The Foundational Killer App of The Apple Watch: Notifications

I just finished watching the Apple Watch keynote. There's one thing that repeatedly stands out throughout the course of the presentation, even though Apple doesn't explicitly highlight it.

The Apple Watch allows you to interact with rich, contextual notifications with almost no friction.

This is far more profound than it sounds upon first read. Let me explain:

TouchID has changed how I interact with my phone. Anecdotally, I've seen many members of the press, VC, and entrepreneur community echo the same. TouchID brings incredibly simple security to the masses.

But TouchID has one glaring shortcoming: it doesn't solve the security challenges associated with consuming interactive, contextual notifications without unlocking your phone. If you want anything more than a simple alert while maintaining strict security controls, TouchID falls short.

And that's exactly where Apple Watch succeeds. Apple Watch can render rich, interactive, contextual notifications on your wrist. And you can interact with them without unlocking a device. Notifications on Apple Watch are an order of magnitude more convenient than pulling out your phone, swiping a notification, and then using TouchID to actually unlock the phone.

This interaction model appears to break security by skipping the step of user verification. But it doesn't. Apple Watch can skip the user verification test via a Bluetooth LE tie to your phone. Apple Watch knows that if you're wearing Apple Watch and your phone is close by, that it's safe to render information on the watch face.

I'm not as convinced about the fitness and health value of Apple Watch given the struggle that other fitness trackers have faced in the market. However, the notifications functionality is a step function better than the status quo. Notifications will be the foundational killer app of the Apple Watch just as the multi-touch UX was the foundational killer app of the iPhone and iPad.

The Fundamental Challenge of Building a Healthcare-Provider Focused Startup

This post was originally featured on EMRandHIPAA.

Over the past few years, the government imposed copious regulations on healthcare providers, most of which are supposed to reduce costs, improve access to care, and consumerize the patient experience. Prior to 2009, the federal government was far less involved in driving the national healthcare agenda, and thus provider IT budgets, innovation, and research and development agendas among healthcare IT vendors.

This is, in theory (and according to the government), a good idea. Prior to the introduction of the HITECH act in 2009, IT adoption in healthcare was abysmal. The government has most certainly succeeded in driving IT adoption in the name of the triple aim. But this has two key side effects that directly impact the rate at which innovation can be introduced into the healthcare provider community.

The first side effect of government-driven innovation is that all of the vendors are building the exact same features and functions to adhere to the government requirements. This is the exact antithesis of capitalism, which is designed to allow companies to innovate on their own terms; right now, every healthcare IT vendor is innovating on the government’s terms. This is massively inefficient at a macroeconomic level, and stifles experimentation and innovation, which is ultimately bad for providers and patients.

But the second side effect is actually much more nuanced and profound. Because the federal government is driving an aggressive health IT adoption schedule, healthcare providers aren’t experimenting as much as they otherwise would. Today, the greatest bottleneck to providers embarking on a new project is not money, brain power, or infrastructure. Rather, providers are limited in their ability to adopt new technologies by their bandwidth to absorb change. It is simply not possible to undertake more than a handful of initiatives at one time; management can’t coordinate the projects, IT teams can’t prepare the infrastructure, and the staff can’t adjust workflows or attend training rapidly enough while caring for patients.

As the government drives change, they are literally eating up providers’ ability to innovate on any terms other than the government’s. Prominent CIOs like John Halamka from BIDMC have articulated the challenge of keeping up with government mandates, and the need to actually set aside resources to innovate outside of government mandates.

Thus is the problem with health IT entrepreneurship today. Solving painful economic or patient-safety problems is simply not top of mind for CIOs, even if these initiatives broadly align with accountable care models. CIOs are focused on what the government has told them to focus on, and not much else. Obviously, existing healthcare IT vendors are tackling the government mandates; it’s unlikely an under-capitalized startup without brand recognition can beat the legacy vendors when the basis of competition is so clear: do what the government tells you. Startups thrive when they can asymmetrically compete with legacy incumbents.

Google beat Microsoft by recognizing search was more important than the operating system; Apple beat Microsoft by recognizing mobile was more important than the desktop; SalesForce beat Oracle and SAP because they recognized the benefits of the cloud over on-premise deployments; Voalte is challenging Vocera because they recognized the power of the smartphone long before Vocera did. Athena is challenging Epic and Cerner by pushing the cloud over on premise software. There are countless examples of asymmetric competition in and out of healthcare. Startups win when they compete on new, asymmetric terms. Startups never win by going head to head with the incumbent on the incumbent's terms.

