EMR Unbundling (Continued)

The post I wrote about the unbundling of the EMR a few weeks ago received quite a bit of attention. KevinMD republished it and Deanna Pogoreic from the Med City News featured it in her own article on the topic titled, What Craigslist can tell us about the future of health IT startups and the EMR market. Combined, the post was Tweeted well over 100 times. Given some of the commentary around the post, I wanted to provide two quick clarifications:

1.  I actually believe that unbundling is good for the bundler. In my post, I talked about how much value Craigslist brought to consumers when they bundled everything into one place on the web (apartment listings, job listings, personals, etc.). Now they’re finding that niche players are coming in and providing superior value and biting off pieces of their business. On the surface this seems bad for Craigslist. But I don't think it is. Allowing competitors to bite off areas of weakness will make Craigslist better. Back when online classified listings were valuable, simply aggregating them into one place was valuable. But now that's a commodity and Craigslist has spread themselves too thin. Competition will force them to pick an area where they can add real consumer value (as they did back when they started). The same will be true for EMRs. Unbundling (competition) is good for everyone.

2.  I probably wasn't clear enough about how long the process of EMR unbundling is going to take. As I mentioned in the post, there are large switching costs in B2B products that don't exist in B2C products. In addition, because of long-term enterprise contracts, strong vendor relationships, risk mitigation and other factors, it will likely take a lot more time for the EMRs to become unbundled than it will for a consumer website like Craigslist to become unbundled. Also, successful unbundling requires the EMRs to open up their platforms for integration -- which will take time. But my overall point still stands. Demand for the best product, over time, will always overcome switching costs and vendor resistance. Doctors and healthcare execs are consumers just like the rest of us. They want the best value -- it just takes them a bit longer to make the purchase.

Internet Marketplaces Should Be Seller Agnostic

When you're running an internet marketplace (Etsy, OpenTable, eBay, Uber, KickStarter, Yelp, etc.), it's very tempting to give sellers the opportunity to buy premium placement. This could be things like homepage placement, better placement in search results or enhanced profile pages. Selling this stuff is certainly a very logical way to monetize your user base.

But the problem with this approach is that every time you give priority to a seller that pays you more money, you've muddied your value proposition and taken an equal amount of value away from your user base.

A good marketplace is one that creates an easy, beautiful, seamless and open buying experience that enables rating and recommendation systems so that users can decide the best sellers and the worst sellers. Selling premium placement effectively circumvents your users' preferences putting you in a race to the bottom.

Sure, by charging for premium placement, in the short term, you'll generate some cash. And you can use that cash to do some marketing so that you can generate more users. But over time, if you want to continue to grow, you'll need more and more money and more and more marketing. That will force you to create more and more premium placement options (subsequently devaluing your marketplace).

The better approach is to prioritize the user and compete in the race to the top. Give your users the best possible marketplace experience and let them decide which sellers should win and which sellers should lose. Those great experiences will result in buyers telling their friends to use your service and that will result in more people going through the experience and more people telling their friends to use your service and on and on.

That's the way to scale. And you can't do it favoring one seller over another. Give sellers a great experience too, but don't prioritize them. Prioritize the user.

Fighting For Mobile Real Estate

The other day I wrote about the unbundling of web services. That's where an aggregator comes along and adds value by pulling lots of different services into one place -- Craigslist and Facebook are good examples. As these companies become successful, competitors come in and bite off little pieces of their service and build slick apps that do one thing really, really well. StubHub and AirBnB are good examples of apps that are 'unbundling' Craigslist.

With this in mind, I came across this chart noting that later this year mobile internet usage is going to exceed desktop usage.

As mobile usage overtakes desktop usage, specialized apps that do one thing really well are going to be more and more important.

As we know, the challenge with a mobile app is that they're very limited in what they can do. You can't do as much on an app as you can do on the desktop. So as mobile becomes a bigger part of our lives I think we'll see more and more of this unbundling.

But I think we'll also see more and more bundling of retailers and merchants. That is, we're not going to download multiple grocery store apps or multiple clothing store apps or multiple travel apps.

Using myself as an example, I travel a lot. I book with 5 different airlines and probably 6 different hotel chains. As we move towards more and more mobile usage, am I going to download 11 apps? Of course not – I’m going to download one -- Expedia.

The interesting paradox with mobile is that while it will certainly continue to force innovation and specialized, "unbundled" web services, it will also drive lots of "bundled" retailer and merchant applications. Consumers will increasingly demand (and need) less and less clutter on their screens.

