Breaking News: Congress Wants to Create National eHealth Network, Legislate Who "Owns" Health Data

Clue - it ain't patients. Google. Microsoft. I hope someone in your healthcare organizations reads this brief. Look especially to the latter 1/3rd.

Browsing Twitter this afternoon, I learned about a House bill draft (HR ____) nicknamed "Health e-Information Technology Act of 2008" from @jesran.

It has not yet been assigned a number, but the draft copy is available here. It looks to be in pre-committee.

Sponsors: Mr. STARK (for himself, Ms. SCHWARTZ, Mr. MCDERMOTT, Mr. MCNULTY, Mr. LEVIN, Mr. EMANUEL, Mr. NEAL of Massachusetts, Mr. PASCRELL, and Mr. LEWIS of Georgia).

IF YOU ARE IN HEALTHCARE, THIS BILL IS THE MOST IMPORTANT THING YOU MAY READ THIS YEAR.

Why is the bill important? Take a look:

• It defines an EHR, and places control of an EHR strictly and SOLELY in the hands of providers and staff (numbers to the left are lines in the bill), p.4:
  

‘‘(1) ELECTRONIC HEALTH RECORD.—The term
18 ‘electronic health record’ means an electronic record
19 of health-related information on an individual that is
20 created, managed, and consulted by authorized
21 health care clinicians and staff of one or more orga
22 nizations, that conforms to standards adopted under
23 section 3003(a), and is made accessible electronically
24 to other health care organizations and other author
25 ized users."

• On p.5, it defines providers as the following, but adds "any other category...determined appropriate by the Secretary":

HEALTH CARE PROVIDER.—The term
2 ‘health care provider’ means a hospital, skilled nurs
3 ing facility, nursing facility, home health entity,
4 health care clinic, Federally qualified health center,
5 group practice (as defined in section 1877(h)(4) of
6 the Social Security Act), a pharmacist, a pharmacy,
7 a laboratory, a physician (as defined in section
8 1861(r)) of the Social Security Act), a practitioner
9 (as described in section 1842(b)(18)(C) of the Social
10 Security Act), a provider operated by, or under con
11 tract with, the Indian Health Service or by an In
12 dian tribe (as defined in the Indian Self-Determina
13 tion and Education Assistance Act), tribal organiza
14 tion, or urban Indian organization (as defined in
15 section 4 of the Indian Health Care Improvement
16 Act), a rural health clinic, and any other category of
17 facility or clinician determined appropriate by the
18 Secretary.

• Pages 5-6 define HIT (line 1 denotes jump to p. 6):

‘‘(4) HEALTH INFORMATION TECHNOLOGY.—
23 The term ‘health information technology’ means
24 hardware, software, integrated technologies and re
25 lated licenses, intellectual property, upgrades, and
1 packaged solutions sold as services that are specifi
2 cally designed for use by health care entities for the
3 electronic creation, maintenance, or exchange of
4 health information. "

WAIT A MINUTE: HIT is "specifically designed for use by health care entities?" Are patients/consumers considered healthcare entities? I'm getting a sick feeling in the pit of my stomach here.

• A new post is born:

"There is established within
8 the Department of Health and Human Services an Office
9 of the National Coordinator for Health Information Tech
10 nology (referred to in this section as the ‘Office’). The Of
11 fice shall be headed by a National Coordinator who shall
12 be appointed by the Secretary and shall report directly to
13 the Secretary."

• Part of his/her job? To pave the way for a "nationwide health information technology infrastructure" that:
  

1. allows for the electronic use and exchange of information
   
2. ensures each patient's health info is secure under 'applicable law' (Hello HIPAA)
3. improves quality
4. reduces medical errors
5. advances delivery of patient-centered medical care
   
6. reduces costs resulting from inefficiency, errors, inappropriate care (say what?) duplicative care and incomplete information
7. ensures appropriate information to help guide decisions is availble at the time and place of care (that one's a doozy - cost? quality data transparency requirements at a national level?)
8. ensures inclusion of meaningful public input (how defined?) in development
9. improves public health reporting
   
10. facilitates research
11. (another doozy) "promotes a more effective marketplace, greater competition, greater systems analysis, increased consumer choice, and improved outcomes in healthcare services" AKA CONSUMER CENTRIC CARE
12. improves efforts to reduce health disparities (wait, healthCARE delivery disparities or HEALTH disparities?)

• Every 2 years, the National Coordinator and HIT Advisory Commitee must update/make new recommendations. This is a VERY big job. Ted Eytan could take it.
  

• When developing recommendations, the National Coordinator must initially refer to DOD and VA, which are cited as models of interoperability for EHRs (GAO report 08-954 p.6-8 specifically cited in the bill) p. 12.

• The poor National Coordinator must ensure that information is collected and transmitted in "a manner that is reliable, accurate, unambiguous and (wait for it...) based on a uniform provider data set (who defines this Uniform Provider Data Set?)." The coordinator's FIRST TRIP should be to Health 2.0. Next trip to New Zealand. Third trip to Medicine 2.0.

• Sensitive health information may be "segmented" ie broken up into little pieces and scattered into the wind to protect our privacy. Great. Good luck putting that broken picture back together, p. 14.
  

• Shocker: To the "maximum extent appropriate" coordinator must incorporate CCHIT ambulatory and inpatient certification criteria.

• National Coordinator will solicit public input via open public meetings and comment periods, p. 16.

• She will also develop a program "(either directly or by contract)" -ummmm, SOMEONE's getting paid...-for the voluntary certification and periodic recertification of HIT systems and components.

• The National Coordinator needs to be an open-source guru too, using definition of 'open source' as defined by the Open Source Initiative.
  

• She will have to "provide for coordinating the development, routine updating, and provision of an open-source health information technology system that is either new" or based on an existing system. This system must be made "publicly available for use" 9 months after adoption of initial standards by Secretary (laughing, wiping eyes), p.17-18.
  

• National Coordinator shall establish a consortium of tech, legal, clinical geeks familiar with open-source. Hello - patients? I'd give my right arm to be on this consortium. Probably literally.

• OH MY GOODNESS. National Coordinator = Merchant of Venice. She may charge "a nominal fee" for the adoption "by a healthcare provider of the health information technology system" p. 19.
  

Wait a minute.

So not only are we not INCENTIVIZING doctors' use of EHRs, we're going to CHARGE THEM TO USE THE NATIONAL EHR SYSTEM?

But wait. It's all ok. If I'm a smaller provider or in a rural area I may get a price break - there is a "significant hardship exception" available to those working in areas with no Internet access (p.53). Also, hospitals may get paid a million bucks to implement (p.59), PLUS discharge volume incentives. Thanks Uncle Sam.

Also, later (p. 44-45) the bill seems to say (I could be wrong on this quick+dirty read) that IF you successfully implement and become a "meaningful user" by 2014 you get $15k. By 2015, you get 12k, 2016, 8k, 2017, 4k, and by 2018 only 2k to line your pocket.

How do they determine 'meaningful use?' Maybe by looking at drug claims submitted via the system.

Oh, and by the way, the National Coordinator has TWELVE MONTHS to develop a strategic plan detailing how to achieve the above objectives. After which case a straightjacket or lobotomy may be necessary.

The plan must also include timeframes.

The National Coordinator has to publish the strategic plan, and then subsequent implementation reports every 12 months. She can create and use task forces and work groups, in addition to the HIT Advisory Committee, for help here.

Of course, the coordinator also has to do a website, which includes grant information for HIT implementation, and appoint personnel. Staff will be funded by appropriated monies from 2009-2013.

Also, the office gains revenues from an "open source product licensing fee" (p. 26).

So, who are the National Coordinator's Knights of the Round Table? The HIT Advisory Committee. Who's on the Commitee?

