How Much Should A Startup Charge Its Early Customers?

Last week I had a conversation with a founder about how much they should charge their first few customers. Cost plus a fee? Slightly below the incumbent? The same as the incumbent? Some fraction of the estimated ROI? My answer to this question is pretty simple: charge as much as you can get, charge whatever the market will bear.

At an early stage, a founder's time and focus is the firm's number one asset. Any compromises made in getting less than the absolute maximum amount that a client will pay creates an unrecoverable opportunity cost. Early-stage companies can't afford to not charge what the market will bear.

Pushing for the max more has other benefits. It helps to determine the product's real worth and the real challenges the client is having in buying the product. When pricing makes buying too easy you don't get a good sense of the challenges you'll encounter down the road, you don't get the real story. It also generates a level of respect from the client (we've all heard the stories of people appreciating things more because they cost more regardless of the true value).

Finally, often a startup's instinct will be to charge less because it'll move the deal along faster. This is a myth. The opposite is true. The larger the deal the more attention it will get, the more senior people will need to be involved and it'll move faster as a result.

This post isn't meant to say that you shouldn't negotiate, do a pilot and be flexible where and when it makes sense. You should do all of that. But in lieu of a defined market price, charge a simple one -- the absolute most that you can get.

The Interface Layer & The New Economy

I've been thinking a lot about this notion of the "interface layer" in web services and how it's changing the economy and the way money flows. The concept of the "interface layer" is pretty simple. It says that the old economy was about building tangible infrastructure -- cars, buildings, stores, etc. And the new economy is about building really slick and beautiful and easy to use web services (interfaces) on top of that infrastructure;AirBnB for lodging, Uber for ride sharing, OpenTable for restaurants, Expedia for planes, etc. These companies don't own buildings, cars, restaurants or planes, but they make a lot of money by allowing consumers to easily access these things. It's no longer about building infrastructure, it's now about building beautiful, slick, mobile, easy to use 'layers'.

One of the big complaints about these layers (or interfaces) is that many believe that they commodotize the underlying asset. Uber users don't really care which cab company the driver is a part of, they just want the cheapest ride that gets them from point A to point B. This detachment from the brand drives down the cost of the ride and drives down the income that goes to the driver. Uber is commodotizing drivers. And drivers need to think really hard about how they're going to separate themselves from the pack if they want to continue to charge a premium.

Uber's layer is winning the taxi space.

But with the increasing use of mobile and the decreasing use of the desktop web, mobile is quickly becoming a platform on its own. And soon, instead of Uber being the 'commoditizer', Apple's iPhone or Google's Android could easily commodotize Uber.

Let me explain. Today, if I want a ride somewhere I go to Uber or Lyft or Sidecar or some other app to book a ride. This is a bit clunky in that it's hard to know which of the services has the best option for me based on the time of day and where I want to go.  I have to download all of the ride sharing apps and scroll through them to find the best deal.

Of course I'm not the only one that's annoyed by this. Very soon (if not already) we can expect that there will be services that will aggregate all of the top ride sharing apps into one so I can pick the best option for me (just like Kayak does for plane tickets).

This would be really bad for Uber. Now they're the one getting commoditized. 

But when mobile is a platform, it gets much worse.

Apple and Google could easily add their own layer on top of these aggregation layers. At some point soon, instead of going to the Uber or Lyft app, I could just open up Siri and say, "give me a ride to SoHo". And Apple will scan all of the ride sharing apps or ride sharing aggregators (even if I haven't downloaded them from the App Store) and deliver the best result. This is absolutely what Siri wants to become -- the entry point to the web.

In an extreme example, I could tell Siri, "take me to my friend's apartment and let's stop somewhere to pick up a bottle of wine that pairs well with Italian food." Siri then decides which ride sharing app, which business directory app, and which wine app to use to bring me the best experience.

Apple could easily cut a deal with a ride sharing aggregator, Yelp and HelloVino (a wine discovery app) and take a fee from each of them. In this case, not only is the Uber driver getting commodotized, so is Uber and so is the ride sharing aggregator.

This is an important issue for any web based service to think about. The new economy might be less about the battle for the most beautiful interface and more about the service that can get closest to the user. And it's beginning to look like platforms rather than interfaces might win the war.

How Mobile Is Impacting Facebook & Healthcare Strategy

Many people used to believe that Facebook was an extremely defensible business and that it would be almost impossible for another social network to compete. It has grown to an enormous scale with massive troves of data and more than 1.5 billion monthly users. The thinking around their defensibility was that because all of your friends and photos and updates are already stored on Facebook, it would be tedious and unnecessary to switch to another social network. Everything you need is there. Why go somewhere else?

Facebook did have quite a bit of defensibility back when the predominant access point to the service was the desktop web. Moving your data to a new social network was painful and impractical. But now that the main access point to social is our mobile phone (more than half of Facebook’s traffic comes through mobile) things have changed dramatically.

We now carry around all of the key elements of a social network on our cell phones. Our phones carry our location, our photos and our address book and allow us to message anyone at no cost from anywhere in the world. With the click of the touchscreen we can view and connect with all of our friends on a new social network and instantly recreate our social graph. We can take a photo and instantly send it to a multiple social networks. We can easily join different social networks with different groups of friends focused around different needs. The friction of leaving Facebook and joining a new network has disappeared. This wasn’t possible with the desktop web, or it was at least much more difficult.

As a result of the increasing use of mobile, we’ve seen lots of new social networks emerge (there are now dozens of social networking apps with 1 million+ downloads in Apple’s app store, including Kik, WhatsApp, Tumblr, Google+, Instagram, Snapchat and many others).

This increased use of mobile has reduced the friction of launching a new social network to near zero and as a result has shifted ownership of data away from the network and back to the individual. Trying to own the data and lock-in the consumer is no longer a viable strategy.

