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/ Without Label / 10 Steps to a Blockbuster Health IT Startup
If you are tired of practicing medicine, or are compelled to be your own boss, or for whatever reason decide to try something new, you should consider becoming a Health Information Technology (HIT) entrepreneur, because health care is a $3 trillion industry undergoing great upheaval and widespread computerization, and as John D Rockefeller used to say, you should try to turn every disaster into an opportunity. As a physician, you have a significant head start when it comes to credibility, and if you are a tiny bit technically inclined, your value will easily quadruple. There are many ways to go about this, and you can follow your heart and try to “fix health care”, or relegate your entrepreneurship to hobbyist levels and work on some app for this or that, or you can judiciously research the market and pragmatically choose an endeavor most likely to yield quick and overreaching results. For the novice and uninitiated, below lays a semi-serious roadmap for hitting the elusive jackpot.

Step 1: Establish Thought Leadership

There is some foundational work to be done first and you should begin long before you actually quit your day job. Thought leadership today means that you have several thousands of followers on Twitter, Facebook, Google+ and LinkedIn. If you don’t have accounts for these social media sites, go ahead and create them, with your real name and credentials, and tie them all together to form a unified identity that can be leveraged across platforms. Start posting fast and furious. This sounds hard, but there are apps out there that will let you cross and schedule your posts. It is very important that you do not take any sides in any political or medical debates, and that you do not express any original thoughts at this early stage. Your messages (about half a dozen per day) should be just hyperlinks to articles and scant neutral commentary (e.g. “interesting study on medical errors”). With the right tools, this should take you about an hour per day. Once people start “following” your thoughtful stream of updates, make sure you eclectically follow the important ones back, but don’t start following a large number of famous people in advance. The sure sign of a thought leader is that he or she has many more followers than he or she is following. Keep this up and let it simmer while you move on to other steps.

Step 2: Educate Yourself

Although you can rise to thought leadership status without knowing much about anything, our long term goal is different, so this is the time to begin exploring issues in health care, most of which you are probably aware of, but you need a deeper level of understanding to initiate decent market research while enhancing your thought leadership. Don’t worry about identifying specific problems and don’t get hung up on possible solutions at this stage. Just read a lot and make Google your best friend. Start with simple searches (e.g. “medical errors”) and follow the links from quality mass consumption media (e.g. New York Times, Wall Street Journal, and Forbes), government sites (e.g. CMS, ONC), and reputable health care sites and blogs (e.g. kevinmd.com, AMA news, Health Affairs, etc.). As you become engaged in this activity, you will discover other publications that are useful, and don’t forget the big medical journals (e.g. JAMA, NEJM). This education phase will cross-pollinate your social media efforts in Step 1 quite nicely.

Step 3: Master the Language

This is the last step before you are ready to speak up in your own voice, and this may be the hardest part for a doctor. As you go through Steps 1 and 2, you will no doubt notice certain terms and phrases that are used frequently by current thought leaders, decision makers and others who recently completed all 10 Steps. Make these phrases your own. You must become conversational in this language to advance to Step 4. So for example, if someone wakes you up at 2 am asking you who the best cardiologist in town is, don’t just blurt out Dr. Heartfelt’s name and go back to sleep. Instead you should immediately state that this question in itself is an example of “lack of transparency in health care” and that “standardized measurement of provider performance is key to value-based decision making by consumers and purchasers”. If you are chaffing uncomfortably in your chair right now, remember that you chose to leave medicine and patients behind, because that too was very uncomfortable, and this Step is very much like learning a foreign language; you don’t have to think or dream in the new language, but you should be able to converse with the natives and eventually write a little too.

Step 4: Formulate a Problem

The first thing to note here is that you need not identify an existing problem, although it would be fine if you did, because many successful businesses provide solutions to problems people never knew they had. This is your opportunity to be creative and innovate. Remember that you are trying to build a business, and not just any business, but a blockbuster HIT business, so you are looking for rather quick and large returns on minimal investment, and there are three well-known strategies to accomplish this:
  1. Find a Blue Ocean – a completely new product where there is no competition
  2. Deploy a Christensen innovation – create a product that is much cheaper than what is currently available but still perceived as good enough by most people
  3. Identify an insertion point in a transaction intensive market and create a very sticky product to fill the hole with 
Unless you can create software to cure cancer, there are no Blue Oceans left in the shark infested waters of health IT, so #1 is out for most entrepreneurs. Christensen innovations are a-dime-a-dozen in health IT, and although some cheap innovations have worked better than others, health care is not a typical consumer market, and cheap stuff is considered almost sinful when life and death are on the balance. This leaves you with #3 which is particularly suitable for highly regulated markets, and ideal for chaotic ones. You may need to go through several iterations, but for illustration purposes, let’s pick one of the many possible roads you could take, and look at the exploding market of software for measuring physician performance.