We are in an era of change in healthcare. Risk based models are slowly becoming the dominant care delivery model, and this is creating enormous opportunity for startups to enter the space. Unfortunately, the government is largely dictating the scope and themes of risk-based care delivery, which is many ways actually stifling innovation.

This is the problem for health IT entrepreneurship today. Despite all of the ongoing change in healthcare, it’s actually harder than ever before to change healthcare delivery things as a startup. There is simply not enough attention of bandwidth to go around. When CIOs have strict project schedules that stretch out 18 months, how can startups break in? Startups can’t survive 18 month sales cycles.

Thus the is paradox of innovation: the more you're told to innovate, the less you actually can.

In Defense of Google Glass

This post was originally featured in Forbes.

John C. Dvorak from PC Magazine UK recently wrote a piece outlining all of the reasons that Google Glass will fail.

He is largely wrong.

Dvorak’s primary thesis is that Google is taking a cavalier attitude towards privacy and that the public won’t stand for it. He predicts that as a result of slow sales (which he doesn’t quantify), Google will shut down Glass in the next year.

There are a few problems with Dvorak’s hypothesis:

Glass is not a walking invasion of privacy

Most peoples’ negative reactions to Glass from a privacy perspective are rooted in the camera. Theoretically, this camera could be recording at all times. Although technically true, that fear is not a logical interpretation of reality. Just because one is wearing Glass doesn’t mean that one is recording. But more importantly, new technologies don’t create new behaviors out of thin air.

In other words, if everyone was so adamant about recording their peers, what’s stopping them from doing that today with their phones? If people aren’t doing that today with smartphones, why will they all of a sudden do that with Glass? Glass’s camera is more convenient than that of a smartphone, but that doesn’t mean people will use it in the most nefarious, privacy-invading way possible. Social norms and self-image will prevent the vast majority of people from recording when inappropriate.

“But what about the creeps in the world?” you may ask.

Just because most people won’t use Glass for nefarious purposes, that doesn’t mean that some people won’t, right? And those bad apples will rot the entire tree, right?

Once again, simple logic comes to the rescue: people who want to record others in public typically don’t want others to know that they’re being recorded. Glass is a particularly awful tool at being discreet. It rests clearly on one’s face in plain sight and forces the recorder to look at the intended target. Google Glass is more likely the least deceptive technology than the most deceptive. Smartphones, given their ubiquity, are far more apt for deception.

Smart glasses in 2014 are where desktop computing was in 1978

Google initially designed and marketed Glass for consumers. Eighteen months later though, it’s clear that like desktops and cell phones before it, Glass will be adopted by enterprises first.

The first real application for desktop computers was spreadsheets (in the form of VisiCalc). In 1978, despite all of its limitations, the Apple II desktop computer was capable enough to render a 2-dimensional spreadsheet of numbers linked by basic addition and multiplication. Business analysts in finance and the corporate world immediately rejoiced because they no longer had to calculate each cell by hand. Spreadsheets made business analysts and executives 10x more productive.

In the early ’90s, Motorola released the first commercial cellphones. Despite their poor performance, poor network coverage, high price, and excessive bulk, business executives bought them in droves. Why? Because there was undeniable value in making phone calls while mobile. They would have gladly paid $1,000 / month for a phone in order to make billion dollar business decisions on the move.

The teams that built Glass intended it for wide-scale consumer adoption, but like Steve Jobs in 1978, were too early. However, early “killer apps” are emerging for Glass for use in the enterprise.

Of course, I have every reason to believe in a wave of enterprise Glass adoption. My company, Pristine, is on a mission to dramatically improve field service, training, and education through Glass. We’ve built a scalable, secure, robust, remote-collaboration suite for Glass to help local technicians fix problems that they otherwise never could have. Rather than struggle with a phone call to remotely diagnose mechanical problems, our customers empower their engineers to share what they’re seeing securely to remotely collaborate and fix mission-critical equipment, leading to massive ROI in healthcare, manufacturing, aerospace, oil & gas, and more.

What Dvorak gets right

While the killer apps for Glass in the enterprise are clear to many, Dvorak is closer to the mark in terms of consumer adoption. Currently, “consumer” ownership of Google Glass is limited to very early adopters who are trying the technology for its own sake, in absence of a truly game-changing application.

