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.

5 Sales Presentation Tips

Here are 5 somewhat random things to consider when giving a sales presentation to a group of people that you're meeting for the first time. 1.  Take their guard down. I don't believe in "always be closing." I believe in "always be leaving." Be clear and open about the fact that it's very likely that the solution you have is not right for your audience (depending on your close rate, it's probably not). This is not emotional, you're simply there to determine whether or not there's a fit. If at any moment you determine that this prospect is not a good fit for your solution you should be ready to politely pack up and leave. You want your prospect leaning forward to learn more, not leaning back trying to avoid a pushy salesperson.

2.  Give credit to the competition. Never, ever bad mouth your competitors. Whatever you say they won't believe you. Compliment your competitors but differentiate yourself by explaining what they do better than you and what you do better than them. In fact, I don't believe that you have competitors. You may be trying to solve the same problem, but I guarantee you're going about it differently. Carve out that niche. Don't say you're better, say you're different. And help craft a framework for the audience on how they should think about the different solutions.

3. Go easy on the data. They don't know you and they don't trust you and most people are smart enough to know that data can be manipulated to tell any story you want. Sell them on the concept. Appeal to their logic or their compassion. Get into the data in follow-up meetings once you've built up some credibility.

4. At least once tell them something your product doesn't do well. Be humble. There's nothing wrong with product flaws. There is something wrong with salespeople that don't recognize that their product has them. You're not selling features anyway, you're selling a concept and a potential business impact. You'll gain credibility and generate a more honest discussion by admitting your weaknesses.

5. Be interesting. Most of the stuff that the people in the room are going to do for the rest of their day is likely to be somewhat boring. Raise the bar and be compelling. Challenge the audience's thinking. This actually isn't that hard and it's much more fun. I don't say this out loud, but when I'm about to start presenting, here's what I'm thinking: "I know you're busy and you're expecting a boring presentation, so I'm going to keep this short, efficient, interesting and provocative. I'm going to make you think about something that you don't think about that much but I think about all the time. And at the end you very likely may not buy this product but I guarantee you'll be glad you spent this hour with me."

As I'm writing this I'm thinking of more and more tips. I'll post more of these soon.

B2B Pricing & Malcolm Gladwell's New Book

Last Sunday night on a late plane ride back to New York I finished reading Malcolm Gladwell’s new book, David and Goliath. It’s not his best work, but it's still thought provoking and worth the time. David And Goliath

The cliff notes version of the book is that it turns out that David wasn't such an underdog after all. He was actually at a huge advantage in his battle with Goliath because he was able to change the rules of the game. Lots of underdogs win by changing the rules of the game so that they become the favorite. To prove his point, Gladwell discusses the civil rights movement, World War II, middle school basketball and many other examples. It's an interesting concept and a pretty good read.

Anyway, as part of his argument, he spends a lot of time talking about the difference between linear curves and U-curves. He argues that there are some things that correlate and may seem like they should sit on a linear curve, but in reality they sit on a U-curve.

Perhaps the most interesting and classic example that Gladwell uses is the correlation between class size and test scores. You might think that the class size/test score graph would be linear -- as class size increases (the X-axis), test scores go down (the Y-axis). That's the conventional thinking.

But it turns out that's not true. The reality is that when class size gets really small, studies have shown that test scores actually begin to decrease again. When there isn’t a range of opinions and when the teacher is too focused on one student, the quality of education goes down. Students benefit from the energy and discussion that comes with having lots of other students in the class. So the correlation between test scores and class size really looks more like a U-curve. Test scores are optimal when the class is around 25 students. Too big is bad and too small is bad.

U Curve

This is also true of crime and punishment. Many believe that as the severity of punishment increases, the amount of crime goes down. But studies have found that there’s a U-curve effect here as well. As punishment becomes more and more severe for smaller crimes, citizens begin to believe that the system isn't fair. That it’s us against them. And they commit more crimes as a result. So you obviously don't want punishment to be too lenient, but you also don't want it to be too strict. Like a lot of things, eliminating crime isn't simple. It isn't linear.

The corollary back to the story of David and Goliath is that you can't improve education simply by adding more teachers and reducing class size and you can't reduce crime by simply making punishment more severe. With complex problems, brute force doesn't always win.

