Barefoot at HIMSS? Just Trying to Follow Dr. Google’s Orders


If you see me in flip flop sandals, Vibram Five Fingers (VFF), or a barefoot-style shoe at HIMSS14 — please withhold fashion judgment. Since Jan 1, 2014, I have been performing a little “care management” on myself — as ordered by Dr. Google — and have been treating my sports injury by going about barefoot or minimally-shod.

Trusting Dr. Google over my Kaiser podiatrist (recommendation: prescription orthotics), and my Kaiser Sports Medicine Doctor (recommendation: wear a medical boot), was not easy. I was driven by: 1) pure desperation to get back to running, 2) A feeling that the KP system had nothing left to offer me, and 3) a high deductible health plan.

When my healthcare was paid for, and the doctor was all-knowing

I began running as a teenager and within a few years had developed posterior tibial tendinitis (pain and swelling along the inside of the ankle/foot). The podiatrist told me I had flat feet/over-pronated, and that I needed custom orthotics. I blindly trusted him, accepted his diagnosis as fact and was soon running again — pain-free and happy. Pre-Internet, I had no easy way (and no inclination) to really understand the biomechanics of running gait and why the orthotics fixed my symptoms.

A few decades later, I found myself again in a podiatrist’s office. I was suffering from some intermittent pain in my left ankle/foot, and assumed I needed the latest and greatest orthotics.

However, this time around I was no longer that oblivious teenager. I had read the book Born to Run and had also witnessed my husband suffer through various running injuries over the years — injuries that immediately disappeared after he started running in a VFF toe shoe.

I distinctly remember asking the podiatrist if there were any exercises I could do to strengthen my foot, negating the need for orthotics. He told me no, my problem was genetic, and that I would need new $300 prescription orthotics.

Turning to Dr. Google Instead of Dr. Kaiser

After running for several months in the new orthotics the pain came back ten fold. In order to simply walk, I began wearing an ankle brace in addition to the crippling orthotic. After 6 months of not running, I was in as much pain as ever, and was desperate.

During this time period (late last year), a perfect storm of events pushed me towards Dr. Google and healthcare consumerism.

I read The Story of the Human Body, by the “barefoot professor”, Daniel Lieberman of Harvard. Lieberman discusses how the habitual wearing of shoes since childhood deforms and atrophies the human foot — causing a host of problems including flat feet/overpronation. Lieberman also rails against the orthotics industry, describing how orthotics cause the foot to progressively weaken over time until wearers lose the ability to walk barefoot.


At the same time as I was learning about the deleterious effects of shoes on the human foot, I was transitioning into a high deductible Kaiser plan via Covered California. This meant that I would pay dearly for each office visit, and, at that point in time I didn’t feel like spending a dime on KP with regards to this injury. I very much felt (and still do) that I had been duped by both the orthotics maker, and the orthotics-salesman podiatrist.

In short, I had nowhere else to go except to Dr. Google, who was available for free, 24/7, instantly. Over a week I obsessively googled various keyword combinations. I found communities of barefoot runners, flat-foot sufferers, and numerous YouTube videos. Most helpful were the videos and blogs that described in detail, exercises to strengthen arches in flat feet. I also learned the important role of the big-toe in supporting the arch (in nearly all womens’ shoes, the big toe is pushed and squeezed to the side, causing the arch to oftentimes fall).

I formed a hypothesis that this barefoot stuff might cure my foot injury, and so on Jan 1, 2014 started slowly going barefoot as much as I could around the house and doing various foot and lower leg strengthening exercises. I wore VFFs and flip flops outside, and got rid of the ankle brace.

Testing My Barefoot Hypothesis, On a Sample Size of One

Wearing orthotics for so long, I hadn’t realized how weak my feet actually were. In going barefoot, I felt could feel just how feeble each tendon, ligament, and muscle was. At the same time (and despite the ongoing soreness), the post tib pain was subsiding. After 2 days barefoot I could walk without much pain.  7 days barefoot and the pain was gone completely. This was after 6 months of suffering.

Some other outcomes: My foot became noticeably wider, more muscular, and lo and behold I developed an arch in my foot. I have tried to prove these outcomes to myself by trying on a narrow shoe that used to fit but now does not, and by observing my footprint coming out of the pool — before it was a blob, now it looks like a normal footprint.