Facebook is well aware of this and has adjusted by rapidly buying up many of these new networks. We’ll likely see more acquisitions like these in the months to come.

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Over the last several years, large healthcare provider organizations and healthcare software vendors have been employing a similar strategy to that of Facebook. Health systems have been growing by buying up ambulatory, community-based sites and employing doctors to build out giant systems that can offer clinical services across the entire continuum of care giving the patient no reason to go anywhere else. In parallel, providers and software vendors have been creating a single patient record (including blood tests, physician notes, imaging and other data) that flows across the entire provider organization and can be easily shared with providers across the system. This avoids all of the classic frustration associated with having to fax your x-rays from one provider to another. Everything exists on the web in one single record. Providers then roll out a patient-facing portal that lays across the patient record where the patient can access all of their data (mostly through the desktop web).

The strategy is simple. Providers are telling the patient to 1.) stay with us because we do everything and you don’t need to go anywhere else and 2.) you can’t go anywhere else because we have all of your data.

But as we saw with Facebook, now that a consumer’s primary entry point to the web is their mobile phone, this strategy has some flaws.

Not only do our phones enable messaging and carry our location and address book and photos, they can also carry data on our movement, our sleep, our heart-rate, the prescriptions we’re taking, our body temperature and, with the use of implanted devices, much, much more. This real-time data that we carry on our phones is arguably more valuable than the data stored in our clinician’s patient record that only gets refreshed while we’re sitting in the examination room.

Increasingly, providers will own some patient data but the patient will own more data and better data.

Like Facebook, healthcare providers are trying lock in their customer by owning the data. But the increasing use of mobile has changed the game. Just like social network users can effortlessly syndicate their own data out to multiple social networks, a patient will be able to syndicate their real-time clinically relevant data out to multiple providers, regardless of which system they’re associated with.

Mobile has put patients in the driver’s seat.

Meanwhile, with the emergence of home care and tele-health and urgent care clinics and apps and implants that manage more serious and chronic conditions, in many ways healthcare has actually become more fragmented. The traditional providers may be consolidating, but new players are creating new channels for care and causing more fragmentation across the industry. Where and when and how care is delivered is being completely reshaped.

But unlike Facebook, large healthcare providers can’t buy their way out of this conundrum. First, because they don’t have enough cash (most are non-profits with microscopic profit margins) and second because healthcare is local. Health systems are no longer just competing with the hospital across the street, they’re competing with web services that are available to the global market.

As a result, large provider organizations are going to have to consider new ways of providing value and will have to select which segments of patients they want to serve.

In short, they can’t own the patient because they can’t own the data.

The idea of locking the patient into one network of providers was always a bit flimsy. But the strategy was somewhat understandable. A lot of this was driven by the trend towards value-based payments and the convenience of 'owning' a patient under that model.

But the lessons of Facebook are clear. Locking up the data is not a path to success.

Social networks and healthcare providers must focus on what they do best and focus on serving the consumer they want to serve and abandon their attempts to win by owning data that isn't theirs to own.

The Importance Of Relationships In Enterprise Sales

One of my favorite questions to ask when interviewing a potential sales hire is: “given your experience in sales, if you had to write a book about sales, and you wanted to sell a lot of copies, what would be the theme or the thesis or the title of the book, what insight would you bring?” Much to my dismay, the candidate will often sit back and say something like, “that one is easy, relationships, it’s all about relationships”.

This is a disappointing answer. And it also isn't true. I don’t think it is all about relationships. Especially when selling innovation. People buy from a seller because they think they believe it'll move their company forward or, more selfishly, they'll get a raise or a promotion or a bonus at the end of the year after they roll out the product. They don’t buy from a company because they like playing golf with the salesperson.

That said, for some products it's different. For some products, successful selling is driven by good relationships.

This got me thinking about which products are sold based on relationships and which aren't.

I think a lot of it is driven by the life-cycle stage of the product and the level of competition in the product's vertical.  For example, when Salesforce.com when out to sell their first cloud-based CRM product to its first group of customers, it wasn’t about building a relationship. It was about convincing early adopters to completely rethink the way they manage their customer data. It was about getting big companies that were stuck in their ways to make a massive mind-shift. You can't do that with a relationship. You do that with thought leadership and creating a vision and great communication. Of course, it probably didn't hurt if they built a nice relationship along the way but there’s no way that was what was driving their deals at that stage.

On the other hand, when Benjamin Moore sales reps sell paint to a commercial real estate developer, it probably is very much about the relationship. The products are more of less the same, so it comes down to price, and how much the buyer likes the seller.

This chart illustrates my point:

When a product is brand new and innovative, relationships matters less than when the product is mature and commoditized by lots of competition.

Of course, the line is probably not this linear. For the first 1 or 2 customers, relationships typically matter a lot (often these are friendlies) and the importance of relationships probably levels out at some stage of product maturity. But I don't want to over-think the simple point.

It’s worth salespeople taking some time to think about how they sell and whether or not the product they're selling is at the right stage for their skill-set.

You might not want a relationship salesperson selling structural innovation and you might not want a disruptive salesperson selling paint.

