Learning from the Signs

This post was originally featured on HIStalk.

As a product manager for a suite of clinical applications, I get to play translator / arbiter among clinicians, programmers, IT, QA, and trainers. I get to see things from both sides of the table: the hospital’s side and the vendor’s side.

At a hospital site last week, I noticed something for the first time. Signs. Lots of them. Everywhere. And by chance, Paul Levy of Not Running a Hospital just wrote about signs, too.

CAUTION. AUTHORIZED PERSONNEL ONLY

NOTICE: RING BELL BEFORE ENTERING.

RESTRICTED AREA. GET PERMISSION BEFORE ENTERING.

Literally everywhere you look in hospitals, there are signs telling you what to do and not to do. Big brother is constantly watching and guiding you, making sure you do exactly as he wants. You don’t dare step out of line, and if you do, the proof that you should have known better is on the video cameras and walls. Ignorance is bliss, and you can’t claim ignorance.

Then I thought about my white collar office job, where we have about 100 employees. The only instructive sign (that isn’t inappropriate or an inspirational poster) that comes to mind is one above the sink that reminds people to refill coffee when it runs out, wash it down the sink, clean their own dishes, etc. The sign is hysterical. Check it out.

It’s interesting to compare and contrast these two vastly different organizational cultures. The practice of medicine is paternalistic, not only within hospital hierarchy’s organizational structure, but even in the doctor-patient relationship itself. "Do what the doctor tells you because he’s the doctor." The connotation around ORDERS is very top-down. It’s a direct order. You must do it.

Of course you must lock your computer when you leave, enter pass codes to go through doors and log in to IT systems, bar code scan everything that you do, and look only at the charts you’re supposed to, all while being monitored by security cameras at every corner. You do your job per protocol, always. There are no exceptions, no oopsies. If there are, big brother knows and there are sure to be forms filed and licenses revoked if you step too far out of line.

Startups are radically different. Anything goes. Sexual analogies and innuendo are woven through most conversations, cursing is rampant and often encouraged, and everyone is trying to make as much noise as possible. You have to be loud to be heard among the other 390,820,324 startups that are just as trivial as yours. There are standouts, but the startup community is just anarchy that pretends not be. The only thing maintaining a semblance of order is a shared dream: build awesome stuff that makes lots of money.

For health startups, this presents a fun challenge. Be crazy, be wild, make noise, and be just little bit obnoxious. But be professional, be sterile, be formal, and always maintain an image that your mother would approve of.

Health IT startups walk on cultural balance beams. It’s a blast.

Samsung@Home

The biggest announcement at Google IO 2011 turned into vaporware: Android@Home. What a shame. The dream was so ambitious. I understand why Google gave up on it though: the reward-to-work ratio was quite small, so Google shifted its resources to projects that would deliver more value more quickly.

There were a few major challenges to bringing Android@Home to market. Collectively, these killed Android@Home:

1. Partnerships with thousands of companies, many of which have very little to no expertise in software. Supporting these companies would consume an inordinate number of resources.

2. Marginal value - most people don't mind turning off their lights, unlocking their doors, or turning off the AC. Sure, these activities could be automated, but the automation really doesn't improve quality of life in a material way.

3. Lack of existing infrastructure - most homes lack the infrastructure to really support Android@Home in a meaningful way. Apartment-dwellers cannot make significant modifications to their homes, nor would they invest in appliances knowing that they're going to move out in the next 1-2 years.

4. Slow adoption cycles - people aren't in a rush to change out their appliances. They're big and expensive. Most people are content with the $1000 refrigerator they bought 3 years ago; they're not in any rush to spend another $3000 on a "smart" refrigerator this year.

5. Oligopolies - ovens, refrigerators, microwaves, washing machines, etc - are capitally intensive to develop, market, and distribute. All home appliance industries are effective oligopolies dominated by a handful of multinational, multi-billion dollar conglomerates. Startups cannot compete.

In retrospect, it's no surprise Android@Home died. The challenges were immense, and the reward not that profound.

Samsung is slowly fulfilling the Android@Home void. Samsung employs hundreds of engineers that understand Android, and Samsung competes in most major home appliance markets. They're slowly integrating Android into every appliance they produce - refrigerators, washing machines, and TVs to name a few. I'm sure we'll see Android make its way into ovens, stoves, and more too. It's probably unlikely these devices will communicate directly with one another, but they'll all connect to smartphones via apps on the phones so that the appliances can be controlled wirelessly and away from home.