Disclaimer: yes, I am a sample size of one, this was a non-controlled study. I acknowledge that I too suffer from Optimism bias and Confirmation bias.  Also, I don’t yet have enough runs under my belt to know whether or not this barefoot transition will really enable me to run injury-free for a long time. (To date I have been able to run 4 miles at a stretch in the VFFs.)  I may get injured tomorrow but for now I am declaring victory.

Analysis: Why Didn’t Kaiser Care if I healed or Not?

Of all healthcare providers, KP as a capitated system should have cared about healing my foot and preventing the need for surgery. However, in this case KP acted completely episodically.

What about population health management outreach? I didn’t receive a single outreach from KP, checking in as to whether the orthotics worked or not. Not even a simple email. (Actually, I am naïve to expect this. KP is a smart actuarial organization and has made the calculation that this type of outreach is more likely to increase utilization for a generally healthy member. Not so for the sickest, most complex patients.)

What about care coordination? I visited a primary care doctor after the fact for a routine checkup. Why didn’t she ask me how my foot was doing? Maybe going through my (very short) medical record was too much to ask? Why then install Epic at $6B?  If this kind of basic care coordination isn’t being achieved within a closed, integrated system who has been on Epic for years and touted by many as the “gold standard” then how do we expect loosely integrated clinical networks to share data?

Note: In Kaiser’s defense, before I visited Dr. Google I did make one last attempt and had a phone conversation with a sports medicine doctor (no deductible charge) who wasn’t interested in talking about orthotics and told me the next step was a medical boot. I asked him about barefoot running and he didn’t disregard it as possibly helpful.

In Summary: Healthcare Consumerism Driven by Complex Factors

With this post, what I want to do is shed some light on the complex conditions driving healthcare consumerism today. In this case, my ACA high-deductible plan offered me some tough love and forced me to take control of my own health — though there are many use cases where these plans might backfire.

There is also the role of tech/IT therein. Aside from the obvious benefits and pitfalls of going to Dr. Google, this use case made me think deeply about just how far providers are from truly harnessing user-generated data. For example, KP in the far future might want to exploit my smartphone’s GPS data to predict if I am trending towards a sports injury in the first place.

I have also written this post as a small way of adding my voice to Dr. Google — I hope it can be useful to anyone who has suffered from similar injuries. You don’t always need to mindlessly believe a podiatrist who tells you that your feet are genetically defective and need to be propped up by an expensive orthotic.

I am now preparing to walk ~8 miles daily through those long hallways at HIMSS, and looking forward to it, though be forewarned, I may be not be wearing the most stylish shoe.


Free February 2014


Readers that have been with us for a few years may recall that February is a very special month for our family. It is our Founder and Managing Director, John Moore Jr’s birthday on the 11th, my birthday on the 15th, and my sisters’ birthdays on the 22nd and 28th. Not to mention all the cousins, uncles, and other family members that happen to celebrate their birth this month as well – and least we forget, just a few U.S., presidents.

In appreciation of our subscribers, Twitter and LinkedIn followers, and this wonderful month that has brought so many people we love into the world, we offer a reverse-birthday present every year: Free February! And this year is a double whammy, as we will be opening up two reports for your reading pleasure.

The first is our first market trends report that got Chilmark Research started and still one of the only of its kind, our iPHR Market Report from 2008. This report brought much needed clarity to an immature iPHR market in 2008, one that is still struggling to find its true place in the grand HIT ecosystem – though as of late there seems to be resurgence of interest in the topic as providers prepare for stage 2 meaningful use attestation.

Despite its age, the iPHR report still has many relevant insights regarding adoption challenges that need to be overcome and where the market needed (and still needs) to go to provide real value to patients and HCOs. We initially offered this up for our Free February in 2012, but this time it will be free forever after today.

The second free report we have is an extremely timely one.

The market is abuzz with all things analytics, which gives me an idea: We should have a contest – guess how many vendors at HIMSS will have “Big Data” displayed on some placard somewhere in their booth?