Measuring quality of care provided by physicians is a government mandate. It is an excellent idea to hitch your business cart to funded federal mandates, particularly ones that are fuzzy, controversial and resented. The HIT market is flooded with EHRs that calculate quality measures and with dashboards and analytic tools that contend to do a better job. All these software tools cost small fortunes and when deployed on the same data, there is no guarantee that they will produce the same results. The raw numbers are rarely enough, and other sophisticated tools are needed to adjust results for comparison purposes. Major controversy exists regarding the quality of the measures themselves, the quality of the processing tools, the quality of interpretation, and to top it off, the measured are very unhappy with the entire affair. You may have your own hard feelings about the situation, which is a good thing, since being driven by a mission is infinitely better than a mercenary approach to entrepreneurship. What if you could step in at the point of purchase and provide assurance to both the measured and the measurers that the tools they are about to buy are reasonably fit for purpose? Not sure how to do this? That’s OK for right now, because first thing is first, and you need to create the need before you can ask people to pay you to satisfy it.

Step 5: Enhance Your Visibility

Now that you selected a business line, you will need an Internet presence and a platform to promote your innovation. You need a website and a blog. If you already have a personal blog or website that may be related to your practice, you will need to reevaluate the content and tone of your writing. More than likely you will be starting from scratch. Your website and your blog are your public image. It is imperative that you make a serious businesslike, yet innovative, impression. The current fashion dictates that your website is very white and very sparse, with very large high-quality dynamic graphics (please, no pictures of you sporting a stethoscope around your neck) and a small amount of tantalizing text in huge fonts. Your blog should also look Spartan and uncluttered. The favored color schemes are greyscale with small colorful accents, or the health care perennial favorite of smoky blue and ash grey with touches of faded neon green. Get this set up professionally and keep the website name on the generic side, just in case you come up with a better or somewhat different idea down the road. Start with a few awe inspiring sentences and build the content as you progress through the remaining stages.

Step 6: Build Public Awareness

Fear, uncertainty and doubt (FUD) is the synonym to “public awareness” in the world of sales, marketing and politics, as you should have learned in Step 2 and began practicing in Step 3 above. Continuing the quality measures example, and using the tools you developed in Steps 1 through 5, you should now launch a campaign to highlight the inability of any stakeholder to place trust in the hundreds of software tools employed to measure physicians’ performance. Don’t go overboard and discredit the shear notion of measuring performance, and do not alienate the software vendors (i.e. your future paying customers). At the same time, use your standing as a practicing physician (e.g. country doc, in the trenches, etc.) to elicit trust from your former peers, consumers and those who must privately (and begrudgingly) accept that when it comes to the actual practice of medicine doctors know better (e.g. payers, government, professional observers). You must use the language you learned in Step 3 and make sure that you are always perceived as an impartial, trustworthy and genuinely concerned visionary (it’s not as difficult as it sounds). Leverage whatever connections you managed to create so far, and those from your previous career, to make your voice heard. Publish, publish, publish…. However, do not let this Step drag out too long since there is always the possibility that a more expedient entrepreneur will help himself to the lunch you are preparing.

Step 7: Forge Relationships

The bad news is that you cannot do this alone. The good news is that if you did a good job in previous steps, and since you have an MD after your name, finding useful partners should be pretty straightforward, particularly if you set up your enterprise as a non-profit. You will need several types of partners and supporters. First and foremost, you will need a couple of big name public and/or private supporters (not necessarily financial supporters) to amplify whatever visibility you managed to create on your own, and to add credibility to your agenda. In our field of endeavor, ONC would be great, but decently sized technology companies with health care aspirations, such as IBM, AT&T or Microsoft may be even better. Large health IT vendors, maybe even sleeping giants like GE or Siemens are also good, and medical centers of excellence or reputable academic centers, like Kaiser, Mayo, Johns Hopkins, Intermountain or Duke, are a fantastic addition. In some cases, medical societies, private insurers and State organizations can add lots of value to your supporter list. If you are truly a country doc, you may need to dig up some old acquaintances from Medical school that chose a different path in life and renew some friendships that you may have discarded along the road. Expect to be buying lots of lunches and learn to not take rejection personally. Remember, you only need one good supporter to start the ball rolling. You will also need a couple of individuals (preferably somewhat known in the industry) with expertise in statistics, health IT standards and software testing, which will not be very difficult to find.

