Future Health 100

A near-careerist with Microsoft, Neupert’s ‘sabbatical’ as CEO of Drugstore.com from 1998 to 2001, was also his entrée to healthcare. He later served two years on President Bush’s IT Advisory Committee, co-chairing the Health IT Subcommittee. By Neupert’s own description, he returned to Microsoft with a mission in 2005, and began lobbying CEO Steve Ballmer on the vast opportunities in healthcare. “It’s not like I had to twist his arm. I just had to persuade him,” he has said. Of the alien companies to enter healthcare (especially tech companies), Microsoft has made the biggest impact. Against market-specific odds and the usual audience of Microsoft doubters, in five years Neupert has pieced together the components for HealthVault and Amalga. As David Harlow blogged recently, “we’ll see how long it takes to realize that potential.” A secondary benefit of Neupert’s agenda: investors and entrepreneurs are emboldened by a perception of Microsoft as a potential buyer of their startups. As in previous decades, Microsoft has not disappointed: since 2006 Neupert has reportedly spent $1 billion on his portfolio, including purchases of Azyxxi (“air traffic control system for hospitals”), Medstory (search), and Global Care Solutions (general IT). This catalyzing function could earn Neupert a spot on our list all on its own, as it encourages risk-taking by smaller innovators who might otherwise sit on the sidelines. 

Writing in Forbes: “Many equate investing in electronic medical records to the paving of the interstate highway. They miss the key attribute. The interstate highway enabled the movement of goods and people. It accelerated new forms of commerce and markets because of the lower cost and speed of transportation. What is sorely needed in health care is a connected health ecosystem that enables the dynamic movement of existing digital data that connects all the points of care—hospitals, physicians, pharmacies and the home. Paying doctors and hospitals to implement electronic medical records is more like repaving selected streets."

Park's first start-up, Boston-based athenahealth, co-founded with  Jonathan Bush, created a huge success out of curing the headache of billing management for medical practices. Having resettled in Silicon Valley, Park recently launched Ventana, with Giovanni Colella. This time, Park is seeking to relieve the mystery of out-of-pocket costs for consumers. Ventana will give us the power to conduct price-sensitive shopping for our doctors and clinics, or specific services and medical procedures. Think: Travelocity for healthcare. Park also serves as an advisor to the social entrepreneurship incubator Ashoka, which delivers telemedicine and low-cost drugs and diagnostics to India's rural poor. Park was recently named a Senior Fellow at the Center for American Progress, where his work focuses on transforming the health industry through IT.

"When designing a health care startup, there are three criteria you need to meet. One, are you solving an important problem for a well-defined customer?  Two, even if your product isn't a financial one, is your customer financially better off if they have your product vs. if they don't?  Three, is there a network effect in what you are doing? Does your product become more valuable to each of your customers as you add more customers?  If you can say 'yes' to these three questions, you'll maximize the probability that your startup will succeed in the brutal [but] wonderful work of bringing innovations into our health care system." 

The first integrated, online program that delivers live visits with doctors. By partnering with health plans and state agencies, American Well has achieved what traditional telemedicine efforts could not: credibility with consumers and scale. An unexpected boon: Providing physicians with the opportunity to deliver care in their off-hours taps a latent talent pool and leverages our stock in a diminishing asset -- primary care doctors. Another net-benefit of 24-hour access to physicians: ER- triage. Fewer needless hospital visits means lower costs. Partners with fh100 companies, HealthVault, to give patients access to their personal records, and ActiveHealth, so doctors may scan medical records for pertinent data prior to diagnosis.

“The U.S. healthcare system fails to provide Americans with timely access to care. Our service, Online Care, creates a new model for healthcare delivery and demonstrates how millions of Americans will benefit from on-demand access to credentialed physicians - whether the consumers are at work, or at home.”

The first integrated, online program that delivers live visits with doctors. By partnering with health plans and state agencies, American Well has achieved what traditional telemedicine efforts could not: credibility with consumers and scale. An unexpected boon: Providing physicians with the opportunity to deliver care in their off-hours taps a latent talent pool and leverages our stock in a diminishing asset -- primary care doctors. Another net-benefit of 24-hour access to physicians: ER- triage. Fewer needless hospital visits means lower costs. Partners with FH100 companies, HealthVault, to give patients access to their personal records, and ActiveHealth, so doctors may scan medical records for pertinent data prior to diagnosis.

“Spending the next decade trying to [electronically] exchange medical records will [only] guarantee we end up with another antiquated system by the time we are done. We need to use technology not merely to distribute medical records, but to redeploy actual medical services and reshape our landscape."

The man behind the $4 prescription drug program. This initiative was most cited by those we polled for the "single innovation of largest impact." Hits our three criteria--quality improvement, cost savings, and access--more explicitly than anything else in this list. Simon joined Wal-Mart in March 2006 as head of the specialty division, which included Wal-Mart's pharmacies. His colleague, Linda Dillman, head of benefits for Wal-Mart, had in place a $3 drug benefit to incent workers to take their medications. Simon saw an opportunity to commercialize the concept for shoppers, many of who are uninsured. He launched it six months later. Since Sept. 2006, the company says Americans have saved more than $1 billion dollars filling prescriptions at Wal-Mart pharmacies. Now has 1,000 generics offered at $4 and last year began pilots of 300 drugs, offered in 90-day quantities, for $10. CVS and Target now have similar programs. Wal-Mart now competes with PBMs by offering a similar program to employers. 

Simon speaking to NPR in 2006:

"We hear stories all the time from our customers, stories about moms who are faced with difficult decisions about how they may have to forego groceries, in some cases, to buy antibiotics for a child who is sick. And we can do something about that, and today we started to."

As head of IHI, Dr. Berwick can take credit for driving numerous national and international projects to improve the quality of healthcare processes, hospital standards and medical outcomes. The venture we like best is the Hospital Improvement Map, an online tool to guide administrators and physicians across the "confusing landscape" of reform demands, and down the "reliable routes" to better care. It launches in September, and will be free. He patronizes the work of other list-members, including: Gawande's surgical safety checklist and Moore's IMP.org. Besides many other leadership positions and board seats, Dr. Berwick teaches at Harvard Medical School and the Harvard School of Public Health.

Sharing the 'good news' with ABCNews:

"We see organizations that are able to cut injuries to patients, dramatically. Mayo Clinic [has] reduced injuries to patients by over 50 percent in two years. We’re working with systems in Scotland [that] are able to get patient safety up tenfold -- one-tenth the injuries to patients! We see dramatic improvements in patient-centeredness; systems that are opening their doors to patients, getting them involved in their own care; the Medical College of Georgia is one prototype I deeply admire. So, give me any dimension of quality and I can find a place in the United States, or abroad, that is knocking the socks off the problem. Now we need to put it all together.”

The Dartmouth Atlas of Health Care. His 1973 research in the distribution and utilization of healthcare services demonstrated wide variations across geographies. Seeking an explanation, he began documenting commonly used medical practices - and their results. From this stemmed the Atlas, and most other research (and journalism) in outcomes-based medicine and cost analysis. Work for which Dr. Wennberg is less well known seeks to engage and enlighten patients in their treatment choices. In 1989 he co-founded the nonprofit Foundation for Informed Medical Decision Making, which distributes "objective scientific information" about medical procedures with interactive media. An example: With support from Wennberg's nonprofit, Massachusetts General mails video tutorials to patients about procedures they are considering, or will soon undergo, including the outcomes data. Think: A Netflix for healthcare. No ivory tower academic, this Jack.

On "What's wrong with the U.S Health-Care System?":

"Well for one thing we're throwing a lot of money at it and we don't [know] what we're getting out of it. [In] the case of the management of chronic illness ... we're actually seeing an increased risk of earlier death associated with high intensity care. And people will ask, ''Well, how could that possibly be the case?" Well, first of all you have to ask the question, what's the science that says that more is better at the patient level? And as I've tried to say many times in my career, the evidence simply isn't there." 

Head of the largest nonprofit health plan and hospital system in the U.S (8.6 million members), was also the earliest private sector chief to commit to an electronic medical records platform. In future b-school cases, when EMRs are studied as the innovation to usher healthcare into the digital age, Halvorson will be chronicled as the "anchor tenant" who validated the proposition to the market. Promotes more progressive initiatives through K-P's Garfield Innovation Center, such as remote physical therapy conducted via Skype and the Wii-Fit game console. A leading voice in the industry's $2 trillion cost reduction pledge. Supports universal coverage. Prolific author.

"There is unprecedented momentum for health care reform, with a real chance of making care better, more accessible and more affordable. Collaboration and accountability are central to this effort and we believe that the most effective reforms will control spending by providing better care for all Americans."

Co-created the first EMR that customers outside Epic's domain could hope to use. Founded in 1999, eClinical Works targeted practices of 15 or fewer physicians and breathed fresh air into health IT with its web architecture, stellar service, and flat rate pricing. Already growing fast in 2007, when F. Mostashari selected it for New York's public clinics (revenues ramping 70% year-over-year; an HBS case study), the exposure elevated eCW to status of "standard-bearer." In April, Wal-Mart selected eCW and Dell to produce an EMR package sold through Sam's Club stores. eCW will eclipse $100 million in revenues this year. Now finds itself in the enviable, but tough, position of protecting its turf. Newly innovative shops now push "ultra-light" EMRs to solo practitioners that cost even less, and require almost no training at all.

Speaking to emrupdate.com in 2007:

"Doctors are often very sensitive people, and many do not choose the profession for the love of money, but rather, for the love of their patients. Unfortunately, they are surrounded by a healthcare system that is all about dollars. If eCW can make it easier for doctors by putting our pricing on our website, so everyone can see they are paying the same ratio, we can also make it easier for ourselves." 

Head of benefits programs from 2006 until she leaves Wal-Mart this month, Dillman has overseen some of the most progressive healthcare initiatives undertaken by any U.S. employer, or vendor. An IT specialist, not a healthcare nob, Dillman debuted Wal-Mart's PHR program, expanded benefits to 1.2 million Wal-Mart associates and dependents, and created the $3-employee prescription benefit that would inspire #4 Simon's $4 Drug Plan. The retail clinics, rolled-out on her watch, haven't been universally successful. Wal-Mart still leases space to 37 low-cost clinic operators like Med Point Express and Quick Health, but other vendors performed poorly or collapsed with recession. Wal-Mart retooled. Last year set goal of 400 clinics by 2010, this time branded under its own name and run by local hospitals or RediClinic. (Now in Simon's portfolio). Sits on the Robert Wood Johnson Foundation Commission to Build a Healthier America, and the Centers for Disease Control & Prevention (CDC) Advisory Committee.

"One of the issues in healthcare is that price is not always a factor in how people make their choices. But that is what Wal-Mart is about. We value price. There is great lesson for us in this. It's that when you frame healthcare in such a way that price is a factor for the customer, they will get involved and they’ll make the right choices." 

Rewards-based plan design and execution. In 2003 Safeway endured especially acrimonious labor strike concerning cuts to workers' health benefits. By 2005 Burd was guiding Safeway through a total benefit re-org. Abandoned tradition of corporations that pay for a set percentage of every worker's healthcare benefits, regardless of behavior. Offered to cover as larger portion of costs for non-union workers who agreed to live "well." (Why should Safeway equally subsidize the worker who smokes and the worker who does yoga?) Uses HSAs as carrot and stick: first $1,000, Burd funds; next $1,000 comes out of employee's pocket. Then employee's minority-obligation (e.g. 20%) for next stage of costs gets triggered. Company is a standard-bearer for how to align the financial interests of workers with their health -- and with the company's bottom line. Burd says Safeway's healthcare costs have remained flat since 2005. Now pushing for price transparency on medical procedures. 

Writing in WSJ:

"Safeway has done nothing more than borrow from the well-tested automobile insurance model. [T]he auto-insurance industry has long recognized the role of personal responsibility. As a result, bad behaviors (like speeding, tickets for failure to follow the rules of the road, and frequency of accidents) are considered when establishing insurance premiums. Bad driver premiums are not subsidized by the good driver premiums."

Longest-serving partner at his very influential firm, he is one of the most prominent investors in bioscience and the acknowledged "godfather" of personalized medicine. Formed the first life sciences practice in the venture industry in 1984. KPCB has funded or supported more than 110 companies that impact the healthcare industry. Several in his portfolio were founded by other list members, like Tethys Biosciences and Genomic Health. (Byers is a director of both.) KPCB also invests in healthcare services, represented by startups like RedBrick Health. 

From a speech at Stanford:

"Genes matter. Patients with cancer, heart disease, rheumatoid arthritis, osteoperosis and other diseases have individual genetic signatures of their manifestation ... So should [molecular diagnostic] tests that will cost $750 to $5,000 be feared by people who want to get a grip on healthcare expenditures -- by the medical profession, payers, FDA, policy makers? Or should they be embraced? They should be embraced, because they can show excellent healthcare economics."