Ah but I digress…

Seriously, every HCO we speak to is trying to get a handle on analytics – to highly varying degrees of success. We see our job here at Chilmark as helping to educate the market on the successful adoption and deployment of HIT so last Spring we published for our CAS clients the much-lauded Infrastructure for Analytics Insight Report. The report digs into what healthcare organizations need to think through when planning the deployment of analytics technologies, the numerous approaches to healthcare analytics tools, and how to build a business case to justify the costs inherent in adopting these solutions – these are all issues that every HCO should pay close attention to. So now we are offering this report for free as well. But this is not a free forever report – you have till the end of February to get a copy so jump to it.

Thanks so much for your continuing to be a loyal reader and please introduce yourself at HIMSS should you be going – we’ll have the entire Chilmark team there.


Three Big Questions for Stage 3 & Patient Engagement

big waveFor many, the delay of Stage 3 of the Meaningful Use program evoked a collective sigh of relief, providing a much-needed extra year to focus on the challenging requirements for patient engagement and interoperability. As distant as 2017 may seem however, the preparation for Stage 3 is already underway in Washington; the vendor community and providers will soon be scrambling to follow suit.

Barring further delays, the timeline is as follows: This fall CMS will release the notice of proposed rulemaking (NPRM) for Stage 3 and the corresponding NPRM for the Standards and Certification Criteria. The former is the programmatic framework for what to expect – measures, percentages, reporting requirements, etc., while the latter is the technical product guidelines for software vendors to follow in order to receive ONC certification as a Stage 3 compliant solution that will enable their customers, if properly implemented and used, to collect those sought-after incentive dollars. The final rule is expected to drop sometime in Q1-Q2 of 2015 – just one year away.

But that doesn’t mean there’s a year to put off thinking about it. In a few short weeks, the Health IT Policy Committee (HITPC) is set to deliver an official recommendation on the topic of Stage 3’s patient engagement requirements to the ONC. From all indications, it appears this super-group of wonks will press for inclusion of patient-generated health data (PGHD – yet another #ONCronym for your twitter streams) into electronic health record systems. The technical experts have defined PGHD as follows:

“health-related data—including health history, symptoms, biometric data, treatment history, lifestyle choices, and other information—created, recorded, gathered, or inferred by or from patients or their designees (i.e., care partners or those who assist them) to help address a health concern.”

At first glance, this is a no-brainer, as we’ve been hearing the clarion calls for such inputs for the better part of the last decade. 60 percent of US adults claim to track their weight, diet, or exercise routine, according to the Pew Research Center’s data. Evidence for the positive impact of this data on quality, satisfaction, and in some cases cost is thin but growing.

But as we are learning through the first two stages of this program as well as the early headaches of ACA rollout, reams of sophisticated studies floated down from the ivory tower do not effective policies make. Despite the need for PGHD, when it is wonkified, ONCified, and held to the temple of the nation’s delivery system, there may be a small disaster in waiting. Below are three questions Chilmark is keenly tracking throughout the remainder of 2014:

What Constitutes PGHD?
The language used thus far raises much speculation about what exactly this inclusion will mean when it hits the front lines. The definition provides only a general description, leaving a lot of possibility for interpretation and application down the road. For many, PGHD evokes the notion of datastreams from the vast array of health and wellness devices such as fitbits and jawbones, Bluetooth medical devices, and of course, tracking apps. Yet the definition above makes PGHD seem to carry more of an health risk assessment (HRA)-like utility, where patients fill out a survey and have it sent to their doctors in advance. Yet another angle is the notion of patient-reported outcomes: clinically oriented inputs from patients with regard to their physical and psychosocial health status. Outfits like ATA, HIMSS and others are lobbying for full inclusion of patient-monitoring and home-health data.

Each of these use cases brings with it a unique set of programmatic and technical components. A popular example as of late is with biometric data: If a panel of diabetic patients are all given Bluetooth glucometers that input into respective EHRs, then what – Will someone monitor each of them? Or are HCOs expected to fit those data into an algorithm that alerts and ultimately predicts any aberrance? This has been referred to as providing doctors with ‘insight’ rather than raw data. That sounds snazzy, but can we realistically mandate the creation of insight?