The Death Of Enterprise Sales

A few weeks ago I was chatting with a guy that specializes in something called "disruption consulting". Basically he goes into mature companies and works with their management teams to help them think through how they would disrupt their own business. This is a healthy exercise for large, successful organizations and something individuals ought to think about with regard to their own company and -- more importantly -- their own role in their own company. This got me thinking about enterprise SaaS sales and the theory that salespeople have become less of a necessity in this new world. As I've written in the past I actually think the opposite is true. Sales is growing, not shrinking, in importance. That said, here are some of the trends that I've seen out there that are giving the skeptics some ammunition:

1. Micro budgets. With the 'consumerization' of enterprise software, lots of companies are letting their employees directly buy and expense their own productivity tools circumventing the traditional buying process. 
2. Pay-per-use contracts. Traditionally enterprise salespeople have sold large buckets of access to their software -- e.g. Salesforce has negotiable pricing tiers based on the number of licenses purchased. Companies like Slack and others are getting away from this model and are pricing based on who actually uses the system. At the end of a month, they look at how many people logged-in and then send an invoice accordingly. This pushes the revenue responsibility pendulum far away from sales and much closer to product.
3. Freemium enterprise software. This is a model where software can be accessed for free by an individual employee and an enterprise deal gets triggered at some critical mass of employee usage (e.g. B2E2B).
4. Standardized contracts. More enterprise software companies are creating click-through agreements that can't be negotiated by the buyer. And there does seem to be a very slow but steady move towards more consistency across companies in what they want a contract to look like. Corporate attorneys will make this really difficult, but the idea does seem to be gaining momentum. 
5. Data in the cloud. The advent of the cloud has made the old-fashioned, big, CIO-based sale a bit less prominent. Cloud-based software programs require much less of an implementation burden and thus much less of the need to sell the bureaucratic IT department. That said, much of the work these teams do has moved towards integration into the cloud, which still requires a hefty sales process.

There's no doubt that the landscape in enterprise sales has changed. And all of these trends are worth watching. But what the skeptics miss is that this is nothing new. Buyers and sellers always been trying to minimize the cost of their transactions. These are just new variations of that process. It simply means that to stay relevant enterprise salespeople must continue to shift their energy towards larger, more complex deals and higher value sales activity.

When real estate listings became available to everyone on the web, real estate brokers didn't disappear (in fact, there are more of them now). They simply started focusing on higher value activity. Instead of their core asset being access to listings, their new asset is helping someone navigate the process of buying a home (over half of home buyers find their home online, but 90% still use a broker to make the purchase).

Similarly, when employees begin buying their own software, enterprise sales teams will just shift their activity towards more strategic, higher value deals. They'll focus on the things that can't be bought or implemented by a single employee.

In short, enterprise sales drives new and incremental growth. It's the hard stuff. The easy stuff gets automated. And diffusion of the greatest innovations and the highest value deals can't be automated.

Companies that aren't growing their enterprise sales teams are likely either very early-stage and don't have enough product to sell, or they're later stage and aren't trying hard enough.

Why Are Salespeople Paid On Performance?

Andreesen Horowtiz had a great podcast a few weeks ago on the topic of Getting Sales Right.  It was a conversation between Peter Levine, a GP at the firm, and Daniel Shapero, who helped build LinkedIn’s initial enterprise sales team. Levine asked a question about sales compensation, and why are salespeople paid mostly on commission where almost every other role is paid a flat salary. Surely companies care about getting the best out of every employee, why isn’t every employee paid mostly on commission?

Two interesting insights came out of this discussion.

1. Salespeople are unique in that they spend most of their time facing the outside world and are constantly being told ‘no’. They face rejection on behalf of their company all day long. To offset some of this pain, when they finally do get a yes and a big win, it’s something that should be celebrated; both in the form of compensation (commission) and public recognition. The commission helps keep salespeople motivated to go get the next one in the face of all that rejection.
2. There have been studies that suggest that when a person is paid largely on commission, they’ll tend to go after a win at all costs. They’ll look for shortcuts and take the quickest path to success. There are lots of roles where that “win” isn’t so easy to define and measure. Further, for some roles like product and engineering, shortcuts could cause longer term damage and stifle creativity and long term thinking.

For these reasons most of the sales teams I've seen are paid largely on commission. But the other side of this issue is the failure rate of sales versus other roles. In nearly all of the companies I’ve worked with, salespeople fail at a far higher rate than any other role. This also begs the question, why?

Are recruiters just really bad at hiring for sales roles and really good at hiring other roles? Of course not. In my view the reason for the discrepancy is that the performance of a salesperson is easy to measure. If a salesperson is failing, everyone knows it. If an engineer is failing it's not as easy to see. That's why you'll often see 30% variances in termination rates between these roles.

The best companies I've seen are aware of this and take this on as a challenge and expose these numbers and try fix the imbalance.  If the termination rate of a sales team is 40% and the termination rate of other roles is 5% then non-sales managers either aren’t measuring performance or they don’t have a high enough bar for success. Measuring success in non-sales roles is hard (that’s a topic for another day). But measuring the difference in the failure rate of a non-sales team versus a sales team is easy. And an important thing to expose. 

Disruption & Access

I came across thIs chart the other day on Twitter showing camera production from 1933 through 2014.

This chart is great because it perfectly illustrates the good and bad parts of disruption. Better, more portable cameras destroyed the incumbents (Polaroid, etc.). But at the same time these innovations massively increased access to and use of cameras (this is the point that most people miss). It's estimated that there were more photos taken in the year 2014 than there were in all of the years prior to 2014. That's incredible.

The fact is that while disruption can cause some short term pain it almost always results in a greater good for those in the industry. More people travel because of Expedia. More people go out to dinner because of Open Table. More people listen to music because of Spotify. More people get a ride because of Uber. And on and on.

This is perfectly analogous to what needs to happen in healthcare and education. We need the incumbent analogs to go away and the innovators to take over and give access to a lot more people at a much lower cost. We just need the regulators to get out of the way and allow it to happen.

Some Thoughts On Apple & Software For Cars

The tech world is buzzing about the rumor that Apple's plans to build a car. They bought Beats a while back because they needed talent that knows how to make things that people will wear (e.g. a watch). And now they're hiring talent from Tesla that knows how to build cars and software for cars. Benedict Evans had a great post on this topic on Saturday where he offered lots of ideas on the risks and benefits of such a venture. Please go read it if you're interested in this kind of stuff.