Healthcare HAL. Medicine is a culture of experimentation, but also tradition. And then sometimes it's just "enlightened guesswork." A heart surgeon with a PhD in mathematics, Dr. Eddy began challenging assumptions about the perceived efficacy of popular medical procedures in the 1980s. He won an award for demonstrating that regular Pap smears in women of low cancer-risk are useless, and later showed that common treatments to deter glaucoma were harmful. (Today we call this supply-sensitive care). Over the years he exposed that most medical decisions are not informed by facts, and eventually coined a phrase for the solution: "evidence-based medicine." His work is now represented by Archimedes, a powerful database that marries mathematical modeling to reams of data about human physiology, disease and interventions to predict what works, and what doesn't. Archimedes has been helpful in selecting cost-effective treatments for diabetes and cardiovascular disease, but like any "AI" computer, its success depends on the data fed into it. Garbage in = garbage out. So Eddy regularly tests Archimedes against historic clinical trial data, to be sure "healthcare HAL" will return the correct results. Archimedes is now owned by Kaiser-Permanente, but in October 2007, Eddy received a $15.6 a million grant from the Robert Wood Johnson Foundation. He's using it to build a web version, called ARCHeS, which will be accessible to a broader range of customers, like small companies or nonprofits. 

To Business Week, 2006: "Our mission is that in 10 years, no one will make an important decision in health care without first asking: `What does Archimedes say?"'”

HowsYourHealth.org Lots of people have contributed to the conventions doctors use to profile patients at the onset of care. No one, until Dr. Wasson, took the trouble to vet and routinize them into a survey that is as universal or easy to use as Hows Your Health? Wasson's survey is also free. Translation: hugely scalable. Wasson's questionnaire builds on earlier tools (like John Ware's SH36 survey) to produce a thorough portrait of one's physical and emotional health. Being web-based, patients can log on to HowsYourHealth.org and survey themselves, crafting a do-it-yourself PHR. Physicians, clinics, or communities can take the basic template and customize it into a no frills EMR ($250 a year, no new hardware or software). Listee Moore made this the foundation of the Ideal Medical Practices Project. The fact that HowsYourHealth isn't slick or over-designed is one reason it appeals; it doesn't feel as if you're being programmed into the lair of the Borg. Try it.

"How's Your Health is a bit like a Swiss Army Knife. The more you understand how to use it, the more you get out of it."

Dossia. Drove many healthcare investments over his career with Intel, where he was CEO from 1998 until 2005 and recently retired as Chairman. These include establishing Intel's Digital Health Group, on-site clinics at Intel campuses, and Dossia, his largest in ambition. A nonprofit consortium of employers, it seeks to promote an open source infrastructure for exchanging patient data, plus a universal personal health that won't be controlled by a single vendor (read: Google or Microsoft). Formed in 2006, includes AT&T, BP America, Intel, sanofi-aventis, Wal-Mart, Vanguard, and others. Each member has contributed millions to "the cause" but objective progress is hard to measure. Still, credit for this powerful (and many thought, unlikely) assembly is Barrett's. It could be used to leverage many additional innovative efforts.

Testifying before U.S. Senate on healthcare in 2008:

"Given the coming age and chronic [illness] tsunami...the old one-on-one physician to patient paradigm will not suffice. We need to move away from physician-centered care [and] toward a patient centric model where delivery and funding are channeled via care teams with a community approach."

Her 2003 report, "The Quality of Health Care Delivered to Adults in the United States,” was first to empirically measure the disparity between care expected and care received in the U.S. The 10-year study polled 13,000 adults in 12 metro-areas, and considered 439 quality-criteria for 30 acute and chronic conditions. Conclusion: American adults receive 55% of recommended care for illness like asthma, cancers and heart failure. Her subsequent studies indicate the ratio is consistent, regardless of geography, socioeconomic status, race, gender, or insurance status. A 2007 report shows children fare even worse, receiving 47% of recommended care. Now called the Community Quality Index Study, McGlynn's work influences current research into geographic disparities of healthcare spending and evidence-based medicine. She is also the force behind RANDCompare, a performance measurement engine, based on her research.

"People have a hard time agreeing on what quality means because it's multi-factorial; it's in the eye of the beholder. But that 55% figure was a clear signal that things didn’t look very good in the U.S. The report's major contribution was allowing us to get on with the conversation. There was a shift from 'do we have a problem or not?' to 'we have a problem and lets get on with it.'"

Bringing design process to healthcare. Mayo innovated the delivery model with "integrated group practice" 100 years ago. Dr. LaRusso is now changing the way Mayo innovates. He opened Mayo's new Center for Innovation in June 2008 with a distinguishing characteristic: he recruited full-time designers to his 40-person staff. Now industrial designers, product designers, graphic designers and process gurus--types who wear black and typically seek gigs at Frog or IDEO--work in a studio on the ward floor alongside the doctors and nurses. This is so they can move more quickly through the iteration, prototyping and test phases of their ideas. One outcome: a pilot for "asynchronous e-consults," or web consultations between doctors. (Asynchronous means not "real time"; a synchronous version is coming.) It's Mayo's take on American Well, but communication is doctor-to-doctor, not doctor-to-patient, and it benefits from being woven into Mayo's integrated care. Importantly, LaRusso also tested e-consult with some non-Mayo doctors in Duluth, a sign Mayo plans to begin exporting its innovations. LaRusso received hundreds of resumes "from the most elite design schools" for a single job post this spring. It is heartening that creatives who might have sought to serve Apple or Nike, are choosing to employ their talents to healthcare. Creating the opportunity for them to do so is an innovation, too. And unlike other of Mayo's innovations, this one is transferrable. A gastroenterologist trained at Mayo, Dr. LaRusso is also the Charles H. Weinman Endowed Professor of Medicine a Distinguished Investigator of the Mayo Foundation. 

Less is More. A major filter in healthspottr's screen for "innovations we like" is whether it helps us do more with less. Dr. Fisher is the principal investigator of the Dartmouth Atlas and a faculty member of The Outcomes Group, a band of "healthy skeptics" who exist to question the popular notion that more healthcare is better. Dr. Fisher's papers, especially Supply-Sensitive Care, offer the data that shows it is not. Turns out that supply and demand behave erratically in healthcare -- more supply actually increases price and lowers quality. Or, a hospital bed built is a hospital bed filled. Defined as "care whose services are not determined by well articulate medical theory, much less by scientific evidence," supply-sensitive care would be excessive testing and unnecessary physician or ER visits. Our Achilles heel. Happily, lots of innovators on this list are attempting to address this (ADM, American Well, HealthLoop) because they also understand that (excepting primary doctors) we don't need more of anything in healthcare; we need to use what we already have better. Dr. Fisher is also a director of research at the Dartmouth Institute for Health Care Policy and Clinical Practice. Scott Shreeve isn't the only one who thinks Dr. Fisher would've been a better choice for HHS Secretary than an insurance industry nob.

Writing in Supply-Sensitive Care: "Hospital beds, once built, will he used."

A forensic pathologist who began his career in the Navy, he first investigated aircraft accidents, then unexpected deaths at Naval hospitals. Also investigated the watershed Billig case of 1986, which publicized the need for error-reduction in medicine, and places Dr. Lord at the origins of the quality improvement movement. Post-Navy he joined SunHealth, helped run the American Hospital Association and Health Dialog. Also worked with #7 Wennberg on the Dartmouth Atlas. As Humana's chief innovation officer, he pushed initiatives to demystify healthcare for members and engage them with gaming. We especially appreciate SmartSummary, a quarterly English translation for members of typical benefits-Greek. Joined Navigenics this spring. 

"These are all progressions on the same basic track of getting people to a place of sovereignty over their healthcare -- putting them on the same level as their doctors in the decision-making. Navigenics represents the next step. We provide people with a science-based view of their future risks, then give them resources to understand how they might impact those risks."

Founded Epic, the very successful enterprise software company that, while not the largest market share, is most-publicly associated with the electronic medical records industry. HIMSS data suggest Epic has five percent of this $1.2 billion market, but EMRs are just a portion of Epic's estimated $600 million (revenues) business. Clients are mainly large hospital systems. Company claims its technology touches 70 million patients. Now also has a personal health record product, with a cute name: Lucy PHR. Notoriously reclusive, Faulkner is said to be a fierce boss with Zen management principles. Founded in 1979, her company remains private and employee-owned.

Judy's mission, as told to  WTN in 2002:

"Do good, have fun, and make money."

ProvenCare. Of all the wellness plans, HSA tools, and care pitches we hear in the name of "patient-centeredness," the truest example of a policy designed with the consumer in mind is Steele's ProvenCare. What could be easier to understand, and more reassuring to receive, than the pledge from your caregiver that "the price is 'X' and will never be 'Y' -- and 'oh BTW, if it doesn't work, you won't pay.'" This is consumer-driven healthcare. Most other "consumer" concepts still have employer-, payor-, or provider-profits in mind, making them decorative, by comparison, to ProvenCare. An oncologist and surgeon, Dr. Steele joined Geisinger in 2001. He initiated Proven Care in 2006 with bypass surgery (CABG), he has said, because it is frequently performed, well refined and has low rates of mortality and complication. It is also more lucrative than other procedures, which just swell the carrot to "get it right." Of course, executing this performance policy would've been imprudent without first routinizing the procedure to minimize error. And so the nut of ProvenCare's success is revealed. It's not Geisinger's talented surgeons. It's the 40-step-guide-to-a-good-CABG. Doctors are incented to follow it, which is Steele padding his odds, but who cares? ProvenCare patients have experienced shorter hospital stays, smaller bills, and Geisinger says readmission rates dropped 45 percent in the first year. Like other check list-innovations we favor ( Gawande), ProvenCare can be replicated for new types of procedures, "ported" to other hospital systems, and it's pretty darned easy to follow. Plus, there are no equipment installation fees. Which reiterates our happy truth: We don't have to invest billions of dollars on technology to make a very big difference in healthcare. Besides ProvenCare, Dr. Steele has created a venture capital unit at Geisinger. 

Speaking to Fast Company 2008: "We shouldn't get paid if we don't do the right thing." 

Founded an early data management tool for physician "decision support." While practicing cardiology in New York City in the 1980s and 1990s, Dr. Riesman moonlighted as a health benefits consultant for Merrill Lynch & Co., and later joined William M. Mercer. Dr. Reisman went out on his own to found ActiveHealth in 1998, and built the ActiveHealth CareEngine. Sold as a service into plans and employers, the engine gathers data from a patient's claims, lab tests or pharmacy-fills, to inform a physician of the best (or warn of the worst) therapy, according to available medical evidence. Purchased by Aetna in 2005, ActiveHealth partners with American Well, and is a key component of Microsoft's in HealthVault.

Chatting with Esther Dyson:

“Much of the talk now is about assembling all the data on a patient – dealing with data standards and getting all the data into a single record. But that’s not enough. What’s the difference if I have piles of paper in a folder, or a fancy Web interface, or even nothing at all? If I don’t have the time to look at it for each patient, it might as well not be there. You need to analyze and apply the data as well – the patient-specific information matched to the best-practice rules that not every doctor can know in every specialty."

Data exchange. In telecom the service NaviNet provides might be called data backhaul. Sounds bland, but mastering the passage of data between parties -- from a hospital to a payer and back again -- is the Gold Rush in the industry. NaviNet will say its business look like this: it pulls data from a provider and sends it to a payer to help doctors check benefits-eligibility on patients in their care. It also pushes data from payers down to doctors, to give them "decision support" in "real time." McKesson's ADM, run by Zubiller, does this, too. But these descriptions fail to convey the consequence of the business. We'll use an analogy. Healthcare looks a bit like the cable industry of the 1980's: Lots of independent systems, each valuable for their control over regional networks, made up of a few central hubs, with thousands of consumers at end of the line. Control of the systems that shepherd data across these networks is the play, not control of the data itself. That's why it looks like the cable business. He who plays the John Malone of healthcare -- "rolling up" the channels rather than the bits -- will get rich. Which brings us back to Morrison. An IT buff, he founded NaviNet (as NaviMedix) in 1998. And the reason we think he has a shot: he already has 750,000 "partners." Morrison was previously a general partner at the venture firm Firepond Partners, where he focused on healthcare IT. He also worked in business development and marketing with Spectrum (a joint venture between IBM and Baxter) and McDonnell Douglas Health Systems.

To Healthcare Finance News:

“As an industry, we’ve always jumped to the end-stage – without looking at the process in between."

Following the 1990's Human Genome Project, Scott was among the first to recognize that harnessing genomic science for the benefit of individuals, rather than for large drug companies, could amplify medical efficacy and also slash costs. Genomic Health uses genetic data to show the potential efficacy of therapies, such as chemotherapy, on breast cancer patients. It has ongoing research in colon, prostate, renal-cell and lung cancers. Funded by Brooke Byers.

"It's embarrassingly easy to see the future. The difficulty is always in the execution. It's shocking how much money we spend without understanding the underlying mechanisms of a disease. By 2012, we’ll spend $80 billion annually on oncology. Yet across oncology, drugs work only 25% of the time, so $60 billion will be wasted! We also know that tens of thousands of early-stage breast cancer patients undergo chemo each year, even though chemo is beneficial in only four percent of all cases. By identifying which patients will benefit from the treatment, we can optimize chemotherapy and cut unnecessary spending. That's a market we want to go after." 

HEDIS & quality measures in health plans. An eminence grise of healthcare consulting. Dr. Milstein's specialty in managed care program design led to, as one colleague put it, "Arnie's obsession with measuring quality." Good for employers and consumers, this led to Dr. Milstein's leading role in the creation of the Health Care Information Data Set (HEDIS), the yardstick against which performance of health plans, on many metrics, is tracked for employers. Matt Holt has called him "the smartest 'purchaser' in health care on quality." For this, The New England Journal of Medicine called Dr. Milstein a "pioneer" in the effort to advance quality in healthcare. Dr. Milstein is also a member of the National Committee for Quality Assurance (NCQA), which presides over HEDIS, and the medical director of the Pacific Business Group on Health, a large employer lobby based in San Francisco. He is a member of the Institute of Medicine. He also lectures at the University of California, San Francisco.