For consumers, the emergence of a killer app will be predicated on a few things:

1. Glass won’t achieve mainstream adoption until you can no longer tell the difference between Google Glasses and regular glasses.
2. Glass needs a killer app. It’s clear that given current hardware constraints, there isn’t a killer app for consumers. Perhaps augmented reality technologies will deliver the killer app for consumers.
3. The price needs to fall dramatically. Luckily, Moore’s law dictates that the price will drop.

So where does this leave Glass?

Is Google going to kill Glass like other high-profile projects (e.g. Wave, Reeder, Buzz)? Doubtful. Larry Page just handed over most of his daily responsibilities to Sundar Pichai so Page can spend more time accelerating commercialization of Google’s most promising nascent technologies such as Glass and self-driving cars.

Instead, I offer this: Glass is going to change the world. But like other world-changing technologies before it (desktop computers and smartphones), Glass will solve expensive problems in the enterprise before achieving broader consumer adoption. Agree? Disagree? Drop me a line at kyle@pristine.io to talk more.

Can Life Sciences Companies Deliver Accountable Care?

This post was originally featured on HIT Consultant.

Healthcare providers continue to assume increasing amounts of risk in care delivery. This has major implications, not just for providers and patients, but also vendors in IT, diagnostics, therapeutics and devices. If providers assume risk, why shouldn’t their vendors?

We’re already seeing this to some extent in emerging health IT companies. Most health IT innovation discussions revolve around driving value through population health, big data analytics and patient engagement. But many of these startups fail to any generate revenue until they prove the value of their solution through improved outcomes or reduced costs.

Life sciences companies, on the other hand, still generate all of their revenue in a fee for service (FFS)-like model. The more implants implanted, the more arteries unblocked and the more pills prescribed, the more these companies are rewarded, even if it’s the same patient receiving their third implant. The life sciences industry is still in the “sick care” business as opposed to the “health care” business.

How can life sciences companies transform from their traditional FFS business model to a new model that assumes risk and drives accountable care? How can they demonstrate value on a per patient basis? How can they re-shape their businesses to be more consistent with new care delivery models? Data.

Risk cannot be assessed without the measurement of data. It’s impossible to understand the efficacy of a treatment for a given patient if the outcome isn’t assessed in a granular, measurable way.

Today, efficacy data for treatments is typically captured at discrete points in time. Usually this happens when the patient sees the physician and the physician records a data point in the patient’s siloed electronic health record. Moreover, life sciences companies are only formally held accountable to data captured during clinical trials. After a treatment receives FDA approval and is commercialized, life sciences companies hardly understand how their treatments are performing in the wild.

The Internet of Health Things... In People

The road to better measurement of product efficacy may lie with embedded sensors. These sensors would capture data 100 or even 1000 times per day, rather than weekly or monthly during physician office visits.

For pharmaceuticals, that likely means pairing sensors with pills and capsules to measure specific changes in chemistry and its effect. In some cases, these sensors could even be ingestible! Imagine after taking medication, the medication itself could measure and report against the key indicators it’s supposed to effect. Companies like Proteus Digital Health are developing some of the core IP in this area already, and have plans to license to their technology to other pharmaceutical manufacturers. In the future, cholesterol-lowering statins are paired with a sensor to measure both the target of the drug (the HMG-CoA reductase enzyme crucial to cholesterol production) and overall cholesterol level. Then this data is reported back to the care team in real time.

Google Contact Lenses monitor glucose levels in real-time. With an always-connected passive monitor, diabetic patients could learn about the peaks and troughs of their insulin throughout the day and better manage their diabetes.

In the medical device world, one could embed sensors right into the device. For example:

Many pacemakers already contain sensors to adjust electrical impulse to match heart rhythms and conditions accordingly. What if that data were tracked historically and tied to particular events (e.g. meals, activities, stress)? Patients would be able to understand how their heart is reacting to their lifestyle.

Or what if the recipient of a total knee replacement also received accelerometers within that implant to measure motion and gait? The patient’s physical therapist could use this data to adjust the rehab schedule and long-term data could be used to assess the success rate of the implant, surgeon and physical therapist. Then aggregating that data could then be fed back to the device manufacturer so they could better understand how their device affects patients.

Onboard Storage of Connected Healthcare Data

Once a medical device captures data, the information could be transmitted to the cloud seamlessly. Patients wouldn’t have to remember to prick their fingers and go to the doctor to see how they’re doing. Just as businesses can take a pulse on themselves through dashboards and data, soon patients will be able to track and manage their health through measurable data in real time.