I wanted to point out two key points he made in the post here.  From the post:

...can Apple create new value in the industry in the way that it did in phones?  With the iPhone, Apple created a new price segment and (with Android following) made the phone industry's revenue much bigger - the average price of a phone sold has more than doubled since 2007. But cars are, pretty obviously, more expensive than phones. Many people can find $400 for a better phone or, this year, a smart watch, if they're persuaded that they really want one, but rather fewer can find an extra $40,000 for a better car, or to replace their car every two years instead of every 4 or 8.  If you're in the market for a $20,000 car, there is very little that anyone can do to a car that will put you in the market for a $60,000 car. Cars do not come out of discretionary spending.

This is an important point. The iPhone was such a success largely because, in reality, they created a new (high-end) category that didn't exist before. The beauty of that high-end category is 1.) it's actually a mass market category because most people can afford a iPhone -- lots of people that make $50k a year have the exact same phone as people that make $30 million a year and 2.) people buy a new device every two years (that's a pretty nice recurring revenue stream for a hardware business).

Generally, neither of these factors have existed in the car business (most people can't afford high-end cars and the average driver replaces their car about every 10 years).

That said, these dynamics are changing a bit. Celebrities like Leonardo DiCaprio have been photographed driving around in a very affordable Prius (Frank Sinatra wouldn't have been caught dead in a low-end car). And while it's unlikely that the masses will start buying a new car every two years, it is becoming clear that fewer and fewer people are going to need to own their own car -- both because of the astounding growth of on-demand rides and the coming emergence of self-driving cars.

Benedict writes about this later in the post.

...self-driving cars might support both an on-demand model and an AirBnB model for cars - does your car drop you off at work and then roll off into the city to earn you some extra money driving other people around? Would people want to do that? Would that reduce the opportunity for 'dedicated' on-demand vehicles? Who knows. Of course, it's also possible that self-driving technology, said to be a decade away now, will remain a decade away indefinitely, as so many other AI projects have done.

In short, on-demand rides, shared self-driving cars and artificial intelligence are going to lead to massive changes in the way we get around and the way we manage our own personal transportation and the things that we do while we're travelling. And all of it -- I mean all of it -- is going to be driven by software that will become a large part of our day-to-day routine. Apple has to be in the middle of that. Apple has to make a car.

Healthcare Technology: Who Owns The Data?

A couple weeks ago I was listening to a panel discussion with a bunch of venture capitalists and someone (I can't remember who) made the point that the value of so many of today's web services comes down to one question: "who owns the data?" For example, while Uber has some nice UI/UX, the real reason they're so valuable is that they own the data. For them, the data is knowing where all the cars are located. I go to Uber because I can quickly locate and communicate with the drivers in my area. I like the app, but the real value is the location data. Same thing with AirBnB. It's not the app, it's the data they have on all the properties that I'd like to rent.

With this in mind, last week I read that Stanford Healthcare announced that they built the first patient facing app that integrates data from devices such as Fitbits and Withings scales into Apple's Healthkit app. Apple can than transmit that data to the patient's provider through the provider's patient portal app (in this case, MyChart, which is built by Epic Systems, a huge health IT vendor that builds software for hospitals and health systems).

This is an enormous step forward for the integration of patient captured health data with provider captured health data. It's awesome news.

But as all of this finally starts to come together, it begs the question: who owns the data?

Or, at scale, which company benefits the most from all of this data floating around?

Stanford? Withings? Fitbit? Apple? Epic?

Well, Stanford is very local, and isn't terribly focused on data collection, so it's probably not them.

Withings, Fitbit and other device makers contribute a relatively small part of human health data so at least for now they're not going to own a large piece of the data pie.

Apple still only owns well under half of U.S. smart phone market share -- and that number is expected to shrink. And they own even less of the market share of the chronically ill patient segment that can really benefit from this kind of data exchange.

So that leaves Epic, the 30-year-old health IT vendor that currently owns a medical record on well over half of the U.S. population. They have long-term contracts with large providers and (presumably) a long-term contract with Apple and will likely cut deals with Android and other smartphone operating systems in the near future.

In short, more than anyone else, Epic will own the data.

But this raises all sorts of new and interesting questions and conflicts. Will Stanford allow Epic to share its patient records with other Epic providers? Will Stanford allow Epic to share its patient records with other health IT companies? Will Epic allow Stanford patient records to be shared with other health IT companies? Will Apple allow Epic to share data captured from an Apple device with data captured from an Android device?

As I've written before, it seems to me that in the long-term, the answer is a Mint.com for Healthcare, where the patient truly owns the data. But in the meantime, the question of "who owns the data?" will be watched closely by investors, app makers, providers, health IT companies and patients. It's going to be fascinating to watch this play out.

The Unintended Consequences of Individual Metrics

Several years ago when I was working with an e-commerce company we came up with a framework for how to grow transactional shopping revenue. We called it "the Box".

The idea was to get shoppers into the box (acquire new users and get them to come back to our sites regularly). And then, once they were in "the box", to make good things happen (get them to buy lots of stuff).

We setup two separate teams: one team was focused on driving traffic and the other was focused on converting that traffic into dollars.

The "traffic driving" team didn't worry about shopping conversions and the "conversion" team didn't worry about driving traffic. We put the teams in silos and told them to focus on their goals. The thinking was that if both teams did their job, overall revenue would grow.

The beauty of the framework was that when weekly revenue grew, we could very easily determine who deserved credit. Was the increase caused by something that the traffic driving team did or something that the conversion team did?  Very rarely was it both. Neither team could hide behind another's success. We could easily identify the initiatives that we're contributing to overall revenue and those that weren't. It seemed like a great model.

But we quickly saw that the structure we setup caused some problems.