Collecting data such as patient allergies or side effects appears a simpler use case on paper. Yet HITPC is appearing to use everyone’s favorite A+ students – IDN’s like Geisinger, Kaiser Permanente, and Group Health Cooperative among others as the basis for their recommendation. As one example, the report lauds GHC’s eHRA model, which is based on a shared EHR and shared clinical staff for data review. As nicely as that may work, Chilmark is skeptical that it’s reproducible in an average clinical setting. Generally, the innovators in the digital engagement space have been the insurers, not the providers. We understand the need to look at innovators in order to prescribe a path for the rest of the country, but in talking to regular folks at urban hospitals, community clinics, mid-sized IPAs –it’s more likely that fluid data is a byproduct of integrated systems, not the other way around.

How Will the Market Respond?
Despite its unpopularity in the C-suite, meaningful use has forced EHR vendors to pull their heads out of the sand and advance their product features. In addition to giving providers a break, part of the reason behind the Stage 3 delay was for vendors’ benefit: “[to provide] ample time for developers to create and distribute certified EHR technology…and incorporate lessons learned about usability and customization.” The Standards and Certification Criteria 2017 edition will play a big role in the next lurch forward, and one can be sure that those new mandated features will be all the rage at HIMSS 2015.

Yet at the broadest level, the evolution of EHRs (billing >> administration >> clinical) appears to be stalling. In exploring the patient engagement market and the to-date limited functionality of tethered patient portals despite Stage 2’s requirements one thing has become clear: EHR vendors will simply not just add new features for the sake of their customers (forget about patients). With new PGHD functionality emerging, we expect new companies to step up to the plate and seek modular ONC-ATCB certification

An example already underway is 3rd party data integration. Over the last few years, device manufacturers, startups, and third parties started seeing the value in injecting their data into EHRs. The emergence of middleware companies who provide integration as a service, such as Nanthealth, Corepoint, and Validic, will continue as PGHD requirements develop over the coming months. Similar companies will start (and already are) filling the void for HRA functionality, portal requirements, patient communication, and so on. We expect that this will only exacerbate the headache faced by CIOs & CMIOs with a long list of purchasing options. Startups take note: It should also set off a shopping spree by EHR companies and other enterprise vendors looking to buy rather than build. Allscripts acquisition last year of Jardogs is one such example.

Will Providers be Ready?
In a word, no. The inclusion of PGHD brings with it an avalanche of procedural and programmatic preparation: data review and quality assurance, governance models and new workflows, the prickly issue of data ownership, staff time and training, liability concerns, HIPAA extension of coverage, ever-increasing insurer coordination, clinician accountability, and of course, patient consent, onboarding, and marketing. With the last one, keep in mind that we now live in the post-Snowden era…

Of course, without details of the required measures, further hand-wringing is unwarranted at this point. But suffice to say there’s a small storm-a-comin.’ As the definitions, rules, and standards of patient-generated health data emerge, we look forward to what promises to be a rich commentary and response to the NPRM amidst the broader discussion in the health IT community throughout 2014.


Payers Refocus Efforts on ROI for Member Engagement

cvrWhat a difference a year has made to the payer market. In late 2012 Chilmark Research published the first version of our Payer Benchmark report — detailing how leading payers were beginning to adopt emerging consumer technologies. We found a market where significant experimentation was occurring, but little if any broad, member wide deployments and a market still trying to understand social media.

This week we are releasing the next iteration of this report – Benchmark Report 2013: Payer Adoption of Emerging Consumer Tech – Payers Continue their Pursuit of the Digital Consumer. Based on the research I conducted for this report, I find it simply amazing to see how this market has shifted over the course of a single year.

For one thing, the traditional health insurance business model continues to erode, as the Affordable Care Act (ACA) has capped medical loss ratios (MLRs) and has completely stripped payers of their ability to underwrite based on health risk.

Meanwhile, payer-provider realignment is ongoing. Hospitals are partnering directly with employers or launching health plans that might compete with payers in the employer market. Likewise, some payers are acquiring providers to more closely align financial interests with healthcare services delivered.  All this bodes well for rising interest in payer-provider-aligned population health management and patient engagement technologies.

In addition, the ACA/Obamacare has come to be seen as inevitable, and Health Insurance Exchanges (HIX) are forcing payers to seek out new places in the minds of consumers and within the broader healthcare ecosystem –  with an increasing focus on engaging and retaining consumers.

Outside of healthcare, the consumer tech space continues to defy our expectations.  It is easy to see how in the past year that emerging, low-cost activity tracking technologies have spread far beyond early adopters.

