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Thinking of starting a Health IT company? Here are top three industry challenges
- tel 14y agoI'm in the 7th month of starting a Health IT company and would be happy to answer (some) questions if anyone has any.
- rficcaglia 14y agoI'm in the 41st month of a Health IT startup and I'd be happy to give you a preview of the questions you havent even thought of :) Honestly if you can't fund full speed (dev, QA, support, sales, mktg, ops, clinical studies) for a minimum three years before the first hospital sale, assuming you are selling to hospitals, then get out now. Happy to shar war stories over a pint!
- tel 14y agoWe're not selling to hospitals, but we might someday... so that's a pretty damn good data point.
- Mz 14y agoI would be thrilled to pieces if either of you emailed me and let me know what you are up to, etc. Thanks.
- sgarg26 14y agoI have been in the health care industry for a long while. Also, working on a health care startup. If people have questions, I would love to assist.
- tel 14y agoI think I could only ask questions with more knowledge about what you've been up to. But I would love to learn more!
- wging 14y agoYour HN profile says you're at CloudAmp, which doesn't seem to be a health IT startup at all. What am I missing?
- rficcaglia 14y agoI'll spare the HN community self promotion, but I am worker bee and other roles at a few startups. Interestingly enough, Salesforce (CloudAmp's specialty) is being used in hospitals! scary, eh.
- tkl 14y agoHi rficcaglia, I would like to buy you a pint, or lunch, or coffee or something. Are you in the Silicon Valley area? Your email is not listed, but mine is. I am interested in natural language processing and machine learning in the medical field. Would you know anything about this?
- rficcaglia 14y agoSure - though I couldn't find your email so here's mine... Just add @gmail at the end of my id. Happy to chat...located in SF.
- chintan 14y agoHow do you find your sales lead? Specifically, my question is how do you identify a potential sale target? Is it through your connections. call calls or online ads?
- rficcaglia 14y agoPublish peer reviewed journal abstracts with data showing efficacy --- yes for software, not only for devices. Then present data at major conferences (though, you cannot be a presenter directly as it conflicts with vendor conflict of interest restrictions).
- chintan 14y agoThanks for the great advice!
- lucidrains 14y agoi've been thinking about how to create something that can disrupt the medical industry for a long time, ever since beginning medical school. the sad truth is that medical industry doesn't welcome software disruptions. software adoption is usually a bureaucratic process due to the direct risk to human health, not to mention HIPAA and other regulations. quality of the software is not as important as selling the software while offering strong credibility and insurance, which makes it significantly harder for the typical small agile team to succeed. i am at the point where im wondering if i should sacrifice my time and efforts on a medical startup or just settle for other challenges that are not so messy. regardless, software will fix our healthcare system one way or the other. it's probably just going to take a long time.
- rmorrison 14y agoI would recommend trying, especially if you have medical training and know the space. While it is difficult, with the appropriate go-to-market strategy and determination you can get a foothold and grow from there.
- guylhem 14y agoMedical credential will help, but not a whole lot. There is some strong interest in the market to keep things as they are, even if they are less efficient. Incentives are not aligned at all.
- lucidrains 14y agoyeah, i've realized this as well. you certainly don't need any medical training to recognize the inefficiencies in the hospital.
- rficcaglia 14y agoI recommend not trying - not for profit anyway - unless you directly influence (did they come to your birthday party?) multiple people at the C-Level at 2 or 3 major hospital prospective customers, ideally academic research centers, depending on your idea
- lekanwang 14y ago"Your customer’s incentives are not straightforward." So true. Don't mean this to be cynical, but if you actually want to have a chance of upending the healthcare system, always clearly identify the flow of money (are costs paid by carriers? providers? Medicare? consumers? are the prices negotiated?), regulation (are fines built into the cost structure? what regulations are relevant? are they incentivized to be ignorant?) , and decision-making (e.g. how billing departments more often decide on the EMR to go with rather than the docs). Then check again, because it's likely you missed a huge underground river. Then the tricky part is to align your business plan with your customers' incentives.