“The call from employers and consumers for individual provider performance measurement is loud and clear."

Personal genomics. One of the handful of innovators in the field of personal genomics to appear on this list, Dr. Agus is an oncologist and co-founder of Silicon Valley-based Navigenics. (The company is now run by list member Lord.) Like other genomic scientists, Dr. Agus is on the  "hunt for biomarkers" because he believes they can help the pharma-tech industry assess a patient's potential clinical response to a therapeutic. That's targeted medicine, which has the potential to cut costs and improve efficacy -- and we like it. Dr. Agus previously founded Oncology.com, a social networking site for cancer patients. He is also director of the USC Center for Applied Molecular Medicine and the USC Westside Prostate Cancer Center, and was previously director of the Spielberg Family Center for Applied Proteomics (proteomics is the study of proteins). He has been an attending physician in oncology at Cedars-Sinai hospital in Los Angeles. After reading this bio it probably won't surprise you to learn that like any overachieving, forty-something-professional in L.A., Dr. Agus has also made a film. It is a documentary, called Who Needs Sleep?. He plays himself.

Blogging on FasterCures.com:

"The technological advances of the past decade have allowed for a unique opportunity to change the slope of the curve of progress versus time – the inflection point as described by Andy Grove in Only the Paranoid Survive – in drug development. I firmly believe that Dr. Grove's [words] are applicable in this case, 'Technology will always win.'"

In 2008 Tethys introduced a diagnostic test that reveals "biomarkers" doctors can use to identify people at high risk of developing type 2 diabetes within five years. Tethys distinguishes itself from other genomics and diagnostics firms by focusing its technology on health risks and diseases that can be modified. Doctors use the test results to focus appropriate intervention strategies on patients most likely to benefit, in the terms of delaying or even preventing diabetes. This improves quality of care and reduces costs. Tethys' diagnostics are applied by Adamas Pharmaceuticals, founded by Went. Went and Urdea serve on each other's boards and partner in a consulting firm, Halteres Associates. Urdea is also a pioneer in diagnostics for HIV, and an alumnus of Chiron. He co-founded Tethys in 2002.

"There is a lack of practical, useful tools available to the primary care physician to identify those patients at highest risk of diseases such as diabetes and heart attack. We identify that smaller group of patients from a very large pool who are at highest risk and [who] will benefit from interventions to prevent onset of these diseases."

Rapid drug development. Marrying diagnostics with therapeutics is good. Taking the power-couple offshore for fast and low-cost manufacturing is great. A chemical engineer educated at UC Berkeley, Went founded Adamas in 2002 to leverage off-patent drug formulations. His firm optimizes these into new treatments for neurological and infectious diseases, including influenza A, the cause of the current flu pandemic. These are then quickly and cheaply produced at facilities in India. Went is a colleague of, Mickey Urdea. By launching their companies in tandem, the pair hopes to leverage the combination of biomarkers and therapeutics to produce highly targeted products with maximum efficacy. Urdea and Went serve on each other's boards, and also run a consulting firm called Halteres Associates. 

Animated data. We really like visual aids that can communicate complex ideas to lay people. Of the innovators who are doing this with economics and health-related data, Hans Rosling is the stand out. His Trendalyzer software takes multi-factor, time series data sets and expresses them in motion graphics that are simple, and fun to follow. We're "unveiling the beauty of statistics," he says. And eliminating plenty of confusion. e-Patient Dave complains, justifiably, about policy wonks and journalists who misuse data to the detriment of knowledge. Hans Rosling to the rescue! He specializes in debunking myths perpetuated by bad stats. We won't explain further, just watch the 2006 TEDTalk. Google bought Rosling's Trendalyzer software in 2006 (for our money, a better play than Google Health) so Rosling's Gapminder Foundation, which built the softare, now functions as a "fact tank," feeding Trendalyzer with numbers. Rosling is also a professor in public health at the Karolinska Institutet, in Stockholm.

 Explaining the origins of Trendalyzer to TED, Rosling recounts testing students on non-graphical data:

"When I was compiling the report I really realized my discovery: I have shown that Swedish top-students know statistically significantly less about the world than the chimpanzees ... But the problem for me was not ignorance. It was pre-conceived ideas ... So this was when I realized there was really a need to communicate data."

A former healthcare consultant for Booz Allen Hamilton, Bush first partnered with #2 Todd Park in purchasing a San Diego birthing clinic in 1997. The pain the pair endured trying to manage their clinic's billing and reimbursements led them to build what is now seen as the exemplary success in healthcare services: athenahealth. Having tackled the headache of billing management for medical practices, today athenahealth offers a range of services. These include an EHR tool, a patient-communication system and, our favorite, PayerView, which ranks insurers based on denial rates, denial "transparency," and the number of days a doctor has to sit on an "account receivable."

Co-founded Definity Health (UnitedHealth) to give consumers a “sense of ownership” of the healthcare dollars employers spend on their behalf. Debuted health reimbursement accounts (now HSAs). Showed consumers understood the financial value of choice. Yet HSA 'efficacy' data usually tied back to points-of-care -- to workers who were already sick. Co-founded RedBrick in 2006 to give consumers a share in the rewards of staying well. Employers offer financial incentives to workers who agree to personalized wellness plans, then hire RedBrick to run them. Payers have tried this before. But somehow outsourcing the biometrics, fitness coaching, and education to this third party spikes retention. Old-school programs average 15 percent participation. Employees of RedBrick clients stick to it 40 percent of the time. One reported a seven percent decline in claims; a $450,000 savings. RedBrick has eight clients and 25,000 enrollees.

“Fifty percent of all healthcare costs are avoidable with diet and exercise. But employers cannot do anything to change employee behaviors. They just need to let go, and put control in the hands of the employee to change, or not. [Safeway CEO] Steve Burd essentially got out of the way. Most companies spend the same amount of money on employees who are engaged in their health, as those who aren’t. Burd said ‘we’re not going to do that anymore. We’re going to pay more for the people who are more engaged.’ Look what happened.”

Founded Eliza with two partners in 1998 to offer automated communication tools that doctors may use to book appointments and exchange information with patients. Overtime, Drane's commitment to improve care with straightforward technologies like voice-recognition software, has evolved into a mission to drive comprehensive patient engagement. Tactics now span Eliza's data-driven, personalized outreach to patients at the very onset of care, to her grassroots campaign to bring dignity to the end of life, Engage With Grace, which she launched last fall.

"Changing behavior is about making huge challenges surmountable – whether it’s healthcare reform or a healthier lifestyle. We can start by finding low-effort/high-impact ways to help people better manage their own health in ways that are reminiscent of good old fashioned fun - from learning the tango to joining a neighborhood hula-hooping group. It’s about moving away from ‘the system’ and towards the sustainable."

Collaborative health and wellness platform. A programmer famous for his contributions to computing tools like graphical web browsers, databases and spreadsheets, after 25 years Bosworth quit "building Lego blocks for adults" at shops like Microsoft and BEA Systems (now Oracle), to focus on "something more salutary." He briefly headed Google Health, but left this year to found KEAS, a web-based service that aims to help consumers stay abreast of their health with "actionable" information. (Bosworth won't say more now, but look for further details in an upcoming Weekly Digest.) Sophisticated programming powers KEAS, but its big value-add is also its simplest feature: graphical presentation of your health status, in color-code. Red, yellow, or green. Helpful is, as simple does. KEAS launches this fall.

"We know that if we don't get people to take more responsibility of their health, and more the routine things out of the doctor's office, we're not going to solve this problem no matter what we do or how much we spend. To do this, we also need to leverage the Internet (we're the only industry that hasn't), but PHR is a term that should never have been invented. People don't want to just look at their raw health data and try to play doctor. What they want is to stop feeling worried and afraid. We will help people understand if they are 'red, yellow or green.' If you are not well, we will help you get to 'green', and most important, we will then help you stay green."

A Yale-educated physician, Dr. Mostashari commanded attention for achieving what most thought impossible: successfully deploying an EMR system into 1,000 community and public health clinics across New York City, giving eClinical Works the sort of "nudge" founder Girish Kumar Navani could only dream of. Authored white paper, calls for more federal funding to support local "boots on the ground," so other communities may replicate his success quickly. Will join Dr. David Blumenthal's Health IT staff in Washington DC. An epidemiologist, previous work includes investigating West Nile Virus and anthrax outbreaks, and early development of electronic disease surveillance systems.

In an interview with The New York Times:

 “There’s no way small practices can effectively implement electronic health records on their own...This is not the iPhone.” 

Patient experience. Cleveland Clinic has many of the features described by Prof. Christensen in The Innovator's Prescription. Doctors are on salary, and the clinic operates in "solution shops" organized by related specialties: cardiologists, vascular surgeons and cath labs are in one; psychiatrists, neurologists and neurosurgeons in another; eurologists are with nephrologists, etc. These aren't the reasons we list him. Not long after becoming CEO in 2004, Dr. Cosgrove visited with a class at the Harvard Business School, and was rebuked by a student whose family member had endured a bad experienced in Cleveland--not from the medical care, but the bedside manners. "Dr. Cosgrove, do you teach empathy?" she asked. He responded swiftly, prioritizing service now, along with science and cost-efficiencies. He hired a "chief experience officer," whose job is to make sure patients feel less like they're at a hospital, and more like they're at a spa. One example: Diane von Furstenberg is redesigning the Clinic's hospital gowns, "so your cheeks don’t flap in the wind when you walk down the hall," Cosgrove says, and because a little dignity goes a long way. They debut in November. A cardiothoracic surgeon, he innovated valve repair techniques, holds 30 patents, and chaired the Clinic's cardiac unit before becoming CEO. As a surgeon in the U.S. Air Force, Dr. Cosgrove served in Da Nang, Vietnam and was awarded the Bronze Star.

Recounting to healthspottr the incident at HBS:

"That started me off on a different journey," he says. "When I started as surgeon mortality was 45 percent. Now it's under one percent. It used to be that they just hoped to be alive, now they want more. They want to have a good experience."

Surgeon-turned serial entrepreneur founded Sermo in 2005. An affinity social network for doctors. The idea is crowd sourcing of medical and clinical expertise; what once happened in doctors' lounges, now happens on the web at scale. Especially useful to docs practicing in areas that lack specialists or the support systems of elite training hospitals. Quality filter: you must be a licensed MD to register. But controversial for its other "knowledge-sharing": To make money Sermo sells access to third parties, like investors, who could tap the network to, say, conduct a blind poll of whether docs will prescribe a new drug from Pfizer. But doctors don't know who is asking, and investors don't know who has answered. That's a leap forward from physicians collecting honorariums to deliver "research papers" at pharma events. And we like innovations that leverage the expertise of 90,000 docs.

On Sermo's break with the AMA:

"The sad fact is that the AMA membership has now shrunk to the point where the organization should no longer claim that it represents physicians in this country...It’s time to turn to entities like Sermo where physicians are establishing a new voice to collectively discuss the future of our profession. There can be no healthcare reforms that have any chance of succeeding without buy-in from physicians.  As a country, we cannot risk another failed reform effort."

PatientsLikeMe. Necessity being the mother of invention, it makes sense that the inspiration for PatientsLikeMe came to Benjamin Heywood and his cofounder-brother, Jamie, while watching another brother, Stephen, fight to outlive the progression of ALS. Having failed to find a cure for Stephen’s illness (their remarkable effort is chronicled), the Heywoods, and cohorts, quickly shifted their focus to address a problem that could be solved: the need in patients and families for expandable sources of information and support, that can also be accessed quickly. That’s a social network. So the Heywoods built PatientsLikeMe. It allows patients to leverage their individual knowledge and experience for the benefit of many, or even just one. As an example of patient empowerment, it is a romantic triumph. But this innovation has a hard benefit, too. It demonstrates the “asset value” that patient-knowledge can be for the system: doctors treat based on data and experience, so sometimes they tap the network to problem-solve, too. Free to users, sells anonymized data for revenue.

Ben on the PLM blog

“Sell, sell, sell” someone recently wrote in a discussion about our business model.  Why? Because they know our goal in selling [data] is to help pharmaceuticals companies, medical device companies, healthcare providers, and others in the industry learn more about patients. We’re giving those companies the kind of information that can help improve the products/services they’re creating for patients."

PatientsLikeMe. Necessity being the mother of invention, it makes sense that the inspiration for PatientsLikeMe came to Jamie Heywood and his cofounder-brother, Ben, while watching another brother, Stephen, fight to outlive the progression of ALS. Having failed to find a cure for Stephen’s illness (their remarkable effort is chronicled), the Heywoods, and cohorts, quickly shifted their focus to address a problem that could be solved: the need in patients and families for expandable sources of information and support, that can also be accessed quickly. That’s a social network. So the Heywoods built PatientsLikeMe. It allows patients to leverage their individual knowledge and experience for the benefit of many, or even just one. As an example of patient empowerment, it is a romantic triumph. But this innovation has a hard benefit, too. It demonstrates the “asset value” that patient-knowledge can be for the system: doctors treat based on data and experience, so sometimes they tap the network to problem-solve, too. Free to users, sells anonymized data for revenue.

