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As I write this, the entire digital healthcare community is emerging from the surprise and urgent need to deliver care to millions more people than we were prepared for as COVID-19 swept the country.
There’s no doubt in my mind that the industry saved (and continues to save) lives by providing medical treatment online and keeping people out of emergency rooms and urgent care clinics.
It’s hard to believe that just 10 years ago, consumer-focused health technology companies were rare.
At that time, I was searching for my next entrepreneurial calling. I was a pre-med & biomedical engineering graduate with serial tech startup experience in online social gaming.
Was there an intersection between these world’s — where I could combine my skill in engaging consumers online with my penchant for helping people live happier, healthier, longer lives?
Lucky for me, it was also the time that Silicon Valley began to turn its attention to consumer- and provider-focused healthcare innovation.
With the advent of smartphones and mobile apps, medical technology experts who built enterprise software like Electronic Medical Records (EMR) and billing systems succumbed to the allure of the much sexier and potentially much more disruptive ideas of transforming the actual healthcare experience.
An explosion of startups fueled the industry’s innovation — nearly 8,000 healthcare-related startups were founded in the last decade.
But most startup teams back then consisted of smug doctors who knew little about building engaging consumer apps or smug tech entrepreneurs who knew little about delivering and selling healthcare.
On Stanford’s campus, I was lucky to meet a group of refreshingly diverse experts — a technologist, a medical informatics physician, a community builder, a privacy lawyer, and a product designer. All of whom shared my passion for creating digital experiences that would transform the way people access and use healthcare.
The group’s core premise was simple and refreshing. Healthcare is a marketplace of supply (doctors) and demand (consumers). Disruption would come from these two parties adopting a new way to “transact” with each other.
We agreed that partnering with a major insurance company or health system could potentially give us instant scale, but we couldn’t imagine these organizations moving quickly enough or even giving us the time of day. At least at that time, they were likely to be more interested in preserving the status quo.
Besides, we were in Silicon Valley, the land of entrepreneurs. We’d do it on our own.
So I joined the team. Now came the hard part — what were we going to build?
In 2010, “telemedicine”— connecting with a doctor online — was not the focus of innovation in the startup community as it is today. And it wasn’t our focus either.
We started by asking: what are consumers’ pain points in healthcare? What did they need or want that the current system wasn’t delivering?
We didn’t have the money for proper consumer research, so we gathered groups of local moms to talk about healthcare — what they did when they or someone in their families got sick, step by step.
We asked them to tell us where the current systems fell short, and what was working well.
When people first experience a health symptom or have a health concern, they take to the internet. In fact, they often want information only, and are not interested in or ready to see a doctor. According to Google’s own estimates, there are 1 billion health searches each day compared to just 1 million doctor visits in the U.S. in the same time periods (one thousand times less!).
But, seeking health information via search engine is likely to be both ineffective and terrifying. Even from reputable sources, online health information lacks crucial clinical context.
Of course, there are many more unreliable sources of information online than reputable ones, and it’s often difficult for the average consumer to tell the difference. In a 2016 blog post, Google admitted “... health content on the web can be difficult to navigate, and tends to lead people from mild symptoms to scary and unlikely conditions, which can cause unnecessary anxiety and stress.”
To this day, at HealthTap we joke that every headache turns into a brain tumor in two clicks or less.
So this was our idea — build an online health information service that instantly provided trustworthy and personalized answers to any consumer health question.
How we did it continues to be what sets HealthTap apart in a sea of digital healthcare juggernauts and upstarts.
The goal was to make doctors’ knowledge instantly accessible at scale. To do that, we took a page from the playbooks of Quora and StackOverflow, which crowdsource answers to questions from experts who respond on a volunteer basis. Then, the answers are qualified based on peer-reviews and user feedback.
The two components of the experience work together. First, the ability to ask an anonymous health question and get a personalized answer from a board-certified doctor in 24 hours or less. Second, the ability for anyone to search this vast repository of valuable content to get instant, trustworthy health information with actual clinical context.
We started by focusing on new and expecting moms asking questions of pediatricians and gynecologists. From there, we methodically recruited doctors from different specialty areas and made them available to answer questions from consumers.
Today, HealthTap Doctor Q&A has more than 90,000 doctors across 147 medical specialties, and millions of easily searchable patient-asked, doctor-answered questions.
Many people ask, why would busy doctors spend time answering questions online for free?
The answer sounds pollyannish, but it’s true. Most doctors become doctors because they want to help people.
As the medical industry has become fraught with inefficiency and inequality, HealthTap gives doctors an unencumbered way to do what they love. HealthTap doctors:
After setting the Doctor Q&A flywheel in motion, we set our sights on the next step: providing care.
Doctor Q&A took care of many issues, but there would always be people for whom the next step was seeing a doctor. So in 2014, we launched virtual doctor visits.
Patients could connect with a doctor on-demand, 24/7 by text or video. Doctors could diagnose symptoms and provide treatment, including prescribing medicine, order lab tests and results, and refer specialists.