With the U-curve in mind, I've been thinking a bit about price increases and how they impact client relationships. Traditionally, companies like to have modest annual price increases of, say, 2% to 5% per year. Companies like these small increases because they reduce the risk of putting a large strain on their client relationships or losing clients all together. And generally, due to inflation and other factors, clients usually find these increases acceptable.

But as you begin to raise the annual price increase more and more you'll generally see clients resist more and more; 2% is acceptable,15% is not. Like the examples above, on the surface, it seems that the correlation between price increases and client resistance should be graphed on a linear curve. As the price goes up (the Y-axis), so does resistance from clients (the X-axis). Keep your price increases low and your clients will be happy.

But I don't think this is true either. As price increases, client resistance certainly increases, but only to a certain degree. At some point, say 10% and up, in order for the increase to make sense there has to be a substantial and fundamental product change. A 20% increase isn't caused by inflation, increased labor costs, or a greedy salesperson. The increase is happening because there's a substantial change in the product and the product's value. As a result, clients should be much more accepting of this change and client resistance will start to go back down -- creating a U-curve. If the increase is sold and communicated properly, clients will begin to recognize that they're buying a much different product, or at least a much more valuable one. They'll understand that the rules have changed. In fact, I'd argue that at some point most clients would welcome these large but less frequent increases more than they would the small, annoying increases that don't show a corresponding increase in product value.

Increasing price is a requirement of any sustainable long term B2B relationship. And like most things, it's not simple. It's not linear. So when considering a strategic approach to pricing, companies should consider the U-curve and not rely on small, inflation-based annual increases that barely impact revenue. They should cancel those increases. That energy is better spent finding ways to change the rules -- to completely rethink product function, value and positioning. To make a splash. To delight rather than satisfy.

In short, the lesson of the U-curve is actually pretty simple. Don't avoid client resistance by keeping price increases small, modest and frequent; get clients behind them by making them big, bold and rare.

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.

Mobile 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).

Massachusetts Healthcare

Each year the state of Massachusetts holds a costs trends hearing where they discuss the drivers of healthcare costs and examine what various healthcare constituencies are doing to rein it in. I came across this response from Partners Healthcare System responding to a series of questions from the state. It’s kind of heavy but definitely worth reading if you’re into this type of thing.

In it, Partners lays out its strategy to reduce costs. The primary driver of cost reduction is population health management.

There are two key components to their population health management plan:

  1. Patient Centered Medical Homes. Partners is requiring all of their primary care providers to become patient centered medical homes which is a team-based approach to care that is led by a PCP working with nurses, mental health experts, case managers and supported by an integrated technology system. This gives the PCP all of the resources and infrastructure to truly manage the health of a patient and keep them healthy and out of the hospital. Rather than seeing the patient and sending them to a specialist or off to the hospital without any care coordination, the PCP has a team that is dedicated to making that patient healthy and following the patient through the entire continuum of care. It’s easy to see how this approach is better than the old model.
  2. Integrated Care Management Program. This is a program that focuses only on the 5% of the population that drives 50% of healthcare costs – i.e. patients that have the multiple, complex conditions. Each patient is continuously monitored by a nurse manager and a PCP that proactively identify and address issues and ensure medication and appointment compliance. Again, the goal being to ensure that these patients are requiring and consuming less and less complex care.

In addition, in partnership with Medicare and other commercial payers, Partners has aligned its population health management approach with its business model as it has begun to take on more and more risk-based contracts so that they’re on the line financially for keeping patients healthy.

Partners is not alone. Most, if not all of the other large providers in the state have similar plans.

Regardless of your opinions on the ACA or your opinions on Partners, it's pretty amazing to see how far Massachusetts has come in being a system that cares for the sick to a system that keeps people healthy.

Imagine for a moment if you were a widget manufacturer and the government came to you and said you have to do something about your revenues, they’re simply too high. You’d say, “Ok, no problem, I’ll just stop making as many widgets, lay-off some employees and close a couple factories.”

You’d make less revenue but you’d keep your profit margin.

The analogy to healthcare is that imagine if instead of cutting its production, that manufacturer actually made a deal with the government and said “Ok, I'll sell fewer widgets. But, you have to agree to pay me a monthly fee for me to proactively go out and invest in programs that will make the community not want or need my widgets. And for every widget that I sell, you can take that out of my monthly fee.”