1. DHS appointees from AHRQ, CDC, CMS, HRSA, IHS.
2. 1 member pick from Senate majority leader.
3. 1 member pick from Senate minority leader.
4. 1 member pick from Speaker of the House.
5. 1 member pick from House minority leader.
   
6. Presidential appointees from Veterans Affairs, NIST, and DOD. Yep. DOD!

In addition, the HIT Advisory Committee contains a very interesting dozen appointees chosen by the Comptroller General of the US. These '12 disciples' include:

• 1 advocate for healthcare patients and consumers (!)
• 2 healthcare provider reps (1 a doc)
• 1 from labor union (uh oh SEIU, make sure we don't get a doc from BIDMC on here too)
• 1 member with expertise in privacy/security
• 1 w/experience improving health of vulnerable populations
• 1 member from health research
• 1 health plans/3rd party payors
• 1 HIT vendor rep
• 1 shall represent purchasers or employers
  
• 1 w/expertise in healthcare quality measurement and reporting
• 1 w/expertise in open source HIT systems
  

The HIT Advisory Committee will have 1 Chair, 1 Vice Chair, one of whom must be from public sphere, one of whom must be from private sphere. Members are paid a per diem rate and are reimbursed for travel expenses. Members serve 3 yr terms, and 10 constitute a quorum.

STANDARDS SHOULD BE ADOPTED NO LATER THAN SEPTEMBER 30, 2011 (p. 33).

But adoption by "private entities" seems to be voluntary (p.34).

The National Coordinator will develop an HIT Resource Center to develop best practices, provide tech support, and accelerate the aims of the bill.

Now let's move on to carrots and sticks.

CMS and other federal agencies "relating to promoting quality and efficient healthcare in Federal government administered or other sponsored healthcare programs" may require providers to implement the system (play or we don't pay, p.40).


Medicare Advantage plans (MAs) get a variety of special incentives described with a rules schedule that's dizzying - check out pages in the 70s.

Also, there's a $115M pot of grants and loans available from 2009-2013.

Grant and loan programs may also be funded by agencies such as AHRQ available for providers and also for states and Indian tribes. Read pages in the 80s and 90s. Grant and loan recipient must demonstrate sustainability of quality improvements and cost decreases.

Medical Education Evolution folks take note - Special grants and efforts to develop academic curricula that incorporate HIT use and adoption in clinical education are proposed on page 99. Requirements are spelled out on pages 100-103. 10M bucks is available for these initiatives from 2009 -2011.

I can hear the contractors salivating now. In fact, I should start a contracting firm. It'd qualify for minority owned discounts and incentives and I'd be competing in a protected space as a female owner/exec for the duration of these funds (2009-2013). How's that for a Health 2.0 business model?


How will Joe Six Pack and Alaskan Hockey Mom learn about this initiative?

No later than a year after this bill passes (and may God have mercy on our souls), the Office for Civil Rights within DHHS will "develop and maintain a multi-faceted national education initiative" (read - poorly designed website with long, counterintiutive URL where they slap up patronizing information and quizzes) to "enhance public transparency regarding uses of their protected health information, the effects of such uses, and the rights of indivuduals."

This office will spend 10M dollars to implement this campaign. Give me 10k and I'll start a bloggers campaign that would reach more people and generate more buzz.

Big Picture Issue? Great. The government will now have access to my EHR. In fact, the government will OWN my EHR, and pay docs to keep it out of my hands.

Or so it seems at first read. On page 125, however, the bill authors tell me patronizingly that I can "obtain from such covered entity a copy of such information in an electronic format," AND that the provider can't charge me for that copy.

Well, at least they ARE saying the data can't be sold without my permission (page 125).

And on page 128 they say that providers can't use this information for marketing purposes, or to send a communication that "encourages recipients of the communication to purchase or use the product or service." In legal language, they're not considering that a qualified "health care operation."

What Happens if Your Data Gets Out?

Breaches and other privacy and security issues are covered in pages from 103-118; Google, Microsoft, and other PHR vendors will want to read p. 110 closely:

• VENDOR OF PERSONAL HEALTH (p. 110)

2 RECORDS.—The term ‘‘vendor of personal health
3 records’’ means an entity that offers or maintains a
4 personal health record. Such term does not include
5 an entity that is a covered entity for purposes of of
6 fering or maintaining such personal health record.

Big Govt. is also going to take on Google and Microsoft. Read page 131 guys. Read it again. And again.

You heard it here first: 1 year after this Act, the Secretary and the FTC will do a study on privacy+security requirements "to entities that are not considered covered entities" (see page 132, line 7, where the gauntlet is thrown, and your advertisers should you allow any, on line 8, and your partners - perhaps even patients and users, line 15). See also "business associate contracts" page 137.

And little PHR vendors, you're not out of the woods either. The government will investigate clients using your site as a cobranded app or customized PHR portal. See page 132, line 19.

Why you should read this bill draft again, and again, and again:

1. It's a mountain of legislation that makes HIPAA look like a molehill.
2. It also systematically reinforces the position of patient as 'other.'
3. Consumers will not have control over personal health narratives. Our input to PHRs is trivial, 'outside' the system and relevant only for our personal use.
4. This bill would ensure that PHRs and EHRs will forever remain disjointed halves of information necessary to improve care.
5. It does not provide adequate time for the government to develop or acquire such a system.
6. It does not provide adequate incentives or support for docs to implement such a system.
   

But, if you aren't using PHRs by 2018 anyway, I'm betting you're out of business sometime in the next 10 years.

Now, what are you going to do about it?

PS - I nominate Dr. Richard Reece for National Coordinator position. I nominate Dr. Stanley Feld to be the next Secretary of DHHS.

Health 2.0 Around the Blogosphere

There's a lot of buzz surrounding Health 2.0 'the movement,' and quite a bit of froth and churn in the young consumer-centric HIT sector. (Blogger's Note: I work with Matthew Holt and Indu Subaiya of the Health 2.0 conference as speaker liaison, volunteer manager, and ranger).

To keep up with news as we ramp up for Health 2.0 in San Francisco next month, I've created Google Alerts for the following terms:

• consumer-centric care
• Health 2.0
• patient-directed care
• Health 3.0
  

Although you have to spend a bit of time reading the Google summaries for each link to separate the wheat from the chaff, it's well worth it to set up an alert for your company name, competitors, and areas of the sector that interest you, like Health 2.0.

Here are some links my Health 2.0 Google Alert recently turned up (as in, this morning):

The latest in Health 2.0 - health coaching from Hummingbird Coaching.

Ian Furst at Wait Times tackles security issues in Health 2.0 using quotes from an excellent piece in Scientific American.

HeartHawk blogs live from Medicine 2.0 on the changing doctor-patient relationship.

Patricia Donovan of the Healthcare Intelligence Network talks about 'injecting' Web 2.0 into healthcare.

And of course, the neatest interview series on Health 2.0, brought to us by Easy Rider David Kibbe...can't wait to see his documentary aired next month. Safe journeys!

David's asking everyone he interviews the same queston: "Are you Health 2.0?" How would you answer, dear reader?

The Nexthealth Business Model(s) - Leave Your Preconceptions at the Door

At Medicine 2.0, Maarten and I decided to be true to our, ahem, unique communication styles.

We knew we'd need to shake people out of their comfort zones to spark hard-hitting dialogue on combustible issues like consumer-centric care evolution. We took a big risk with our particular brand of casual informality, but we think it paid off.

We did a lot of things differently. There is nothing in this list your organization cannot and should not be doing before presentations/demos.

A few examples:

1. We posted our presentation on Slideshare.net BEFORE our timeslot so potential attendees could decide if we'd interest them. Not interested? Don't attend. Luckily, plenty of people did.

