Idag tänkte jag ägna mig åt lite självkritik utifrån ett hälsoekonomiskt perspektiv. Ofta när man vill motivera en hälsosatsning ekonomiskt så är det marginalkostnad i förhållande till marginell nytta som är intressantaste verktyget att använd, speciellt i sjukvården där man oftare finjusteras budgetar och ökar eller minskar anslag för olika typer av satsningar, snarare än genomgör stora verksamhetsomvälvande projekt.
I fallet e-hälsa, vi kan som exempel ta en webbaserad coachning för diabetespatienter, så handlar marginalkostnad om vad det i en driftsituation kostar att leverera tjänsten till ytterligare en patient och hur stor nytta tjänsten skapar för den patienten.
Web-coachningen för diabetespatienter kommer att ha en marginell nytta som är större än marginalkostnaden fram till ett visst tröskelvärde då kostnaden överstiger nyttan. Efter att man anslutit en stor grupp användare är det kanske en större andel ointresserade patienter kvar, patienter med dålig datorvana eller patienter som inte talar svenska. Alla dessa faktorer tillsammans gör då att marginalkostnaden ökar och den marginella nyttan minskar.
Det här är ren hälsoekonomi 101. Problemet jag skulle vilja belysa är de politiska mekanismer som kan få e-hälsolösningar att ”misslyckas”.
När e-hälsa förs in på den politiska dagordningen för beslut om satsningar så riskeras att nyttan överdrivs på vägen fram till beslut. Då förleds beslutsfattare att tro att en för stor satsning är det som ger maximalt utfall.
Istället kommer den marginella nyttan bli lägre än förväntat och satsningen kommer att bli dyrare eller kommer inte att ge de hälsoeffekter som utlovats.
En annan utmaning är att man på politisk nivå behöver ganska mycket moment för att få till en satsning och då är risken att man stoppar in för mycket pengar i lösningen i tro om att mer pengar ger större nytta t ex när man försöker skala upp en lyckad pilotsatsning genom att skjuta till mer pengar.
Tvärt om ger detta en sänkt marginell nytta, kanske till den grad att den totala nyttan för hela satsningen äventyras.
Om man ska sammanfatta detta så är mitt främsta budskap att det för varje enskild lösning finns en avtagande marginell effekt, ”one size doesn’t fit all” när det kommer till e-hälsolösningar. För att e-hälsa ska kunna leverera den nytta som förutspås krävs att många olika lösningar får verka parallellt istället för att man försöker bygga ”den bästa” lösningen för varje hälsoområde. Vidare måste lyckade pilotprojekt tillåtas växa till sig i ”affärsmodellen” innan de går att skala upp.
Den här veckan gästas min blogg av Alexander Börve som skriver om sitt USA äventyr från i somras där han begav sig över till det stora landet i väster för att undersöka möjligheterna att kliva in på den amerikanska e-hälsomarknaden med sin dermatologitjänst. Se även Part 1, The Land of Opportunities och Part 2, The journey. /Oskar
A three-week summer trip to California: San Diego 12 July and Silicon Valley 19 July 2011. By Dr Alexander Börve, Founder and CEO iDoc24- ask the dermatologist in any device, 24/7.
Part 3 of 3, Lessons learned
You want to be the best in your field? To be the best and make a thriving company you have to be where it happens! During my trip I really learnt something and the Silicon Valley bug has bitten me.
Prepare for your trip- Networking
To meet people use your local network, people who have been there before, who can CC you in any mail to an acquaintance in Silicon Valley. Then you pick up the lead and prepare for a meeting, coffee, lunch or beer. At this stage do not try and do your investor pitch, but do your elevator pitch and see how people react. Then absorb all the free advice and new contacts, which you then follow up- this is how your network grows. That is how I managed to come home with 100 new linked in connections in three weeks.
Investment
Look up any competitors or start ups in the same field. Who have invested in them? Try then to book meetings with the CEO of that company get acquainted and then see if you have a win-win situation and even ask if you can contact their investors or if they can guide you in the right direction.
Although you have to realize that people are spammed in the Silicon Valley, it is not only you who is knocking on peoples doors, make sure that you buy beers, lunch or coffee and thank them in a follow up mail.
