on demand. This is a significant win for all parties:

For the patient - the patient will been treated more quickly than they otherwise would have, which reduces clinical risk and allows the patient to go home sooner. Approximately half of all wait times in ERs can be attributed to waiting for the right provider to arrive.

For the local provider - the local provider will spend less time hunting down the specialist in need, and will finish the exam with the patient more quickly, leading to increased throughput. The local provider may even go home sooner and see their children sooner :).

For the consulting provider - the consulting provider derives an enormous efficiency benefit. EyeSight saves them the pain of driving in or walking over. If the consulting provider is forced to leave their clinic, their clinic schedule will fall behind, leaving all of their patients unhappy and frustrated.

For the ER - the ER benefits by improving throughput, reducing risk, and ultimately increasing HCAHPS scores (which have a high correlation with wait times in outpatient settings).

Last week, the clinical teams at RIH went live with Pristine EyeSight. ER physicians are using EyeSight to securely beam in dermatologists to provide live consultations of skin wounds, rashes, and lesions in the ER. Because dermatologists work in fast-paced outpatient clinics, it's been difficult for dermatologists to come into ERs to see patients. Using Pristine EyeSight, we're improving access and outcomes in ways that were never before possible.

Looking ahead, there are even greater opportunities. We started with dermatology in the ER. We can't wait to leverage this technology with other specialties in the ER, and throughout the hospital.

We've been working with RIH's leadership team for months, and couldn't be happier with the results. We'd like to send a special shout out to Dr. Paul Porter, Dr. Peter Chai, and Dr. Roger Wu for their tenacity in helping us through the Institutional Review Board (IRB), IT, and administrative processes so quickly and diligently to make this a reality.

And lastly, as CEO, I'd like to thank our team for all of their hard work to make this a reality. We've been refining the system for a long time to ensure high reliability and performance. Our client success team has also done a spectacular job in training and deployment.

The Irony Of Healthcare Standards

This post was originally featured on EMRandHIPAA.

Healthcare delivery should be standardized. Medicine is, after all, primarily a science. Providers must diagnose and treat patients. Clinicians must form hypotheses, test hypotheses, and act. As providers obtain new information, they must adjust their thesis and repeat the cycle until patients are treated. Although there is an art to patient interaction, the medical process itself is scientific.

Science is based on repeatable, nullable hypotheses. Diagnostics and treatments are too.

And yet, it’s widely known that healthcare delivery is anything but standardized. Even basic pre-operative checklists vary dramatically across locations. Although some of this variation can be accounted for by physical constraints and capital limits, most of the aberrations can be attributed to management and culture. Checklists and protocols attempt to standardize care, but even the protocols themselves are widely debated within and between organizations.

It’s also widely known that most innovations take the better part of two decades to roll out through the US healthcare system. For an industry that should be at the cutting edge, this is painful to acknowledge.

There’s a famous saying that vendors represent their clients. It should be no surprise that major health IT vendors are slow to innovate and respond. Providers are used to slow changes, and have come to expect that of their vendors. Since providers often cannot absorb change that quickly, vendors become complacent, the pace of innovation slows, and innovations slowly disperse.

In the same light, health IT vendors are equally unstandardized. In fact, health IT vendors are so unstandardized that there’s an entire industry dedicated to trying to standardize data after-the-fact. The lack of standards is pathetic. A few examples:

Claims – Because insurance companies want to reject claims, they have never agreed on a real standard for claims. As such, an entire industry has emerged – clearing houses – to help providers mold claims for each insurance company. In an ideal world, clearing houses would have no reason to exist; all claim submissions, eligibility checks, and EOBs should be driven through standards that everyone adheres to.

HL7 – It’s commonly cited that every HL7 integration is just that: a single HL7 integration. Although HL7 integrations share the same general format, they accommodate such a vast array of variety and choice that every integration must be supported by developers on both sides of the interaction.

As a technologist, the lack of interoperability is insulting. Every computer on this planet – Windows, Mac, iOs, Android, and other flavors of Linux – communicate via the TCP/IP and HTTP protocols. Even Microsoft, Apple, and Google play nicely within enterprises. But because of the horribly skewed incentives within healthcare, none of the vendors want their customers to interact with other vendors, even though cooperation is vital.

Perhaps the most ironic observation is that technology is widely considered to be hyper-competitive. Despite hyper-competition, the tech giants have coalesced around a common set of standards for communication and interoperability. Yet health IT vendors, who operate within a vertical that prides itself on its scientific foundations, fail to communicate at the most basic levels.

Keep It Simple, Stupid!

This post was originally featured on EMRandHIPAA.

There are an enormous number of startups trying to solve the medication adherence problem. Broadly speaking, these startups are trying to solve the problem through three avenues:

1) Hardware, i.e. smart pill bottles

2) Semi-intelligent software driven reminders

3) Patient education

The most effective solutions are likely to incorporate all three.

The hardware space has been the most interesting simply because of the variety of solutions cropping up.AdhereTech and CleverCap have developed unique pill bottles that control and monitor dispensing via proprietary smart pill bottles. They also incorporate software for notifications. Unfortunately, all smart pill bottle makers are bounded by FDA regulations because they physically control medications through a combination of hardware and software. FDA regulations will slow time rollout of these solutions to market and create enormous new expense.