2. We posted our ENTIRE research paper on Scribd for public review. Critique away. No copyright. Again, before our presentation.

3. We twittered the hell out of our upcoming session, as well as the rest of the conference, which let us make new friends and meet bloggers we'd only interacted with online. Of course we invited them all to attend.

4. We also posted qualitative aspects of the Nexthealth model/application up on our blogs, including our 'warm and fuzzy' elevator pitch.

When you do things differently, it generates comments you might never have expected.

Scott Shreeve left an interesting one on the Nexthealth Elevator Pitch post asking about our business model.

Scott says: "The only problem I see is that you are offering the service for free, you are giving away your technology, are not accepting ads, and you do not plan on using anonymized user information in any revenue generating way."

He's right on all counts.

"This leads to the big BM question (no, not that kind of BM) - how on earth do you plan to be around without any source of revenue. You either have a sugar daddy funding your every business whim or you will be out of business in short order. Would love to hear you describe the sustainable business model that will allow you to provide this valuable service."

It's such a good question I'll answer it here.

First Scott, if you find a sugar daddy (or sugar momma) please do send them our way. We'd love to talk.

It'd be a dream come true to develop a collaborative relationship like the one enjoyed (with great results) by Jay Parkinson and Myca. Probably no one else would be visionary enough (read: crazy enough) to take us on. But who knows. There are some amazing folks in healthcare, as we discovered this week.

Second - How do we expect to make money off the Nexthealth application?

By winning the lottery of course. Or gathering a few million via a VC round. Or being acquired.

Just kidding (at least about the first one), but I think far too many Health 2.0 firms have a similar bubble approach (relying on ad revenues in a rapidly morphing marketing world or charging only for premium services which are utilized by a small subset of users).

The short answer is that we don't. We're not trying to make money off the application, that's why we're throwing it out there as a public good.

Make no mistake, this isn't totally a selfless act of altruism. Many of the Nexthealth crew are more sinners than saints! Although we're social entrepreneurs working to spark change and global healthcare innovation, we realize the value of forging a new path with this sort of big splash.

After articulating our mission (connecting people online and offline to improve healthcare) and vision (people will be able to access healthcare goods and services, online and offline, at will), we decided very early on there would be things we wanted to build that should be set free "open source" style rather than siloed and privatized to death.

If you allow a company to put this kind of application to bed in a corporate stable you'll make a lot of money, yes, but you're not going to get the same relative neutrality and objectivity of which a completely NFP app is capable of doing.

Read: You will not be able to generate trust among digital health natives if you're selling off data on the back end with no opt-out a la Patients Like Me, especially once your users find out about it (and who wants a Health 2.0 version of Facebook's Beacon crisis?).

They may not know PLM is doing this yet, but when users (and potentially the media) uncover this I wonder if we'll see some of the first 'negative' HIT/Health 2.0 coverage - the nascent industry may still be too young for people to understand the implications and react in a critical manner.

This is why we won't gather your data and sell it at Nexthealth. However, you WILL have the option to make it available, open-source, to public health researchers (anonymized of course). We'll provide links and you can send it to them at will, or not.

That said, we have explored a few various ways to monetize use of the decision-support search app without sacrificing the relative neutrality and objectivity of the tool.

Some ideas include click-through plans, entering the Knight News Challenge and other similar unique open-source/NFP funding grant programs, etc., but more on those later.

And besides - we've got plenty of talents, skills, and plans that can be monetized. Call us foolish. Call us idealistic. Call us naive. Call us many other things. I'm sure that will happen. We are a new kind of 'business.' We will make many mistakes.

But we're trying not to make the mistake of disguising selflessness for selfishness - an integrated "do not cull out" approach to altruism and a healthy attitude towards capitalistic profit guide our decisions in kind. If a good would cause more momentum in the public domain, we'll drop it there. If a good can be privatized, yet still work in concert with our goals, we'll do it for a paycheck.

This isn't the last application Nexthealth will produce - it's the first of many.

We're thinking ahead to sustainability for the collaborative and other projects already in the design life cycle (including others that will generate revenue). We've got multiple other plans in the works. In fact, Martijn Hulst and Jacqueline Fackeldey present some additional ideas and concepts this week in Holland. Break a leg both!

At Nexthealth, we generate a different business model, with different principals 'shepherding' the project, for each product.

You'll be seeing both more 'public' and 'private' goods developed by the Nexthealth team, sometimes in relative 'isolation' and sometimes in cooperation with other organizations.

This application is the getting-to-know you handshake from our group. It's the best business card in the world - showing we're capable of producing with limited resources and extreme creative prejudice. Consider it our proof of concept, the ultimate whitepaper.

In order to understand why we'd be crazy enough to do research, detail a new model, nearly kill ourselves trying to design/build an app, and then be totally committed to giving it away for free without 'commercial bias' or interference, you have to know a bit more about the group nuts enough to try this.

The short version: Maarten and I are social entrepreneurs who are part of a health innovation COLLABORATIVE (Nexthealth) with a page here. The model/application we described at Medicine 2.0 is just ONE of the projects we have in the works. The collaborative produces both 'public' NFP goods, and 'private' FP goods, and we don't separate the two in our daily business activities.

So, about Nexthealth (the group):

NOTE: I'm taking a stab here at putting 'how we work' into terms many readers can follow...some of my Nexthealth Dutch buddies may have other descriptions (Jacqueline, I know you'd die before using the "PM" acronym for instance:).

1. We are a hive collaborative nonprofit founded in April in the Netherlands (following the first Health 2.0 Unconference NL) with two 'arms': NL and the US. I'm mostly US, the others are mostly Holland, although there's some definite flux.

2. Nexthealth has a core group of 6, but our initiatives almost always involve others recruited from the hives of our personal and professional networks.

A basic snapshot of how our current workflow looks:

• Someone's radar picks up a project they're interested in doing. Sometimes we find it, sometimes it finds us. They bring the idea back to the group (6) - usually first via email, Twitter, Skype, and other social web tools.
  

• Much discussion ensues. Normally the person (or persons - Maarten and I often work as a team) who introduce the idea becomes a 'Project initiator' or internal PM (except many of us call ourselves 'firestarters' - that's just the way we roll).
  

• Sometimes the discussion is kicked offline in one of our famous meetups, but often we get rolling without having seen each other in person (ROPE and ROWE), and have multiple projects and initiatives on the whiteboard (literally) during our next face-to-face.
  

• Sometimes the person who introduces a project just throws it out for discussion and another core member becomes the initiator.
  

• IMPORTANT NOTE: The initiator isn't static. If a project reaches a stage where the initiator loses interest and/or doesn't have the skills/time to continue (most common), someone else picks up the ball and runs with it. We find this change happens, oh, less than 25% of the time (estimate) as we each tend to introduce things about which we're invidividually passionate.

• We decide, kind of individually and collectively, if the project has anything in common with our goal and 'ideal' healthcare system: first, does it connect people, online and offline, interested in improving healthcare? Second, does it work towards semantic interoperability of health - "consumers will be able to access healthcare goods and services, online and offline, at will?" If the answer to one or both of those is yes, chances are we'll take it somewhere.

• Kickoff! The project initiators (and other core members) recruit/recommend resources (human and otherwise) to complete the project. The initiator largely directs the initiative and keeps the group updated on progress via the social web.

• The Payola: Sometime we get paid (for profit, "private" goods) and sometimes we don't (NFP, "public" goods). If we get paid as a group, the revenue will be split according to prearranged terms based on who works on the project. Obviously we aren't making much money yet - the group is bootstrapped for now, and each of us have other gigs outside of Nexthealth (all in healthcare).
  

Also Scott, let me apologize for leading you and other readers on a bit over the last few days.

