By MATTHEW HOLT

Andreesen Horowitz’s digital heath investor Julie Yoo has been building quite the theory of the present and future of health tech. I am going to try to write up a longer response to her but first, please view her presentation on the New Tech Stack for Virtual-First Care — a compelling 8 minute watch. And then have a quick read about how I am (trying to) put her in context.

Her first argument is that the digital services that you need to run health care (things like accounting/revenue management, network management, credentialing, pharmacy, etc, etc.) are getting really good. That means that startup digital heath companies can build services really quickly. No argument there. The second part of her argument is that incumbent organizations will also use these tools (actually already are using these tools) to improve their offerings.

Her argument is somewhere in the middle of three themes I’ve been banging on for a while.

My first argument is that too much VC money has been spent on new tech companies intending to prop up the incumbents and the incumbents by definition can’t change to become the type of virtual-primary care first chronic care management consumer friendly organizations that we need. I called this the Lynne Chou O’Keefe fallacy (which is why Julie wants one of her own!) and wrote it up on THCB about a year ago.

The second is the rather longer theme that I (with Indu Subaiya) have been banging on about called “Flipping the Stack”. The basic idea is that health care services now have the potential to go from an event-driven, encounter-driven acute-care delivery model to one where technology is able to measure, manage, message and monitor patients wherever they are, and that virtual services and physical interventions are layered over the top.

The third is my idea about the “continuous clinic” which is an attempt to describe the activities that an organization needs to run a 24/7 patient management organization. (I’ve presented on this many times but haven’t totally written it up–a version of how it might work for COVID patients is here).

Somewhere in what Julie is doing and in my fumbling towards new models is the idea of what a new health system will do and what it will look like.

Of course the related question is who will be the players? While we have United Healthgroup buying anything that moves and the incumbent hospital systems collectively sitting on an Apple/Google sized mountain of cash reserves, it’s hard to see the current system being changed dramatically by the people running it now.

But it needs to.

If you need to be reminded why, take a look at the comments about half way down in this piece in which a patient blogger Luke O’Neill asked his readers about their relationship with “their” doctor and the health system. And then consider whether we should trust the current incumbents to make that transition.

I’ll be back with more on this next week….

Matthew Holt is the publisher of THCB

By MATTHEW HOLT and INDU SUBAIYA

Indu & I have been talking about Flipping the Stack in health care for about 3 years. 2 years ago we wrote an article for a general hospital audience which appeared in the 2019 AHA SHSMD Futurescan magazine. I was talking about the changes in home monitoring that might come about due to COVID-19 and remembered this article. The one that got published went through a staid editing process. This is the original version that I wrote before which was rather more fun and hasn’t seen the light of day. Until now. Take a look and remember it is 2 years old–Matthew Holt

Over the past twenty-five years most businesses have been revolutionized by the easy availability of cloud and mobile-based computing systems. These technologies have placed power and access into the hands of employees and customers, which in turn has created huge shifts in how transactions get done. Now the companies with the highest market value are both the drivers of and beneficiaries of this transition, notably Apple, Facebook, Amazon and Alphabet (Google), as well as their international rivals like Samsung, Baidu, Tencent and Alibaba. Everyone uses their products every day, and the impact on our lives have been remarkable. Of course, this also impacts how businesses of all types are organized.

Underpinning this transformation has been a change from enterprise-specific software to generic cloud-based services—sometimes called SMAC (Social/Sensors/Mobile/Analytics/Cloud). Applications such as data storage, sales management, email and the hardware they ran on were put into enterprises during the 80s and 90s in the client-server era (dominated by Intel and Microsoft). These have now migrated to cloud-based, on-demand services.

Twenty years ago the web was still a curiosity for most organizations. But consumers flocked to these online services and in recent years businesses followed, using GSuite, AWS (Amazon Web Services), Salesforce, Slack and countless other services. Those technologies in turn enabled the growth of whole new types of businesses changing sectors like transportation (Uber), entertainment (Netflix), lodging (AirBnB) and more.

What about the hospital?

Hospitals and health systems were late comers to the enterprise technology game, even to client-server. In the 2000’s and 2010’s, mostly in response to the HITECH Act, hospitals added electronic medical records to their other information systems. The majority of these were client-server based and enterprise-specific. Even if they are cloud-based, they tend to be hosted in the private cloud environment of the dominant vendors like Epic and Cerner. Of the major EMR vendors only Athenahealth had an explicit cloud-only strategy, and its influence has been largely limited to revenue cycle management on the outpatient side.

However, the hospital sector is likely to move towards the trend of using the cloud seen in other businesses.