These and other macro forces are pushing payers toward the digital consumer in ever more multi-faceted ways.  For example, payers have drastically pulled back from their flurry of experimentation in 2012, and are now focusing their efforts into fewer, more precise areas where they foresee strong potential for ROI.

One change from 2012 is the pull-back in creating mobile app versions of member service portals, as have health & wellness app launches. (This makes sense: in general, very few payer-launched or payer-owned mobile apps have gained any kind of significant traction, with iTriage as a notable outlier, and they already had good traction prior to acquisition by Aetna).


While payers may have pulled back from rapid experimentation along certain lines, this does not mean that they have given up on the digital consumer. To the contrary, we continue to see growing investment in payer-owned consumer platforms, biometric tracking initiatives, the next generation of social media, and more… all detailed in the report.

This report profiles an expanded set of payers as compared to the first edition, across commercial, Blues, and provider-aligned categories. These innovative payers are exploring the wild west of digital consumer engagement and learning as they go. The report describes their experimentation in detail, what initiatives are working and why, and where promising new territory might lie. Any organization that is looking to build-out a strategy that leverages consumer tech for member/patient engagement will find this report invaluable.

We hope our subscribers enjoy the read…as much as we enjoyed the research.


What’s in Store for 2014?

zoltarThat time of year once again where we collectively look into our crystal ball, or throw the sticks or maybe even look at the coffee grinds dripping down the sides on our coffee cup to see what may be in the year to come. Making these predictions for the coming year is almost a rite of passage for any self-respecting analyst firm and what the heck, from our vantage point, we may have a slightly better view into the future than most.

So in keeping with some sense of tradition here at Chilmark Research, the following are our ten predictions for 2014, plus one (think of it like a baker’s dozen).

Meaningful Use (MU) stage two delay provides little relief to IT departments. Many breathed a sigh of relief when HHS announced that stage two timeline would be extended. Yet despite that extension, IT departments will remain overwhelmed in 2014 coping with a host of other initiatives, from ICD-10 to HIPAA compliance to preparing the organization for changing models of reimbursement and of course MU 2.

Best-of-breed solutions proliferate. Despite the desire to have as few as possible IT vendors and their solutions within an organization, department heads take it upon themselves to adopt new solutions as IT departments are not able to meet all the needs of the organization at this time, nor are EHR vendors capable of delivering new offerings in a timely manner. We anticipate analytics and care coordination to be high among list of adopted best-of-breed solutions. This will create its own host of problems several years hence.

Consolidation continues unabated in mid-market. Much to the concern of payers, large provider organizations will continue to purchase their smaller brethren to extend their reach and improve care coordination. Payers will fight back with lawsuits (monopolistic tendencies of providers) and by making their own acquisitions. Payers will be particularly attracted to the dual eligible market.

Bloom is off the rose as physician dissatisfaction with chosen EHR rises. OK, yes this is a no-brainer as we have been seeing discontent rise throughout 2013. But this discontent will escalate as smaller organizations increasingly realize that their EHR is ill-suited to address the needs of tomorrow in a value-based reimbursement world.

Limitations of deployed HIE becomes increasingly apparent. It’s one thing to put in an HIE infrastructure, quite another to embed HIE capabilities into clinician workflow, especially across a heterogeneous EHR community. Couple that with a growing realization among leading HCOs that to truly support clinicians at point of care, far more data is required to flow through the network and you end up with a lot of future head scratching as to where the real value realization will be derived from the HIE now in use.

Re-prioritization moves patient engagement to back burner. Despite the strong efforts of ONC/HHS to promote the concept of patient engagement, providers, no longer having the stage two gun to their head, will reset priorities on other, more pressing matters.

One third of stage one, MU-certified EHRs do not or choose not to certify for stage two. The HITECH Act created a false market for EHRs that led to the proliferation of vendors and their solutions. Unfortunately for many an ambulatory practice, their chosen EHR vendor will not have the resources to refine their product for stage two certification leaving smaller practices with the unenviable task of having to find a new vendor. Thankfully, a price war is anticipated as vendors look to build customer bases and subsequently valuations before inevitable acquisition.