Maarten and I have been working on the research/model just since the latter half of April. Things have been moving so fast we haven't provided substantive information (operations, people, etc.) about the Nexthealth group itself as quickly as we should have.

At Medicine 2.0 there was so much conversation about the model (and where healthcare is going in general) that we didn't get around to specifics of business models for the group and the application.

That's no excuse, however.

I've tried to remedy that oversight here.

In addition to doing completely new research in Health 2.0 (and trying to act as a bridge between 'commercial' and 'entrepreneurial' Health 2.0 types and 'research' and 'academic' Medicine 2.0 types), we're operating under a new type of business model, a hive collaborative, with our current 'alpha' workflow process detailed above.

Also keep in mind that this is an organization just learning to hold its head up....we're in the infancy of Nexthealth. Our birthmonth is April 2008.

We recognize the org. structure is liable to morph and go through various refinements as the 6 original principal founders (myself, Maarten den Braber, Martijn Hulst, Jacqueline Fackeldey, Niels Schuddeboom, and Jeroen Kuipers) determine what's next for each of us individually as well as for the collective.

Some will stay, some will go. We'll add new members, new strategies, and new revenue streams as we learn to crawl.

But with this sort of commitment to sparking global healthcare innovation, skinned knees and elbows are inevitable. It's how we react to the stumbles that'll show whether or not we're one of the groups to be running at the front looking for what's next.

Nexthealth Elevator Pitch

This is where healthcare is going, the gold standard of semantic interoperabilty.

Consumers WILL be able to access healthcare goods and services online and offline at will.

This means consumers will have many choices to make in healthcare - how? where? when to access? which sources are credible? which providers protect my privacy? which hospitals provide services online and offline?

At Nexthealth, we use a database and graphic UI to organize knowledge so users can organize their health choices.

Nexthealth is literally the launch pad and the landing site for healthcare decision making.

It's a neutral, free interactive process for anyone who needs to make a healthcare decision - consumer or producer.

You won't see ads on our site. We don't charge subscription fees and are organized as a nonprofit. We're a credible, trusted, 'helpful' partner in consumers' time of need.

When your health is on the line, a lot of emotion and subjectivity is involved.

This model supports rapid decision making in very stressful situations. We provide a logical, rational, clear scaffolding that guides you through making tough choices in tough times. But we're not making diagnoses, we're not a 'recommendation' engine. Think of Nexthealth as an objective exoskeleton, providing the framework to break healthcare decisions down into manageable bits and pieces.

We start directly with the consumer searching for health decision support. Througout the process we facilitate navigation to other resources with health-related information we do not provide ourselves, but rely on trusted Health 2.0 partners to architect. We refer users to these partners.

Armed with that information patients go about the next step in the decision process, which is further defining what's important for their decision. The end of a user's interaction with the model is when they subjectively determine that they have made their decision ("Click the button").

Let's take a closer look at the experience of being a patient. With a devastating diagnosis, a consumer is suddenly required to evaluate options for treatment based on personal life goals. Most of us don't know we have choices in healthcare until that terrible moment arrives.

Suddenly, you need to be able to decipher a stunning array of options - which hospital is the 'best' for this condition? Which doctor is rated highly by patients and has a low malpractice rate? Where can I talk with other people who have lived through something like this?

Say you go to Google. Good luck sifting through search result for ones that mean alot to you. Current search engine optimization techniques sell the consumer short - we value search based on keywords, terminology, rather than the meaning each word has, the impact a diagnosis has on our daily lives. We can't search for healthcare resources based on the decision we need to make - right now we can only search based on the phrase someone else determines has meaning and relevance.

Who or what is there to help consumers make these decisions in an objective way? Right now? No one. Nothing. But Nexthealth fills the gap between current services, content and community online, and how consumers move towards action, the do/buy decisions required to go forward.

At Nexthealth we don't judge your decision. We don't put any limits on the process. Bring your baggage. Have a seat. Use the tool for as long as it takes. As many times as it takes. We walk you through four specific, concrete steps to arrive at a decision. When to start, stop, communicate, or abandon the process is entirely up to you. Like decision-making in the real world - maybe you're not ready to take the next step. Don't worry, no pressure.

Bring a box of tissues, your anger and confusion. We'll help you bring simple, welcome clarity to the process of determining where you are now, and provide the support system that helps you create a roadmap to where you're going next.

Need help making the decision? At every step of the way, Nexthealth gives you the option of connecting with Health 2.0 content and community sites that support your decision process. We've done the due diligence and provide partners without commercial bias.

We don't charge you anything to use the Nexthealth tool. Ever. And we don't sell, rent, or give away your information. We firmly believe the tools to make better, more informed healthcare decisions should be open-source, in the public domain, available at no cost.

The only thing we're selling is the barn-burning concept that you have choices to make in healthcare. Who's in the driver's seat? You are. We're the wheel, the brakes, the chassis. How fast you need to travel is up to you.

Are you ready to map your next steps? 3.2.1. Liftoff.

It's your health - what's next?

Health 2.0 Moving Forward, Going ROPE, Doing Good: Ted Eytan, Matthew Holt , Organized Wisdom Push the Envelope

The combined talent, willpower, business acumen, and capital in the room at Health 2.0 will be a force with which to be reckoned...and getting ready for the event usually kickstarts some interesting discussions as everyone prepares to bring the A-game.

Two of my favorite bloggers this morning offer up innovative views on work environments and 'do good, be well' initiatives.

Here are the goods and why they're relevant to Health 2.0 and consumer-centric care:


1. Ted Eytan details a new "Results Only Patient Experience" (ROPE), built on the platform of Best Buy's Results Only Work Experience (ROWE).

Why Does it Matter?

• It's already happening in the Health 2.0 sphere - Organized Wisdom is the first Health 2.0 company to go completely ROWE. Better yet, OW takes a collaborative approach, sharing their "Getting Results Toolkit" - read all about it here.

• I've been a ROWE worker 2x, first as an analyst and business development director, now as an all around healthcare ranger, blogger, and social startup junkie. It's not all peaches and cream and working in your pajamas (although yes, I have worked in PJs). The typical day Ted posts comes perilously close to describing some of my weekdays, especially when I lived in downtown Baltimore or when I'm at home in Rotterdam. Self-management is a must. And yeah. It can be a hell of a lot of fun. I don't think anyone who knows me would call me a slacker (at least I hope not...).
  

• ROWE works 'best' for certain types of organizations and personalities, but certainly does privilege the knowledge-worker class who can afford to do work from anywhere (literally - I'm typing this blog entry sitting in a tent at Chincoteague Island, Va). LOTS more healthcare organizations could go ROWE, or, more appropriately, could "ROPE & ROWE" (nice nautical imagery there Ted).
  

• The bottom line about why I love being a ROWE (and shortly, advocating for a ROPE environment using the Nexthealth app) worker: it's all about results. What I get done. Not when I get it done, or even necessarily how long it takes me. And the real beauty is that I get a hell of a lot more done working from anywhere I'm comfortable than when I'm stuck in a cubicle drinking lame coffee or listening to my coworkers rave about the Sex and the City movie.
  

• Also, consider this: in a daily 'normal' work or classroom environment, the time you spend with rear parts in the seat is the most important thing - it's more about attendance than it is about output. In class, I'd finish work early and whip out a book. In a 'traditional' 9-5 I'd finish work early and be bugging supervisors for something else to do, a new project, etc. I was a pest. A productive pest, but a pest nonetheless. Now, if I finish something early, it's on to the next thing.
  

• MARKET RESEARCH: If you want to get a better look about what kinds of organizations in your area are offering ROWE environments, just go to your local Craigslist jobs page. Click the "telecommute" button, et. voila. Search results tailored to ROWE workers or organizations exploring the concept. Note there probably aren't many healthcare orgs in the list of results. Here's an example of results from my home-away-from-home, Washington DC, this morning at 9:07 am.
  