In short, the apps that will win the fight for real estate on our home screens will be those that serve a very narrow function very effectively (buying a plane ticket) while at the same time offering the broadest variety of options (tickets from every carrier).

BlackBerry's Rise And Fall

The Globe & Mail had a great profile of the rise and fall of BlackBerry last week that’s worth reading when you have some time – it’s a fairly long piece. It got me thinking, BlackBerry is going to make a great business school case study some day. Anyway, I’ve always been of the opinion that BlackBerry didn’t fail because of hardware. As a very loyal user for eight years, I've always believed that they failed because they were way, way too late to the app game. I remember buying a new BlackBerry long after they launched the app store and finding that the app store didn’t come installed. I had to go download the App Store app so I could start downloading apps. And when I downloaded it I found that it was super hard to use. It’s clear that apps weren't a priority for BlackBerry.

When Apple released its App Store it was the core part of the phone. It was easy to use and the app options were nearly unlimited. The advent of apps literally made the iPhone 100x better. That's not an exaggeration. And for some reason BlackBerry missed this opportunity and got into the app game way too late. As a result they literally had no chance of competing against the iPhone or the Android.

I’ve always wondered why they missed this and the Globe & Mail article offers some insight. Check out this excerpt:

Trying to satisfy its two sets of customers – consumers and corporate users – could leave the company satisfying neither. When RIM executives showed off plans to add camera, game and music applications to its products to several hundred Fortune 500 chief information officers at a company event in Orlando in 2010, they weren’t prepared for the backlash that followed. Large corporate customers didn’t want personal applications on corporate phones, said a former RIM executive who attended the session.

Surely BlackBerry had lots of problems but imagine operating in a super competitive business and having one group of customers holding you back from creating the best product you can for another group of customers?

Blackberry could’ve tried to serve both sets of customers but intrinsically and culturally their corporate customers put them at a massive disadvantage when it came to innovation and serving the consumer.

What a paradox: it seems that what once made BlackBerry so successful – large corporate contracts – may be the thing that eventually caused their demise.

Craigslist, Facebook & EMRs

Benedict Evans has a phenomenal post up on his blog where he discusses the future of LinkedIn. Go read it, it’s excellent. In it he talks about the law of bundling and subsequent unbundling of web services. He uses Andrew Parker's brilliant image below to illustrate the point.

Craigslist came along and bundled everything into one place and, as a result, completely dominated. They destroyed multiple businesses in the process (including the rental and roommate web service I worked with just after college). They were immensely successful.

But now we're seeing the unbundling of Craigslist. Small players are coming in and biting off small pieces of their business and providing superior value. AirBnB does room rentals better than Craigslist, StubHub is a better ticket reselling service, LegalZoom is a better place to find legal services, etc.

Craigslist detractors believe that this will be death by 1,000 cuts.

Craigslist isn't alone. This is exactly what Facebook has been going through over the last several years: Twitter is attacking the status update, Foursquare is attacking the location feature, Instagram is attacking photo sharing (so much so that Facebook was forced to buy them), Vimeo is attacking video sharing, etc.

Of course, while unbundling is bad for the bundler, it’s great for the consumer. Consumers get more value, more features and easier to use web services.

When I saw the Craigslist image I couldn't help but think of the large EMR (Electronic Medical Record) companies -- Epic Systems, Cerner, Athena, Allscripts, etc. These companies have provided immense value by bundling and integrating a massive amount of clinical data with a nearly endless variety of healthcare related software services. They manage ambulatory clinical data, inpatient clinical data, practice management, patient communication, prescription filling, patient scheduling, billing, meaningful use compliance, population health, specialist referrals, patient engagement, risk management and many other things under the same platform. And just like Craigslist and Facebook, they've benefited hugely as a result.

But you can begin to see some cracks in their armor. As clinical data moves to the cloud, more and more startups are coming along and biting off small pieces of the EMR business and providing better value. This is the beginning of the unbundling of the big EMRs.

That said, what's easy to do in b2c software isn't so easy in b2b software. There are significant switching costs associated with switching health IT vendors and most hospitals and health systems are very risk averse and will take their time adopting new technologies (it's much easier for an individual to buy a ticket on StubHub than it is for a hospital to buy a new patient portal).

But with the dollars that are flowing into healthcare focused venture capital and the excitement around those investments, it’s only a matter of time before we see this unbundling accelerate and see more value flowing to providers and patients. And that's a good thing for our healthcare system.