Clinical analytics remains a hot, yet immature market. Leading HCOs are all clamoring for analytics to help run their operations and improve care delivery processes. But despite the high demand for such solutions, EHR vendors are still behind the curve in delivering such capabilities, the buyers still are not quite sure exactly what they want and rarely have the resources to begin asking the right questions. The best of breed vendors themselves struggle to keep up with market demand, leading to longer then anticipated deployment times.

Cloud-based EHRs become de facto standard for small, ambulatory practices. Pricing pressure will grow fierce in the ambulatory market and in an effort to lower cost of sales, shorten product lifecycles and improve customer service, ambulatory EHR vendors will move to cloud-based services for their solutions. Some push-back will occur over concerns of data governance and privacy. Physicians taking this path will need to review terms and conditions of such contracts carefully.

Payers increasingly become part of HIE fabric. In mid-2013, payers became increasingly involved in the HIE market partnering with leading providers in some communities to share data and improve care coordination. While providers have instinctively been reluctant to partner up with payers, the move to value-based contracts and the strong skills and critical data that payers can provide is forcing providers to re-evaluate their previous stance. falls short – payers wring their hands. has far more sign-ups than detractors anticipated but falls short of administration goals, especially for the young and healthy. This leads to payers to continue wringing their hands over adverse selection of new enrollees and the likely higher risk profile as a result.

There you have it folks. Now let’s see how the year plays out and just how close these predictions are to reality come early 2015. Either way, never a dull moment in this market for the foreseeable future.




mHealth13: Lots Going On, But Few New Developments

precamAnother year, another mHealth Summit.

HIMSS’ younger sibling has slowly grown over the last five years, a period that has seen a Precambrian explosion of companies and advances in mobile tech. However, despite some early hints of maturity, the mHealth Summit revealed the mobile healthcare market’s overall identity confusion. Replace the old, or integrate with it? Add more functionality, or pare down and simplify? Is this a market driven by need, or want? Beyond the hype and the bold claims set forth by the usual suspects, mHealth’s central challenge is one of adoption: Neither consumers nor health care organizations are picking up mobile for healthcare at the pace and scale that vendors are claiming and hoping they will.

Evangelists have defaulted to pointing out the broader trends, waving around the hockey stick charts of mobile phone adoption worldwide, and referencing data about consumer mobile searches for healthcare data. We’ve seen those too. But let’s just be honest here for a moment – nobody cares if we are all becoming handset hypochondriacs. When we talk mHealth, we hope for clinical interventions, enhanced communication, behavior improvements, incorporation of patient-generated data, and so forth. To give credit where it is due, tireless efforts by HIMSS and their tradeshow peers, the vendor community, the public sector, and many others have begun to result in a vision for how mobile tools can improve how we plan for, pay for, deliver, and otherwise manage health care.

But it is still largely just a vision as we are not quite there yet. Progress is bubbling up along with a fresh set of challenges. Here are some more thoughts from DC, from regulation to startups, and product strategy to marketplace realities.

Can Someone Please Regulate the FDA?

The FDA’s recent ruling on mHealth has caused more confusion than it has cleared up. The agency offered little direction in its September ruling, sending mHIMSS’ network of experts scrambling to provide translation and guidance for the rest of us. Regulation is a central concern as this industry keeps trying to move past Powerpoint platitudes and into mobile-enabled clinical care in the home. As such, regulation aimed at protecting consumers generated much buzz at this year’s summit, with over half a dozen sessions involving some aspect of FDA regulation and still others geared towards privacy, security, BYOD policy, etc.

23andMe’s recent shaming by the FDA was a harsh reminder that regulation is serious business. Much can be written about this subject (Dan from Athena, a panelist at one session, does a nice job here) – but suffice to say it has become clear that HHS’ goals are out of sync with those of the FDA, which seems to have very little appetite for even the potential mitigation of an iota of patient safety for the sake of innovation. As heard at the water cooler after one regulation-focused session, “This is like HIPAA on steroids.” Unfortunately, this risk aversion is anathema to the nature of the risk-taking crop of entrepreneurs and innovators who have lined up to take a crack at driving improvements in healthcare.

If Startups are the Answer…What is the Question Again?