Step 8: Float Some Innovative Ideas

Once you have your infrastructure in place, it’s time to present your baby to the world. A word of advice here is in order. Health IT is a domain where intellectual property has no meaning; hence you better have your ducks in a row and ready to hop into the pond before you present anything specific. Going back to our example, after you, and your powerful sponsors, have convinced everybody that instilling some order in the chaotic market of quality measurement will save lives and money, you should now present your reasonably detailed plan to test and certify software that extracts and computes quality measures from clinical and administrative data. There are multiple methods you can utilize to make the case for the urgent need of a trusted and verified seal of approval for tools that affect the health of people and the revenues and expenditures of health care organizations. The nature of the partnerships you forged in previous Steps will dictate much of the marketing effort, but be prepared to help organize industry collaborative sessions and perhaps some conferences on the subject of quality and value-based payments (grind your teeth and keep your feet moving). Goes without saying that you will need to continue writing and speaking about quality and the pitfalls of disorganized and non-standard tools to measure performance, and hopefully by now you will be an invited keynote speaker at various industry venues.

Step 9: Deploy Your Innovation

Yes, Step 9 requires significant investment of funds. However, staying with our illustrative example, note that there really is no tangible product here, because there really is no problem that needs solving, so your only measure of success is going to be the number of vendors that voluntarily submit to your approval process. You will need a couple of market leaders to be early adopters (like anchor megastores in a mall), and if you picked your partners wisely in Step 7, you should be all set. From here on, you’re in maintenance mode with gradual expansion of value added services related to your original innovation.

Step 10: Enjoy the Ride

If all goes well with your startup venture, a liquidity event should become available to you in five years or so. Of course, every innovation is unique and your mileage may vary, but the principles are going to be very similar to those described here. You will have a few ups and many downs, long stretches of self-doubt, humiliation and borderline clinical depression, punctuated by the giddiness of a sudden breakthrough. The odds are overwhelmingly against you, and very few startups go beyond just starting up, but all in all, this is a most exhilarating journey.

These items are provided solely for entertainment purposes and are not intended as a substitute for consultation with a medical professional, preferably a psychiatrist specializing in midlife crises.

10 Steps to a Blockbuster Health IT Startup

If you are tired of practicing medicine, or are compelled to be your own boss, or for whatever reason decide to try something new, you should consider becoming a Health Information Technology (HIT) entrepreneur, because health care is a $3 trillion industry undergoing great upheaval and widespread computerization, and as John D Rockefeller used to say, you should try to turn every disaster into an opportunity. As a physician, you have a significant head start when it comes to credibility, and if you are a tiny bit technically inclined, your value will easily quadruple. There are many ways to go about this, and you can follow your heart and try to “fix health care”, or relegate your entrepreneurship to hobbyist levels and work on some app for this or that, or you can judiciously research the market and pragmatically choose an endeavor most likely to yield quick and overreaching results. For the novice and uninitiated, below lays a semi-serious roadmap for hitting the elusive jackpot.

Step 1: Establish Thought Leadership

There is some foundational work to be done first and you should begin long before you actually quit your day job. Thought leadership today means that you have several thousands of followers on Twitter, Facebook, Google+ and LinkedIn. If you don’t have accounts for these social media sites, go ahead and create them, with your real name and credentials, and tie them all together to form a unified identity that can be leveraged across platforms. Start posting fast and furious. This sounds hard, but there are apps out there that will let you cross and schedule your posts. It is very important that you do not take any sides in any political or medical debates, and that you do not express any original thoughts at this early stage. Your messages (about half a dozen per day) should be just hyperlinks to articles and scant neutral commentary (e.g. “interesting study on medical errors”). With the right tools, this should take you about an hour per day. Once people start “following” your thoughtful stream of updates, make sure you eclectically follow the important ones back, but don’t start following a large number of famous people in advance. The sure sign of a thought leader is that he or she has many more followers than he or she is following. Keep this up and let it simmer while you move on to other steps.

Step 2: Educate Yourself

Although you can rise to thought leadership status without knowing much about anything, our long term goal is different, so this is the time to begin exploring issues in health care, most of which you are probably aware of, but you need a deeper level of understanding to initiate decent market research while enhancing your thought leadership. Don’t worry about identifying specific problems and don’t get hung up on possible solutions at this stage. Just read a lot and make Google your best friend. Start with simple searches (e.g. “medical errors”) and follow the links from quality mass consumption media (e.g. New York Times, Wall Street Journal, and Forbes), government sites (e.g. CMS, ONC), and reputable health care sites and blogs (e.g. kevinmd.com, AMA news, Health Affairs, etc.). As you become engaged in this activity, you will discover other publications that are useful, and don’t forget the big medical journals (e.g. JAMA, NEJM). This education phase will cross-pollinate your social media efforts in Step 1 quite nicely.