You’re on your own
People will share their experience with you and give you advice, but they will not do anything more than that, It is up to you to make any calls, meetings and sort out any follow up connections. The first impression counts, so dress up like everybody else not too over dressed but just plain and nice. People will focus on your weird orange just bought off the shelf Nike shoes (I did that mistake, thankfully expert coach and great connection Teri Dahlbeck advised me on that, I should change into some more subtle attire for any next meeting to make a first good impression).
FDA & Liability
The US is a difficult market to crack. Healthcare has to be taken seriously, considering the federal authorities power. Consider Google’s fate this summer, when they were fined $500 million for giving access to Canadian pharmacy advertisement to US customers.
More complicated than first thought. Some serious advice!
Here is a an extract from an e- mail conversation with a Doctor and investor from Stanford University about iDoc24:
“You do not need FDA approval for iPhone and Android Apps. But, your providers need to be licensed in the states and they can only offer consultation to residents of the state in which they are registered. Also, you have reimbursement and liability issues that need to be worked out in the US, and these issues added to already existing competition make the US an unattractive business, unless you just want to license your technology to one of the big telemedicine players in that case you would have the VA system, American Well, and Teladoc. They may also just look at your technology and say this is great and make their own or buy an American equivalent of your technology.
I would focus on Europe. Figure out where in Europe Teledermatology is not practiced, try to understand regulatory and reimbursement in these countries, and build the business model.”
Conclusion
Three weeks in the US might not have been cheap, but it was cheaper than moving my start-up without knowing the consequences. The best advice is to build your business where you know your market and where the “fruits hang the lowest”.
Gästbloggaren Alexander Börve tar gärna emot tips och synpunkter och nås på alexander@iDoc24.com
Den här veckan gästas min blogg av Alexander Börve som skriver om sitt USA äventyr från i somras där han begav sig över till det stora landet i väster för att undersöka möjligheterna att kliva in på den amerikanska e-hälsomarknaden med sin dermatologitjänst. Se även Part 1, The Land of Opportunities. /Oskar
A three-week summer trip to California: San Diego 12 July and Silicon Valley 19 July 2011. By Dr Alexander Börve, Founder and CEO iDoc24- ask the dermatologist in any device, 24/7.
Part 2, The journey
My plan is to set up shop with my start up iDoc24- Ask the skin doctor in any device, anytime, anywhere anonymously 24/7, somewhere in California; San Diego or Silicon Valley.
San Diego
I bought a €1000 return ticket Gothenburg- LA including a car rental for a week, since my first stop was San Diego. The first thing I did when I landed was to find a store that sold Pre-Paid mobile telephone cards. I got a T-Mobile one month pre-paid all you can eat subscription for $70: Unlimited calls, text messages and data. I set my Google maps location and drove to my first meeting with Dermlite, which was in Orange County on my way down. A good hour meeting, no deals, just they know who I am now and I made a good first impression. Next stop my motel in San Diego ($80/night), and settled in. I contacted my Swedish host Tomas Hagenfeldt who showed me around San Diego and also helped me meet all different kinds of useful people for setting up business, like lawyers, angels, VC, and other start ups. I paid a $90 fee to go to a San Diego VC meeting and there I met with investors who referred me to people in the Silicon Valley where I heading up week after. I also met with a Swedish start up already present in San Diego Great Connection, who are into the transfer of ultrasound images via mobile telephones.
I was also introduced to Erik Nowacki who heads the Swedish consulate in San Diego. The consulate offices also house the Swedish American Chamber of commerce (SACC), who has trainee students working on promoting Swedish business in San Diego. I also met up with SACC in San Francisco, and Innovation Norway who were also very helpful connecting me with people.
During the day I would have a lot of meetings, then in the evening I choose my new hub, where I would want to meet people and “pitch” my idea to the people on the street. I chose an upmarket restaurant bar called “Sear sucker”, which was right in the Gas Lamp district. The place had a big bar, so I would place myself there and order some beer and take a treat from their menu. After a couple of minutes you were making small talk with the person next to you: “where are you from?” I told them where I was from and why I was there and did my elevator pitch to see their reaction. This scenario would go on all evening and all week! A great way to meet people and get a feel for your concept to US market. Be prepared that people will not like it and only look for problems, like how not to get sued….