The traffic driving team, in an effort to drive traffic (as opposed to revenue), found some quick, easy and suboptimal ways to drive traffic to our sites. For example, they'd email millions of users with an offer from a high-end car company. The response rate would be great and traffic grew, but nobody bought (low conversions). Users just clicked around and looked at the cars because they were interesting. Most weren't planning to buy, or if they were they were planning to buy offline.

At the same time, the conversion team put brands that converted well (such as Target and Wal-Mart) front and center on our websites. While those brands did convert well, they produced small average order sizes and didn't pay us a significant commission. Combine that with the fact that the traffic driving team wasn't pushing shoppers to the offers that the conversion team was promoting and we quickly found that our user experience was disjointed.

It became clear that we couldn't have our teams operating in silos. To maximize revenue, they had to work together. They had to collaborate. They had to do more than just their own job.

This initiative underscores the challenges around siloed teams and metrics. When high performing people are given clear objectives with quantifiable metrics attached to them, they'll very often accomplish those objectives. And there will very often be unintended consequences from that accomplishment.

All of that said, even after that experience, I still strongly believe that managers must create clear, measurable metrics for every employee in the organization that only that employee can control. It's a crucial part of an accountable, high performing organization.

But at the same time managers need to closely monitor whether or not those siloed metrics are positively or negatively impacting the overall health of the business. Setting up a framework where individuals and teams are focused on producing impactful work week to week is the (relatively) easy part. Getting multiple teams focused on snyergistic activities that add to the overall value of the business is much more difficult. And much more important.

Mint.com For Healthcare

Vince Kuraltis, a healthcare IT consultant, tweeted this the other day:

He’s referring to the fact that each of his healthcare providers has a different patient portal run by a different IT vendor with a separate log-in and separate data and functionality. Providers are launching patient portals to allow patients to view clinical records, refill prescriptions, email their providers, etc. The point is to better engage patients in their health. It's a very important effort. But as Vince points out, the disconnected and fragmented experience can be really frustrating for patients.

This challenge is quite similar to the challenge that banking faced years ago as they took their customer experience online. Personally, I have accounts with Bank of America, Fidelity, eTrade, American Express and a few others. All of these accounts have separate web “portals” with separate log-ins. That's frustrating. But not really. Because I spend very little time on any of them. Most of my time is spent on Mint.com, where I’ve integrated all of these accounts into one place. From there, I can view all of my transactions and balances, track expenses and create budgets. It's great. It's has award-winning UI/UX and everything is one place.

Mint has taken the bottom-up approach. They started by building a platform for the consumer. And the consumer allows data from multiple vendors to be integrated into their account.

Healthcare needs a similar bottom-up approach.

We need a portal that allows us to integrate all of the data collected on us from our dentist that runs Dentrix software, our primary care doctor that runs eClinicalWorks, our gastroenterologist that runs Epic, our wife’s OBGYN that runs Cerner and our child’s pediatrician that runs Allscripps. All of that data could be neatly compiled into a really user-friendly website (and app), similar to Mint. If I move to a new area and select a new primary care provider, she could simply tap into my account and view all of my scans, test results, prescriptions, etc.

As we consider all of the controversy around forcing EMR vendors to become more interoperable and share patient data with one another, in some ways, you can argue that this isn’t their role.

Why should Bank of America freely pass data they’ve captured about me to Fidelity (a competitor)? They don’t want to do this because they want me to stay with them, not make it easy to use other vendors. Why is that any different than asking UCLA Medical Center to pass my data to USC Medical Center? It would be nice if they did, but I'm not sure it's the government's role to force them to do something that might not be aligned with their competitive interests.

The bottom-up, consumer led approach circumvents this entire conflict. We need a patient portal that starts with the patient, that allows providers (and their EMR vendors) to plug-in (if they'd like). Not the other way around.

Real World Healthcare vs. Venture Capital

Fred Wilson, the well-known venture capitalist, wrote a blog post last week with some technology predictions for 2015.  He touched briefly on healthcare:

the health care sector will start to feel the pressure of real patient centered healthcare brought on by the trifecta of the smartphone becoming the EMR, patients treating patients (p2p medicine), and real market economies entering health care (people paying for their own healthcare). this is a megatrend that will take decades to fully play out but we will see the start of it in 2015.

All of these predictions are spot on, of course -- the patient will become more and more in control of their care.

But if you talk to the people on the ground you'll find that these things aren't really being talked about or worked on at the provider level.

Case in point, John Halamka, the CIO of Beth Israel Deaconess Medical Center, considered one of the most innovative thought leaders in healthcare technology, wrote a post the other day reviewing some of the key health IT issues on his plate during 2014 with some predictions for 2015. In short, he's focused on implementing software that will facilitate accountable care workflows inspired the Affordable Care Act; meeting government electronic medical record adoption standards (Meaningful Use); and complying with government regulations around the protection and security of personal health information (HIPAA).

These are very different things than the things that guys like Fred Wilson are thinking and talking about. Venture Capitalists are completely focused on the patient. Real world healthcare operators (CIOs) are primarily focused on meeting government requirements.

This disconnect -- or, at least, that degree of separation from the patient -- isn't the fault of CIOs; they have no choice but to focus on the urgent and intense demands coming from the government to ensure that they continue to receive government incentives and avoid penalties.

Venture Capitalists are focused on where healthcare technology and the patient are going (e.g. where the money will be). Given the intense regulation, health system CIOs don't have that luxury.

All of that said, for the most part, I think government intervention into healthcare IT has been a good thing. Healthcare execs are totally focused on efforts to increase quality and reduce cost. Most stakeholders (providers, payers, regulators) have gotten behind value based care payment models -- the winds are all going in that direction. And providers are now fully onboard with electronic medical record adoption (at last check ~80% of providers are using them). None of this could've happened this quickly without government intervention.

But now that the groundwork is laid, it's time for the government to back off a bit and let the market start to drive more of the innovation in healthcare IT. Providers need the room to move their businesses and IT investments away from meeting the requirements of restricting, top-down government initiatives and closer to providing tools that are centered-on and built around the needs and desires of the patient.