Expect Samsung to sell modular, configurable packages for the "connected home" in the next few years. I find it hard to believe that Samsung is putting Android in everything it makes with no long term vision of connecting them together to sell a dream: the smart home. It's pretty easy to envision the marketing campaign. If Samsung is willing to provide all of those appliances at competitive prices with non-smart appliances, they could provide a very compelling package to home builders such as Dr Horton, and custom-home builders alike.

(International) White Collar Healthcare

This post was originally featured on HIStalk

I visited Peru a few weeks ago to present a hospital-wide HIS and EHR to three hospitals. Over the past three years, I’ve presented EHRs and HISs in half a dozen countries including Peru, Canada, the UK, Saudi Arabia, Iraq, and Malaysia.

I am worried for these staff at international hospitals. I thought EHR implementations were difficult in the US. It’s going to be nearly impossible abroad. They are going to make a lot of terrible mistakes on the path to health IT success.

I’ve argued before that mistakes are good, but these folks abroad will make far more mistakes than they should. I see two fundamental problems: an expectation problem and an executional ability problem. Both are rooted in a lack of modern white collar organization and skills.

The first and perhaps most glaring problem is contract structure. Many international governments don’t actually understand what they’re purchasing. They look at EHRs as an isolated bubble. They structure the tender as if the EHR is a physical product. The vendor must commit to a hard timeline, and if the timeline is missed for any reason, the vendor is penalized.

The governments do not budget for deployment costs, training, or support, but expect a "warranty" on the software. They will not pay for deployment or training expenses as they occur. Perhaps most egregiously, the hospitals will not pay their vendors a penny until the hospital issues a seal of approval on the final, delivered product. They have adopted a hardware contract — for example, a contract for a hospital bed — and applied it to an organizational-wide process change. This is a recipe for disaster.

US industry veterans know that this is untenable. No vendor would ever agree to those terms. EHR vendors have performed dozens if not hundreds of deployments, but for the employees at each hospital, it’s usually the first time. No vendor would take on employee incompetence risk like that, especially across language and cultural boundaries. And of course no vendor would incur the enormous costs of an entire deployment without compensation. That’s absurd.

Given the contract structures, it appears that hospital management abroad simply doesn’t understand what they’re purchasing. Hospital EHR vendors are not software companies, but services companies.

In Peru, our demo was scheduled from 10:30-12:00, and we provided free lunch afterwards. We had requested 1.5 – 2 full days just as we usually do in the US. The hospital informed us that 1.5 hours would be sufficient to present the entire application to all departments in one room together (including translation time) despite our strong suggestions to the contrary. Perhaps I could’ve done it if I rapped the demo at 344 words / minute. Shame on me, I guess.

We arrived an hour early to ensure we’d have adequate time to set up and test the projector — you never know what kind of IT infrastructure you’ll find in international hospitals. Three nurses were already in the presentation room. We thought there might have been another brief presentation scheduled before ours. There wasn’t. They had been told to show up at that time, and we had no clue why. Most of the rest showed up on approximately on time.

The rest filed in over the first 30 minutes of the demo. Two were actually talking on their cellphones as they walked into the room. Although we told them that I would pause for questions every five minutes, they constantly interrupted. Each was far too concerned with their very specific, totally-out-of-context questions, with no regard for the their 39 colleagues in the room.

I didn’t really even give a demo. I just answered sporadic questions from people in rapid succession. Most of the time they didn’t even want to see how the software accommodate their request, they just wanted to know if it could it. Clearly they haven’t been burned by software salesmen before.

Coordinating thousands of people to effectively manage large volumes of clinical and administrative data in a 24/7 environment is extremely complicated. Each employee only sees and understands a small piece of the system, and yet their decisions impact dozens of other people throughout the organization. EHR deployments require sophisticated white-collar organization. People need to show up on time, do their jobs, learn to compromise, and work with others in a fast-paced, dynamic environment.

Healthcare as a profession has never promoted or fostered white collar organization and teamwork until very recently, and only in the US because of the Meaningful Use push. Historically, healthcare delivery has centered around a single individual, traditionally the physician. But modern medicine is collaborative by nature. People need to know how to work in teams across multiple projects, disciplines, and managers.

Most American clinical professionals have struggled with this over the past few years. In Peru and most other countries, computer literacy is measurably worse. I estimate that 80-90 percent of the population has never used a computer in a significant fashion. In the US, it’s probably inverted: 80-90 percent are computer literate. There’s no way an organization can make the transition when 80 percent of people are struggling to use a mouse and keyboard.