When Selling A B2C Marketplace, Worry About The C, Not The B

A traditional tactic for enterprise salespeople is to be very focused on their prospect’s business – their strategic priorities, their competitors, what keeps them up at night, how they’re growing, etc. But when you're selling a marketplace the focus should be less on the prospect’s business and more on the consumer. Some examples of these businesses include:

• Yelp
• Etsy
• Open Table
• WorkMarket
• Expedia
• Skillshare
• Amazon Marketplace

These businesses are selling their marketplace. They're really just a middleman between a business and a set of (hopefully) engaged consumers.

It's important for Open Table’s restaurant salespeople to understand their prospect’s business, but it’s much more important for them to understand the consumer. What do they want to eat, when do they want to eat, what kind of experience do they want, how do they want to be marketed to, etc. And most importantly, why is Open Table going to be their destination when they look for a restaurant?

Your customer’s know their business better than you do. There’s not much you can tell them that they don’t already know. But they very likely don't understand the consumer as well as you do. So when you’re selling a marketplace, don’t bore them by trying to be an expert on their business, educate them by being an expert on the consumer.

In An Internet Marketplace, Competiton Helps

Fred Wilson had a good post yesterday talking about the Fallacy of Zero Sum Game Thinking in internet marketplaces. The Zero Sum Theory suggests that as more sellers come onto a marketplace it hurts the early adopters. I’ve worked in internet marketplaces in 3 different industries -- real estate, e-commerce and now healthcare -- and I can tell you that this theory is a myth. I posted the following comment on Fred's blog:

The zero sum game theory is really just a misunderstanding of how good marketplaces drive traffic and acquire new users.

If most of Etsy's traffic came from them buying SEM or running TV ads, then yes, there is a fixed amount of traffic that sellers are competing for. But I'd bet that the vast majority of Etsy's new buyers come to them organically. That is, a buyer has a good experience on Etsy, then tells a friend, and that friend tells a friend, and that friend tells a friend, and on and on.

More sellers >> more good buying experiences >> more buyers.

The beautiful thing about marketplaces where traffic is driven by a quality buying experience (and word of mouth) is that instead of sellers competing with one another for traffic, they actually rely on one another for traffic.

I recommend checking out the original post. There's some great stuff in there on how, despite the controversy, Spike Lee raising money on Kickstarter actually increased funding for lesser known filmmakers. Great topic.

Spreading Innovation

There’s a long but good Atul Gawande article in this week’s New Yorker worth reading that’s relevant to what many of us are trying to do -- spread innovation and change minds. He writes about why some new innovations spread quickly and others don’t.  Talks about the fact that doctors adopted anesthesia really quickly but it took them years and years to begin sterilizing operating rooms (arguably a more important innovation).

Talks about the critical importance of the human factor in spreading innovation – and how a simple treatment for Cholera (a mix of sugar, salt and water) never spread in Bangladesh until human beings went out on foot and sold it, door to door.  Also uses a more relevant analogy:

This is something that salespeople understand well. I once asked a pharmaceutical rep how he persuaded doctors—who are notoriously stubborn—to adopt a new medicine. Evidence is not remotely enough, he said, however strong a case you may have. You must also apply “the rule of seven touches.” Personally “touch” the doctors seven times, and they will come to know you; if they know you, they might trust you; and, if they trust you, they will change. That’s why he stocked doctors’ closets with free drug samples in person. Then he could poke his head around the corner and ask, “So how did your daughter Debbie’s soccer game go?” Eventually, this can become “Have you seen this study on our new drug? How about giving it a try?” As the rep had recognized, human interaction is the key force in overcoming resistance and speeding change.

Some SEO Insights

I picked up some good insights on search engine optimization (SEO) over the last few weeks. For those that aren't familiar, SEO is the process of affecting the visibility of a website or a web page in a search engine's "natural" or un-paid ("organic") search results. So these are not the 'bolded' results at the top or right hand side of a Google search page. 80% of users click on the organic links instead of the paid links (personally, I almost never click on paid links).

16% of Google searches that occur each day were never searched for before.

Google’s primary job is to satisfy the user, so they’re going to send the user to the place that will make them the happiest. So the primary drivers of good SEO results (in no particular order) are:

1. Number of inbound links to the content
2. Amount of content
3. Recency of content
4. Click-through rate (from search result to click)
5. Stickiness of site (time spent on site)
6. Lack of dummy content (content that isn't relevant to the page or topic)

There have been incidents in the past where e-commerce sites would intentionally and blatantly ripoff a portion of their customers -- causing those customers to go to the internet and write bad reviews with links back to the offending site. It used to be that this kind of behavior would cause the site to be listed higher in organic search results (more links = higher SEO score).