The Consumerization Of Procurement

The other day I was talking to a founder of a B2B software startup about how hard it is for big companies to buy things. Even at a super low price point (a couple hundred bucks a month) software purchases still have to go through a litany of approvals. I was telling her how almost exactly two years ago I wrote a post titled, Individual Employee Budgets, where I predicted that employees would have their own discretionary budgets that could be used to buy things that would make them more productive and profitable employees. With the growing trend towards the consumerization of enterprise and the ability for anyone in their basement to build and distribute a great productivity application to millions of employees, individual budgets, I thought, would be a requirement for companies to succeed and retain employees. For smaller purchases, traditional procurement eventually has to get out of the way.

I still believe this will happen, but it's moving much slower than I predicted.

That said, two years after writing that post, when I think about the software I use to get my job done, much of it is 'consumerized'. That is, it's sold directly to me and in order for me to use it my company doesn't have to go through a painful procurement process. Software like Wunderlist, Google Maps, TripIt, Sunrise, Feedly, Evernote and Google Docs, to name a few. There are only a couple of applications that I use that were procured through a traditional procurement process -- and most of those aren't as useful or as easy to use as those that I procured myself. Self-service software has to be really, really good as the switching costs are near zero.

It's disappointing that the way companies buy hasn't become more flexible as enterprise software has become more consumerized and easy to procure. Employees are ready for self-service productivity tools and software makers are ready to build and distribute them. The only thing we're waiting for is for big buyers to let it happen.

7 Lessons From A Tough Negotiation

Lots of people that know me know that I'm huge fan of Bill Belichick, the coach of the New England Patriots. The thing I like about him more than anything else is that he never, ever makes excuses. When the Patriots lose a close game, the media will ask him about the weather, the referees, the tough schedule, the rules, the player injuries, you name it. And he never acknowledges any of it. He only talks about the things that his team can control. As a result, he's the winningest coach of the last decade. He obsesses about what he can control and ignores everything else. That is the exact approach people should take at work -- especially when negotiating a deal. You can't control the prospect, the prospect's attorneys, the bad economy, your product capabilities, the law, or your executive team. You can only control your own actions. And when you fully take that approach, you'll find that your energy won't go outwards towards things you can't control, but will instead go inwards towards things that you can. That's how you get better. That's how you win.

I recently finished a long, painful and frustrating 3 month negotiation. Thinking back on it, I'm tempted to blame the other side or blame other factors for why it was so long and so frustrating. But that's not helpful because I can't control any of that. I can only control what I do and try to do it better.

So with Bill Belicheck in mind, here are seven tactical things (that I can control) that I'll do better next time:

1. Never assume the deal is done. Make sure you have asked and asked and asked about the other side's approval process. More often than not someone is going to come along to do one final review of your deal. Document their process and track to it.

2. When you've created urgency, continuously validate that the other side values that urgency. Over a long negotiation they may not.

3. In addition to urgency, throughout the negotiation continuously reinforce your value and why the other side should want to partner with you. Don't get too caught up in the weeds and the specifics of the deal and neglect to remind the other side why they wanted to partner in the first place.

4. Have a 'time and energy walk away point'. Most negotiators know the concept of BATNA (best alternative to a negotiated agreement) but don't forget to include your own time and energy in that calculation. Take this really seriously. Focusing on a deal that is too time consuming has an exponentially negative effect. You can dig yourself deeper because you're not focusing on other opportunities and you lose your leverage (you need the deal more now because you have fewer options now because you've been too focused on this one deal).

5. When you're down to the last few items, setup a recurring daily meeting with the other side until it gets done. It's amazing how you can lose weeks if you don't do this. People get busy and each side may use time lags to build leverage.

6. When things get ugly, negotiate in person. Your situation will improve 10x faster in person than it will over the phone.

7. Bring in other people. I tend to be a lone wolf when it comes to these things. It's better to have multiple personalities involved. Two people are harder to read than one and the other person will always think of things you haven't.

Enterprise Software For Patients

Most readers know that an EMR (electronic medical record) is the back-end software that runs a healthcare organization (think ERP for healthcare). EMRs have been around for a while. Recently most large hospitals and health systems have begun building out the patient-facing version of their EMR; allowing patients to communicate electronically with their doctors, refill prescriptions, schedule appointments, view clinical information, etc. I've written at length about the differences between B2B software and B2C software and how B2B software is generally not very good (particularly from a usability perspective). And it's not very good simply because it can get away with not being very good. B2B companies really just need a good salesperson that can lock-in long-term contracts to be successful.

B2C companies, on the other hand, need an incredible product to be successful. If your user experience isn't flawless, you cannot survive in the B2C space. The switching costs for consumers are near zero -- the user experience must be incredible. Product is much more important than distribution.

Applying this to healthcare, if you're a hospital and your EMR is hard to use, your employees will still use it because they have to.

But if your patient portal is bad you will lose patients instantly. It's too easy for patients to switch to something else.

The Healthcare Information and Management Systems Society (HIMSS) published a good report last month talking about patient portals.  They noted that despite the difficulty of building a wonderful online consumer experience and the totally different skill set required to execute on it, 80% of hospitals surveyed chose their patient portal vendor simply because it was the same vendor that provides their EMR (the top three portals are made by Epic, Cerner and McKesson). All of these vendors have been building B2B enterprise software systems for more than 30 years. They're all wonderful companies. But they have no idea how to build a patient facing product. Their management, engineering talent, sales force, culture and DNA is all about B2B. They have almost no chance of building a world class consumer product. That's not a knock on these companies, it's just reality. You can't be really good at both.

