Rebuilding the Healthcare Delivery Stack, Brick by Brick

Imagine for a moment that you just walked into your doctor’s office for an appointment. Instead of filling out six pages of forms on a clipboard, the receptionist hands you a tablet that already contains all of your information. You just have to make sure it’s current.  

Once inside the exam room, your doctor enters on time and proceeds to spend the majority of your appointment focused on what ails you. They don’t have to spend 5-10 minutes asking you the standard questions because your medical record is already pulled up in front of them.

Later, as you walk out the door, your phone pings with a scheduling link for follow-up lab testing. Less than 24 hours later, your doctor follows-up with the test results and a care plan. In a few weeks, she even checks back to see how you’re doing. 

To enable this experience of seamless and proactive healthcare, we need to rebuild the healthcare delivery stack. The two most popular software systems in our current healthcare infrastructure—Epic and Cerner—were developed over 50 years ago. These legacy systems have struggled to adapt to new care models and to incorporate new technologiess. The following trends make this an opportune time to start rebuilding the stack:

• Omni-channel Care Delivery: One Medical pioneered omni-channel care, which brought hundreds of doctors, nurses and other support staff into a single care delivery platform that blends in-person and online primary care. Creating this type of unified platform for patient health requires different technology. These days, there is a “One Medical” for hundreds of given diseases in the U.S. and abroad, as well as direct competitors to One Medical. The recent acquisition of the original One Medical by Amazon for $3.8B shows the growing value of the space. Behind the scenes, a new stack can allow these players to focus on their core business. First generation omni-channel platforms, such as One Medical and Carbon Health, built their own technology stacks. But new age startups and incumbents need software tooling to avoid redeveloping some of the core modules to speed up their go-to-market and ensure their business can prioritize care delivery and patient experience.
• Value-Based Care (VBC): This is a relatively new system that changes how providers are reimbursed, and is meant to incentivize providers to focus on patient outcomes. In the fee-for-service model, more expensive procedures would net greater payments for the provider.  The electronic health record (EHR) is the core piece of the healthcare technology stack and current EHR’s are optimized for the classic fee-for-service environment. EHRs are supposed to be able to capture physician notes, facilitate the translation of these notes into CPT codes, then use these codes to bill patients and insurers. Since the EHR sits at the core of the legacy healthcare stack, it drives new healthcare companies to this old paradigm. In a value-based care (VBC)  environment, providers need tooling to understand and monitor their populations in order to identify at-risk patients and recommend the appropriate intervention at the right time. Even simple things such as being able to quickly review glucose monitoring data at scale or knowing when a patient is admitted to the hospital is very important. New technology has to be built to facilitate these features.
• Progressive Regulation: Regulation is often derided as something that prevents progress and raises costs, but it can also be used as a tool to establish higher quality baselines. There are new regulations that should increase the amount of information about patients and ease its transfer. The access to higher quality information at an individual and population level should improve outcomes within both. Examples are the Trusted Exchange Framework and Common Agreement (TEFCA) that pushed the adoption of the FHIR standard for medical information, and Health and Human Services’ rules on patient data access and interoperability that require providers and payers to create APIs for patients (and third party applications) to access data. Data underpins each workflow from automatically filling out forms to helping predict which disease a patient might be more susceptible. 

I recently  interviewed a dozen early and mid-stage patient care delivery startups to understand how they were thinking of their stack. I see a number of companies utilizing a similar playbook from the technological revolution in enterprise, commerce, and banking. To start, developer-first tooling allows smaller players to compete. Headless platforms and components with sensible, well-documented APIs, make it easier to develop products rapidly. Startups are first adopters, then as the new technologies’ advantages become undeniable, they spread to more established players. This is important because urgent care networks and hospital groups are still where most care is delivered and where most money is spent.

Based on my interviews, there is a lot of white space for any company solving the following pain points:

• Integrations: This includes components like messaging, scheduling, and forms. Currently, care delivery startups knit these services together and sometimes sync them with the EHR. They want a platform that can make these linkages without dictating a care model. API-first EHRs like Canvas are trying to ease this burden. 
• Customizable Patient Interfaces: Products, services, and goals vary within each care delivery model. For instance, one company provided a list of needs just for scheduling that included coordinating groups, recurring visits, in-home care, in-office care, and family care for varying members. They want a company that can provide the simple cases out of the box, then give them an easy-to-implement framework to make their differentiators. Patient experience companies like Source Health and Develop Health are building these frameworks.
• Customizable Workflows: Within the patient-care business, there are many tasks that are similar  across companies. They are looking for workflow tools which also do the simple things out of the box, while also allowing them to easily develop tools that can fit their care models. Companies like Photon Health and Butterfly Labs are trying to make select workflows easier.  

Change can often be subtle, but over the years these subtle changes can add up to create a radically different landscape. Think of your banking experience: You can now transfer money with a few clicks and you can leave your wallet at home and pay with your phone. Opening a new bank account can happen online in less than 10 minutes. 

Right now, startups are emerging with products that make me think that the modernization of healthcare is underway and is about to pick up speed. In a few years, visiting the doctor might look more like my earlier vision, one where scheduling is a 3-click process, intake forms are no longer required, and instead of entering information into a computer, your doctor spends the bulk of the visit where it really matters, focused on your care.