- guylhem 14y agoAs a health IT professional who did try, and will try again in 2013, this article is spot on. There are differences between France and the US - especially in the mindset - but the payment system is very similar. In fact, the current french system (used for hospital billing since 2004, and tested for 10 years before that) was based on the US medicare DRG approach. My job is to make patients pay as much as we can legally make them pay, using any mean necessary as long as it is legal. In the past, my unit was the single most profitable in the whole hospital, by large. So I tried to sell things, and failed. I would like to insist on the "incentives" topic with a quick example: I previously developed production analysis software to find and exploit the cases where an hospital could be more efficient and thus make more money (long story short, see one of my previous posts on http://news.ycombinator.com/item?id=4826314 http://news.ycombinator.com/item?id=4826314 for more details) As I like to say, this is as good as printing money - I can say precisely what should be changed in a billing statement, why, how much it will gain, and the probability to find matching evidence in the patient file. I can calculate an expected return, so that on small cases you can use unqualified personnel, while it might be worth to have a doctor study every page of the patient file for high profile cases (since, if you don't have evidence to back your billing claim, you are legally liable - it's not unusual for a large hospital to be fined sums with 6 digits if during an audit mistakes are found) I tried to sell the software, with a commercial partner. In a year, we could only find a single client in the whole french public hospital system!! Want to know why? The improved productivity - short term financial gains - can be used to demonstrate that the civil servants in charge were not as efficient as they should have been, or that they should hold to that level of efficiency in the future. That's just like the OR example in the article - they don't want to be more efficient because basically, making more money is a liability to the top management personal career. I was quite disgusted by this twisted way of seeing things. Medical credentials did not help me. Efficiency was not welcome. Improving one's profile, even at the expense of whole hospitals profitability, was. I did not explore that much, but there seemed to be a demand for a service to selectively reduce profits, to maximize government subsidies in some units - something utterly disgusting for a libertarian. I didn't think I could do that, so I stopped. I will try again very soon, but now I will make sure to carefully study the incentives, and do something I can morally agree with.
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- eclipticplane 14y ago4th challenge: what's legal in one state may not be legal in another and may change with every legislative session. If your customers are physicians and other practitioners, the state laws are even more complicated as to who any data belongs to. In some areas, any data about patients is technically owned by their physician. If you're contacting patients, your attorneys will debate at length whether something is legal under the rules of HIPAA. In the end, it will be a much ado about nothing, because HIPAA is barely policed or litigated over. So you'll end up with a large legal consulting fee, a confusing legal opinion, and no clear direction on whether to move forward or not. The next attorney will have a wholly different opinion. Healthcare law in the US is absolute shit.
- mcphilip 14y ago> 2. Good enough is not good enough I don't think this really sinks in until you work in the industry. As an example, I knew of a developer who accidentally forget to make a list page scrollable and it got through QA that way. I heard rumors that ultimately the bug resulted in a patient being given the same immunization twice since the user was unable to scroll down the list page. And that's a relatively benign example...
- jordan0day 14y agoI'm not sure the point the original article was trying to make -- in reality, a lot of HIT software is terrible. "Good enough" would be significantly better than a lot of the crap that is out there.
- sachinag 14y agoThis article understates the issues delivering software solutions to patients, providers, or payers. The lack of data standards has completely crippled the ability for new companies/products to innovate and break through. When I worked at a healthcare VC, we deemphasized IT in favor of medical devices because the path for success is much clearer and easier to trod. The reason I can be so confident that it's the data standards, BTW, is because the DICOM data standard exists for medical imaging. IIRC, the founder of Heartlab invented the format, it somehow escaped a proprietary home, and dozens of companies innovated on top of it. The existing EMR vendors - GE, Cerner, Epic, etc - all have proprietary data standards for storage and interchange. My due diligence on this revealed that the companies would each have to spend three years re-writing their software against a common data standard. Of course, they should have to. It would help patients immensely and all sorts of innovations would spring forth, just like after DICOM.
- drstewart 14y agoWhat about HL7?
- lucidrains 14y agoit's delimited by pipes... i mean, it is a standard, but it's far from ideal.
- narcissus 14y agoTechnically it's delimited by whatever character is decided to be the delimiter, which is even better :) Having said that, it still seems to get data between all sorts of systems in the hospital.
- markmark 14y agoIn my experience with HL7 it's a standard, but every single system you talk to you need to write custom code to handle them, because everyone talks the "standard" a bit differently. [edit] and as for the XML v3, nobody uses it. Nobody.