As we transition to a world where the patient is in the drivers seat, exposing patients to old fashioned enterprise software code is a terrible idea. Hospitals shouldn't let a piece of software touch their customers unless it's been vetted and tested fully and it's clear that patients love it. If you check out the satisfaction scores for most patient portal apps you'll find that most patients despise them (one of them had 2,000 reviews in the iOS app store and more than 1,500 of them were only 1 star).

Patients are becoming consumers. They want slick, easy, mobile, beautiful, simple and seamless web experiences. If the software that touches patients doesn't give them that they're going to go somewhere that does.

Now, in defense of these hospitals let it be known that there aren't a lot of great consumer-focused software companies building out patient portals. So in the short term they might have no choice. But I'd encourage CIOs that are making patient portal investments to consider the consumer, and to cautiously enter into flexible and short term contracts with these patient portal vendors.

You wouldn't buy groceries from the company that washes your car and you shouldn't buy a patient portal from the company that built your EMR.

15 Things I Know Now That I Didn't Know Before I Started

When I interview job candidates, one of the questions I almost always ask them is: "If I was going to start doing your job tomorrow, tell me something that you know that would make me better at the job that you didn't know before you started?" You can learn a lot from the answers you get. With that in mind, 2014 marks the 15th year that I've been a working "professional". During that time I've worked with start-ups in e-commerce, real estate, finance, biotech and healthcare. I've been in some fast-paced and really competitive environments. And I've made a lot of mistakes and learned a lot of stuff that I didn't know before I started.

So I thought I'd put together a list of 15 key things that I've learned (one for each year) that have helped make me successful. Specifically, these are things that I didn't know or appreciate before I got into the real world. Here we go:

1. It's a grind. Work is hard and painful and complicated. If it's not a grind then you're probably not trying hard enough. Get comfortable being uncomfortable.

2. Be candid. Try to facilitate a work environment where if someone is doing well you tell them instantly and if someone is not doing well you tell them instantly. Get used to being honest and upfront about what's working and what's not. This is only hard when your culture isn't used to it. Force people to get used to being candid.

3. Assume that most people are lazy and incompetent and what you want from them isn't important to them. This definitely isn't always true, but you're better off assuming it is.

4. There's no such thing as sales. There are just two parties trying to do something good for themselves and their families. Everything is driven by self interest. Never defer to a buyer. They're not doing you a favor, they're getting something and you're getting something. You are equals. Act like it.

5. Cannibalize yourself. Too long to describe here. I wrote a post on this a while back. But in short, put yourself out of business before someone else does.

6. Always do the the right thing. Don't take credit for other people's work. Publicly recognize your peers that are doing good things. Share your ideas and insights with other people. Don't go over your boss's head. Help people. Don't one-up people. Do the right thing. Don't think about this from an ethical perspective. That might make it too blurry. Think of it practically. I'm telling you with 100 percent certainty, it might not feel like it at the time, but I promise you that doing the right thing is better for you in the long term.

7. The worst trait in a colleague or a boss is insecurity. Avoid insecure people. And avoid insecure managers like they have a contagious disease.

8. Manage yourself harder than your manager manages you. Don't even make it close. If your performance is being actively managed by your manager you are losing. Get in front of it. Innovate on how you should be measured and developed and managed. Never fall behind on this.

9. Try to find the trifecta job. Something that you're good at, something that someone will pay for, and something that you love.

10. Firing someone is almost always the best thing for the person being fired. I've worked in a lot of cut-throat environments and I've seen a lot of people get fired and I've fired a lot of people. Not once can I point to a time where it wasn't the best thing for the person and the company. Both sides always wind up in a better place. And be respectful to people that get fired. Someone that is awful at their job could easily be a top performer somewhere else and someone that is awesome at their job could easily be a bottom performer somewhere else. It's all about fit.

11. Credentials are meaningless. I've worked right alongside several Harvard Business School grads and several software engineers from Apple. There's absolutely no correlation between success at work and these credentials.

12. Hiring good people is really difficult. The traits I look for are grit, adaptability, curiosity and humility. These things are almost impossible to measure in a traditional interview.

13. Admit when you're wrong. If you're the kind of person that can't admit when you're wrong, please stop being that kind of person. Being wrong and admitting it 1,000 times is way, way better than being wrong one time and not admitting it. Embrace being wrong.

14. Be a lynchpin. Seth Godin has a book on this that you should read. But the point is that you should run as fast as you can to be a completely critical piece of your organization. If you're not that, then try harder or move on to somewhere where you can be.

15. Always think in terms of metrics. Whenever you think about an initiative or a new role or a team structure, think of what metrics it will impact. If what you do every day doesn't impact your company's key metrics then you're not a lynchpin.

Pitching Innovation: Short & Simple

I've never been a big fan of the psychology of sales. I've always felt that if you're challenging a buyer, providing insights, selling efficiently and helping them understand a problem, the psychological side will sort itself out. But the fact is there's absolutely a psychological impact that comes with your approach (hopefully a positive one).

I thought about all of this a few weeks ago while sitting on a plane reading Pitch Anything by Oren Klaff. Early on in the book he talks about the evolution of the human brain. There are three fundamental layers of the brain that have been built on top of one another as the human species has evolved. We started with the 'crocodile brain' and then added the mid-brain and then added the neocortex part of the brain.

The first and most fundamental part of our brain is the crocodile brain. This is basically the thing that keeps us alive. We use it to recognize danger and threats. It's an extremely simple part of our brain. It can't think critically and it can't reason. Its only purpose is to protect us.

When you walk into a room to pitch something this is the part of the brain that your buyer is using. The buyer's crocodile brain is on high alert. The buyer is asking themselves questions like: Is this person going to hurt me? Is this person trying to fool me?  Is buying this product going to get me fired? Should I trust this person?

In that first interaction, these are the things that the buyer cares about. That's their focus.