I recently learned about PillPack, a startup that just raised $4M. They compete asymmetrically in the medication adherence by not making any hardware at all!

The problem with the pill bottle is that there are dozens of pills in a single container. Measuring and controlling output and consumption is intrinsically a difficult problem. PillPack solves these problems by simply averting the issue entirely. PillPack pre-packs pills by dose. This is particularly valuable because they pre-pack multiple kinds of medications that need to be taken at the same time.

PillPack doesn’t yet have any intelligent software that monitors when medications are taken. But with granular packaging, sensing and controlling the medications becomes dramatically easier than ever before. I suspect this will the marquee feature of PillPack 2.0. Once they add the ability to detect when a pack is opened, they can begin adding intelligent software alerts and reminders to patients and their families.

PillPack has a far more lucrative distribution strategy than companies who have to produce and distribute hardware. PillPack can scale their customer base incredibly quickly through B2C marketing. B2C marketing isn’t easy; Pillpack faces a significant challenge in terms of patient and provider education, but it’s one that’s definitely addressable. If PillPack’s service is as good as I think it is, they should develop incredibly happy customers, which will lead to recurring revenues and strong referrals.

The moment I saw Pillpack, I immediately recognized it as one of those “duh” business. We’re going to look back in 10 years and wonder why this wasn’t always around. Their solution solves so many of the pain points around taking medications on time and is coupled with a lucrative business model that feeds off of recurring revenues from long term customers.

The genius of their business is that they are tackling the medication adherence problem from a unique angle: packaging and distribution. They’ve bundled that solution into a simple and elegant package (pun intended) that helps patients avoid the pain of the modern US healthcare system: going to the pharmacy, fighting with the pharmacist, and manually tracking when to take how much of each medication.

Full disclosure: I have no relationship(s) with PillPack.

The Blinding Power of Monopolistic Hegemony

I am an incredibly lucky founder. My startup, Pristine, is piggy backing off of the success of Google, and even Apple, in many profound ways.

Pre-iPhone, people could only conceive computers as Windows-like desktops. A computer was not a microprocessor running an operating system, but rather a keyboard, mouse, monitor, and Windows.

Why? Why would people – not just laymen, but even technologists – allow themselves to be fooled by Microsoft into thinking that computers could only exist as Microsoft envisioned them? The simple answer is that desktop-bound Windows computers were the only form factor the world knew. People hadn’t seen them manifest as touchscreen cellphones, so they couldn’t imagine them as such.

The iPhone changed everything. Android accelerated the mobile revolution. And people’s eyes were opened to the fact that computers aren’t bounded to Windows.

Then the iPad happened, and the general public learned that tablets don’t have to be bounded by desktop-centric UI elements such as scroll bars, small buttons, and right clicks. With the iPhone as a foundation, the iPad accelerated the shift away from Microsoft’s vision of computing.

Because of the success of the iPhone and iPad with consumers and in healthcare, Pristine has been incredibly blessed to find a larger-than-expected niche of folks that simply accept that the eyeware form factor will change computing at the point of care. We’re seeing interest not just from IT staff, but doctors, nurses, and even administrators. It’s been incredible to see how receptive medical professionals have been to Pristine.

With hindsight, it’s easy to say “duh” about the iPhone. But pre-iPhone, the future of mobile computing looked bleak. Microsoft skewed the world’s perceptions: because they adapted desktop Windows to mobile, including a stylus and start menu, people never experienced computers that weren’t molded after desktop Windows. Had the iPhone and iPad not happened, Pristine would not be seeing the early success that it has been.

Microsoft’s hegemony over technology for the better part of 20 years is perhaps the single greatest form of destruction of value since the inception of the modern technology era.Although the proliferation of the monotonous Windows accelerated PC adoption by instituting uniformity, it subsequently slowed innovation in the world’s most innovative sector. This is only possible to assess now that the hegemony has been broken.

The power of hegemony is clear: an inability to understand how the world can function any other way. Now I understand why suppressive governments – such as those in Iran, Saudi Arabia, and North Korea – prevent their populations from interacting with Western Cultures and ideas. People can’t know if they don’t know.

Crowdsourced Calendar Management

Crowdsourced Calendar Management

Busy executives hate managing their own calendars. Emailing back and forth to find mutually agreeable times, creating calendar invites, and scheduling time conference systems is time consuming and mind numbing.

Executive assistants tend to take care of this kind of a thing so that executives don't have to. It makes a lot of sense.

As a seed funded startup that's just beginning to generate revenue, Pristine can't justify spending cash on an office manager or executive assistant (although cheaper alternatives such as Zirtual are compelling). At the same time, I am super busy and attending meetings all day:

I used to manage my calendar myself. I hated it. But I found a way to outsource 90%+ of my calendar management to.... the crowd....for free!

Google Calendar has a function that creates a unique URL that allows anyone to share their calendar publicly without sharing any details. This allows others to see one's schedule for scheduling purposes without compromising the potentially sensitive information contained in one's calendar. I placed that URL in my email signature, and whenever I need to schedule a meeting, I simply point folks to the link in my signature. I win because I don't have to think about calendar invites anymore, and the other party wins since they spend less time emailing back and forth.

I have outsourced my calendar to the public. I love it. Here's a screenshot that can get you started to set this up for yourself.