"PatientsLikeMe is changing the rules in medical care by giving patients in depth information on outcomes, treatments and symptoms that they can use to make more effective decisions on managing life changing illness.  What we measure we improve." 

Ventana. Dr. Colella may be the best qualified for healthcare entrepreneurism of anyone on this list. It is a resumé to make credential-conscious VCs drool: technical expertise, operational experience and a track record of execution. (Read: ROI!) Trained in psychiatry and neurology with an MBA from Columbia Business School, Dr. Colella practiced medicine for a decade before working as a consultant with the Boston Consulting Group, SAI, and finally Sapient. In 1999 he cofounded RelayHealth, an early innovator in online consults between doctors and patients with a service called webVisit. A progenitor, if crude, of services like American Well. Dr. Colella sold it to McKesson in 2006. McKesson has since leveraged some Relay assets into ADM. Most recently, and with list member #2 Todd Park, Dr. Collela cofounded Ventana, which aims to be the Travelocity for healthcare. An ambitious model to attempt in this industry, but we wouldn't bet against him. 

At the time of RelayHealth's sale:

"Physicians have increasingly Internet-savvy patients...patients with chronic diseases -- the cost of which accounts for more than 80% of all healthcare spending -- will embrace online chronic care management provided by their own personal physicians."

Surgical safety checklist. You know him for his books and the New Yorker piece on McAllen, a narrative rendition of Wennberg's life's work. While Dr. Gawande's writing makes a valuable contribution to educating the public on the healthcare system's (dys)function and economics--and earned him a MacArthur award--we list him for his quest to reduce error rates in surgical ORs. A seemingly simple mission, when compared with trying to bring lay people up to speed on the factors and consequences of "services distribution and utilization variations...and outcomes," this does not mean it is easy. When we called, Dr. Gawande was in the Middle East, just one more leg of a global trek to promote his WHO surgical safety checklist to as many hospitals and clinics as he can. Like Wasson's innovation, Gawande's is less about new matter than it is about new method. Error comes from inconsistency, as he wrote, "a simple step forgotten" can cause death. So the surgeon and staff at HSPH produced a rules-set for routine. Its particular purpose aside, this is a model innovation for many reasons: it is discrete, requiring no supporting technology and has no shelf life (washing your hands will always be safer); it is easy to use; easy to replicate; and free. Distribution = Xerox. Would that all change in healthcare were so straightforward. 

 The ex-scientist with a doctorate in chemistry happens also to have been an investment banker. Left Wall Street, then the lab, to enter venture capital in 1997, just as dotcom and genomics bubbles were inflating. Recently described by a peer as Sand Hill Road ’s “hot hand” in healthcare. Small wonder: funded several of the companies launched by other list-members, including Todd Park, Jonathan Bush. Also CodeRyte. A Crown Fellow of the Aspen Institute. Has appeared on Forbes Midas List twice.

“Healthcare IT is exploding as an investment sector after years of second tier status.  This is a result of the confluence of several trends. Most importantly, Washington DC has put a spotlight on improving and driving adoption of information technology in medicine, both via the HITECH act with incentives for meaningful use of EMR’s as well as the efforts to evolve the physician payment structure from fee for service (volume) to pay for performance, which will require much more data and therefore better technology.  This has raised the profile of the opportunity space in the eyes of talented entrepreneurs.  Secondly, the success of Athenahealth’s IPO has shown those entrepreneurs that one can be very successful in this sector – a powerful proof point after so many years of primarily mediocre results. As a result healthcare IT is becoming regarded as a vibrant, innovative arena, rich with promise to solve hard problems, have a big impact and create substantive value. This is a beacon for start-ups, dramatically increasing the flow of the best and brightest minds to build great companies, something that is desperately needed in the healthcare sector.”’

Build-it-yourself text messaging system. Admittedly, Ken Banks doesn't know much about health. What he does know a lot about are open source programming and mobile networks. With them he built FrontlineSMS, a free software platform that lets you build private text messaging networks with only a laptop, a mobile modem, and a bunch of cell phones. Install the software, plug in your phone to your PC, input phone numbers of people you want to reach--like patients or nursing staff--craft a message, and hit send. You're now a text message jockey. The best part is that it's two-way, so recipients can reply to you to ask questions. You could also run surveys. Ken built FrontlineSMS with developing countries in mind, were Internet access is poor. It has been used for elections monitoring in Nigeria, by aid workers in Afghanistan to alert each other of Taliban attacks, and in Zimbabwe, Iraq, Cambodia and El Salvador. In 2007 Josh Nesbit heard Ken speak at Stanford. Inspired, Nesbit and friends have since customized Ken's source code to make FrontlineSMS:medic. At a clinic in Malawi, doctors doubled the number of TB patients they could see with the time they saved by not having to leave the clinic for basic rounds. In the U.S., rural physicians, or primary care doctors on a budget, could use this to communicate with patients (take your meds!) or with colleagues. It requires GSM, but if you're within these AT&T or T-Mobile coverage areas, you're good to go.

"There are some meaty challenges in global health, but there are also some simpler problems that can be solved. Like just giving health workers the ability to communicate, [so] when a doctor leaves the hospital he can to order a blood test. There are some simple things you can do."

Early proprietor of direct practice medicine for the mid-market. Current Health is also a test lab for Dr. Shlain’s homegrown care improvement tools. Like HealthLoop: A web hosted communications tool that helps him collect automated feedback from patients under his care, on a platform they already use—email. A patient registers for HealthLoop. Then each day, for a duration set by Dr. Shlain, the patient receives an email with a multiple choice question requiring a single-keystroke response: ‘Are you the same? Better? Or worse?’ Responses feed into an EMR. According to triggers set by Dr. Shlain that consider the patient’s history and current treatment, HealthLoop alerts him if he needs to change a script, make a house call, or suggest the ER. A light and easy fishnet for data, HealthLoop improves quality and reduces costly ER visits with minimal intrusion to patient or doctor.

“These tools help, but the defining factor of good healthcare won’t be new technology, or more sophisticated drugs and procedures. It is a population that values their health like any other investable asset. Patients who value their health this way are more engaged, and have more meaningful relationships with their doctors. This usually makes for happier doctors—and happier doctors always translates into better outcomes.”

The industry's first crossover celebrity. A pediatrician with an MPH from Johns Hopkins, Dr. Parkinson promoted his nascent primary care practice on his blog in September 2007, largely as convenience to himself. Responses, first driven by artists in Brooklyn who followed "Jay" for his digital photography, were sweeping. Soon, Canadian entrepreneur, Nat Findlay, was reading about Parkinson in magazines like WIRED. With backing from Findlay and the Canadian government, Parkinson is now Medical Director of Hello Health, and the industry's Pied Piper for online primary care. Hello Health has one retail practice in NYC, but its big bet is the enterprise play: a subscriber-based platform that doctors nationwide can use to run their patient-facing and back-office functions; Hello Health gets seven percent of revenues.

Innovations in primary care. Dr. Berkowitz also calls himself "Change Doctor" and "Dr. Lyle." He's an internist with a particular knack for IT. He has written a lot about how other physicians can successfully adopt their EMR systems, and we love it that he's against "grand interoperability goals". He calls it over-interoperability. A few years ago, Dr. Lyle had a patient named Peter Szollosi, a Chicago businessman who worked with the real estate developer, Sam Zell. The illness was complicated, and Mr. Szollosi died, but not before his family decided to establish a nonprofit to advance healthcare in his memory. This is how the Szollosi Healthcare Innovation Program came about. At SHIP Dr. Lyle is working on web tools to help physicians share information. An example is ExpectED: these are digital "expect notes" that doctors send to an ER in advance of a patient's arrival. It's an electronic "hand off" that saves time and reduces risk of errors at the point of admission. 

Blogging on over-interoperability:

"We better be careful what we wish for! Because if I get every piece of data for every patient, I will never get through my day."

The Innovator's Prescription. We call out the book only as shorthand for everything in it, and if you're on this site, we expect you've already dog-eared your copy. Dr. Christensen's thoughts on strategy and disruptive innovation have been a guide to entrepreneurs in many industries, healthcare being one of the most recent. Some call him "the Muse." The concepts in his series of books repeat themselves enough so that you needn't read them all to reap the benefits. We recommend this title not only for subject relevance, but because it seems to pack the most in and isn't a snooze to read. We wish to call special attention to pages 8 through 17, where Dr. Christensen and his coauthors explain, in unmistakably plain terms, the very first step in successful innovation of any kind: understand the job that customers are trying to do. He illustrates this with the "case of the milkshake." Read it again. 

Promoting health as a capital asset. A gastroenterologist with a passion for economics, Dr. Gardner has been influential by proselytizing to employers the importance of assessing employee health as they do any other capital or working asset. At its minimum, this idea says that a worker's health is as indicative of his potential economic contribution to the company as is his education or job experience -- and, therefore, is as deserving of reinvestment as are employer-funded job training programs. Health is obviously a better indicator of potential operating costs. Dr. Gardner continues to help clients put these ideas into practice as a way to improve their benefits plans, through his consulting arm, Human Capital Management Services. The current wave of wellness and employee incentives programs, and the mini-industry of services startups that peddle them, is an outgrowth of Dr. Gardner's work. His nonprofit, the Health as Human Capital Foundation, promotes his research to policy makers. Dr. Gardner lectures at the University of Wyoming Colleges of Business and Health Sciences.

Writing on the reform proposals:

"It’s necessary to continue to offer affordable insurance for unanticipated catastrophes, fund health accounts that grow over time and provide support for the five percent making difficult health and medical care decisions, but the new administration shouldn’t mandate existing, expensive coverage for the other 95 percent until we fix the moral-hazard-laden cost problem."

Just 36, is one of the very promising innovators inside the strategy arm of behemoth McKesson. Spent the last year incubating Advanced Diagnostics Management, McKesson’s answer to the excessive testing that bloats cost overruns. Launched in March, ADM pulls patient data from payor vaults and delivers it to physicians in real time, so they may order only the necessary and safe tests for their patients. We like ADM’s "de-coding" feature even better: McKesson says doctors can use it to instantly inform patients of how much a test will cost, and whether their insurance will cover it. A partial-dividend of the RelayHealth acquisition, we assume ADM is a pilot in McKesson’s grander plan to dominate data exchange -- just as soon as that heath information superhighway gets built.

"Intelligent diagnostic decisions need smart pipes. To make good clinical and financial choices, providers need automatic access to rules for coverage and cost. ADM catalogs these rules as web services for providers, payors, and labs to exchange. We're starting with genetics, with the medical benefit to come."

A light EMR. Everybody wants one, lots of people say they've built one. So far just "lots of pledges, plenty of turns and no prestige," as it was put to us, pithily. Then one innovator on this list pointed us at Horner, and MIE. "Two guys out in the middle of Indiana, but they've been clever. The products are good, but don't screw up your workflow. They get it, they're the first to do so." MIE's slogan says it all: Finally! An EMR that won't revolutionize the way you practice medicine. Even if they don't get the apps just right, this is the first company we've found that clearly understands the real provider need. (Recall Christensen's first rule of innovation.) Horner cofounded MIE with Eric Jones in 1995. It is a regional health information organization (RHIO). He has stripped down its standard EMR, WebChart, to a $100-a-month version for single practitioners called, "m.i.EMR" (that's half the cost of eClinicalWorks). Their PHR, NoMoreClipboard.com, requires no explanation to patients. And Google recently selected MIE to provide the EHR system for its onsite employee health clinics. Google Health will plug in, but it says something that the "most innovative technology company in the world" opted for two guys from Indiana, instead of building for itself. 

"We’ve redefined how physicians and hospitals keep and share medical information, and thus helped transform how many area-doctors practice medicine.  We’re very proud of the role we’ve played in putting the latest medical-records technology to work in medical practices and hospitals." 

As National Coordinator for Health Information Technology under George W. Bush, he was the first national leader to show the importance of health information technology to healthcare reform. His 2004 report, A Framework for Strategic Action, laid out a 10-year plan with objectives and parameters that remain relevant today. A physician turned-entrepreneur, Dr. Brailer founded CareScience, an early attempt at outcomes-based care management and information exchange; it was sold off in 2003. With capital from CalPERS and other pension funds, he now invests in growth companies through Health Evolution Partners. Also runs the influential, invitation-only conference series, Innovation.

"A key lesson for innovators is that heath care start-ups rarely see hockey stick growth. Experienced entrepreneurs who come into health care with the expectation that success will happen "right now" because of the stimulus funds will be disappointed. This is an industry that rewards steady growth – that's why our firm is named 'Health Evolution Partners,' because change in healthcare has to do with incremental change." —Dr. David Brailer

Licensed anesthesiologist and serial entrepreneur. His first company, Medical Present Value helps doctors manage the reimbursement process. Another, PTRx, is a prescription benefit manager; includes mailorder drug fulfillment for members. His current project is like a cooperative for individuals in or out of plans. Tenzing Health seeks to give a collective of consumers the scale to negotiate for the specific programs they want from their doctors, clinics or local hospitals. We see it as a valiant attempt to circumvent the command-and-control wielded by insurance plans. Name derives from the famed Nepalese sherpa who ascended Everest with Hillary in 1953. Has a companion service for doctors called Ascend. Read more about Tenzing in our Weekly Digest.

"We want to serve solo consumers who would otherwise have little influence on the market. By bringing them together as a community with Tenzing, they become 'the invisible hand.' Since patients are the source of all healthcare dollars, gravity is moving in our direction anyway. Providing the agency service is just a important facilitating step along the way to the market finding a new equilibrium, where the patients are in the middle of the system."