For us, telemedicine was never the end in itself, but rather just one step in what would ultimately be a comprehensive virtual healthcare experience.
Of course, not all medical issues can be solved with virtual care.
In many cases, HealthTap doctors recommend that patients follow up with a specialist, engage with a primary care provider to manage a chronic illness, or even go to the emergency room.
Technology could make that better, too.
So we built a system whereby HealthTap doctors could seamlessly hand off care to the right in-person provider. Through partnerships with clinics and practices, like the one we recently announced with Cerner and their on-site and near-site employer clinics, we made it easy to access nearby doctors who accepted a certain insurance, share medical records, and make appointments — all from the HealthTap platform.
As we continued to expand HealthTap’s role in patient care, we gained a vital insight — people aren’t good at following doctor’s orders.
Sometimes they forget important pieces of what the doctor said, are overwhelmed with the volume of instructions, or write down the information but lose the piece of paper. Often people know what they’re supposed to do, but forget to do it in the moment.
Technology could help here, too.
Because HealthTap already saved all doctor’s notes from virtual visits for future doctor and patient access, we decided to turn these notes into digital treatment plans with automated reminders and checklists for patients.
This way, doctors only recorded the information once (software creates the treatment plan), and patients didn’t have to write anything down, remember, or keep track of anything.
Their treatment plan was always a few taps away. And it reminded you to take your medication, show up to an appointment, or complete your therapy exercises.
Naturally, when people follow their doctor’s orders, they get better health outcomes. Another example of virtual care and in-person care working together to support patients’ health.
It's just that people aren’t always good at following doctor’s orders.
At HealthTap, we believe that patients should have access to their own medical records at will, and that doctors can provide better care when they have access to comprehensive medical information.
As we all know, access to and ownership of consumer medical data is fraught with controversy. Tech giants, like Google (Health), Microsoft (HealthVault), and Apple (Health Records), have launched consumer-owned integrated health record platforms. But none have achieved the level of consumer adoption that these companies expected. At least not yet.
We think there are two main reasons for lackluster adoption.
HealthTap solves for both.
Patients provide a wealth of information before and during their virtual doctor visits because they know it’s directly related to their care.
HealthTap does most of the work for our patients and our doctors by automatically recording and safely storing HealthTap records in one place, and making it easy to upload records from other sources.
By building applications and digital services on top of an interoperable medical record, we were able to merge provider-entered medical data with patients’ self-reported medical data successfully at scale.
Now, with memberships like the CommonWell Alliance, HealthTap can also sync data with hospitals and health systems nationwide based on a set of agreed-upon national standards.
This means that only HealthTap safely stores medical records from our own doctors and others, and provides 24/7 patient- and doctor-access to them — and the records are part of the same digital experience as the care itself.
We can’t discuss digital healthcare without touching on AI and “chatbots.”
For HealthTap, using machine learning and AI was a natural progression as we continued to enhance and improve our customer experience. We already knew that people want to understand their symptoms and either get instant online care or guidance about what other kind of care they should seek. It was abundantly clear in the pattern of questions people frequently submitted to our doctor network.
By 2015, people had billions of data points from user searches, questions and answers, and reasons for virtual visits. This created an opportunity to develop an AI-powered symptom checker that could be used to support our human doctors, and vise versa.
In the beginning, we started with a list of symptoms and conditions that were both common and potentially “easiest” to be diagnosed by computer algorithm, like cough, fever, and back pain. Then we created a conversation-style interview experience to:
When patients used HealthTap AI and subsequently saw a HealthTap doctor online, we automatically sent the results to the doctor in the form of pre-populated visit notes. That saved the doctor time and labor and allowed her to go straight to asking more detailed questions and providing treatment. Then, the doctor’s diagnosis was fed back to HealthTap AI to further train the algorithm.
While there are several AI-powered symptom checkers available today, none that we know of automatically provide results to human doctors at the time of care and use the human doctors’ findings at scale to train the model continuously.
People want to understand their symptoms and either get instant online care or guidance about what other kind of care they should seek.
HealthTap's product development journey over the last decade in many ways resembles the typical journey for consumer in healthcare. It started with the need for online information; then connecting people to care virtually, while enabling discovery and appointments for care locally; and then fulfilling treatment plans while helping consumers adhere to them to manage their conditions. To top it off, we added a layer of artificial intelligence to orchestrate the consumer journey to achieve better and more optimal results.
We call it engaging consumers from query to cure.
As we look to the decade ahead, there is a tremendous opportunity to integrate multiple and disparate health systems and data sources in a way that’s low-friction for consumers and providers. You begin to see a picture of end-to-end, seamless consumer applications with a comprehensive and connected set of flows.
Essentially, the emerging idea is to create a “Digital Front Door,” which lets consumers and providers easily access and navigate various types of care, providers, methods of payment, and more.
You begin to see a picture of end-to-end, seamless consumer applications with a comprehensive and connected set of flows.
This year brought a confluence of circumstances punctuated by the COVID-19 pandemic. As I type, the ground is shifting beneath our feet.