Step 3: Master the Language

This is the last step before you are ready to speak up in your own voice, and this may be the hardest part for a doctor. As you go through Steps 1 and 2, you will no doubt notice certain terms and phrases that are used frequently by current thought leaders, decision makers and others who recently completed all 10 Steps. Make these phrases your own. You must become conversational in this language to advance to Step 4. So for example, if someone wakes you up at 2 am asking you who the best cardiologist in town is, don’t just blurt out Dr. Heartfelt’s name and go back to sleep. Instead you should immediately state that this question in itself is an example of “lack of transparency in health care” and that “standardized measurement of provider performance is key to value-based decision making by consumers and purchasers”. If you are chaffing uncomfortably in your chair right now, remember that you chose to leave medicine and patients behind, because that too was very uncomfortable, and this Step is very much like learning a foreign language; you don’t have to think or dream in the new language, but you should be able to converse with the natives and eventually write a little too.

Step 4: Formulate a Problem

The first thing to note here is that you need not identify an existing problem, although it would be fine if you did, because many successful businesses provide solutions to problems people never knew they had. This is your opportunity to be creative and innovate. Remember that you are trying to build a business, and not just any business, but a blockbuster HIT business, so you are looking for rather quick and large returns on minimal investment, and there are three well-known strategies to accomplish this:
  1. Find a Blue Ocean – a completely new product where there is no competition
  2. Deploy a Christensen innovation – create a product that is much cheaper than what is currently available but still perceived as good enough by most people
  3. Identify an insertion point in a transaction intensive market and create a very sticky product to fill the hole with 
Unless you can create software to cure cancer, there are no Blue Oceans left in the shark infested waters of health IT, so #1 is out for most entrepreneurs. Christensen innovations are a-dime-a-dozen in health IT, and although some cheap innovations have worked better than others, health care is not a typical consumer market, and cheap stuff is considered almost sinful when life and death are on the balance. This leaves you with #3 which is particularly suitable for highly regulated markets, and ideal for chaotic ones. You may need to go through several iterations, but for illustration purposes, let’s pick one of the many possible roads you could take, and look at the exploding market of software for measuring physician performance.

Measuring quality of care provided by physicians is a government mandate. It is an excellent idea to hitch your business cart to funded federal mandates, particularly ones that are fuzzy, controversial and resented. The HIT market is flooded with EHRs that calculate quality measures and with dashboards and analytic tools that contend to do a better job. All these software tools cost small fortunes and when deployed on the same data, there is no guarantee that they will produce the same results. The raw numbers are rarely enough, and other sophisticated tools are needed to adjust results for comparison purposes. Major controversy exists regarding the quality of the measures themselves, the quality of the processing tools, the quality of interpretation, and to top it off, the measured are very unhappy with the entire affair. You may have your own hard feelings about the situation, which is a good thing, since being driven by a mission is infinitely better than a mercenary approach to entrepreneurship. What if you could step in at the point of purchase and provide assurance to both the measured and the measurers that the tools they are about to buy are reasonably fit for purpose? Not sure how to do this? That’s OK for right now, because first thing is first, and you need to create the need before you can ask people to pay you to satisfy it.

Step 5: Enhance Your Visibility

Now that you selected a business line, you will need an Internet presence and a platform to promote your innovation. You need a website and a blog. If you already have a personal blog or website that may be related to your practice, you will need to reevaluate the content and tone of your writing. More than likely you will be starting from scratch. Your website and your blog are your public image. It is imperative that you make a serious businesslike, yet innovative, impression. The current fashion dictates that your website is very white and very sparse, with very large high-quality dynamic graphics (please, no pictures of you sporting a stethoscope around your neck) and a small amount of tantalizing text in huge fonts. Your blog should also look Spartan and uncluttered. The favored color schemes are greyscale with small colorful accents, or the health care perennial favorite of smoky blue and ash grey with touches of faded neon green. Get this set up professionally and keep the website name on the generic side, just in case you come up with a better or somewhat different idea down the road. Start with a few awe inspiring sentences and build the content as you progress through the remaining stages.