"Mr. Vaccine." Biochemist who joined the University of California, San Francisco in 1968, Dr. Rutter was a principal actor in the formation of the biotech industry. Cofounded Chiron (Novartis) in 1981 and developed the first recombinant vaccine for Hepatitis B. He contributed to the sequencing of the HIV genome in 1984, and discovered and cloned the Hepatitis C virus in 1987. Spawned therapy research for cancer and metabolic disease. These accomplishments aside, we list Dr. Rutter for Synergenics, a consortium he established in 1991 to help biotech startups rapidly develop and commercialize their products. Has founded or collaborated in 12 startups since 1992, including: iMetrikus in 1998, an innovator in remote monitoring and patient data collection, and ReLia Diagnostic Systems, which makes a low-cost kit for remote diagnostics. Honors include his election to the National Academy of Sciences and the American Academy of Arts and Sciences, his name is plastered on about half the buildings of the UCSF campus.

In 1994, speaking of Chiron, and the importance of scalability:

"A small company like ours produces products that must and should be provided to the world's populations. The issue has been how to do it." Rutter founded Synergenics so other entrepreneurs will have it a bit easier then he did.

Risk capital. Hull co-founded Cardinal Partners in 1996 to focus on medical device, life sciences and, more recently, healthcare services businesses. Big as it is, the community of influencers in healthcare is small, and Hull co-invests with two other venture capitalists in this list: Bryan Roberts of Venrock (athenahealth);  Barbara Lubash of Versant Ventures (CodeRyte).

Co-founded Definity Health in 1998 to give consumers a “sense of ownership” of the dollars employers spend on their behalf. Debuted health reimbursement accounts, now known as HSAs. Definity proved consumers understood the financial value of choice. Sold to UnitedHealth for $300 million in 2004. Raised $175 million to launch Lemhi Ventures in 2006. Founded Carol, an early attempt at a healthcare retail exchange, where consumers could comparison shop for healthcare packages offered by local providers. Launched in 2008, gained little traction. Regrouped, now applying its technology in places where demand is a bit more concentrated: back-offices of payors, employers and providers. Services mainly help payers and employers with reimbursement redesign, or help doctors link payments to health outcomes they produce. He is CEO. Lemhi has funded six other companies.

To the StarTribune in 2008:

"Everyone talks about how health care is broken ... What's really frustrating for me, working with employers, is that employers are always talking about [health benefits as] their money.  I would be sitting there saying, 'No, no, it's not really your money. It's really a proxy for compensation that you have promised this individual.'"

Rosetta Stone for bacteria. What began as research to understand how certain bacteria create luminescence, evolved into the discovery of how all bacteria communicate. The mystery was that single-cell bacteria can't light up on their own, yet when their numbers reach a critical mass, they magically "switch on." Bassler wanted to understand how the bacteria know that there are enough of them in one place to concert their efforts. In scientific terms: she sought to understand how bacteria detect environmental cues to regulate their gene expression and behavior. Their method, she determined: bacteria talk. A questionable premise, the work won her a 2002 MacArthur Fellowship. It gets better. Having determined that bacteria gab, Bassler and her Princeton lab mates set out to translate the language. No surprise, bacteria are multi-lingual. But there is a "bacterial Esperanto." They found it, and like any good team of code breakers, immediately began trying to interrupt it. They are now experimenting with molecules that can send "jamming" signals, preventing bacteria from communicating and executing gene expression. Essentially, they've built bacterial "silencers." For healthcare this means harmless molecules that could one day replace harmful, resistance-prone, antibiotics. It's tough to evaluate the impact on health quality and costs such work would produce. 

Speaking to NPR: "The goal of scientists is you hope that the thing you're working on is bigger than the thing you're pipetting into that tube at that moment.  We always knew we were working on something bigger than bioluminescence, but we didn't think it would be what it turned out to be. It's just been so much better."

Ideal Medical Practices Project A licensed family practitioner, Moore spent time at Berwick's Institute for Healthcare Improvement, working on projects for process improvement in hospital systems. He quickly saw a hole: None of the models developed at IHI were applicable to small practices -- where most primary care doctors wish to work. Also a mentee of  Wasson, Dr. Moore took the tools at HowsYourHealth.org, added appropriately-sized process tips, plus an online curriculum, and created a starter-kid for doctors who also want to leap forward, but can't afford $40,000 in IT or a days-long seminar just to learn how to use it. Dr. Moore's kit is a means to an end. The goal is to foster patient-centered care at the "mirco level." So far, 120 practices have been through his pilot. He believes Ideal Medical Practices can position solo doctors to serve employers, which is one way patient-centered care could become economically viable for them. The IMP kit is free and grant-supported. Dr. Moore also consults to Hello Health. 

"We are bootstrapping the primary care practice of the future. Independent, small practices can step up to the plate -- they can do it. We just need to give them the tools."

 The Emerick Ethics Index. Tom Emerick spent the better part of 25 years working in benefit design for companies like Burger King, BP, and most recently, Wal-Mart, where he worked alongside Dillman and Simon, as Vice President of Global Benefit Design. Emerick came away with many lessons, but one stood out. It requires some explaining. Often Emerick’s role inside companies was to decide where an approved medical procedure would be performed—this hospital, or that one? The criteria used to make these decisions typically included: cost, past performance of the provider, and risk to the employee from any travel. But the ethics of the procedure, and the ethics-record of the providers, were almost never considered. Emerick thinks this is why many procedures that could be performed -- and were covered -- were performed, whether or not they were medically necessary. (“I saw lots of inappropriate organ transplants,” he says). Emerick argues that if “ethical constructs” were added to the filters used by decision-makers like him, then situations like McAllen, TX wouldn’t take place so often. “Transaction happy” hospitals would eventually get caught in the screen,  and employers could send workers to hospitals that just perform what is necessary. All this boils down to one realization: currently in the healthcare system, “quality” is judged according to competence—was the procedure successful?—not, was it the right thing to do? And while we have chapter and verse on the substance of ethics, Emerick couldn’t find a tool suitable for measuring ethical performance by providers. So he built one. The Emerick Index sets objective criteria for ethical performance, and will rate providers against these over time. One day, employers could decide where to source care for their workers, informed by cost, competence, and whether a hospital does the right thing. It’s an ambitious idea, but with fee-for-service on the ropes, seems well-timed. And we like people wiling to try tough things.

"I saw lots of inappropriate organ transplants."

For Medpedia. An early player in social media, in 1999 Currier founded Tickle, a site for online psychological assessments (e.g. Myers Briggs). He sold it to Monster Worldwide in 2004. A bad user experience on WebMD pushed Currier to apply his skills to healthcare. As the name implies, Medpedia uses the open source, indexing frameworks of Wikipedia to disseminate information at scale. But it takes several advancing steps that are especially relevant in this vertical. One, all contributors must identify themselves to deter “bad actors,” and while anyone can suggest new information, only PhDs and MDs have editing privileges. Think: Wikipedia with cops instead of a neighborhood watch. Two, Medpedia has social networks for self-described groups of professionals, where they can exchange research and accelerate debates on ideas. Think: a LinkedIn for docs that does an end-run around the turgid peer review industry. Three, it offers social networks for patients; but being open source, is closer to Ning than PatientsLikeMe. Currier thinks facilitating live communication between its doctor and patient groups is the next step. Unlike World Health Wiki, Medpedia eschews advertising. Its revenue model “is unclear” but will likely root to custom building mini-Medpedias for associations, med schools, or businesses. We imagine this last category being small to medium-sized employers that want their workers engaged in wellness, but don’t have the budget for RedBrick Health. If it works, that’s: Wikipedia + LinkedIn + PLM + American Well + RedBrick + PubMed. We’re not at all sure he can pull it off, but innovation depends on such experimentation.

“The world has got to take care of itself. Patients know as much as the doctors [so] hierarchical systems will change, but where is the Ning for patient communications? We’ve built the version 1.0 for that. Now, if you want to maintain your privacy about your ID or medical information, then MedPedia is not for you. Transparency is a necessity.”

World Health Wiki. Economist by education, now an expert in network collaboration systems for corporate clients. Has spent last decade piecing together a global collaboration system for healthcare providers and consumers. Open source and built on architecture of the much-loved referencing tool, Wikipedia, Rybeck and team are doing a runaround the 'interoperability" problem ideologues and industry incumbents have exploited for years. Like Wikipedia, WHW is a Lego system. Each submission, or new page, is a brick plugged in to the base. Unlike Wikipedia, WHW pages can be personalized. Some will be public: a physician's home page. Others, private and secure: a patient record created by the physician. We needn't bother divining a common language, Rybeck says, because people will search in, and demand results in, the languages they commonly use. A patient in Warsaw will search for a doctor in Warsaw, in Polish. (Wikipedia has multiple language editions for this reason.) Ditto medical standards: a Polish doctor needs to see a diagnostic code consistent with his 'language' -- so why make him learn something new? Launches in 2010. Will be free.

"We need a ubiquitous system that you can use around the world, but it needs to have regional specificity to be useful. There are some great networking systems out there. But they're not open, so they have no ability to expand with other networks, or to different [affinity] groups. The catch is, unless you have an open reference system in the center of your network, you’re a one-off. Wikipedia is the Sun in this solar system. We will have spoke-wikis branching off it for public or private groups, for commerce, social networking -- anything."

The Double Agent. In addition to his primary care practice affiliated with Boston's Beth Israel Deaconess Hospital, where he is a staff physician, Dr. Sands is a medical informatics advisor and head of healthcare-related business solutions for the network equipment giant, Cisco. In this role, Dr. Sands helps Cisco and its business partners with clinical transformation using IT. An early adopter in his own right, Dr. Sands wrote the first peer-reviewed article on the benefits of using email in clinical practice, in 1998. He also architected Beth Israel's PatientSite, one of the early EMR-EHR web platforms to integrate "social networking" for doctors and patients. Dr. Sands was also a primary physician in the care of e-Patient Dave, whose web chronicles of an ordeal with late-stage cancer elevated both men to minor celebrity in the healthcare industry. Since e-Patient Dave's recovery, Dr. Sands and Dave DeBronkart (his real name) have become a vocal duo in the campaign to formalize patients' roles in medical decision-making and healthcare reform. Dr. Sands is also an assistant clinical professor of medicine at Harvard Medical School and when he isn't teaching, splits his time between Boston, and Mountain View. We figure he hides the cape in his closet.

On the slow pace of IT adoption:

“What it boils down to is a business case for the individual physician. We’ve done a poor job of educating physicians on the fact that there are benefits here for their bottom lines. You’ll probably cut down on phone volume. You will make patients happier. But [doctors] still ask, ‘what do I get out of it?’ In medicine we’re not generally being held accountable for our patients’ happiness. In real business we would be."

Risk capital. Co-founded Versant Ventures with Ross Jaffe in 1999. An early supporter of healthcare services and IT. Portfolio companies now include RedBrick Health, an outsourcer of employee wellness programs founded by #31 Kyle Rolfing, and CodeRyte, which uses natural language processing to automate the burdensome process of diagnostic coding for physicians. Also Skylight (interactive communication for hospital rooms), Advanced ICU (telemedicine for community hospitals), and Titan (surgical centers). Earlier in her career, Lubash held executive roles at health plans, and managed one of the first electronic medical records installations in the U.S. for Harvard Community Health Plan. She was recently named a director of the California HealthCare Foundation.

Speaking to BNET on succeess with healthcare IT:

"[It] depends less on innovative technology than on convincing customers your product offers real value."

Syndication-based data security.  Jonathan Hare's Resilient Trust Networks is the second data security shop here that's trying to balance the weight of patients' need for information against their need for privacy. Resilient uses a syndication model: it moves the data of one group of people (or system, or service) into a network that includes information or "intelligence" of other groups. Then it brokers information to other relevant information in the network, at arms length from the original groups, so the parties no longer need to worry about violating identities or privacy policies. Hare has heavyweight talent, and the language here is a little above our pay grade, but what we call "blind-matching" (this patient: that trial), Resilient calls "trust-brokering" with "zero-knowledge protocols." With partners like these, Resilient could also be used to help disparate software systems talk to each other, a boon the healthcare industry's interoperability issues. Hare is a serial entrepreneur of the software applications industry (he founded Consilient and Evolve), but he found him through powerbroker David Brailer. Hare has been a member of the Health IT Standards Panel's Security and Privacy Technical Committee and of the Markle Foundation Personal Health Technology Council (with  Adam Bosworth).

Dr. Brailer, on Mr. Hare: "He is one of the true innovators in healthcare with a spark and an imagination for how [we] could do something in a way that hasn’t been done before. I collect these people."

Continuity of care record. A family practitioner and thought leader in health IT, Dr. Kibbe is best known for the Continuity of Care Record, an open standard for patient electronic health records. CCR does two good things: it is a "patient-centric summary" of a person's medical data, and does not reinvent the wheel by digitizing everything ; two, because CCRt uses XML, it can circumvents the "interoperability" problems created by the custom software systems between large health organizations. This makes a PHR truly portable. Kibbe first published his standard in 2006. An entrepreneur, Dr. Kibbe's companies included Canopy Systems, which made web-based software for case management, and was acquired by A4. He remains a senior advisor to the American Academy of Family Physicians on issues of technology. He is a frequent contributor to The Health Care Blog and an editor on Medpedia.