Looking forward, I hope medical schools incorporate more white collar, team-based project management training. The vast majority of the content of medical, nursing, and therapy schools is, in technology terms, "memorizing a big database." The medical training schools teach the art of working with patients, extracting information, and other soft skills, but the fact remains that there’s a reason students are staying up all night studying: they have to memorize lots of clinical stuff. Stuff that computers already know. Medical schools should teach students how to work with each other and with the tools of the future so they can provide the best collaborative care.

Smile

I've sold a few different goods and services in my young career: electronic health records and dreams; I've never sold anything "traditional," such as a cars, homes, devices, computers, etc. I can't speak to what it takes to sell these kinds of commoditized goods, but for the kinds of abstract goods I've been selling, I've discovered the most powerful sales tool of all time: the human smile.

The human smile is infectious. It makes people happy. It makes the salesman approachable. And it's so incredibly simple and effective.

Everyone has seen charismatic salesmen on infomercials. I've been intrigued by their ability to keep people engaged and excited. Smiling is the foundation for the entire sales package. The smile turns business-focused, money-hungry salesmen into fun and exciting people with something interesting to say.

Too many salesmen are focused on making money. That's a classic sales/marketing mistake. Sales and marketing aren't about money, they're about the customer's perception of the good/service being sold. That's the only thing that matters. When salesmen forget that, they tend to focus on making money, which means they're focused on themselves, not the customer.

Smiling lends itself to being friendly, approachable, and believable. It lends itself to being human. People buy from and invest in people that they like. But they have to be real, down-to-earth people; they can't be phony. The smile can't be forced; it has to be genuine.

I've identified 3 forms of smiles. The most obvious is the fake, forced smile. When a salesman is desperate, this smile tends to rear its ugly head. It looks an awful lot like this. You can tell that I'm uncomfortable, and not living in the moment. I'm not going to earn a penny.

The second and third types of smiles are more difficult to distinguish. Salesmen, because of the nature of their jobs, sincerely enjoy talking with other people. The act of selling makes them happy. I call this smile the "living-in-the-moment-smile." The living-in-the-moment-smile looks something like this (picture from fraternity semi-formal):

The third smile is one of pristine passion. You only see this smile when people are doing something that they believe in with every fiber of their existence. Salesmen entrepreneurs tend to sport this smile. It looks something like this:

99% of life just isn't that exciting. When people find someone whose amped up on life, who believes in what they do with unfiltered, uncontrollable energy and passion, they want to believe too. They want to be in the other guy's reality, because from the outside, it looks so much better than their own.

The power of the human smile is bounded only by your imagination. So dream big and smile.

What if Google Does it?

This post originally appeared on HIStalk. 

I’m a nerd. Instead of watching Hollywood movies, I watched the entirety of Google’s 3.5 hour keynote from their recent developer conference, Google IO. I really appreciate watching and learning from technology companies operating at spectacular scale. They put on quite a show (at least for geeks like me).

One hour and eighteen minutes (the link should take you the right spot in the video) into the keynote, Google executives unveiled new discovery and curation features for the Android Play Store for apps for teachers to use in class. Google hired a team of educational content experts to review and curate in-class apps. Google will release certified apps to a special section of the Android Play Store that educational IT staff and teachers can peruse.

Google will also provide tools for educational IT admins to centrally manage and distribute those apps throughout the school per teacher, class, grade level, and more. Google is dramatically simplifying IT management in large bureaucratic organizations that can’t attract top IT talent. This is a godsend for teachers who have wanted to deploy apps in class, but who haven’t had the necessary IT support.

This is a brilliant concept. In highly regulated, slow changing industries such as healthcare and education, the biggest barriers to adopting and integrating third-party apps into the core workflows are fear of inaccurate information and IT distribution and management challenges. Google is doing a tremendous favor for the educational system. This move will materially improve the uptake of in-class apps.

Obviously, this begs the question, "Why doesn’t Google do the same thing for healthcare?” Happtique and Healthtap recognized this need some time ago. They’re curating apps and providing IT infrastructure services to help manage and distribute those apps to employees along different job functions, roles, locations, etc.

Unfortunately, Happtique just hired a new CEO, which is never a good sign at a pre-revenue, pre-scale startup. Healthtap raised $24M to pursue other markets, but recently moved into the app curation and distribution space. We’ll see how well they fare. It’s too early to render any final judgment.

If you know anyone at Google – particularly anyone on the Android Play Store team – who can pull some strings, can you please refer them to this blog post? I’m sure that with just a little spark, Google can do for healthcare what they’re already doing for education.

Sorry Happtique and Healthtap, it looks like you’re going to be a classic case of "What if Google does it?"