The mHealth Summit is becoming an official party for the world of healthcare startups, the overwhelming majority of which are now tech plays involving a smartphone app. Driving  (and capitalizing on) this trend, Health2.0 and StartupHealth each had a strong presence at this year’s Summit. Starting up a tech outfit is cheaper, cooler, and easier than ever before. It is certain that we badly need an injection of the energy, creativity, talent, and perspective of the entrepreneurial crowd – and the injection of capital from the long and growing list of VC firms and corporate investment arms doesn’t hurt either. Historically, we’ve all wondered whether these fledgling companies are ready to take on healthcare; For the first time, this year’s summit evoked the question of whether or not the industry is actually ready for these startups to disrupt it.

One seasoned VC at the Venture+ Forum, a daylong prelude to the actual conference, actually advised startups NOT to design products based on the ACO model, as value-based reimbursement is frankly not here yet; startups who need revenue in short order may be better served by basing their business model and strategy on the FFS-driven status quo. This notion, that innovation might be “too early” is not new in healthcare; several tales emerged across multiple sessions of failed good ideas like telemonitoring companies in the 90’s and premature doctor messaging networks in the early 2000’s.

The uphill road faced by startups is a broader reflection of our healthcare system’s challenges: Target customers have a deeply engrained resistance to change, are overburdened and under-resourced, and in many cases, still seemingly think of mobile tech as fools’ gold. Despite the occasional pilots or acquisitions trickling into our twitter feeds, there was a noticeable absence of “big” announcements or deals at the Summit.  So while we anticipate the majority of the dozens of startups who exhibited in the StartupHealth Pavilion will not be around in 3-5 years, perhaps this is just an evolutionary phase.

To be sure, there are still plenty of half-baked ideas out there. Some of the young companies we chatted with, from monitoring hardware plays to software engagement outfits, were woefully underinformed about some fundamentals: the need for properly structured data (Literally: “What’s HL7?”), the ignorance of a multiple-portals-per-patient approach, and even uncertainty of the difference between inpatient and ambulatory care. And these were not salespeople, they were founders.

Even startups that “make it” face an unclear future. At the Venture+ Summit, one company with multiple live pilots announced it recently closed a plump Series A round, but when we circled back with the CMIO at one of those hospitals, he had this to say via e-mail: “They are doing something with our [subspecialty] folks. I’m pretty sure it’s not large. I’ve visited with [founder] several times, but I don’t see how what they offer scales to a diverse patient population.” A myopic focus on a delivery system niche might help to secure funding, but reflects how startups are encouraged by their investors to think about scaling in terms of adding customers, rather than going deeper and wider within one organization. What is best for the startup might not be best for the HCO.

By the Darwinian school of thought, successful companies will be the more adaptive ones who are aware of market dynamics beyond the cookie cutter slide deck stats and buzzwords. Indeed, in observing some of the successful players and a engaging diverse set of discussions at this year’s summit, we gained some valuable insight about how mobile integration into the broader health enterprise necessitates product pivots, strategy shifts, and of course, a little bit of luck.  For example, simply singing about “data” holds less appeal than it did a few years ago: HCO’s are stretched thin due to health reform, MU, ICD, and so on – they are really only interested in things that will save them money or make them money. Pharma wants specific value-adds, such as adherence, or trials recruitment. Moreover, it’s still proving tricky to incorporate user-generated data into the enterprise.

A noteworthy example of a company capitalizing on these trends is Validic. Originally conceived as a wellness platform in 2010, they had trouble landing customers until last year, when they pivoted into an integration platform for device-generated data. Sales have since taken off, with support from blue chip investors like Mark Cuban, and are on track to have 30M lives covered by Q1 2014. As other entrants identify badly needed pieces of the puzzle, we hope to see more such gaps get plugged. The takeaway here is that product strategy matters a lot in mHealth, and a recurring theme out of this Summit was that embedding a key piece of technology within other products is a safer way to create new distribution channels. In a word: Partnerships.

The Rising Tide will Lift all (Partner)Ships

mHealth companies of all types are sensing that the quickest path forward in today’s competitive, overregulated, and change-resistant healthcare environment is to join forces with others. For startups, this might mean changing product strategy to provide the equivalent of a middleware service. More established companies like Nuance have positioned themselves squarely as leaders in a certain niche (voice recognition), setting themselves up to refine and evolve their technology based on emerging needs of the marketplace, while expanding their footprint through their partners’ deployments. In their case, they have added early “AI” functionality that interacts seamlessly with clinicians’ voice commands to guide them towards more accurate diagnoses (think autocorrect for dictation.) This “Trojan Horse” strategy leaves them poised to capitalize in multiple areas from ICD-10 to the coming wave of smartphone-driven patient engagement plays, as evidenced by their presence in Sharecare’s latest app. Tellingly, healthcare has grown to comprise half of their business.