2. Over at The Health Care Blog, Matthew Holt and his wife Amanda share their own 'do good' goals. Matthew's asking companies who want to mine his brilliance to help buy a kid a bike. Amanda, who just had some pretty serious back surgery, will also sport supporting companies' colors on during her upcoming training rides (and yep, we'll probably see some photos on THCB).

Why Does it Matter?

• Social entrepreneurship is arriving early to the Health 2.0 stage, considering the conferences themselves have been around for just under 2 years. Matthew and Amanda are doing something really neat here, and bravo to both of them for helping spread the wealth to benefit Saigon Childrens' Charity. To my knowledge, it's the first time they've 'asked' us, the readership, to help out a crusade. This is an awesome step and the first time I've seen something like this done outside of Doc Rob's sending Zippy all over the world and outfitting us all in Zippy wear to help fight kids' brain cancer.
  

• A fascinating conversation from #gnomedex on Twitter.com last week began when Beth Kanter (@kanter) raised almost 4k in under an hour SIMPLY by having those in attendance begin to tweet about the event. Her social philanthropy demonstrated a few things brilliantly: peer pressure in giving works (for good or ill), almost anyone will give $10, and you have to coordinate a few things brilliantly to cut through the noise with an 'ask' - right time, right place, right people spreading your message, and right amount.
  

• Doing good is contagious. Doing good is viral. But we don't always (or even usually) give because we're saints.
  

• If your competitors start do-good initiatives, and you don't, you'll look like a boob. Is this the 'right' reason to give? Probably not. Nor is the fact that giving in this case will get you a photo and nice writeup on The Health Care Blog.
  

• I had a great Twitter discussion with @michah, who was at #gnomedex (type this into the search field at www.summize.com for all the #gnomedex Twitter feeds) about whether or not people were giving to Beth's initiative because of competitive pressures or a desire to 'help.' To a certain extent, the values conversation in giving is often overly simplified, and this type of value judgment is only relevant if we're speaking from the pulpit, or Valhalla, which none of us are.
  

• BOTTOM LINE: Give for whatever reason you give. The important thing is that you give. Try not to judge others for what they get in return. This is the hybrid model of social philanthropy at work - do some good, get something good in return. Call it the bartering of philanthropy if you will, but it's how this system has always worked (sponsorships for events, launches, etc). Even those little balloons you buy in the checkout line at the grovery store are the barter system of philanthropy at work: You get to write your name and paste it on the window proving what a generous person you are. Final bottom line: Try not to fool yourself about reasons and motivations for giving. Be clear about what you want people to give, and what they'll get in return, just as Matthew's done at THCB. And if you don't want anyone to know what a good person you are, give and keep quiet about it.
  

And for goodness' sake people - buying a bike for a kid in Saigon is only 25 pounds....

Nexthealth Model on The Way...

After hours of feverish coding, emails, phone calls, and international Skype chats, we saw the first Flash animation elements and very rough mockup of our Nexthealth model.

I will tell you that after 3 hours of sleep, with a team of 3 calling in from an office in Baltimore, MD, a family vacation on the Potomac in southern Maryland, and a library in Amsterdam, what we're doing seems even more incredible.

Try using Skype video chat, holding up a graph mockup of the website you've just drawn, showing it to a partner in Holland, while also talking on the land line to your web design partner in Baltimore, who's also walking you through an online mockup of the application.

This is the way thought moves to action in tomorrow's healthcare innovation teams.

Even more amazing than the multi-channel method of communication we've adopted is the way this thing is being built.

Nexthealth co-founder Maarten and I met online at Tony Chen's Hospital Impact Ning site last year before I moved to Holland, and we met a sum and total of once in person before kicking off the Health 2.0 Unconference NL in Amsterdam last April.

We drew the graph we're turning into an interactive roadmap to consumer-centric care on a small whiteboard in his apartment the first time we met for dinner to discuss the Unconference. He drew an x-axis, I drew a y, and we were off.

We've been drawing and refining this &^% graph on cocktail napkins, flipcharts, and available forearms ever since.

Talk about collaboration - it gets even crazier.

I recruited Brad Sugar, our web guru extraordinaire, after being left high and dry via a recommendation from a friend who flaked. Oh yeah. And I found Brad (or he found us) on Craigslist. LAST THURSDAY.

The very rough teaser: We're building an interactive, 'free range' decision support model that lets healthcare users create a roadmap to consumer-centric care.

Health 2.0 sites give us content. They give us community. But consumers still have to find ways to integrate that information and social networking in a way that supports the choices they have to make about what's next for their own health.

It goes beyond needing to verify credible sources or incentivize behavior - first we have to give consumers tools to help them make choices that are relevant to their needs, wants, and lifestyle.

Who or what currently helps a patient answer the question: Which hospital do I choose for my knee replacement surgery - hospital A or hospital B?

Who or what currently helps a physician answer the question: How competitive am I with other docs in my practice area and local environment?

The Nexthealth model walks users through the process of making these decisions in a non-intimidating way.

This baby is the first of its kind. Free to use. You won't see any ads on the site. You won't have to pay to play.

You'll be able to test it anonymously, sign up by yourself or with a strategic planning team. Send someone plotted points. Maybe even connect to other Health 2.0 firms using a search function, but that'd be phase II.

We're building the site, graph, database, and animations in (deep breath) just under 2 weeks. We hope. To say this is one of the most intense work periods of my professional life would be the understatement of the century.

This is an incredible commitment of time, energy, and brainpower by three people who believe in the 'holy grail' of semantic interoperability for health: Consumers will be able to access healthcare goods and services, online and offline, at will.

We also believe this needs to go free-range rather than be kept in a consulting firm's closet somewhere, to be parceled out hospital by hospital, physician group by physician group.

We're talking about providing something real, concrete, to help accelerate our system's evolution to consumer-centric care.

Maarten den Braber and I will present research on the evolution of consumer-centric care at Medicine 2.0.

If you'll be in the Toronto area September 4-5th, please join us.

To the friend who told me at the last Health 2.0 show that I was ready to get something started - You were right. More than ready. I was afraid of failure, and it was holding me back.

And maybe the worst will happen - we fail. Maybe the graph doesn't work, or maybe only our friends and family use the tool to make us feel warm and fuzzy.

But it's time to stop talking about how to bring consumer-centric care to the fore and try something new. If we fail, we'll keep trying. Building other decision-support applications.

Nexthealth is on the way. And it's just the first step.

Weekend Roundup: Whereby Jen, Nexthealth Really Get Going and American Well, Hello Health Make Waves

I'm doing a lot of blog/news scrubbing lately as we ramp up for Health 2.0, just over 2 months away in San Francisco.

Fasten your seatbelts ladies and gentlemen; the lineup this show is bigger and better than ever. Companies are showing amazing features. Line up for tickets here.

Meanwhile, perennial Health 2.0 favorites continue to make headlines:

• American Well CEO Roy Schoenberg is interviewed by David Williams at Health Business Blog. Well worth a listen.

• Hello Health's frontrunning physician Jay Parkinson gets some more coverage at The Brooklyn Paper here...pay attention to Jay's title = do you need a Chief Imagineer?

Analyzing the business models of many Health 2.0 firms, you begin to notice something in common.

Despite the astonishing size and spending power of the hospital segment, MOST have taken one look at the siloed, low-margin marketplace and run frantically in the other direction, towards market-oriented, consumer solutions that 'sell' direct to the individual (whether they charge the consumer as part of a freemium model, are VC-funded, or operate using ad-based revenue models).

Many Health 2.0 firms are helping us nibble away around the edges, building a consumer-centric system user by user, providing solutions at an individual level. There are strong exceptions, luckily, American Well is one, with a business-model oriented around the current payor market.