Silicon Valley
I had already made contact to meet Adiba Cremonini who is miss networker for the Swedish community in Silicon Valley. When I was settled in I had a few meetings that I had set up myself and then I met with her. She took me to a Silicon Vikings event, where I met other Scandinavian entrepreneurs, business people, angels and interns. A great mix of people. I tried to meet as many people as possible- “elevator pitch”- grab a business card, then Linked in and follow up e-mail. I met Sven Otto Littorin at the event, who has been a visiting scholar at the Stanford Wallenberg Hall. He did a great job of showing me the Stanford campus and he gave me insight in the Stanford community. It was great to meet him at Stanford, as he was not a politician he would have been in Stockholm. Within a day he even gave me some top contacts in Sweden that should help my start up.
Every day I would meet people that would tell me to meet this and that etc. I managed to go by the Black Box Mansion, which is a big mansion with European entrepreneurs loitering around. I met the host Bjoern Lasse Herrmann who introduced me to more people and more connections. He later invited me for a dinner they have every week where I met another bunch of interesting people.
Follow up
Now I am home and got lots of work to do. I really learnt something and the Silicon Valley bug has bitten me. There are problems of course to make a move: Visa, investors, leaving your home in Sweden. But now I have 6 months to try and rectify this and iron out any problems. The 3 weeks cost me a total of $4000. Moving my company there will probably cost $50 000 even before hiring people. The latest in Silicon Valley is that a computer engineer wants $150 000 and options, so be well prepared before you take the plunge. And BTW I gained 7 kilograms of fat during the trip!
Gästbloggaren Alexander Börve tar gärna emot tips och synpunkter och nås på alexander@iDoc24.com.
Den här veckan gästas min blogg av Alexander Börve som skriver om sitt USA äventyr från i somras där han begav sig över till det stora landet i väster för att undersöka möjligheterna att kliva in på den amerikanska e-hälsomarknaden med sin dermatologitjänst. /Oskar
A three-week summer trip to California: San Diego 12 July and Silicon Valley 19 July 2011. By Dr Alexander Börve, Founder and CEO iDoc24- ask the dermatologist in any device, 24/7.
Part 1, The land of opportunities
You want to be the best in your field? To be the best and make a thriving company you have to be where it happens!
A good example is Heineken, the Dutch brewer that started 1864 in Amsterdam and is ranked as the third largest brewery in the world, with an annual beer production of 139.2 million hectolitres. The success of Heineken beer can be granted to Alfred “Freddy” Heineken, a brewer and salesman. Just after the World War II he went to live in New York for two years. There he was taught the ropes of American advertising and marketing. In its green bottle, with “export” on the label, and priced to match its suggestion of exclusivity, it caught on in the United States and elsewhere as a beer for special occasions. People were amused by, and perhaps even believed, its claim to be the beer that “refreshes the parts that other beers cannot reach”. Mr Heineken said he wasn’t really selling beer. “I was selling warmth, gaiety.” Mr Heineken went to the city where good marketing is vital in order to make a successful company.
Where to establish yourself
If you want to be the best fashion designer, where do you go? Answer: Paris or Milano. If you want to be the best banker where do you go? Answer: London or New York. If you want to become an actress or actor, where do you go? Answer Hollywood. If you want to start a successful and thriving start-up company, where would you go? Answer: Silicon Valley. Go where there are other people just like you. Why? Because you will find the following:
- A culture of collaboration: There is an informal air of collaboration in Silicon Valley. It’s network-building friendships. It’s informal mentorships. And it’s everywhere.
- Aligned incentives: it’s not unusual to work late on a Saturday night understanding you are part of a greater mission. Seeing others around you who have cashed out when their start-ups were acquired — and then do it again and again — is both a motivator and a reminder that the entrepreneurial spirit is about the hunt.
- Critical mass of talent: From engineers to marketers, to investors, to venture capitalists, to legal eagles, the proximity and concentration of this talent creates something special.
- Respect of intellectual property: This makes people feel more at ease with sharing and discussing their breakthroughs, which is absolutely essential for using the network to refine ideas.