That’s literally what’s happening in Massachusetts healthcare. The hospitals are taking on a completely new approach to business and caring for patients. Their model is rapidly becoming one where they will not make money when people get sick, they’ll make money when they’re not treating the sick.

This stuff is great to see.

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.

What To Do When A Prospect Goes Dark

The CEO of a startup that I’ve been doing some consulting for wrote to me with the following question about a prospect that went dark. I know this is a challenge that comes up for a lot of people so I thought I’d post my response here. Here was the question:

I have a question for you. If a lead that you've been pursuing / developing for like over 6 months goes unresponsive to two emails, what do you do? In most instances where the development time has been that long, usually someone has said "yes" or "no" or "not now" but this is the first time of just radio silence.

Thoughts? And one backdrop to this is that our point person that we were working with for the 6 months left for a new job, we were handed off to another person that we had met with maybe for the last 3 months but in a different division.

My answer:

Your question is a good one. This is always a challenge. A few thoughts:

1. One approach could be to just get the person on the phone live. Block out some time during the day and just call the person (though I know it's hard to get people live these days). If you reach them, be clear that you're not pushing things -- that you just thought you'd call to check in to see where things stand as you're trying to prioritize projects for next year, etc. You want to gauge if there's still some interest.

2. If you reach out again by email, look for the 'no'. That is, do not reach out with the purpose of moving the conversation forward; reach out with the purpose of finding out what's going on. If it's a no that's great because you can put your energy in another direction. It’s hard to say no to salespeople, make it easy for them. something like "hi, sorry to reach out again, we're in the process of prioritizing projects for next year -- assume I shouldn't include you on that list? Please confirm when you get a moment. Thanks so much."

3. Another alternative would just be to back off. Remember nobody wants to date the guy that keeps calling and texting begging them to go out. Keep that credibility, you have better things to do than reach out to them. Perhapsgive it a couple months and reach out when you have a real update -- new clients, new funding, product improvements, etc. and setup a meeting to give them an update on what some of their competitors are doing, etc.

4. Finally, you'd know better if it's appropriate but you can always reach out to others in the organization. Just to validate that you're talking to the right person. There may be other groups interested in the product -- you can always try to go up to more senior execs. But if you do be careful to position that conversation as broader than the initial one you had (a CEO level conversation as opposed to simply a business unit conversation).

I don't know the situation well enough to accurately pick the right approach but I hope some of that is helpful.

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.

Criagslist Image

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.

ACOs vs. HMOs: This Time It's Different

Last week I came across this article titled, Balancing AMC Mission, in the New England Journal of Medicine. The article talks about how Massachusetts hospitals – specifically Mass General and Brigham & Women’s – have reduced costs in response to Massachusetts' healthcare reform bill passed back in 2006. As part of the reform, these hospitals participated in risk-based based contracts with commercial payers and Medicaid and Medicare. The contracts, covering 400,000 lives, have them share risk for medical expenses for patients who see primary care physicians (PCPs) in their network. If the cost of caring for the patients that see a PCP in their network exceeds that of a comparison group, they pay a penalty; if it’s lower than the comparison group, they share in the savings.

A lot of people have compared this approach – commonly known as an ACO (Accountable Care Organization) -- to the HMO failure of the 1990’s. The authors in the article point out a few reasons why this time it’s different that I thought were worth posting here:

  1. While the focus of the approach is on coordinating care through a PCP, specialists are much more involved in the coordination this time through automated referral management, virtual visits from specialists, team based care and home monitoring. As an example, they’re reducing costs for diabetes care by automating referrals to diabetes counselors and they’ve identified opportunities to do phone consultations with specialists, as opposed to face to face visits.
  2. They’ve added 71 “high-risk care managers”. These managers work closely with the PCP in coordinating the care for 200 high-risk patients. The additional investment in this population is a huge step forward. As we know, the 80/20 rule applies to healthcare – 20% of patients drive 80% of costs.
  3. They’ve consolidated all of their clinical and administrative systems into one electronic system – allowing for better, more efficient care coordination.
  4. Risk is now shared across their hospitals and their physicians group as opposed to centering risk and responsibility on the PCP.

These are significant differences that have resulted in some early signs of cost reduction. It’s refreshing to see super successful, massive hospitals getting on board and innovating as we move towards a system that manages health instead of manages sickness.

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.