But there are very few, if any, adaptive, fast-moving, Health 2.0 companies providing decision-support resources for existing brick and mortar players, including hospitals.

Someone needs to connect individual and systemic solutions, and provide non-intimidating, accessible ways for hospital teams to plot a roadmap to consumer-centric care using existing needs and future wants.

And they need to do it in a way that drives viral, rapid transfusions.

Some of you are sensing some dramatic irony here. So yeah. I'll admit it. The Nexthealth folks are working on this.

As a result, I'll beg your indulgence - blog posting will be a bit light for the next 2 weeks as we work on building a killer app. and getting speakers ready...see you in Frisco.

This Summer's Blockbuster = Mission Impossible: Reaching for Perfect 10s in Healthcare

NYTimes Quotation of the Day (8.6.08):

"How could they take away this beautiful, this most perfect thing from us, the one thing that separated our sport from the others?"
- Bela Karolyi, a longtime coach, on the dropping of 10.0 as the top score in Olympic gymnastics

First, a disclaimer. I've been watching entirely too many superhero movies this summer, and all the Olympic coverage has me sickly preconditioned to break out into spontaneous cheering at any time (ahh, but do I cheer for the Netherlands, the US, or both?!)

Luckily, the healthcare industry is in such desperate need of a global makeover that you can cross-pollinate creative metaphors for change from just about anywhere. So away we go.

Maxims and metrics that hold true for one industry often hold true for others.

You can't get a perfect score in gymnastics anymore. That's probably a good thing, especially if one of the most famous coaches of all time believes the opportunity to be 'perfect' is the only distinctive thing about the discipline.

But hospitals, doctors are regularly expected to hand-deliver 'perfect 10s,' at least during inpatient hospital treatment, resulting in never-events that will no longer be covered by CMS (Medicare/Medicaid).

Now, I'm all for the pursuit of perfection.

I've occasionally turned down a project because I didn't think I could complete it at anywhere near my normal level of energy and drive. I'm young, still malleable, still testing my horsepower, and largely (although not hopelessly) optimistic.

I've reached the point with work where if I'm not passionate about an initiative, overdrive-engaged in a cause, devoted to achieving a certain effect, I try not to take on the assignment. It's exhausting, yes, mostly in a good way.

When I lose my excitement for the job, it'll be time to switch gears. Old I'll accept gracefully, tired no way. That hasn't happened yet. But I still say yes too often. I'm still looking for the perfect 10.

I should say no more often, for this very reason. Or at least accept the fact that I'll reach peak energy for about 3 months and then go through trough periods of near burnout (3-7 days). I'm no Olympian, and I do myself and others a disservice by copping to that perspective.

I'm trying to deflect a strong dose of that perfectionism towards being a better team player. If I can't serve the cause, however, I'm happy to connect other star athletes and help A-teams go for the gold.

Healthcare is definitely an ego-centric, OCD friendly-three ring circus (hello compulsive handwashers). We always seem to be reaching for the perfect 10.

With several conspicuously glaring omissions (infamous 'doctor' handwriting, lack of interconnectivity between admissions, care planning/delivery and follow up data, minimizing importance of patient-centric approach and involvement, etc.) healthcare is an industry obsessed with the pursuit of perfection.

Although we use terms like 'sick' and 'healthy' - what do these really mean? There's a reason our measures for recording and discussing a person's total health are highly subjective, while individual, isolated clinical results are related in quantitative terms.

Without numbers and lab values, we might actually come to feel we have little control over our health, and then where would the industry be?

We include both subjective and objective measures (SOAP notes) and observations on a record because both are absolutely vital in our conversations surrounding the pursuit of 'perfect' health - pursuit being the operative word.

But in sickness and in health, for richer and poorer, perfection is a pipe dream.

Unlike winning the lottery, it's statistically impossible, not just improbable, for any of us to be in 'perfect health.'

Patients never operate at a 'perfect 10' on the health scale. Even the best of us.

Doctors never operate (literally and figuratively) at a 'perfect 10' on the care delivery spectrum. Even the best of us.

Nurses never operate at a 'perfect 10 ' on following docs orders, administering meds, etc. Even the best of us.

You get the point. Perfection is healthcare's mission impossible.

And just like the blockbuster action flick series, we have our heroes, who pull impossible stunts in the name of improving the industry.

Granted, I follow these heroes with as much slightly occluded slavish devotion as friends who read Marvel comics, or rabid Apple or Converse All-Star devotees.

Don't get me wrong. We all need heroes. Many of us want to take a turn wearing the cape.

Do you want the good news or the bad news first? They're one in the same: American healthcare is Gotham City, so plenty of us will have a turn to play with superhero stuff.

We need people who reach for the impossible to show us lesser mortals how we can be involved in the dirty, underwhelming everyday work, the wire tapping, the surveillance, the analysis, the commentary and programming addressing what's going right, what's going wrong in American healthcare and how we might tweak programs, start companies. Heroes that shoot for 10s encourage us to shoot for 7.5s.

We're a paternalistic, patriotic, parochial bunch. And despite the pragmatism above, I remain glass half full on most healthcare reform efforts reaching for what's next.

So why the harping on perfection?

First, it's nearing election time, and we're seeing the monolith approach to policy evaluation for both candidates.

Monoliths work in dictatorships (until the populace revolts in attempted coups), monopolies, corporate sponsored white papers, and other flat, tired storylines.

Creative commons are slightly messy around the edges. Peer to peer networks defy the isolated superhero theorem. Service design means observing people interacting in the wild - and you can't tie up singular solutions with a neat uni-product bow. The Cloud is morphing all the time. Collaboration breeds singular productivity with a side order of randomness.

Reaching for a 10 results in a 7.5 and a bunch of flak. Some collateral damage, mistakes, tragedies are unavoidable, but that doesn't mean you completely stop trying.

I'm reading a lot about 'saving' healthcare. Doing some late summer introspection, I'll be the first to admit buying into and using such platitudes on occasion. Ok. On many, many occasions.

There are several reasons I'm increasingly concerned about American healthcare's pursuit of perfection.

1. It's impossible to achieve a perfect 10 in American healthcare. One big blowout routine won't save our system. We need a web of individualized, interconnected, tangled, messy micro-solutions which maximize targeted impacts.

2. The expectation that a mass-population policy approach like federally-funded universal healthcare will make everyone healthy (and many wealthy) doesn't pan out. There is no Neo waiting in the wings to free us from the tangled matrix of missed opportunity and mangled administration we've created. Or rather, we need to cultivate a multiplicity of internal Neos.

3. When we're after the pursuit of perfection, often we make terrible mistakes. Chew on this maxim personally. Now chew on it professionally. Tough to swallow both ways, no? Hubris and smirking self-satisfaction that arises from creating polarizing 'one size fits all' perfect 10 routines cultivates tragedy at least as often as it perpetuates creativity. Today is the anniversary of a 'perfect 10' solution the US used to put a halt to WWII - in 1945 we dropped an A-bomb on Hiroshima, killing at least 66k instantly and dramatically escalating the costs of future conflict ('soft' human capital and 'hard' capital).

So why am I still here? Why haven't many of us opted out? Why are second and third generation healthcare bloggers continuing to form groups with early pioneers and reach for the perfect 10?

There's hope. We keep trying to perfect the routines:

1. Why do we keep searching for what's next in healthcare, no matter where we live, no matter where we work, no matter how our system is organized?

2. Why are people fascinated with defining and redefining Health 2.0? We're having the largest ever Health 2.0 US event in October.

3. Why are global hives of people coalescing without pay, spending personal time and money to revise outdated systems approaches?

Many of us realize perfection is unobtainable, but improvement is absolutely unavoidable. What role do you want to play (insert your own comic book/action hero alter ego here)?