On THCB about health IT's "Gordian knot":

"The upshot is that the term "EHR" is no longer very useful. It creates more confusion than it resolves. This is more than a quibble. One can never be certain what EHR refers to: health data in electronic format; a technology that is designed to handle electronic health records in some fashion; an EHR software program... It is not necessary to accept this confusion."

Patient advocacy. Face of the e-Patient movement started by the late Tom Furgeson, e-Patient Dave is an advocate for patients' rights in the traditional sense: he lobbies for dignity, autonomy, and self-determination in their care. As the name implies, he pushes social media as the tool to use. But it is an economic argument Dave makes that matters most to us. Dave agrees that patients belong at the center of care, where things are "done for them, not to them" (as one enlightened doctor put it here). But Dave goes further. Patients should do things for the system, too. As he learned from his own cancer ordeal, patients are a source of knowledge and authority that even the best doctors can only pretend to. Medicine is still mostly experimental, so doctors need all the data they can get. It's why doctors crowd source with each other. So why can't we do a better of job of leveraging the latent resource in patient-knowledge, too? This is more than patients being engaged. It is about the system recognizing patients as a necessary actor in a more efficient utilization of healthcare resources. With a system strapped to the point of breaking, we can't afford to leave any asset untapped.

One tip, learned the hard way, on data: "We need to be clearer about what we’re reading. Plus, it appears we could be more vigilant about what our own professional policymakers – and even our MDs – are thinking. [There are] uncomplicated ways to improve our comprehension. First among them is to stop talking in percentages and talk instead in raw numbers."

"Use your arithmetic skills; don’t settle for ten year figures. You can do it. Your first assignment: when you hear someone say “over the next ten years,” divide by ten."

Genomics impact trial. The (in)famous cardiologist is now Director of the Scripps Translational Science Institute, with an NIH grant. Dr. Topol will use the money to conduct research in things like genomics, stem cells, and applications of wireless technology. But we don't list him for his past accomplishments, or his efforts to develop new science. We acknowledge his trial to investigate whether some of that new science is worth doing in the first place. As part of the Scripps Genomic Health Initiative, last fall Topol began a 20-year trial to determine if 10,000 people who undergo genetic testing show any signs of behavior modification after the fact -- do they change their diets, exercise more, seek preventative care? In other words: is there an impact? Too often in technology and medicine, new things are done, simply because they can be done. But innovation for innovation's sake just wastes of resources. We like this trial, and appreciate the companies supporting it (Microsoft, Navigenics and Affymetrix), even if they view it as market research ("It's intended to be the foundational study of preventative genomic medicine," it has been said). Still, as exciting as personal genomics is, at a time of reform, we need to ask whether the hippest science in healthcare is worthwhile -- or is it being done because it can be sold? 

Dr. Topol speaking to the WSJ last fall:

"Anecdotally, it looks like some people are benefiting but this [study] is the only way to demonstrate this once and for all," said cardiologist Eric Topol

Father of the retail clinic. Co-founded QuickMedx in 1999 after a bad emergency room experience with his son. Convinced him of the demand for convenient, appointment-free access to medical care. Early success spawned competitors. QuickMedx renamed MinuteClinic and later acquired by CVS. Krieger has since funded or helped found several successful healthcare startups, his most current being Zipnosis. It offers a "mobile app" Q&A to collect information from a patient that a doctor needs to make a diagnosis. We like their tagline: "Healthcare in your pocket."

Christensen in The Innovator's Prescription:

"Retail clinics are closer to a 'new market,' rather than 'low-end' disruption, in that they compete predominantly against nonconsumption. For example, over 60 percent of patients who receive care at retail clinics do not have a personal care physician at all."

Pioneered health gaming. A doctor of psychology and communication, Dr. Lieberman was an early researcher of the benefits of interactive media on cognition and behavior. In the 1990's, she developed some of the first interactive games designed to help children with chronic illnesses, like Nintendo's  Packy & Marlon (diabetes) and Bronkie the Bronchiasaurus (asthma). Clinical trial data gave hard results: children who played Packy & Marlon incurred 77 percent fewer diabetes-related emergency and urgent care visits. Her work is a precedent to Omidyar's efforts at HopeLab. Now affiliated with the University of California, Santa Barbara, she is also director of Health Games Research, an $8.25 million program of the Robert Wood Johnson Foundation. Its first grantees were announced in May.

"There is tons of research of interactive media on learning and behavior change, and we draw on all of that. But there is also a huge body of research on behavioral health. [Taken together] we know how to design messaging that will change people’s concepts and change their health." 

Shared medical appointments. There is more than one way to leverage a diminishing asset of doctors. The first clever way is to give a doctor more opportunities to reach individual patients by leveraging his time with technology. (The founders of American Well are very good a this.) The second clever way is to give the doctor the opportunity to reach more patients at one time. We do this by putting multiple patients in front of the doctor, at once. These are called shared medical visits (SMAs), and while they aren't sexy, they are effective, and they have no installation costs. Dr. Noffsinger pioneered this concept, as "drop-in group medical appointments," in the 1990s. It turns out that many patients are indifferent to one-on-one time with a doctor -- they just want time with the doctor. When patients are in groups, more information is exchanged, because more questions are raised in front of a diverse set of potential responders. This benefits doctors as well. As an innovation shared appointments hit all marks: extend access to doctors; create efficiencies with resources; and expand knowledge, which is good for quality. We like ideas that can be ported with toolkits. Dr. Noffsinger has one: Running Group Visits In Your Practice, is coming this summer, and it includes a video. 

Interviewed in Managed Care: "The ideal physician to do an SMA is terribly backlogged, has access problems, doesn't see any way out of this conundrum, and is not getting home till 7 or 8 at night."

On-site employer health clinics. By the time Ed Krieger stumbled onto his idea for a consumer retail clinic in 1999, Jim Hummer had been running Whole Health Management for 12 years. He was one of the first to see the opportunity in helping self-insured employers bring their healthcare services "into the tent." Whole Health originated as an on-site health provider to the federal sector. Hummer purchased the business in 1987, renamed it in 1991, and by the time he sold Whole Health to Walgreens in March 2008, he was running 70 clinics for private-sector employers including Continental Airlines, Sprint, and Qualcomm. Whole Health is now part of Walgreens' Take Care Employer Solutions unit. Previously, Hummer founded IVY Medical Group, a large ambulatory care practice and was also involved with Simplicity Health Plans. Named regional Ernst & Young Entrepreneur Of The Year in 2008, Hummer now invests in healthcare startups through his firm, Luxemburg Capital.

"For entrepreneurs, my advice is to understand the economic forces that shape the healthcare industry.  In this understanding, [you] can identify levers that will create permanent and lasting improvements to the efficiency of the industry and the shape of competition within the industry."  

Bringing Toyota Production to healthcare. Sometimes an innovator is the person who thinks up the new idea (Steve Jobs: the PC). And sometimes an innovator is someone who executes on that idea, to the advantage of a group who might otherwise not have benefitted from it (Michael Dell: delivering the PC to millions, for less). Kaplan is an innovator of the Dell-school and his contribution is the successful execution of the "Toyota Way" within Virginia Mason Hospital. Customizing the manufacturing principles of an automaker for a healthcare environment seemed wacky nine years ago. Kaplan recognized the need for fresh ideas in an industry stale with habit. In 2002 he began funding trips to Japan so VMH staff could learn how to replicate Toyota's efficiency tactics -- all designed to limit overproduction and waste, and to save time. Many examples of the Virginia Mason Production System involve using visual cues to cut down on processing time for ordinary tasks: like flip charts with pictures to indicate patient-status; a place card near the bottom of a stockpile of supplies to indicate when it's time to re-order. Simple things make a difference, and time saved from menial tasks benefits patients. In 2008 Kaplan said Toyota procedures cut wait times for patients by 85 percent, lowered inventory costs by $1 million, and reduced labor costs by $500,000. An internist, Kaplan has been with VMH since completing his residency there in 1981. He now teaches seminars on VMPS.

to the Seattle-Post Intelligencer: 

"We get so wrapped up in the seriousness and specialness of health care, but we also have to open our eyes to other industries -- we're way behind in information specialists and taking waste out of our process. Toyota is obsessed with the customer and customer satisfaction ... all those things Toyota was about was what we wanted."

Health economics of the aging. We might call him the Wennberg of the west. Dr. Garber, an internist, is another leading mind in the research and development of tools to help us understand the economics, and effectiveness, of healthcare a bit better. Where Wennberg studies variation, and McGlynn quality, Garber's work also focuses on the elderly, and in particular, the resource-deprived eldery. It is a critical area of focus for reform -- and an area in which more entrepreneurs will surely emerge to serve.  Dr. Garber is also a professor, by courtesy, of the Stanford Business School. He is the founding director of both the Center for Health Policy (CHP) and the Center for Primary Care and Outcomes Research (PCOR) at Stanford. Dr. Garber has developed methods for determining the cost-effectiveness of care and  how clinical practice patterns influence technology adoptions here and other countries. He also leads the Global Healthcare Productivity project, which includes collaborators from 19 nations. Garber is a staff physician at the VA Palo Alto Health Care System, associate director of the VA Center for Health Care Evaluation,  and a member of the National Advisory Council on Aging (NIH). Garber has received numerous honors and awards, including the Young Investigator Award of the Association for Health Services Research (now AcademyHealth). Dr. Garber  teaches medicine as the Henry J. Kaiser, Jr. Professor and Professor of Medicine at the Stanford Medical School. He is a professor, by courtesy, of Economics, and of Health Research and Policy in the Stanford Graduate School of Business.

Direct practice medicine. Co-founded Qliance Medical in 2006, but was one of the earliest physicians to convert to the direct practice model, with Seattle Medical Associates in 1997. Qliance eschews insurance, trading the reimbursement hamster-wheel for pre-paid subscriptions. But where other direct practices charge extra for office visits or house calls ( Shlain), Qliance charges a $99 initiation fee, and then at most $129 a month for unrestricted access to its physicians and nurses. All direct practice models give physicians more time with their patients, and patients seem to feel they are getting higher-quality care. Dr. Bliss also says that Qliance saves individuals up to 50 percent and employers 35 percent, on their healthcare costs. But the jury is still out on a few points: does direct practice actually improve outcomes? And, while the business model works in boutique situations, can it scale? We'll find out: this month Qliance raised $4 million in venture to fund expansion.

To Pharma Knowledge:  "I love insurance - I own plenty of it. But if we don't move away from our current system, we're going to bankrupt the country."

Health animation.  Animation has been used for years in med schools for simulation and by surgeons in ORs. Listee #14 Wennberg is DVDs to share complex medical information with patients. Baker's Visible Productions is to health animation what Pixar was to cartoons. These are colorful, precise, 3D-digital representations of anatomical structures, entire biological systems and medical procedures. It's Fantastic Voyage, anatomically correct. This is a quality improvement: Better understanding helps everyone, and Visible makes medical knowledge attainable to lay people with ease and speed. The stuff is expensive (law firms are a client base), but Visual's work is finding its way to the public through Discovery's HowStuffWorks, and by Dr. Oz, who has used it on Oprah. Check out the angioplasty clip.

"A picture is worth a 1,000 words."  

Process improvement perfected. In his own bios Dr. James credits "medical pioneers Florence Nightingale and Abraham Flexner" for inspiring his devotion to quality improvement tools. More recently, Dr. James was described to us as a "disciple of Deming" -- that being, W. Edwards Deming, the legendary American statistician and manufacturing guru. Most people in healthcare didn't know who Deming was when James began talking about him in the mid-1980's. Heck, most people still don't. Deming went to Japan after WWII and is widely credited, by the Japanese, with helping to establish the processes and quality controls that evolved into the Toyota Production System ( Gary Kaplan). Here is the original list of Deming's 14 Points. We call attention point number three, which has been interpreted to mean the elimination of "variation", which is most easily achieved through establishment of routine: a.k.a checklists and checklists. Meanwhile, back in Utah, Dr. James has tooled, and retooled, his own quality improvement methods in his role at the Institute for Health Care Delivery Research, at Intermountain. James uses it all now, Deming, Toyota, and lots of data. Most recently IMH was able to reduce the length of hospital stays for patients with pneumonia by an entire day. IMH has been recognized by the Dartmouth Atlas and President Obama for operating at costs 30 percent lower than peers. Matt Holt called James, "the best known name in clinical process improvement." In 2005, the National Committee for Quality Assurance (NCQA)recognized Dr. James' "vision and energy in making the U.S. health care system better." In addition to his role at IMH, Dr. James is adjunct professor at the University of Utah School of Medicine, Department of Family and Preventive Medicine.

Testifying before the Senate:

"Even with major advancements in measurement, for most clinical conditions quality measurement is not sufficiently precise.. .That fundamental truth has another face: It is easy to scientifically demonstrate that, for most clinical conditions it is impossible to build an evidence-based best practice guideline that perfectly fits any patient. As a result, achieving 100% performance on most quality measures means that a subset of patients received substandard care." 

