April 15, 2017 Leave a comment
December 16, 2013 Leave a comment
The current paradigm of office visits every three months for PWDs (people with diabetes) is not the right model (nor is it for other similar chronic conditions). The management of diabetes requires a patient to make dozens of daily self-management decisions. “How much insulin should I give for this slice of pizza? Do I need to eat a snack to prevent my blood sugar from going low before I go for a jog?” Diabetes related questions and issues do not occur on an every-three month basis in synch with this current model for office visits. They are predictably unpredictable. Accordingly, to best serve our patients, our system must be flexible and nimble.
In the current model, I see a PWD in my office and let’s say, for example, that we decide together to make a change to his insulin to carbohydrate dosing ratio. He then leaves my office and we wait three months to reconvene and see if that dosing plan change is working or not. It’s not that it takes three months to decide. We could probably know within a week or two if the change is working. It’s just that healthcare isn’t set up that way. Our entire world now, in every industry and facet of life, is about data, analytics, and metrics. Other industries have learned that rapid feedback loops are effective. Adjusting a PWD’s insulin to carbohydrate dosing ratio should be no different. By the time he comes back to my office three months later, the opportunity for learning may already have been lost. Neither one of us has gotten timely and relevant feedback about our decisions. We may have lost the opportunity for a teachable moment. Healthcare needs to develop a new model where these feedback loops are much tighter and much faster, actually capitalizing on opportunities for teachable moments. (Sidebar: One doctor who realized this years ago was Dr. Jordan Shlain, who founded HealthLoop) Research studies show that PWDs are more successful and confident with managing their diabetes when they feel like they have the backup and support of their clinical providers looking over their shoulders to make sure things are going ok. If we were to design the system from scratch to accomplish these goals, we probably would not have built it to rest on the concept of office visits every three months.
So, what should be the future model of a Diabetes and Endocrinology clinical practice? Here’s what I imagine my practice looking like in the (hopefully near) future. Instead of having 16 office visit slots per day of 30 minutes each, I imagine myself seeing 5 patients a day for 45-60 minutes each, allowing us to take our time working together in person and truly addressing the needs and goals of the patient. These longer visits are essential for a patient new to my practice, a patient with a complicated or unknown diagnosis, a patient with complications or a major change in their disease state, or for discussing major changes in therapeutic course or strategy. The rest of my day will be spent using a dashboard to do remote population management, looking for trouble spots among my patient population and focusing in on those, and doing telemedicine, connecting with patients through video-chats to make more minor adjustments and to do brief “check ins.” Ten minutes spent with a patient at the point where there is a teachable moment like a low blood sugar from walking the dog might be more effective than a standard 30 minute office visit every three months. We’ll have to test this hypothesis, of course, but we must try it.
This is why I’m brimming with so much enthusiasm and excitement about working with the non-profit, Tidepool, who is building an open data platform and a new generation of software applications for the management of type 1 diabetes. Tidepool will provide us with the technology infrastructure to reach this vision of more frequent feedback loops and teachable moments. I’m also very excited about the work that my UCSF colleagues, Drs. Ralph Gonzales and Nat Gleason, are doing to pilot the use of telephone visits and e-visits with patients in place of office visits. Their work is paving the way toward demonstrating efficacy of e-visits, helping to achieve payer reimbursement so that such a model can take root.
December 11, 2013 1 Comment
I recently had the fortunate opportunity to be part of the inaugural UCSF Lean Launchpad course, formed by Erik Lium and Stephanie Marrus at UCSF, founded by Steve Blank, and taught by Steve and our digital health cohort instructor, Abhas Gupta. This was a very intense and demanding ten week class that was not about reading and memorizing and taking tests, but about going out and talking to people; “getting out of the building,” as Steve famously says. The fundamental insight that led to the offering of this course was that scientific and clinical innovation in healthcare does not happen in a vacuum. While everyone knows how important it is to test and validate scientific hypotheses, it turns out that it is just as important to test and validate your business hypotheses. Moreover, these should happen in parallel. This business model hypothesis testing cannot be outsourced after your scientific validation is completed. This business hypothesis testing cannot be done by sitting in your office and bouncing ideas off colleagues. Just as we demand data to prove scientific hypotheses, we need data to prove business hypotheses. Otherwise we’re just guessing.