Despite snark, hold fast to belief in healthcare heroes. They often disappoint us. That's called being human. They occasionally amaze us. Ditto on being human.

Shoot for the impossible. Only then do we start to believe in the improbable goals. Perfect 10? Doesn't sound half bad. That's called having faith.

Now act on it. If you need somewhere to direct that drive, I know plenty of all star teams looking for semi-heroes. Sometimes a 7.5 may as well be gold.

This is Hello Health

Welcome to Williamsburg Jay, Sean, Devlyn & Co! May you live long and prosper.

The Hello Health launch party on Thursday was perfect timing - it's easy to feel cynical about where 'primary' healthcare in the US is headed.

Then you perch on the edge of the Hello Health exam table in an office streamlined to provide the best in patient-directed, consumer-centric care, backed by Myca's custom software apps, and a little bubble of hope expands at the base of your throat. Five days later, the bubble's still there.

If you live in Williamsburg - do yourself and your health a favor (especially if you're a freelancer/creative type who's currently un/underinsured) - check out Hello Health.

A few quick questions for the Hello Health crew (which I didn't ask in person - too busy running around snapping photos and drooling all over your new digs):

1. Plans for service design/design collaborative in health?

2. When/where will the next branch open? (Please say DC...please say DC)

3. How do you compare Hello Health to the much bandied about misused and abused 'medical home' renaming of traditional primary care?

4. Serious estimates for scalability? How long to establish baseline goals for Brooklyn practice - how many patients - how long to establish next branch - will this run as a sort of franchise agreement - when/where can I buy one? (grin)


More photos from the launch on Flickr here...net denizens take note - Jay's got some interesting endorsements from the webtech/HIT community.

Many thanks to the Myca folks (excellent hosts) for taking this leap - your software app is a thing of beauty - can't wait to see my docs using it (in the US AND in the Netherlands - why stop with a cross-country bus trip when there's an international need for this kind of solution?).

Thanks also to the Organized Wisdom gang for the whirlwind Big Apple tour, and Sarah Greene for the sparkling company, invaluable conversation, bathroom bites of wisdom, and hospitality.

Anyone interested in visiting Hello Health - it's worth the trip. Trust me.

Take a Look at What's Possible When You're an e-Patient: Courtesy of Maarten, aka "Dutchcowboy"

This is what it's like to be an e-patient, uncut.

Click here to see the latest in Maarten's "Patient 2.0 Journey," including a video interview.

Maarten also shares scans showing Theo (his tumor) has shrunk 50% after the second round of chemo (Yeehaw and giddyup little doggy!), and in we find Mr. Maarten and family also has a snazzy new lime green swimming pool.

Maarten, one question - when's the e-patient pool party? :) Do you have to be bald to get in? (I'm not beyond it, but don't think it would be as flattering a look for me...best of luck with going in for your next round!

Anatomy of ZocDoc.com: "Category Killer" for Doctor Search & Scheduling?

"I wish my industry wasn't 15 years behind." - Dr. Jay Parkinson, Myca, Hello Health

During our interview last month, Jay Parkinson mentioned Hello Health's intention to use ZocDoc.com to schedule specialist appointments for patients. Embarrassed to report I'd never heard of the company, I did what any good (read: nosy) blogger would do - visited the site.

After 5 minutes, and a fortuitously timed email from a good friend in DC asking for a specialist recommendation, I was wishing the ZocDoc crew would pack up camp and move to the nation's capital.

Then ZocDoc's Trevor Leb shot me an email with more info, and I was hooked. Yesterday I spoke with two members of the company's leadership team: Cyrus Massoumi, CEO (cofounder) and Dr. Oliver Kharraz, COO (cofounder).

The ZocDoc team has garnered an impressive array of awards and publicity since launch in September 2007, including a TechCrunch prize. After talking with cofounders Cyrus and Oliver about the business model and strategic goals, I think the buzz is well-deserved - this is a breakout Health 3.0 firm.

Anyone who wears prison-orange scrubs (NY Tech Meetup) and invokes the voice of God (TechCrunch 2007) to demo the firm earns my respect - it's about time HIT firms approach the level of creativity and scrappiness exhibited by their mainstream consumer tech cousins.

But don't take my word for it - read our interview (lengthy but worth it) and decide for yourself. That's what consumer-centric care and participatory medicine is all about, right? Using information available to make up your own mind?

Q: It's not about size, but it is about numbers. Can you share search numbers for ZocDoc.com?

A: (Cyrus) Sure. We have a little north of 25k visitors per month. The interesting thing about ZocDoc is that we're geographically constrained – an overwhelming percent of our users are in NYC, and we're growing at a rate of 20-50% per month.

Q: Are you growing without advertising?

A: (Cyrus) Yes. Minimal advertising – a lot has been word of mouth, and we've gotten a lot of really good press (Wall Street Journal Blog, NYTimes). We launched at TechCrunch last year, and they picked us as one of the hottest 40 startups in September of 2007 (Watch the presentation – I've never seen a Health 2.0 startup invoke the “voice of God” during a demo). We're self-funded up to this point (NOTE: ZocDoc has received some funding from angel investors, including former backers from Facebook, but hasn't raised an institutional round). We want to grow virally – grew 70% last month.

Q: How many ZocDoc users are leaving ratings, both self-identified and anonymous? Do you have info on the percentage of users that choose to rate anonymously?

A: (Oliver) That's an interesting question. I don't know right now how many patients self-identify – but we do read through reviews to ensure they don't include offensive content - so I can tell you early on people were more reluctant to put up their names. Now people use the rating system more because their friends use it, so they're more comfortable including names.

Q: Right now on ZocDoc I can pick a Dentist, Dermatologist, or Primary Care Physician – what are people requesting on the waiting list, and what are your plans to expand practice areas (when will ophthamology go online, for instance?)

A: (Cyrus) We're seeing requests for ortho, ENT, mental health, and general family care – lots of families want to use us for pediatricians, OB/GYN. Our goal by the end of year is to have 10 specialties live on ZocDoc. We want the 80 percent of practice areas that people go to most frequently, the other areas are sort of the long tail - we want to solve the 80 percent problem (More support for the 10-80-10 rule – ZocDoc is providing online scheduling for the Middle 80). We want as many people booking using our platform as possible, this makes it as useful as possible. That's the reason we made our API available, because the platform can enable companies like Jay's Hello Health to do things that they just weren't able to do before. Other people that have approached us with other ideas. We have people building applications for an IPhone. Our API is very broad, Jay is using it for his practice, but imagine we have a button on your IPhone where you can geolocate a doctors office near you and set up an appointment . With regard to other partnerships, we have 10 employees, we just can't pursue all these types of partnerships with this size, that's why we released the API. We also think of our function as a little more broad. We've been compared to the OpenTable of healthcare, but if you use the travel analogy, look at SABRE, which powers travel reservations – that's really our goal, to be THE platform people are using to book doctors appointments.

Q: One of the touchy areas of Health 2.0 relates to business models (or lack thereof) – tell me a bit about ZocDoc's model and revenue structure?

A: (Cyrus) Sure. Practitioners create a profile for free, but if they start using the scheduling service and such there's a subscription fee that physicians pay. The fee varies. When we launch a new specialty we make it free for a time to encourage adoption and so we can learn more. Right now practitioners use our web based calendar to make times available. We also have integrations we've built for leading practice management solutions and we charge fee to access these in addition to using the ZocDoc calendar.

Q: Tell me about expansion plans....what's your current staff strength? See you're hiring for some key positions (VP Operations, VP Membership Sales) Where do you want to be by the end of 2008? Also, you're currently only available in NYC – what other regions do you want to reach?