The problem for you as a seller is that when you're pitching, you're not using your crocodile brain. You're using your neocortex brain -- the most sophisticated part of your brain. You're thinking critically. You're giving insights. You're talking about details. You're probably showing detailed charts and graphs. You're probing, engaging and being thoughtful.

But the crocodile part of the brain doesn't understand the neocortex part of the brain. So you're completely missing the mark. You're speaking different languages. You might as well be speaking German to someone that only speaks English. Being smart, in this case, is actually hurting you.

As I said, I don't like diving into the psychology of sales, but there are some good lessons in here.

This insight is a great reminder that when you're meeting someone for the first time, talk to their crocodile brain. Keep it short, simple, concise and clear and don't try to do too much. Save the fancy charts and data tables for next time. Nobody is going to seriously engage with you until you have credibility and some level of trust. That's the goal of the first meeting: build credibility and trust. And try to get to the next step of your education process. But forget about complex models and detailed financial analysis. They won't listen to it, they won't digest it and they definitely won't believe it. Save all of that for the next meeting, after you've satisfied their crocodile brain.

Also, on the topic of keeping your presentation short, Klaff points out that in 1953 when James Watson and Francis Crick introduced the double-helix DNA structure (e.g. the secret of life), the presentation that earned them the Nobel Prize, was five minutes long. That's right, the most important scientific discovery of our time was pitched in five minutes.

Regardless of what you're selling, something tells me that in your next meeting you don't need to be pitching for the full hour.

On The Web, Bad Reviews Are Good

The Wall Street Journal had an article a while back on online doctor reviews. It noted that 25% of patients are now viewing doctor reviews before booking an appointment.  For the segment of patients that either don't have a doctor or are unloyal to their doctor (about 60% of patients) this ratio is far higher and growing fast. Like most products and services, patients want to see what the community has to say before "buying".

This has fairly significant consequences for providers. In some ways this trend is commoditizing the big hospital brands. It used to be that you’d want to go to a doctor that was affiliated with one of the prominent hospitals in your community. In some ways this is still true; but today, if a doctor has good online reviews from other patients, the patient doesn’t really care as much which health system the doctor is affiliated with. The doctor can gain trust from patients without the big brand. The community replaces the brand. The larger implication of this is that in the future health systems will have to focus more on their product (cost and quality) and less on their brand. But that's an issue for another day.

The article notes that many providers are uncomfortable with patients posting reviews about them for the world to see. This hesitation is completely understandable. But smart providers will embrace reviews rather than avoid them.

Case in point: just look at Amazon. There are 536 one star reviews of the new Kindle Fire on Amazon.com. Why would Jeff Bezos ever allow negative reviews to be posted about his product on his own website?

The answer is simple: it’s all about  trust. Bezos knows that the bad reviews increase trust and actually end up helping him sell more Kindles.

When eBay started many years ago, most of their transactions were small purchases like Pez dispensers and other low-cost items because buyers were worried about giving their credit card to a stranger over the internet.

Fast forward to today and eBay sells all sorts of very high ticket items on their site -- they sell tens of thousands of cars over their mobile app. That's right, people buy cars on their phone.

In order to buy a car on your smartphone you have to really trust the seller. That trust comes from reviews. It never would've happened without the trust that was built through seller reviews.

Providers need to embrace this as well. And some already are: Cleveland Clinic, the University of Utah and other big hospitals are now allowing patients to post negative reviews of their doctors on their websites. Like Bezos and eBay sellers, these providers understand that the trust gained from being transparent about a provider outweighs any negative perception that might come from bad reviews.

From hotels to taxis to healthcare, we're seeing that the community is trumping the brand. Reviews from the community create transparency, and transparency creates trust, and trust creates growth.

Enterprise Software: Sales Still Matters More Than Product

Last week I spoke to a guy that works for a multi-billion dollar, publicly traded company that makes the software that runs a health system's daily operations. The software that he sells is used by thousands of health system employees all day, every day. He told me that, in most cases, when selling his product he does not do a demo. No product demo at any point in the process. So the executive team at a health system buys his software and then forces thousands of employees to use it every day (locked into a 5+ year contract) without ever seeing or testing its usability. As I've written many times in the past, this is why most B2B software is awful. Because it can be.

In big enterprise software, good selling is unfortunately still far more important than a good product.

Do What Computers Can't

I read Peter Thiel's new book, Zero To One, the other night. I highly recommend it. It's a quick read (about 240 pages) and is full of great insights on startups and growth. He talks about the fears that the public has over technology. At one time, everyone was afraid that globalization was going to take all of America's jobs because there'd be someone overseas that would do our jobs cheaper than we would. Instead, American jobs have simply transformed. While's there's always some short term pain caused by a transforming economy, unemployment isn't all that much different than it was 20 years ago. The new fear is that software and technology will take all of our jobs. Thiel points out that this is a myth as well. See this excerpt:

Now think about the prospect of competition from computers instead of competition from human workers. On the supply side, computers are far more different from people than any two people are different from each other: men and machines are good at fundamentally different things. People have intentionality—we form plans and make decisions in complicated situations. We’re less good at making sense of enormous amounts of data. Computers are exactly the opposite: they excel at efficient data processing, but they struggle to make basic judgments that would be simple for any human. To understand the scale of this variance, consider another of Google’s computer-for-human substitution projects. In 2012, one of their supercomputers made headlines when, after scanning 10 million thumbnails of YouTube videos, it learned to identify a cat with 75% accuracy. That seems impressive—until you remember that an average four-year-old can do it flawlessly. When a cheap laptop beats the smartest mathematicians at some tasks but even a supercomputer with 16,000 CPUs can’t beat a child at others, you can tell that humans and computers are not just more or less powerful than each other—they’re categorically different.

I love this. There are things that humans can't do as well as computers and things that computers can't do as well as humans. There is now and will always be a ton of opportunity to do things that computers can't.