Step 6: Build Public Awareness

Fear, uncertainty and doubt (FUD) is the synonym to “public awareness” in the world of sales, marketing and politics, as you should have learned in Step 2 and began practicing in Step 3 above. Continuing the quality measures example, and using the tools you developed in Steps 1 through 5, you should now launch a campaign to highlight the inability of any stakeholder to place trust in the hundreds of software tools employed to measure physicians’ performance. Don’t go overboard and discredit the shear notion of measuring performance, and do not alienate the software vendors (i.e. your future paying customers). At the same time, use your standing as a practicing physician (e.g. country doc, in the trenches, etc.) to elicit trust from your former peers, consumers and those who must privately (and begrudgingly) accept that when it comes to the actual practice of medicine doctors know better (e.g. payers, government, professional observers). You must use the language you learned in Step 3 and make sure that you are always perceived as an impartial, trustworthy and genuinely concerned visionary (it’s not as difficult as it sounds). Leverage whatever connections you managed to create so far, and those from your previous career, to make your voice heard. Publish, publish, publish…. However, do not let this Step drag out too long since there is always the possibility that a more expedient entrepreneur will help himself to the lunch you are preparing.

Step 7: Forge Relationships

The bad news is that you cannot do this alone. The good news is that if you did a good job in previous steps, and since you have an MD after your name, finding useful partners should be pretty straightforward, particularly if you set up your enterprise as a non-profit. You will need several types of partners and supporters. First and foremost, you will need a couple of big name public and/or private supporters (not necessarily financial supporters) to amplify whatever visibility you managed to create on your own, and to add credibility to your agenda. In our field of endeavor, ONC would be great, but decently sized technology companies with health care aspirations, such as IBM, AT&T or Microsoft may be even better. Large health IT vendors, maybe even sleeping giants like GE or Siemens are also good, and medical centers of excellence or reputable academic centers, like Kaiser, Mayo, Johns Hopkins, Intermountain or Duke, are a fantastic addition. In some cases, medical societies, private insurers and State organizations can add lots of value to your supporter list. If you are truly a country doc, you may need to dig up some old acquaintances from Medical school that chose a different path in life and renew some friendships that you may have discarded along the road. Expect to be buying lots of lunches and learn to not take rejection personally. Remember, you only need one good supporter to start the ball rolling. You will also need a couple of individuals (preferably somewhat known in the industry) with expertise in statistics, health IT standards and software testing, which will not be very difficult to find.

Step 8: Float Some Innovative Ideas

Once you have your infrastructure in place, it’s time to present your baby to the world. A word of advice here is in order. Health IT is a domain where intellectual property has no meaning; hence you better have your ducks in a row and ready to hop into the pond before you present anything specific. Going back to our example, after you, and your powerful sponsors, have convinced everybody that instilling some order in the chaotic market of quality measurement will save lives and money, you should now present your reasonably detailed plan to test and certify software that extracts and computes quality measures from clinical and administrative data. There are multiple methods you can utilize to make the case for the urgent need of a trusted and verified seal of approval for tools that affect the health of people and the revenues and expenditures of health care organizations. The nature of the partnerships you forged in previous Steps will dictate much of the marketing effort, but be prepared to help organize industry collaborative sessions and perhaps some conferences on the subject of quality and value-based payments (grind your teeth and keep your feet moving). Goes without saying that you will need to continue writing and speaking about quality and the pitfalls of disorganized and non-standard tools to measure performance, and hopefully by now you will be an invited keynote speaker at various industry venues.

Step 9: Deploy Your Innovation

Yes, Step 9 requires significant investment of funds. However, staying with our illustrative example, note that there really is no tangible product here, because there really is no problem that needs solving, so your only measure of success is going to be the number of vendors that voluntarily submit to your approval process. You will need a couple of market leaders to be early adopters (like anchor megastores in a mall), and if you picked your partners wisely in Step 7, you should be all set. From here on, you’re in maintenance mode with gradual expansion of value added services related to your original innovation.

Step 10: Enjoy the Ride

If all goes well with your startup venture, a liquidity event should become available to you in five years or so. Of course, every innovation is unique and your mileage may vary, but the principles are going to be very similar to those described here. You will have a few ups and many downs, long stretches of self-doubt, humiliation and borderline clinical depression, punctuated by the giddiness of a sudden breakthrough. The odds are overwhelmingly against you, and very few startups go beyond just starting up, but all in all, this is a most exhilarating journey.

These items are provided solely for entertainment purposes and are not intended as a substitute for consultation with a medical professional, preferably a psychiatrist specializing in midlife crises.

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