- A capacity to celebrate failure: The saying in the Valley is ”fail fast” so that we can move on to the next thing. The feared alternative are ”zombies” — companies that should be dead, but continue to linger, keeping their founders and engineers hostage to their mere existence. Silicon Valley is filled with entrepreneurs who got lucky on their first try. But many only succeeded on their second or third attempt.
- Worldwide attention: Who reads a tech blog from any European country? Sweden, Norway, Germany, Spain, Poland, etc? Not many. Who do all the European tech bloggers follow and get their next story from? Yes, that’s right the Silicon Valley Tech blogs like TechCrunch! So if you are in the Valley you have a better chance hyping your start up to get into a Valley tech blog and then it will get into all the European tech blogs, translated into 15 different languages!
My journey
My plan is to set up shop with my start up iDoc24- Ask the skin doctor in any device, anytime, anywhere anonymously 24/7, somewhere in California; San Diego or Silicon Valley. The service is simple, got something on your body that you do not know what it is and you are slightly worried; send us a picture with text and you will have an answer from our dermatologists within a couple of hours. The great thing is that we do not know the person that sends in a case to us, you are anonymous! So you guessed it, 35% of incoming queries are on intimate genital worries…. And you can imagine, with thousands of sexually active uninsured geeks in Silicon Valley, my service will probably get a lot of traction right there!
So, the plan is to set up shop in early 2012, get investment and work hard, making it a global mHealth company.
Article References:
- Heineken Wiki, history
- The 5 Secrets of Silicon Valley by Naeem Zafar, http://bit.ly/o9HQJi
Gästbloggaren Alexander Börve tar gärna emot tips och synpunkter och nås på alexander@iDoc24.com
Nyss hemkommen från MIE 2011, EFMI:s (European Federation for Medical Informatics) årliga konferens, i år förlagd till Oslo, där jag var med och representerade epSOS semantikarbetsgrupp.
Övningarna jag deltog i gick ut på att hitta sätt att dela framsteg kring semantisk interoperabillitet mellan tio-talet EU-finansierade projekt. Ett riktigt bra initiativ från några EU-projektseniorer. I korthet går det ut på att sluta uppfinna hjulet i varje projekt och istället hitta ett antal gemensamma byggstenar för europeiska hälso-it-projekt som t ex ICD-10, vissa Snomed urval, mm. Väldigt pragmatiskt alltså, me like!
Något som slog mig på konferensen var att många inom MI-forskning fortfarande när drömmen om den semantiska webben. Den semantiska webben för er som inte minns är en pre-google, pre-watson vision om ett indexerbart internet där system kan förstå vilken kunskap som finns där ute och där robotar på nätet kan söka svar på frågor formulerade av människor, allt med hjälp av finurlig XML.
Semantisk interoperabillitet ger med denna ansats en väldig fokus på att skapa bra ontologier för de domäner man vill ta sig an. Varje projekt tar fram en egen representation av verkligheten, många projekt går och går i ett evigt sökande efter den perfekta modellen.
Vad är då egentligen en ontologi? Ontologi är framför allt ett tacksamt ord att använda eftersom det till skillnad mot t ex informationsmodell eller terminologi inte är så väl definierat. Konsensus från konferensen verkar vara att en medicinsk ontologi är ett organiserande av medicinska termer, men Snomed CT är INTE en ontologi.
Men det är klart att vi behöver ontologier, framför allt behöver vi enas om hur vi ska representera verkligheten i våra informationssystem så det går att använda informationen utanför den kontext där den skapades. Vi är idag väldigt bra på att hålla reda på sjukvårdsadministrativ information, gärna sånt som har med pengar att göra: datum, organisationer och diagnoser. Men när det kommer till hälso tillstånd så blir det sämre. Jag gick på några presentationer av storslagna antologi-projekt men frågan som punkterade vilken tjusig modell som helst var ”Har ni så här strukturerad information i journalen/systemen?”, ”Nej…” : P
En helt annan sak jag tar med mig från konferensen är en idé om några gästinlägg från min konferenskompis Alexander Börves äventyr i USA. Mer om det inom kort.
*TOCO, terminontoklassixonomier, är uppdiktat av Christian Lovis.