- error54 14y agoAs a current developer for a health IT company, much of this is true. Even with the current incentives to go electronic, many doctors just simply prefer paper charts and are willing to forgo the $40k a year just to keep things the status quo. My particular company is growing by leaps and bounds because we started with a very simple Practice Management model and grew out from there whereas I see a lot of startups try to jump directly into EMR's which can be a tough market to crack. But for anyone looking to get into Health IT, I highly recommend it. Healthcare is a multi-billion dollar industry that is in dire need of some disruption and the programming challenges are both interesting and rewarding (shameless plug: we're hiring).
- FireBeyond 14y agoYou should also consider the pre-hospital field - a paramedic/EMT in the field with a Toughbook, etc (where they're not still with paper) is typically using horrible software, with little flexibility to what by nature can be a rapidly changing encounter. I see this every day, and hear the cursing that accompanies it, and think to myself that there is so much that could be done to improve this.
- error54 14y agoThat's a really great idea and honestly, our biggest problem now isn't a lack of work but rather a lack of programmers. The entire health care industry from the EMT's up to the hospitals really needs an overhaul as some of the software used is decades old.
- desigooner 14y agoWhat I've observed is that it's hard to get the decision makers listen to you and often, they're unwilling to invest any more than they've already done towards any solution. Granted these conversations were mainly concerned with a SaaS based solution targeted towards HR & Administrative Operations vs. the field techs.
- z00mer 14y agoe54 : What are your contact details?
- FireBeyond 14y agoSome quite good points: "For example, inside a hospital, operating rooms (OR) are often profit centers, and emergency departments (ED) are often cost centers. The hospital may be receiving subsidies to maintain its EDs based on its ratio of OR profits to ED losses, in which case a product that ultimately makes ORs more profitable may not be worthwhile to the hospital." To an ambulance service (emergency and pre-hospital medicine is my area/passion), IFT (Inter-facility Transport) is a near guaranteed paycheck, 911 response is generally a cost center. DrChrono has it good, because the government will pay their customers (the doctors and facilities) for the implementation. But it's definitely an area that could do with some work in unseating some entrenched and ultimately complacent incumbents.
- skue 14y ago> DrChrono has it quite good, because the government will pay their customers Only if their customers can document, attest, and verify that they meet the standards for Meaningful Use as required by federal law to receive their subsidies. And this can be a considerable burden for the smaller practices that DrChrono targets. Plus consolidation within the industry means their market is shrinking as larger hospital systems buy up small practices and move fold them into to their hospital-grade EMR systems such as Epic, Cerner, and MEDITECH - all while these larger EMR companies are concurrently giving their products to small practices in order to become regional standards. Plus, for those remaining practices they have a LOT of competition - there are literally thousands of outpatient EMR solutions, including Practice Fusion, which is well established and free, meaning providers can pocket the subsidies. DrChrono is a great technology, but don't think they don't face their own challenges.
- xxpor 14y agoIs 911 response REALLY a cost center? Around here, to get an ambulance, it's $500 (IIRC) up front + $16(!!!!!) a mile. And the closest hospital might be 10 or 15 miles away. And I dont think this includes material costs (any drugs, etc.)
- FireBeyond 14y ago911 response, unless ran very well, and / or miserly, is absolutely often a cost center. You have "frequent fliers" who you may see several times a week, without insurance. Billing sends them a bill, but there's no realistic expectation of payment. You can't, even as a private agency (and should 't - for better or worse, I'm a proponent of "socialized" medicine, even in bastardized form) refuse a patient transport, though about the best you can do is advise a patient that their insurance is unlikely to pay if the ambulance transport does not have. "medical necessity", even with (especially with) Medicare (who requires us to get a document from the physician stating the necessity of "transport in a fully equipped BLS/ALS ambulance"). Add to that Maintenance, drug purchase (must be kept stocked and current, even if rarely used), fleet Maintenance (driving code in a truck carrying N extra 10-15000 lb at high speed places a lot of strain on a vehicle), insurance (likelihood of an accident), insurance (malpractice in this area is usually carried by the agency, not individual), regulatory and other costs, costs of maintaining sufficient crews on duty so you can respond even when others are out doing long distance transports (hospitals to nursing homes, home, or stabilized patients to bigger or more appropriate hospitals) or transporting your frequent fliers, and it begins to add up.