A: (Cyrus) We'll probably double in size - or more – in the next 6 months. Half of those staff people will be dealing with practitioner-facing roles, lining up physicians to use the service and training them. We have a pretty extensive waiting list of doctors. We haven't had a lot of work to grow our waiting list. We jumped from listing 1 to 5 percent of dental practitioners in Manhattan with no activity on our part. Started with dentists, then added primary care docs 5 months ago, and added dermatology 1 month ago. We're also building developer base because there are so many interesting expansions. In this market too, really talented developers are really hard to come by . If you know any please send them our way, we've been very selective. Entrepreneurs have told us the first 20 employees are the most important in the company. Since September we've had 1200 people apply at ZocDoc – we're bringing on employee number 10 now. With Trevor (who set up our interview), we had to talk to 100 people before we found him, so we're really trying to get a very quality team.

Q: Why go head to head with a multitude of other doc search and ratings firms? What's different about ZocDoc? Who do you consider to be competitors?

A: (Cyrus) I actually had an issue, one year ago during a January flight from Seattle to NYC, when I landed I ruptured my eardrum. It was a horrible experience. I went to my insurance company website and it just didn't cut it for me. It took me four days to get to a doctor. NYC has highest density of docs in the world, Tel Aviv is number 2. There's an oversupply of doctors in NYC, but the information was just bad on my insurance company website. If you pull up your insurance company website, and pull out 10 doctors names, at least 20 percent of them are going to be bad – maybe even the doc has died and is still on the insurance company roles for years. The other thing ZocDoc supplies is who is really good (according to other patients). We're the category killer for patient booking online. You see your practitioner's availability instantly. You don't have to spend a whole day making calls. The second thing is that we're the only site on the internet I'm aware of that confirms patients are the only ones leaving feedback.

Q: So how does that process work?

A: (Cyrus) The doctor confirms the patient has showed up. Then the patient gets an email inviting them to leave a rating. If a patient doesn't show more than once, they're actually locked out of the system. Practitioners love that habitually bad patients are locked out of ZocDoc. Our no show rates are significantly lower than practitioners own no show rates. This is because we send so many reminders. After booking, patients receive reminders at 1 week, one day, and 1 hour ahead of time. We also verify the individuality of each patient – you must provide a phone number and that phone number is verified.

Q: Ok, so how do you get docs to join? Active recruiting? Do they find you? How do you expand the ZocDoc pool, and do docs get anything from joining other than new patients? NOTE: One doc reports 20% increase in patient flow – do you have staff managing physician relations?

A: (Cyrus) Doctors find us, and sign up on our waiting list. We'll go and say opthamology is next because we had great waiting list. Then we look at the distribution of practitioners – you have to have availability every few blocks – so we don't want one doctor in the Upper East Side. In every neighborhood we need a selection of doctors. We make a concerted effort to fill in the gaps so to speak.

Q: Seems like I got different results when I entered “I'm paying by myself.” Can docs vet prospective patients ability to pay using the service (I see that there's an optional place for me to enter my healthcare coverage information and how I'll be paying) does this automagically weed out physicians who don't accept my form of payment?

A: (Cyrus) From our perspective patients want someone who's in network for them – that has very heavy weighting in how search results show up. They're weighted using an algorhythm so that in-network practitioners show up first, but all docs do show up. Our goal at all times is to operate completely in the patients' best interest. We have had practitioners approach us with requests for search optimization services like Google, but won't do that, because we put patients first in 100 percent of everything we do. If patients don't trust us, we will not be successful.

Q: Has that happened yet? Has a patient come to ZocDoc with an issue about scheduling, or a complaint about a physician, etc.? How did you solve the issue?

A: (Cyrus) Ok, here's a good example. A patient booked an appointment on Saturday. The practitioner got the email about the appointment in his car, and he was stuck in traffic. We love the Saturday appointment, so we were on top of this. The practitioner told us he was going to be late. Our COO Oliver called around and found a dentist who could see them on Saturday.

A: (Oliver) We get love letters from our patients on a regular basis. I practiced for a few years, and I never got that feedback from my patients, so it's quite nice. We had dentists open on Thanksgiving Day. I wouldn't have known who to give a call to on Thanksgiving Day – so we had patients with dental pain on Thanksgiving day, I would never have known.

A: (Cyrus) Here in NYC, GHI is HMO specific insurance – it takes month before primary care doctors can see GHI patients. If they use ZocDoc, we're going to have 10 primary care docs who could see them in a week.

Q: I'm not a doctor, but I have a friend in DC who knows I'm in healthcare, so she's asked me for a recommendation for a specialist. I don't know anyone, but if ZocDoc was there I'd refer her. Any plans to expand into other regions?

A: We hope to be in DC soon. We're letting people submit requests to the waiting list and vote for expansions.

Q: Tell me a little bit about your backgrounds. How did you get into the Health 2.0 sphere?

A: (Cyrus) We've all been entrepreneurs – our entire management team has done startups before. We're involved in health because we do believe we are changing the world. There is a very big altruistic element to what we're doing. Doctors love us and patients love us. It's a real problem that many, many people have. Both of us (CEO Cyrus and COO Oliver) left McKinsey directly. It was very compelling because it was just needed, no one else is doing it.

A: (Oliver) It's been a really great start. Being a doctor myself I know I wanted to do something in the healthcare space. It's about how you can really move the needle – quality is great, but we've gotten to the point in this country where we can only make incremental quality improvements. Coming from Europe myself (Germany), our access is sort of a little bit easier – there's not this sort of scheduling issue, you just walk into a doctor and see them. This is a problem here and we need to make it easier. The experience proves that we are right, scheduling is more of a pain point. It's a very obvious. People hate the way the system works right now because it's inefficient for all parties.

A: (Cyrus) Our entire management team comes from families with doctors in every generation. So we all grew up in the healthcare industry.

A: (Jen) As the daughter of a nurse, you know what I'm going to say next right? You need someone with a nursing background (laughter) to round out the team.

Q: I see ZocDoc is on Facebook – are you using other social networks like MySpace, Plurk, Britekite, Twitter?

A: (Cyrus) Yeah, anyway we can reach people and get them to talk in a viral manner. You can imagine docs who are on FaceBook, right? Well, what if you are able to book an appointment directly via their FaceBook page.? One thing we keep in mind – that 80 percent number (healthcare for the Middle 80)– pare it down to solving 80 percent of the problems. A lot of the healthcare people go after these are things that are on the long tail.

A: (Cyrus) Also your earlier question about partnerships is interesting. We have our feedback system. People don't book doctors appointments often enough for there to be specific social site just for this. But we have waiting lists in other parts of the country – San Francisco, DC, Boston. We had an opthomologist in South Dakota email us. But the ability to do one-off partnerships takes a lot out of the entire team. Going in and doing deals in the short term – it's something we'll consider. We are talking to a lot of players in the Health 2.0 space. That's why we made our API available. At this point it's probably more effective to pound the pavement and do things our own way. It's early, is what I'm trying to say.

Q: Everybody hates this question, but final thoughts about where you think healthcare in the US is going?

A: (Oliver) That's a very broad question - where it's going from the consumer perspective – I think there will be more responsibility that consumers will have to take on as they make more decisions. But right now, there's not enough information out there for patients to make these decisions well, so I think that is certainly one of the areas where more innovation and more products are needed. From a physician perspective, we're at interesting crossroads right now. I think many are waiting to see what the next Administration will do. And with respect to universal healthcare – it has a lot of potential. And I really hope it will get a good stand. This may be a politically contentious view, but we need to be getting to the point where people are covered earlier in the disease process, where we don't have to catch them in latter stages of 3 diseases in the ER

Q: Thanks very much gentlemen for your time. As an e-patient and consumer-centric healthcare advocate I'm encouraged to see a service like this. Hope to see you at Health 2.0!