With healthcare technology, there’s an opportunity to make a lot of money, but at the same time, do tremendous good by creating efficiencies, increasing access to care, and lowering costs.
The U.S. spends approximately $3.65 trillion per year on healthcare. Yet by some measures, at least two thirds of ER visits are unnecessary or non-urgent. And most of the 883 million primary care visits in the U.S. annually can be replaced with more efficient virtual visits (a $280 billion market).
Of course, the industry knew about these factors years before COVID-19, and has been grappling with how to improve the system (and make money doing it).
One of the most popular theories on how to do both is to create the “digital front door,” meaning the first point-of-contact for consumers seeking healthcare products and services. When customers come to the front door, the healthcare enterprise guides them along their desired path.
Popular thinking is that everyone in the industry should create a digital front door, as captured in this article from the influential J.P. Morgan Healthcare Conference: “Create the Digital Front Door — or Someone Else Will.”
It’s true that having a digital access point is essential for providers and insurance companies to simply participate in the modern consumer market. It's akin to every retail brand standing up their own e-commerce experience. As a result, insurance companies and health systems are launching their own, branded apps with largely overlapping and commoditized functionality, like accessing medical records, scheduling appointments, messaging your doctors, checking your bills/claims, and starting a telemedicine visit.
However, I don’t believe that insurance companies, hospitals, and health systems should spend significant time and effort to create their own "best" digital front door. They have different work to do — like improving the delivery or payment of healthcare. Major tech or retail companies and technology startups are better suited to successfully create digital experiences that are truly differentiated and scale nationally. In fact, many have even already tried.
So given the massive commercial opportunity, why hasn’t one company emerged as a clear leader? The best answer is probably: it’s complicated.
As I mentioned in my last post, aggregating healthcare records and data puts work on the consumer, and as of yet, there’s not a clear benefit for them to do it because there's not a compelling benefit.
Google Health, Google Helpouts and Microsoft HealthVault were all shuttered. Even Amazon’s joint venture with J.P. Morgan and Berkshire Hathaway, Haven, is struggling. Apple Health Records has yet to achieve meaningful adoption by consumers, providers, and developers.
Looking at every sector of the industry, there’s no clear answer as to who would be successful alone.
Ben Thompson’s aggregation theory helps explain why Internet companies like Amazon, Google, Expedia, Netflix, and Uber transformed their respective consumer markets. They aggregated online consumer demand to steer customers to whatever group of suppliers they decide to work with.
The same will be done for healthcare. Rather than a front door, I think of the ideal distribution system as an open marketplace.
The aggregators, or distributors, in my prediction will be consumer tech or retail companies. Those with the best online experience will attract the most consumers, and thereby attract the best suppliers.
The suppliers include those insurance companies and providers, and those that offer the best products and services will win, competing equally in an open marketplace.
No longer do distributors compete based upon exclusive supplier relationships, with consumers as an afterthought. Instead, suppliers can be commoditized leaving consumers as a first order priority. By extension, this means that the most important factor determining success is the user experience: the best distributors win by providing the best experience, which earns them the most consumers, which attracts the most suppliers, which enhances the user experience in a virtuous cycle.
— Ben Thompson, Stratechery
Not surprisingly, talking about a successful marketplace means a reference to the famous Amazon Flywheel, which most people reading this are likely familiar with. In a nutshell, create a lower cost structure, create efficiency and lower prices, which attracts consumers, which attracts more suppliers competing for the consumers, and so on.
The winning formula for healthcare:
A marketplace like this could offer up a variety of doctor visit options with transparent pricing and consumer reviews, which could be booked and paid for through the platform.
Consumers will not search for specific products and services. Instead, they’d start with a symptom or concern, and the platform would guide them to the best healthcare products or services for their needs.
The competitive moat would deepen as the brand grows stronger and the technology continuously improves at processing natural language queries, triaging cases with machine learning, and matching consumers to goods and services.
Building this marketplace requires holistic thinking, operational excellence, and sheer will.
We should strive to have an engaging, comprehensible, interoperable healthcare marketplace, enabling access to urgent care, primary care, specialty care, meds, labs, & goods, virtually, locally, or at-home.
I already outlined the advantages and challenges of each kind of player in the industry. But there’s one thing we haven’t addressed yet: the U.S. government.
I recently had an exchange on this topic with Dr. Geoffrey Moore, the renowned organizational theorist who wrote “Crossing the Chasm,” and he made a valid point: The government will be wary of any single private entity controlling access to the nation’s healthcare system.
That’s why I believe there will be a handful of powerful collaborations made up of lead players from each area, maximizing the strengths of each player.
Surely, insurers will continue to innovate ways to effectively pay for care all Americans. And providers will continue to innovate ways to reduce the cost and improve the quality of care. We now also need organizations focused on creating national consumer brands and aggregating Americans’ demand for healthcare goods and services into efficient private-sector marketplaces.
The future titans of healthcare will be the ones who unlock this vision, and they will usher in an era where healthcare is more affordable, convenient, and accessible than ever — a feat no less historic nor less impactful to the field of medicine than the inventions of antibiotics or vaccines.