- ryanteo 14y agoHi everyone, happy to chime in from an Asian perspective. I'm Ryan, based in Singapore and tried to co-found an online platform for procurement of medical supplies for private clinics. Faced many of the industry's frustrations as expressed in this discussion too. Would be happy to share my experience too.
- yen223 14y agoHi, I'm curious, how big, do you think, is the medical IT market in Singapore?
- superchink 14y agoI'd say it's pretty big. I'm somewhat familiar with a national project for exchange of clinical data and it's in the hundred million dollar range.
- Mz 14y agoFor those saying they would like to chat, I have started a posterous group called Health IT: http://health-it.posterous.com/ http://health-it.posterous.com/ Consider yourself invited.
- Mz 14y agoFor those interested in joining, you may have to shoot me an email to be added. My gmail account: talithamichele.
- ams6110 14y agoI would add that "agile" development is a hard sell to institutional customers. They want one or two releases a year, tops. Certainly not monthly and absolutely not continuous. "Change management" committees will become your own little hell.
- intractable 14y agoIn my experience, one of the most significant hindrances has been access to and communication with medical personnel: - Medics, especially specialists / surgeons, have extremely busy schedules, often holding down both public & private patient responsibilities as well as performing duties for their specific colleges etc. - The level of IT-savvy amongst healthcare pros is generally low. - They seem to have a different logic to us IT folk, answers are nebulous for non-medics and hard rules are very difficult to pin down. Ask the same question n times and you will get n different answers, from the same respondent. When you find a medic who is willing / able to help and towards the positive on all the above axes, you must hold onto them with a death grip.
- rficcaglia 14y agoSurprisingly I work with a lot of MDs who think communication and lack of professionalism and thoughtfulness in software engineers is a significant hindrance to success. - Medics have extremely busy schedules and so they don't want to have their time wasted by lack of data, lack of rigorous testing, and risk to their patients. Software pros work in cozy offices not splattered in patient fluids, from 11AM - whenever, and yet don't expend the extra effort to statistically test data, design efficient algorithms and user interfaces, etc., before throwing something over the wall as a MVP. - The level of healthcare savvy among software pros is generally pretty low - MDs seem to have a logic that focuses on quality, meticulous attention to detail, going the extra distance without added compensation, acceptance of hard and legally binding rules about ethics, data collection, privacy, security, efficacy, peer review, etc.. Run the same software program n times and you will get n different bugs, from the same software developer. When you find a software pro who is willing / able to help on all the above, you do need to hold on to them (and pay a high market salary, with good health care benefits, and reward them for quality and precision vs. MVP attributes.)
- sgarg26 14y agoIn the current environment, health care IT solutions will go further if they help professionals and patients do 'more with less' instead of 'more with more'. The dynamics in the article are real, but there are tons of way around the challenges posed. The article to me says that the market has yet to be cracked, but the opportunity is still pretty huge.
- rficcaglia 14y agoUnfortunately the entrenched attitude is do 'less with more'. There are ways through the challenges posed - but not 'around'. YMMV. Until patients pay directly for their care and have transparent pricing, I don't anticipate real innovation. (of course examples exist of innovation within the current system: Athena Health, One Medical, PracticeFusion, ZocDoc - but all of these took quite a lot of time and effort and funding to punch through the barriers noted in the article...so yes, it is possible, you are correct). That said the current (US) system rewards existing thinking and does not encourage efficiency and outcomes and patient satisfaction.
- pionar 14y agoThis could really be for any enterprise IT company.
- wging 14y agoEh. If you send out two shipments of Doritos, nobody dies. If you administer a med twice, a patient very well could die. Consequently, if you make it even 1% more likely that a med will be administered twice, patients will die.
- rficcaglia 14y agoAbsolutely true. That said, software should never replace human thinking (until the singularity, Ray) and the clinician must be the final authority. Same goes for pilots - the software can help, but as too many pilots have discovered, looking only at the instrument panel (especially one instrument) is a bad idea, speaking from experience ;)
- anon6567 14y agoI got this pitched to me a couple of months back, but why not start a Yelp-like medical tourism service? Americans can save a ton of money going to S. Korea or anther country with similar healthcare standards at the fraction of the price. It would have to be elective surgery, but you can save a ton of money.
- dawson 14y agoOT: There are a lot of people in this thread thinking about starting or joining a Health IT company. I'm hiring (> 7) engineers, happy to help (answers questions, make introductions etc) or hire, email is in profile.