The Business Model Canvas and Lean Launchpad provide the framework for innovators to literally get out of the building and talk to dozens of customers, partners, and others to help validate, or more often, invalidate, their hypotheses. Without doing this, talented people will often waste literally years of effort pursuing a product that nobody really wants to use and that nobody will pay for.
This is not news to the world of entrepreneurs at large, who have heard these ideas from Steve, Eric Ries, and others for years. However, I think this is still a novel concept in the life sciences and healthcare. Without validating product-market fit, revenue strategy, channels, and the other parts of the business model canvas, healthcare innovators are hurting their chances at disseminating their products to reach broad audiences. To fully realize the efficiencies of translational medicine, healthcare has to buck the belief that science and commercialization happen sequentially rather than in parallel. One caveat: There’s obviously something still to be said for early basic science, where one can explore basic mechanisms without having the constraints of having to worry about commercialization. But for anybody who is working on the more translational end of the innovation spectrum (i.e. the entire digital health industry), doing this is mandatory.
It was amazing to see the changes in strategy among the teams in our class as the weeks went by. Making Friends started out planning to build a game to help socialize children with autism, but realized along the way that parents and special needs schools were much more interested in having a dashboard to communicate and track the childrens’ progress. Tidepool, for whom I’m a medical advisor, started out thinking that our early customers would be tech-savvy 20-somethings with type 1 diabetes, but quickly learned that the most interested customers would be parents of children with type 1 diabetes (see the video about our process here). The Lean Launchpad class was filled with similar stories — we all found that most of our initial guesses were flat out wrong once we went out and talked to people. As Steve always notes, one smart person is not as smart as the collective wisdom of hundreds of customers.
Following these lessons will be crucial to future successful innovations in healthcare and I sincerely hope that this curriculum spreads throughout the healthcare community. We in healthcare have to have the courage to get out of the building and test our assumptions early instead of blindly plowing forward. We should apply the same rigor to our business plans and dissemination strategy as we do to our science. We should shed the attitude that, “if we build it, they will come.”
A hearty thank you goes out to all of those who designed this curriculum and ran this class.
May 20, 2012 1 Comment
On Wednesday, I was in New York along with other members of GreenDot to make our presentation to the judges and audience as semi-finalists in the Sanofi Data Design Diabetes Innovation Challenge. Our mission at GreenDot is to collect diabetes related data from all sources into one platform and make it more accessible, intuitive, and actionable.
The energy in the room during the five semi-finalist presentations and afterwards was phenomenal, and really exciting to be part of. The people in the room, both semi-finalists and attendees, all have incredible energy and passion about innovations in health care, and there is no doubt in my mind that many major improvements will be forthcoming from everyone who was there. I’m really happy to be a part of this competition and have the chance to meet so many wonderful people.
For the first time, I even had the exciting experience of meeting someone who recognized me because of this blog! (Thank you for reading, Anna!)
To vote for GreenDot, click here. We’ll find out on May 24th whether or not we move on in the competition to the final two.
A few photos from New York and Demo Day:
May 1, 2012 Leave a comment
DiabetesMine is sponsoring a contest asking for people with diabetes to tell everyone about their biggest needs in a 2-3 minute video. Contest details at: http://www.diabetesmine.com/2012/05/announcing-the-2012-diabetesmine-patient-voices-innovation-contest.html.
March 30, 2012 1 Comment
See the press release here from Fast Company and also announcement on Sanofi’s competition’s blog. Our team is comprised of Saleh Adi, Yao Sun, Jenise Wong, and I, all physicians at UCSF. I’m sure I speak for our whole team when I say that we are thrilled, humbled, and honored to be moving on in the competition. Congratulations as well to the other semi-finalists. It is great to be a part so many wonderful innovators around the US and the world trying to move diabetes care forward.