Bioengineering incubator. Dr. Yock, a cardiologist, founded Biodesign eight years ago to cultivate innovations and "technology transfer" in the areas of engineering and medicine to improve healthcare. Himself a serial entrepreneur, Dr. York's own engineering contributions include the Rapid Exchange™ balloon angioplasty system, and a Doppler-guided tool called theSmart Needle™. Biodesign is a part of Bio-X, Stanford's interdisciplinary research program. It accepts ten fellows each year, from Stanford's engineering, medical and business schools. The program begins with an innovation boot camp, and fellows spend next several weeks in area hospitals to identify "new needs." Divided into teams, the rest of the year is devoted to developing solutions, and business models to support them. Venture capitalists play a vetting function at the end, and typically one or two fellows receive funding to take their concepts to market. Examples: HourGlass (obesity) and Spiracur, which addresses ulcers in diabetes patients and has recently raised $20 mllion in venture funding. (KPCB.)  Dr. Paul Yock is the Martha Meier Weiland Professor of Medicine and Mechanical Engineering (by courtesy) and holds a courtesy appointment on Operations, Information and Technology in the Stanford School of Business.

In 2004: "We are, I think, being hit over the head with the point that there is a fusion now going on between the mechanical aspects of medical device design and the biochemical and biologic aspects of medical device design." 

Serial incubator. Dr. Makower is also a serial entrepreneur. Of his many companies, a standout is Aclarent, which transformed treatment for allergies by applying balloon angioplasty technology in place of more invasive, and more expensive, surgical procedures. The process is now called "balloon sinuplasty." We list Dr. Makower for his incubating role in healthcare innovation. He founded the medical device incubator, ExploraMed, in 1995, and co-founded Stanford Biodesign with Paul Yock, where he is a consulting faculty member -- he calls himself a "real world mentor." Dr Makower is also an investing partner at New Enterprise Associates. He previously founded TransVascular, (Medtronic), EndoMatrix (C.R. Bard) and until 1995, managed Pfizer’s strategic innovation group, which he founded. Dr. Makower has more than over four dozen patents on medical devices in the fields of Cardiology, ENT, Orthopedics, General Surgery, Drug Delivery and Urology. He is a Consulting Associate Professor of Medicine at Stanford University Medical School. In addition to his medical degree (NYU), he holds a mechanical engineering degree from MIT, and an MBA from Columbia University.

Risk capital. An ex-investment banker who worked with legendary boutique, Wasserstein Perella & Co. His work focused on mergers and acquisition in the healthcare industry. Left Wall Street in 1998 to found Psilos with two partners. Portfolio focuses on healthcare services and IT, and has included ActiveHealth Management (Aetna), founded by Lonny Reisman, and HealthScribe, an outsource transcription provider, sold to Spheris. A current investment is Click4Care, a maker of decision support software. The firm also funded  Tony Miller's Definity Health.

National Venture Capital Association Prediction Quotes:  “The demand for healthcare solutions is growing, and with it, venture investing opportunities. As the country moves towards universal healthcare insurance, the need for products and services that deliver quality care at a reduces cost to the system is paramount." 

Genetic benefit management. The concept behind Lofberg's new company, Generation Health, is simple. He wants to do for genetic testing what pharmacy benefit managers did for prescription drugs: make genetic testing more accessible to employers and employees, by negotiating deals with vendors on their behalf. The "GBM" will be doing its part to wring costs from the employer's healthcare burden, by making the targeted therapy that avoids waste and improves outcomes --and is only possible through genetic testing! -- available to covered-workers. Of course the "GBM" makes money on the transactions in the process. We think the idea of applying the PBM business model to the innovation of genetic testing is a good one. If the success of Medco is the guide, then Lofberg has the best chances possible of succeeding with it. (He ran Merck-Medco through the 1990s, growing revenues from $3 billion annually, to $23 billion by 2002.) And this strategy for "democratizing genetic testing" is the better path for consumers, when the alternative is waiting for "retail testers" to slash prices. Generation Health launched last fall with money from Highland Capital Partners, and others. Lofberg cofounded Medco and ran it as Merck-Medco from 1988 to 2002. (It is now known as Medco Health Solutions.)

To Dave Williams on:

"[Success] hinges on our ability to demonstrate with both clinical and economic modeling that the benefits of the tests actually far outweigh the actual cost of the testing."

Can you reinvent primary care within the insurance model? Everyone says 'No.' Tom Lee says 'Yes.'  Dr. Lee is the fifth physician-entrepreneur to appear on this list (Shlain, Bliss, Parkinson, Moore) -- and the only one with a business model that still embraces insurance.  Lee's 1Life Healthcare may look like a "concierge model" from the website -- high tech, high touch care, delivered to a panel of patient-members -- but Dr. Lee's 1Life only charges patients $150 a year to join, and "everything else is co-pays and insurance." There are no other out of-pocket fees. We're not sure how he can afford to do this, and he's not saying much. Of course capitalization helps: Earlier this year 1Life raised $8 million from Benchmark Capital, the backers of eBay infamously profiled in the book, eBoys.  He clearly has plans to scale. (His anchor practice is One Medical Group.) Dr. Lee himself doesn't spend much time with patients anymore. A previous co-founder of ePocrates, he's got a knack for IT, and is flexing that side of his brain building the technology platform that we suspect makes it all possible. He also has a habit for provocation. When Dr. Lee blogs, he tosses hand grenades; like his notion that clinical practice could go the way of the newspaper business, being totally dis-intermediated by online delivery. Such ideas spur his peers to think -- about new ways to innovate themselves onto safer ground.

Blogging on iHealthBeat: Commodifying Content Through IT: Could Physicians Be Next?

Consumer-driven healthcare. It is difficult now to read a newspaper article about health reform, or white paper on healthcare economics, without tripping over the word "consumer" at least half-a-dozen times right at the top. Even congressmen use the word, and depending on your industry, you might say "patient-centered" (a doctor) or "employee-focused" (a CEO). The idea here is one and the same. Dr. Herzlinger coined and began promoting the term "consumer-driven health care" in her 1997 book, Market-Driven Health Care. Among the thought leaders in this list, hers is a premier voice. Also in the 1990's, Herzlinger wrote of "focused-factories," describing integrated teams of providers who would be organized around a disease. Aspects of this concept are present in Christensen's "solution shops." Among Herzlinger's several books, Who Killed Healthcare? was selected as one of ten books "that changed the debate" by the U.S. Chamber of Commerce. She has received the Pioneer in Health Economics award from Consumers’ for Health Care Choices and is distinguished as the first woman to be tenured, or given a chair, at HBS. 

To Managed Care on "focused factories":

"I use the term 'factory' purposefully to be provocative. The people in the factories made the changes. They figured out, and continually figure out, how to improve the production process. It's not a top-down process, it's an organic process that's led by the people who actually do the work. An HMO is a top-down process. That's not the lesson from the American economy. The lesson is it's bottom-up. It's the people who actually deliver the services who will re-create the services."

A cure for coding. Ask any doctor what the three things they hate most are and you're sure to hear the following, in varying order: EMR data input; reimbursement; and coding. The first two will continue to be a pain for some time. The third just got a bit easier to address (but only a very little bit). Dr. Resnik, an expert in computational linguistics and natural language processing, developed the technology behind CodeRyte, a startup that automates diagnostic coding for physicians. Talk about wringing out efficiencies: the entire industry of coding consultants could  be downsized with this stuff. Dr. Resnik is a past recipient of the Rubinoff Award, which is granted annually “for an advance in innovative application of computer technology.”  He is an Associate Professor in the Department of Linguistics and the Institute for Advanced Computer Studies, at University of Maryland, College Park. He has an affiliate appointment in Computer Science. Others run the company, but Dr. Resnik still serves as a technical advisor. CodeRyte is funded by list-members Roberts and Hull.

In fact there a leading man behind the non-profit Cochrane Collaboration. A doctor of epidemiology, Dr. Chalmers vision for the Cochrane project grew out of his earlier research in perninatal epidemiology. In 1992 he received funding from the National Health Service to extend his work -- and did he ever. Published quarterly by a network of volunteer editors, this is an edited collection of "systematic reviews" of healthcare procedures and interventions from around the world. It is designed, to help over-burdened practitioners stay current on relevant research and evidence in their fields, and to shift the prevailing bias in medical publishing toward English language producers. 

"Unpublished evidence may be important; and more easily accessible research reports tend to exaggerate the benefits of intervention." Right now the Collaboration is the largest  "crowd-sourced" healthcare encyclopedia on the Web, and informing consumer education, medical decision-making and research, globally. It may soon have competition: Currier. Rybeck. Dr. Chalmers is also Editor of the James Lind Library, also In Oxford.

Disease management. The industry's biggest priority, and its weakest spot. It's a no-brainer to make money (or save it) off people who want to live well.  One advantage in starting a new business to serve the employed and the incentivized, is that your customer base self-selects for those most likely to help you succeed (this doesn't mean you will succeed, but it sure helps a lot.) Acute care makes for medicine's shining moments; an area with comparatively discrete problems, when it comes to innovation and strategy, there are also usually easier to solve. Keeping the unwell from getting worse is a not only a Sysiphean task, its unlikely ever to be glamorous. This is why entrepreneurs flock to genomics or chronic disease prevention, but tend to leave the unattractive stuff of diabetes-day-to-day to patient run social networks, under the noble banner of self-care. (We have one startup that defies the stereotype; it addresses diabetes ulcers.) Kennedy "is someone to watch," peers say for things like Life 2. HMC, the disease management of massive WellPoint, claims service to more than 34 million people now and Kennedy's returns are impressive: $110 million in savings in her three years there. We admire her for stamina, too.  Before HMC, Kennedy ran or built disease management units for Empire Blue Shield (360° Health), CorSolutions,  and Oxford Health Plans. Heck, someone's gotta do it.

My Health PAL.  The San Mateo-based startup has been operating in stealth for more than a year, preparing to debut what we'll attempt to describe as an "artificial intelligence- wellness assistant."  This is because the company's technology is based on a DARPA-funded project called, PAL. 'P-A-L' stands for Personalized Assistant that Learns. Some years ago, DARPA began working on a computer-based assistant that could learn, reason, and respond to dynamic sets of information. It worked, and eventually military personnel on the ground in Iraq used a version of PAL, augmented with social media, to keep each other informed of IEDs and other threats in real time. Now Social Kinetics, (founded by a few guys with security clearance) is attempting to apply the same AI technology to help people live with "practices that support greater health, well-being and happiness." This is machine learning, meets personalized medicine, meets personalized  trainer. Or, for those of our readers of an age to remember Knight Rider, this is KITT with a calorie-counter.  If there is a continuum of companies in this "consumer wellness aids" space, then we see this way: Redbrick on the far left (human interaction); KEAS in the middle (computer-aided collaboration) and Social Kinetics on the far right (machine learning). Imagine getting up in the morning to a wellness assistant that could recommend a breakfast based on your behavior the day before!  Villa became CEO of Social Kinetics last year, and is largely responsible for its focus on the healthcare vertical. He was previously a healthcare consultant, and most recently, COO for the Employer Division of Revolution Health.

An 'eHarmony' for clinical trials.  How many more ill people would participate in a clinical trial if: a) they had access to a web-matching service to help them find just the right one? and b) such a service included iron clad privacy? Robert Shelton thinks this answer is many. We think he's right. Shelton's company Private Access is trying to strike a new balance between the need to access information, like medical records data, can the competing desire to keep patient privacy in tact. He's built something he calls a "privacy aware architecture" which takes discretionary information from parties and facilitates "blind" matching between them, while at the same time keeping other data protected (rather like a dating service). One use for Private Access is by researchers, who can use it to recruit clinical trial candidates in a more cost-effective manner. Patients may now search for trials more aggressively, with the comfort that only certain bits of their personal information will be shared. We need this: Enacct says only 3 percent of cancer patients participate in clinical trials. That's not enough.

Speaking to highlighthealth.com: "It is also a play on the words “privacy” and “access,” which most people tend to think of as being a 'pick one or the other' choice, whereas we believe that both attributes can and must be achieved if we’re ever going to truly transform healthcare to function with less cost and greater efficiency."

Price transparency. A guiding voice on many topics in healthcare economics, from the future of Medicare to the obstacles facing consumer-driven healthcare. Current complaint: the hospital pricing "monstrosity" -- because patients can't be enlightened consumers without a clear understanding of the price of goods they are buying. His proposal for achieving transparency concerns mimicking the "diagnosis-related groups" used in Medicare. Prices for DRGs could be used as benchmarks, to which hospitals could then apply regionally specific conversion factors to account for economic variations. (A hospital in New York City will not be restricted to the prices of a hospital in Topeka.) The catch is in the conversion factors: who will determine them? He has ideas about that, too. We don't know if his idea will fly, but transparency is pet topic here, so we're rooting for it. Dr. Reinhardt has experience with pricing in healthcare: From 1986 to 1995 he served as a commissioner on the Physician Payment Review Committee, established in 1986 by the U.S. Congress. He has also been a member of the Institute of Medicine of the National Academy of Sciences since 1978.

Blogging in the NYT in January:

"In a nutshell, my proposal calls for applying to all patients the payment method developed by Medicare during the 1960s and 1970s and mandated upon all American hospitals by the Reagan administration in 1983. This approach has been so successful that in the meantime it has been adopted by other industrial countries as well — notably by Australia, France and Germany."