Still larger in scale is the ecosystem approach, where vendors provide the plumbing, the infrastructure, and/or the devices, and bring on a spate of partners for actual health care products and services.  The model to emulate here is QualComm, who had the largest floor presence and has steadily turned their 2net platform into a rich offering of dozens of devices, apps, and other solutions to over 200 diverse customers worldwide. Not as successful are the Telecoms: AT&T and Sprint both seem to be building anemic versions of such a platform with small handfuls of promoted partners, while Verizon continues to stubbornly insist it is a real health care company, hiring a CMO and building out complete but wobbly-looking platforms for remote care management and virtual visits. There are no paying customers yet, but they did have a sweet video you could watch on loop at their booth.

As an aside – There is mounting eyebrow-raising going on internally at Chilmark with regards to all things telecom. Rather than focusing on a couple of obvious features where they could offer unique value – televisits, or pre-loaded smartphones, for example – these tech-driven, resource-loaded, and market-permeating behemoths seem to be trying everything and doing nothing well. One VC’s pithy remark to startups applies equally to this crowd: “Revenue is the greatest proof of concept.” Despite having the largest booths at the conference, our probing of the TeleComs did not result in a mention of a single live paying customer in mobile – just internal launches, repeated defaulting to old HIE partnerships from years ago, or shifty mentions of forthcoming press releases in 2014.

All of this simply confirms what we already know: The connected health model will be built upon a best-of-breed ecosystem of companies and technologies, rather than one soup-to-nuts vendor offering. This is highly different from the monolithic world of EHR and HIE vendors that many CIOs are used to planning and budgeting for. Indeed, one of the reasons for the lag in adoption in mobile health to date may well be that decision makers are simply overwhelmed with all of the options that are out there. As companies die on the vine, get acquired, prove their salt, or join partnerships, this menu will condense. In the meantime, working with one vendor who can offer a large, curated menu of solutions is simply an easier, albeit more expensive, option.

Conclusions and Awards

We look forward to seeing the continued maturity of this market, as well as this conference. While relatively well-run overall, the sessions were repetitive and watered-down at times, with a decidedly mixed quality of speakers and plenty of off-topic or mistitled presentations. Three days may be too much at this juncture, as many sessions were sparsely attended by the afternoons (By Wednesday the place was a veritable ghosttown), but as we have pointed out before, this conference is ultimately about HIMSS’ bottom line. Seemingly the agenda was designed to fill the cavernous Gaylord Convention Center, rather than curated to any extent for attendees’ benefit.

Moving forward, we hope to see less of the bad, most notably the abysmal (Note to HIMSS: ABYSMAL!) wi-fi access, mediocre keynotes, and session overload/redundancy. We also look forward to more of the good stuff, from effective customer service (notably, the highly responsive twitter support) to the occasional talks by thought leaders (fantastic insight this year from Harry Greenspun, Lisa Suennen, Stuart Blitz, Matt Hendricks, Stephen Bloch) to the welcome diversity compared to the annual HIMSS conference – at one point this analyst was on an escalator between an elderly Indian woman in a sari and an African gentleman wearing a kufi. Good stuff.

To close, here are our awards for vendor swag:

  • Best: Imprivata’s black gripped gloves. Timing is everything, and in the middle of a snowstorm, free winter gear wins.
  • Runner-Up: GopherMD’s Gopher – Stuffed Animals? Yes please.
  • Second Worst: Everything else – pens and keychains? Yawn.
  • Worst: Ionu’s “Digital Privacy Please” door hanger. My room didn’t have a standard privacy sign for some reason, so I thought it was a clever (albeit cheesy) touch when Ionu’s branded sign was slipped under my door the next morning. I hung it on the doorknob, but to my later dismay the housekeeping service came in anyway. Just another example of a vendor not being able to deliver on the promises in their advertising.