I watched the horror movie Get Out the other night and laughed to myself as it struck me as an ironic metaphor for my seven-year journey in Healthcare IT. The movie premise depicts a guy who has started to get serious with a seemingly great girl and is invited to her parents’ house for the weekend only to discover a dark truth about the family from the people working for the family who desperately try to communicate this secret to him.
When I founded TigerText with my physician brother in 2010, we identified everything that a business professor might define as a golden business opportunity: a massive, growing industry rife with operational challenges using 40-year-old technologies (pagers, faxes, and whiteboards) that drive increased costs and worse outcomes for customers. And yet, like the movie, there were many people (probably about 50+ venture capitalists) warning us to Get Out and not venture forward. “Healthcare IT is where great ideas go to die” “The sales cycle will kill you” etc.
While there was some truth to their warnings, I remain more optimistic than ever as to the long-term impact that real-time, asynchronous mobile communication will have on healthcare. For the past 5 months, I have barnstormed around the country visiting several of our large health system customers (about 34 to be exact). And while I have been guilty of indefatigable optimism in terms of timing (Hey, I’m an entrepreneur after all), I observed a fundamental shift in the mindset of health system leadership to meaningfully address healthcare workflow. This sentiment was noticeably absent previously.
Much of this evolution can be pinpointed to what I refer to as the “Post-EHR” era we are entering. The tens of billions of dollars in capital spent to digitize health information over the last 10 years are now largely complete. This expense was a necessary step to set the table to meaningfully address health costs. But as venture capitalist, Bill Gurley, wrote in a recent blog about the Healthcare IT landscape, “Most large healthcare IT systems are chosen based on one primary objective: revenue management.” In other words, they’re not really where you go to get things done at the point of care to improve patient outcomes but where you go to put things in a legal record that you can code and bill for later. EHRs are a powerful “System of Record” that need a viable “System of Action” to truly impact health delivery.
But what constitutes a viable “System of Action”? It is something that not only provides communication but also addresses fundamental challenges inherent to healthcare workflow. First, healthcare is shift-based in delivery. I analogize it to a play where the actors change every night. The play (in this case the Patient) remains the same but there are naturally going to be lines flubbed or direction messed up when you change up the cast continuously. It is no wonder that medical error is the #3 killer in the U.S. and communication is often listed as the #1 contributor to error.
The problem with shift-based workflow led us to spend 2 years and tens of millions in R&D to create Roles-based messaging functionality (ie Cardiologist on call, Third Floor Charge Nurse, Transport Services, etc) that integrates to any third party scheduler for automatic Role assignment. Many times, clinicians don’t care exactly who they are trying to reach but more importantly the Role assigned to a patient. And when a physician starts her shift, she doesn’t just enter into the Role but also inherits the conversations that the Role has engaged with preceding her shift. This assumption of pre-existing conversations ensures continuity of care. Shift-based workflow is largely why there are still 2 million pagers in use in U.S. healthcare. They address a real workflow pain point around passing the baton but completely lack the continuity of care context that is so important to patient care. Clearly, pagers are well past their due date.
Second, healthcare communications are vital, rendering Security and Reliability non-negotiable when providing health communications services at scale. This is why we have invested tens of millions of dollars into building a platform that provides four nines of system uptime with full audit trails, HITRUST CSF Certification, real-time reporting and transparent uptime publishing. Messaging probably has a lower tolerance for failure of any technology today. It is likely a statement as to the fantastic reliability of unencrypted SMS. It just works. And if a messenger doesn’t “just work” people won’t use it (or will revert back to non-compliant SMS). So it’s an extraordinarily high bar to set as you have to provide the dial-tone reliability of SMS with all of the other under-the-covers administration and security requirements that a large health system expects.
Third, the patient must be at the center of much (but not all) healthcare communication. This is the proper orientation for healthcare workflow but one that is different from traditional asynchronous messaging. Specifically, clinicians want to communicate as a care-team and create threaded conversations named after the patient. These patient-centered conversations created by care-teams are often populated by Roles which are in turn rolled up into Patient Lists. With each Patient-Centered conversation comes the opportunity to create group task lists and integrations to the System of Record (EHR, HIE) to track events as they are logged and followed up. And when you put the patient at the center of the care, massive improvements in outcomes are unlocked. Reduced length of stay from better response times, lower re-admission rates from better care coordination, faster responses to critical lab and sepsis alerts, higher patient satisfaction scores because of better customer service, and reduced toil and burnout for Physicians and Nurses not wasting time tracking things down and waiting needlessly for responses.
The improvements in outcomes we are seeing (We will begin to publish some of them this year) are quantifiably real, while the reduction in costs is eye-popping. We believe there are tens of billions of dollars in annual savings to be realized by streamlining healthcare communications while making things better for patients and clinicians.
What is most exciting to me is that as we reach scale of engagement (users open our app over 20x a day sending hundreds of millions of messages every month) and number of users (hundreds of thousands of daily users across 4,000 companies) across the U.S., we begin to see opportunity to drive even more value for our customers through AI machine learning.
Hospitals and organizations currently using TigerText.
The unstructured communication running over the TigerText platform will serve as a massive trove of workflow insight that will be furthered through advanced analytics of Role-based cohorts. In addition, messaging has a unique ability to drive network effects across healthcare that is different from any other enterprise vertical. Unlike most industries where an employee typically only works at one enterprise, healthcare workers are often affiliated with multiple hospitals and networks and thus need to communicate on both an intra- and inter-enterprise basis.
So as I look to 2018 I am glad we didn’t heed those dire early warnings when starting out. Indeed, reality is turning out much better than the movie. I am feeling optimistic not only for TigerText but for healthcare in general. We are on the cusp of a lot of positive unlock of productivity that we are now seeing on a weekly basis amongst our customers. And I think this is still just early days.
Cheers to a Great ’18!