Upton Sinclair of healthcare. A neurosurgeon by training, you may know him as the author of Flatlined: Resuscitating American Medicine. It is the physician's  contribution to muckraking, in the tradition of Sinclair's The Jungle. Where Gawande's accounts of hospital mishaps and errors manage to sustain a sense of awe for medicine's capacities, Dr. Clifton's account delivers a balancing perspective: outrage. Publisher's Weekly called it  "An eye-opening, sausage-maker's perspective on contemporary medicine." Another said Clifton shines a light on the "dead elephant in the room."  Dr. Clifton is the Runnells Distinguished Professor of Neurosurgery at the University of Texas Health Science Center at Houston, where he has practiced his entire career. He was  a Robert Wood Johnson Foundation Health Policy Fellow  and a Senior Research Fellow in the Health Policy Program at the New America Foundation. Also in the spirit of Sinclair -- 'a man informed, is a man transformed' -- Dr. Clifton now devotes his time to transforming healthcare through policy reform.

Blending sustainability with healthcare. By now you've probably read about how Werbach, the one-time president of the Sierra Club (its youngest ever), who left behind left-wing environmentalism to force change on corporate America, from the inside. He began consulting to Wal-Mart and slowly helped the retailer remake its external, and external, image from "Earth offender" to a leader of green thinking. He used programs like Personal Sustainability Project (PSP), which included individual wellness initiatives by Wal-Mart associates. Not long after, the global advertising firm, Saatchi & Saatch, acquired Werbach's consulting firm, Act Now. Today, Werbach is using his new platform, Saatchi & Saatchi S,  to promote initiatives that strive for a more holistic kind of sustainability. He calls it a "blue" campaign. A central tenant: health for the planet must start with wellness for humans. (The extra "S" stands for sustainability.) Clients include Kaiser Permanente and WellPoint. As always Werbach is an agitator for change. We like that Werbach is pushing this inter-disciplinary thinking, since approaching change from more than one vantage point also offers his audience more than one opportunity to embrace it; where revamping a healthcare plan seems too daunting, personal sustainability programs can offer an easier point-of-entry to the path toward transformative innovation. 

"Our purpose is nothing short of building a world full of happy people contributing to a healthy planet."

Check-in kiosk for clinics. Dr. Gonzales has been experimenting with a computer kiosk to speed-up patient screening at an urgent care clinic of UCSF, since 2005. Called the UTI Self-Management Kiosk, it screens women with urinary tract infection symptoms (a condition which makes long waits especially undesirable), using interactive video, a touch pad, and a series of standardized questions to identify those patients who needed a see a doctor, and those who don't. The kiosk prints a report for each patient to explain symptoms, a medication, or treatment options. If a script is warranted, the kiosk prints it and the patient is referred to a doctor for signature, only. Only women who need examinations are required to stick around. In Gonzales' 2005 trial, 30 percent of women processed and diagnosed by the Kiosk left the clinic without waiting. Patient feedback was positive, and an audio feature was especially helpful for the literacy-impaired. The kiosk is now fully integrated into the clinic workflow, and Dr. Gonzales is recruiting for a supplementary trial. The hope: his kiosks can be programmed to screen multiple conditions for broader use. Dr. Gonzales has also been awarded two grants from RWJF to study the overuse of antibiotics. 

Speaking to RWJF: "I feel like I'm very tuned-in to the quality of health care delivery from the consumer perspective," Gonzales says. "I think that comes from growing up in an environment where your entire livelihood depends on delivering a high quality product and service. A lot of that has been lost in medicine. We're not as customer-oriented as we need to be."

Fresh face of Health 3.0. If you were seeking a face to put on the long future of healthcare -- the future that's around the corner, not just down the road -- then Berci Meskó is your guy. He hasn't even graduated from medical school yet (that happens next month), but this enterprising young man in Debrecen, Hungary has already launched a "medical web 2.0 guidance service" to counsel doctors twice his age on how to use Web2.0 tools to run their practices a bit better. It's called Webicina, and while the advice is relatively simple, we like it because Berci basically offers his tips in a CliffsNotes-like format; there are short lessons, and easy to parse lists of additional resources such as wikis, and slideshows that he collects for you. We like kits, and Berci offers them. He recently published a list of disease-specific guidance packages: Rheumatology2.0, Drepression2.0, Radiology2.0, etc. Simple as they are they'll save you time (why we call them CliffsNotes) and they are a tiny example of the specialization folks of the Christensen-school like so much. Perhaps Berci should call them "solution kits." ScienceRoll, his daily blog is a fun summary of Berci's latest discoveries from other innovators, and a must-read for us. He apparently succeeded in getting Web2.0 course accredited at his medical school, and he also likes to engage in simulation on Second Life. The soon-to-be Dr. Meskó graduates from the University of Debrecen Medical School and Health Science Center next month. Being of the next-generation, he's naturally diving right into the most progressive area of medicine: he plans to begin his PhD program in personalized genomics in October.

Personal genomics. Cofounded 23andMe in 2006 with Linda Avey to commercialize genetic testing. Powerful science with huge potential, and 23andMe has helped galvanize the debate over genomics. But the company has an Achilles heal more obvious than its peers': it delivers a wealth of genetic data, but no therapeutic strategy as a follow-up. For us, healthcare innovations either elevate quality, lower costs, or expand access. Genomics applied to a single person can address only the first two criteria; that's "targeted therapy." So while one question nags all personal genomics companies (Lord, Agus, Scott) -- will a person who discovers she is at risk of diabetes, actually take steps to mitigate it? -- for 23andMe, it is more pressing. And unlike its peers, the company does not focus its resources on diseases where risks could be mitigated. How much value is there in revealing to a person that she is at risk of Parkinson's, if there is nothing that can be done? An innovation that is not applied to produce an outcome might just as well be art. (One blogger called 23andMe "navelgazing.") Still, there are huge potential benefits for drug R&D, if the company can price (or fund) its kit low enough to collect genetic information en masse. If this is the long-term plan, then 23andMe is better positioned to succeed than most, as it has access to extremely deep pockets. Once $999, the kit is now just $399. We're told an even cheaper kit is on the way. But will it be cheap enough?

To Fast Company:  "The "spit party" concept was we had people walking around in lab coats that said "spit coach" on the back. It gave a good levity to Davos. People aren't really used to it -- how often do you have to spit in a tube? It requires a bit of coaching because we do require a fair amount of saliva."

Pioneer of online care. A practicing pediatrician since 1993, Dr. Greene was one of the earliest physicians to begin delivering advice to patients over the Internet when he launched DrGreene.com in 1995. Among many awards, Dr. Greene was recognized as one of the “Top 25 Most Influential Forces in Healthcare IT.” Dr. Greene is a regular contributor to many media outlets, and is the author of four books. Focuses on healthy child-rearing. Believes if parents can foster good habits in their children from birth - healthy behaviors will persist through adulthood. Dr. Greene advocates organics and is a past president of the Organic Center. He is a Clinical Professor of Pediatrics at Stanford University School of Medicine, an Attending Pediatrician at Packard Children's Hospital, and a Senior Fellow at the University California San Francisco Center for the Health Professions.

Speaking to Sprig.com: "On the positive side, when food is grown organically, it has on average 30% more antioxidants, the things that help prevent and repair damage, and so I got very excited about helping to prevent and repair health issues in kids and adults."

Change agent. And he’s for hire. This is a compliment. Dr. Shreeve, an emergency medicine physician, took his first stab at entrepreneurship in 2002, when he founded Medsphere with his brother, Steve. In a clever play, the Shreeves commercialized a public domain version of the VA’s EMR system (VistA), and sold it to  hospitals and state health systems for less than, say, Epic. It only took a few sales to do well—very well. Then they hit a speed bump common to startups: a dispute with their investors. The Shreeves wanted to go full blown open source; the VCs said ‘No.’ And the industry watched the bizarre eight-digit lawsuit unwind all the mojo. Shreeve has since rebooted. Consulting through his  Crossover Health,  he tries to help other startups avoid some of the pitfalls of entrepreneurship, while pushing the boundaries. One such partner is Shlain, with whom he's trying to democratize the concept of concierge medicine.  Shreeve is a ubiquitous blogger, and he recently revisited an old theme -- that now has renewed currency: CODE RED - How Proprietary HIT Vendors May Screw Up Health Reform. He is positioned to influence innovation in one other way: Shreeve is one of a handful of health-entrepreneurs consulting to the X Prize Foundation on it's Healthcare X Prize. Basically, he's helping the prize-pickers determine the framework for giving away all those millions.

Health savings accounts. You know you've arrived when you're spoofed on The Onion News Network. Goodman's think tank, National Center for Policy Analysis, has been an ardent opponent of universal coverage. The satirical "news piece" surveys children who concur -- because universal coverage would mean they'd have to go to the doctor instead of to the playground. (It's funny!) Seriously, Goodman, a doctor of economics, has been writing about healthcare domestically, and abroad since 1980, when he published his book, National Health Care in Great Britain -- three years before founding NCPA. Since then Goodman has been a clear voice for free-market approaches to reform, and he is widely credited with evolving Tony Miller's concept for a health reimbursement account into the contemporary health savings account. Dr. Goodman's blog is probably the best source for a quick survey of the policy debate from the conservative side of the aisle. He likes to claim credit for killing the health reform initiatives of the Clinton Administration, and published an exhaustive response to Sicko, the Michael Moore "documentary" on the U.S. healthcare system. 

Risk capital. The founder and former CEO of the somewhat controversial Human Genome Sciences, Haseltine devotes most of his time to promoting healthcare innovations in India. He picks India, friends say, as the lab for discovering "future healthcare," because all at once it has advanced technologies, sophisticated consumers, and the neediest communities in the world. India also lacks institutional barriers to change: no legacy systems or procedures, and no "installed base" of payers to stand in the way. Dr. Haseltine's foundation also seeks to nurture collaboration between art and science. A former instructor at Harvard Medical School, he is now an adjunct professor at the Scripps Institute for Medical Research, and is a correspondent in business, science and art for The Atlantic. Dr. Haseltine is also President of the William A. Haseltine Foundation for Medical Science and the Arts.

Trumpeter of  Alzheimer's conundrum. As CEO and Chairman of Pitney Bowes, Mr. Critelli was another who lent his voice to the call for quality-enhanced outcomes. (McGlynn is a fan, which is just about all we needed to know.) At Pitney, his focus was always to invest more in prevention, diagnosis and disease management, than on technologies for addressing acute diseases, he says, "because we can have a more positive impact on more people and can lower costs at the same time." (We think so, too) Since leaving Pitney he has continued to advocate for cost-reductions and has, in particular, patronized work being done in Alzheimer's because it is already the third-costliest disease, and yet lags in funding compared with HIV/AIDS, cancer, and heart diseases. This is an area of health costs that is ballooning. It needs Critelli.

quoting The Wall Street Journal on his blog:

"…a dollar spent on medical care is a dollar of income for someone. ..It may be the single most important fact about health care in America that you or I need to know."

Risk capital. We might just as easily dubbed him "The Insider." Mr. King-Shaw's particular talents are very much in demand now, as innovators in healthcare try to navigate the changing landscape in Washington.  Prior to founding his private equity firm in 2005, Mr. King-Shaw served in several government positions, including  Secretary of the Florida Agency for Health Care Administration and Deputy Administrator and Chief Operating Officer of the Centers for  Medicare and Medicaid Services.  President Bush named King-Shaw to the President’s New Freedom Commission on Mental Health in 2002. Mansa specialized in healthcare companies, and Mr. King-Shaw serves as a director of several companies represented here including athenahealth, and BioIQ.

Portable self-testing kits. Like many other innovations chronicled in this list, BioIQ was inspired by a misfortune. Bellante's cofounder lost his father to diabetes, a loss that Raja Jindal believes could have been easily avoided if disease-prevention and detection was a priority in our health system. It's not, and it won't be any time soon. So BioIQ has developed a series of easy-to-use test kits, and other online diagnostic tools that, at a minimum, increase customers' odds of detecting diseases such as colorectal cancer and high cholesterol -- in addition to diabetes. A goal of BioIQ is to inspire and empower consumers who are not now engaged in wellness -- or who are simply too busy to go to the doctor -- with convenient opportunities to become more active in their healthcare. It's unclear whether consumers are ready for self-testing but BioIQ makes it easy for them to try it on for size. With less than $70, ordering an A1/c diabetes test is as easy as buying a book off of Amazon.com. Tests for thyroid disorder, kidney disease and osteoporosis are coming.

To socaltech.com:

"We decided to create a system for individuals who were not engaged with the health system, and provide them with the tools, technology, and the medical information out there, and take it to them in a way that they are used to be marketed to, as with any consumer product."

The industry conscience.  Some innovators create new things. Some innovators fashion the business models that bring those new things to your door. Often these events can't take place without someone who is willing to cut a big check, which is why we have VCs and risk capital-types in this list; innovation demands patronage. And then sometimes it just requires a bit of prodding. It isn't fair to limit the role Peter Lee plays to this -- although he does run one of healthcare's biggest purchasers. But of the many catalytic things Mr. Lee does for the industry, one is to remind members of the moral imperative of their occupation.

Lee drafted a letter a few years ago excoriating healthcare's chiefs over what he termed a  "poverty of ambition." It was meaningful coming from him, more so than if it had come someone else, Lee being one of the largest purchasers, and all. Successful businesspeople will often borrow the saying: 'Never let the perfect be the enemy of the good.'  This brings up the uniqueness of healthcare:  it's big in workers. It's big in customers. it's big in dollars. It's just big. But unlike every other trillion-dollar industry, this is the only one that in peacetime and at peak-performance, must still measure its success in lives, and in deaths. It matters more how hard we try, Lee was telling them in his missive and compromise is not a virtue. So we add Peter Lee to our list, because somebody has to be the one to move the goal post.