To prevent this, Google has started to use something called sentiment analysis or opinion mining. By applying an algorithm against a variety of social media sites, discussion boards, blogs and news sites, Google can get a pretty good sense of whether or not the internet likes your site. And if they do, you'll rank higher.

Of course, sentiment analysis is complicated and not 100% reliable (due to cultural factors, language nuances and wide-ranging contexts) but is a useful way for Google to ensure that individuals aren't gaming the system.

In short, I think the key insight is that if you want to rank high in SEO over the long term, you have to do the right thing. You have to give users a site that makes them happy. You may be able to fool Google for a little while, but they'll eventually catch up and when they do you can forget about SEO as a source for acquiring new business.

The UP By Jawbone

The other day I bought a Jawbone UP, the popular health monitoring device that tracks steps, sleep and sleep quality. I’ve only been using it for a few days but so far so good. I mostly bought it for the sleep monitoring feature, and because I've been generally a bit anxious to test out a health monitoring device.

I’m slightly obsessed about the amount of sleep I get. Often there are nights where I get a good night’s sleep, but I don’t think I did so I worry about it. UP has begun to put my mind at ease – I’m actually getting more sleep than I had thought. The sleep part of the app monitors how long it took me to get to sleep, how long I slept and even deciphers periods of deep sleep versus light sleep.

I measure my daily workouts fairly closely and I use the MapMyRun app for my outdoor runs so the step measuring feature isn’t all that useful to me. Though I think over time it’ll be interesting to look back at the data to see how much I’m moving, and how I'm moving more or less during different periods. I also like being able to view my general activity levels in contrast to my rest.

The wristband itself is good. It looks decent on my wrist, seems durable, the controls are really responsive and it's easy to sync. The iPhone app is fabulous. It’s easy to use and has a seemingly endless number of ways to slice the data it collects.

There are a few more features I haven't used yet that I'll try out in the coming weeks. Lots of people believe that this kind of self-monitoring is the future of healthcare (particularly to help monitor various physiological statistics and behavior change for people with acute illness and/or high risk factors).

I'll write another post on my experience with the UP in a few months after I've compiled a bunch of data.

The Big 4 Internet Companies (Continued)

A year ago this month someone asked me this question: if I had to invest in one of the big four internet companies -- Amazon, Apple, Facebook and Google -- which one would it be? Without hesitating, I chose Amazon. I wrote a post about my reasoning at the time.

One year later, I thought I'd check in to see if I made the right choice. Here's how each of the stocks performed in 2012:

• Facebook - down 17% (since their IPO in March)
• Apple - down 1%
• Google - up 33%
• Amazon - up 47%

So it turns out I made the right call. Too bad I didn't put my money where was my mouth was.

That said, it's not a completely missed opportunity. I definitely think there's still a lot of money to be made on Amazon. I'm probably even more bullish on them now then I was 12 months ago.

My iPhone's Home Screen

I had a conversation the other day about the apps I have on my iPhone's home screen. I thought I'd capture the list here. Here's a screenshot.

Foursquare. I like 'checking in' because it keeps a record of the places I've been. I don't interact with people on it but the 'explore' function is good for finding new bars, restaurants and coffee shops. It's better than Yelp in many ways.

Twitter. I don't Tweet all that frequently but I check my feed multiple times a day.

Reeder. This is where I read the blogs that I follow. I check it multiple times a day.

Facebook. I'm trying to move away from using Facebook. I hardly ever post though I check it a couple times a day.

Google Maps. The best mapping app I've ever used. I use it constantly when I'm on the road.

LinkedIn. I interact with people through LinkedIn almost every day. I also check it sporadically for news and other updates.

WEEI. This is an app for my favorite Boston sports talk radio station. I listen to it pretty much every morning.

TripIt. This app keeps me organized when I travel. I wrote a post about it a while back.

Instagram. I don't use it that much but I have it on my home screen as a reminder to take more photos.

Podcasts. I listen to multiple podcasts a day.

Weather. Very simple app. I've preset the cities I travel to most frequently so I can easily find out what to expect.

Kindle. I don't use this app all that often as I prefer to do long form reading on a larger device. But I try to crack it open while I'm on the subway.

Music. I have lots of music apps (screenshot below). I'm still trying to determine the app(s) that work best for me. I probably use Pandora the most these days. I'm going to write a post on this in the coming weeks.

Settings. I have this on my home screen so I can easily manage wi-fi connections. I wish there was an easier way to manage these on the iPhone.

Clock. I use the alarm clock app daily.

WordPress. I've actually never written a blog post on the app but I use it often to capture new ideas.

So that's my home screen. It'll be interesting to see how this changes over time.