As patients better understand the impact of their treatments, they’ll react, creating virtuous cycles for effective treatments and vicious cycles for ineffective treatments. Patients will rightfully demand a new implant at no cost if their implant is shown to be statistically inferior to what they otherwise should have received.

Concluding Thoughts

Accountability has profound implications for the life sciences industry at every layer of operations. The entire product development, regulatory and commercialization strategies need to be re-thought around accountability. The most lucrative therapies will be those in which patients can clearly see and feel the benefits of the treatments.

Software is eating the world. Life sciences companies will need to embed intelligent software into their products and connect the local devices to proprietary cloud-based services. This will require massive changes in the development processes.

Regulatory processes will change. Perhaps the most important question to answer as a result of the regulatory process will evolve from, “Is the treatment safe and effective?” to “For whom is the treatment safe and effective?”

But commercialization strategies will change the most. The most successful life sciences companies won’t rely on providers as much to manage on-going success with a given therapy. Life sciences companies will employ data scientists to identify trends and patterns proactively. The data models will need to account for dozens, if not hundreds of variables. There is simply no way providers will be able to make sense of this data on a per-treatment basis so these companies will need to get more involved and develop a (even perhaps automated) direct relationship with the patient.

Healthcare is finally on a march towards accountability. And although it’s been a painful march, the march continues. The effects are slowly permeating throughout the healthcare ecosystem at every layer. It’s often said that un-innovative industries are that way because that’s what their customers demand. Hospitals have traditionally been FFS, but are transitioning to assume risk. Thus, it’s only natural that their vendors will be forced to do the same, although they may be kicking and screaming along the way. 

Smart Glasses Will be the Internet's Portal to the Physical, Hands-On World

This post was originally featured on the Huffington Post.

The Internet has been the most democratizing technology of all time. It has enabled knowledge, ideas, culture and expertise to be transferred between people and places more quickly than ever before.

We've seen entire industries disrupted by the Internet including newspapers, magazines, encyclopedias, libraries, travel agents, music, taxis, hotels, the Yellow Pages and more. All of these industries were predicated on controlling proprietary information flows. When the Internet brought the marginal cost of communication and information transfer to $0, the old business models failed and new ones emerged that took advantage of a fundamentally new way to communicate.

What About Non-Information-Based Businesses?

The industries that have been disrupted are, at their core, information-based businesses. The Internet hasn't transformed industrial enterprises and more hands-on industries such as manufacturing, warehousing, energy, healthcare and field service. Operationally, these industries are remarkably similar to their 1960s counterparts: They still rely on airplanes and cars to move workers around to do things -- inspection, audit, diagnostics, repair and service. Why can't people communicate virtually in these scenarios across distances to address the problems at hand? Why hasn't the Internet virtualized communications around real-world, hands-on collaboration?

The Internet hasn't yet disrupted many hands-on industries not because the Internet is deficient or because management is incompetent, but because the Internet end-points have been deficient. The client devices we've been computing with -- desktops, laptops, phones and tablets -- are simply not designed for hands-on jobs; using these devices in hands-on settings is simply ergonomically impractical in most cases.

Enter Smart Glasses: The Internet's Portal to the Physical World

Today, we are finally on the cusp of the industrial Internet. Using smart glasses (like those manufactured by Vuzix, Google and others) as a portal, the Internet will reshape traditional industries by bringing information and expertise where it was previously not possible: into hands-on arenas.

Field service in particular is ripe for disruption. When mission-critical equipment is down, business operations come to a halt. Using glasses, workers will be able to remotely collaborate to diagnose and repair problems. Rather than waiting hours or even days for the right people to arrive, workers will begin collaborating immediately and fix problems and order of magnitude more quickly than ever before.

This problem manifests in all kinds of industries: airline manufacturing (e.g. conveyer belt not working), pharmaceutical manufacturing, contract research organizations (CROs), HVAC refrigeration (industrial, commercial, academic), midstream and downstream oil and gas, and telecom.

Healthcare is also ripe to adopt glasses. Smartphones are remarkably filthy. Why are healthcare workers touching these devices all day while taking care of patients? This seems like a recipe for accelerating the growth of hospital-acquired infections.

There are incredible opportunities ahead. By breaking old assumptions about who can do what and where, entire industries can be reshaped. Just imagine being able to extend the knowledge and insight of your best workers to the periphery of your distributed workforce. Or training your customers on a new machine daily over the course of the first month, instead of 0- and 30-day trainings.

The future of traditional industries look remarkably different -- for the first time in a long time -- through Glass.