What Digital Health Entrepreneurs And Investors Can Do To Combat Disparities In Health
In 2002 the average life expectancy for a person born in the United States had reached 77 years old, an increase of 7 years over a forty year period, reflecting an impressive 10 percent gain. Yet beneath the surface, there were glaring disparities – such as a five year difference in life expectancy between a Black and White baby born that year – that suggested the improvements in overall life expectancy were covering up differences in the multitude of factors that contribute to life expectancy.
The same year, the Institute of Medicine (now National Academy of Medicine) published a landmark report on inequities in healthcare, specifically acknowledging and making recommendations to address remarkable racial and ethnic disparities in access to high quality care.
We’re now 18 years on, and the medical and broader healthcare community continue to struggle not just with its role in addressing ongoing racial disparities in health, but its place in solving for structures and systems that contribute to those disparities but are outside the traditional practice of medicine. Beyond this, while those in the medical community condemns conscious racism (issues that continue to crop up), they have just begun the process of recognizing and addressing unconscious biases.
Increasingly, members of the medical community are voicing their frustration with “staying in their lane.” They want to advocate for clinicians’ roles in broader policy debates. The fact that George Floyd’s dying words – “Please — I can’t breathe” – were noted sixteen times in a New England Journal of Medicine article is just one signal among an expanding galaxy of clinician voices raising awareness of their desire to play a more active role in addressing such issues.
The Promise and Perils of Technology
Ten years ago, as part of the American Reinvestment and Recovery Act, the federal government began implementing the EHR Incentive and its sister Meaningful Use programs. Designed to prompt physicians and hospitals to adopt and “meaningfully use” electronic health records (EHRs, the programs invested $35 billion in taxpayer monies in the hope that digitizing paper records would create an underlying infrastructure to support a nationwide shift from “fee for service” to a “value-based” reimbursement model. This shift would, conceptually, help to achieve the Triple Aim in healthcare, including a focus on improving health outcomes at a population level. Improving outcomes at a population level necessarily entails thinking through and developing plans of action related to communities’ access to care, quality of care provided, and other social determinants of health that may constitute between 20% and 60% of healthcare spend.
In the past five years, the private sector has invested more than $30 billion in digital health. Many key areas of investment target opportunities that seemingly should help to reduce disparities and inequities in health: use of telehealth technology can improve access to care, artificial intelligence and clinical decision support can reduce human errors and bias, remote patient monitoring can help keep patients out of hospitals, transparency tools can help reduce costs of care, and patient engagement can empower people to find the care they need.
Yet despite the promise of technology, all is not well.
For instance, while telehealth utilization has increased exponentially during Covid-19, recent studies suggest that there are disparities in use among different communities. The underlying digital divide is likely exacerbating challenges in access to care. The burgeoning telehealth ecosystem is simply layered on top of a public health infrastructure (or lack thereof) that does not acknowledge existing inequities.
And while the promise of artificial intelligence in healthcare is in large part due to the ability to systematically analyze more data than any person can and remove human bias from decisions, there is evidence emerging about the limitations of AI and how bias can be built in unintentionally even in healthcare settings.
“If you’re not consciously thinking about the importance of diversity, you can wind up with primarily upper class white men building technology for a population that is far more diverse and with different needs. And without any malicious intent, you can wind up with bad outcomes,” says Carlo Perez, CEO of Swift Medical, a developer of a digital wound management platform.
What can and should entrepreneurs and venture capitalists be thinking about as they seek to develop and deliver innovative solutions that reduce, rather than exacerbate, existing disparities and inequities in health?
Recognizing One’s Own Limits: “I Solved the Problem I Understood”
Gil Addo is CEO of RubiconMD, a technology platform that connects primary care providers (PCPs) with a network of specialists. RubiconMD’s mission is to democratize and bring medical expertise into underserved communities by leveraging technology that allows PCPs in those communities to tap into a worldwide network of experts. It was born of Addo’s own personal experience. When his grandmother was diagnosed with a brain tumor, Addo observed her need to travel repeatedly thousands of miles to receive a specialist’s care. He asked himself a simple question: why did she have to travel so often to see her specialist, rather than having the healthcare system meet her where she was, at least as much as it could?
“I solved the problem I understood,” notes Addo of his desire to start his company. Initially, Addo and his cofounder Carlos Reines tapped into their network to build a team to help them bring their technology to market. As they started to gain traction in the market, they became aware of their own limitations of experience and background and how this was holding them back in certain ways, including about their communities’ needs. Realizing this, they began to think about how to systematically build diversity in RubiconMD.
Likewise, Carlo Perez and his cofounders drew from Toronto’s diverse community to staff and build Swift Medical. Siobhán Gibney -Gomis, Director of Business Development, talks about how having a diversity of experience, ethnic, religious racial backgrounds helped Swift build a wound visioning and management platform that is empathetic to both patients and caregivers in different settings. “We believe it’s important for technology companies to be reflective of the populations they serve, so they can build solutions from the roots up that meet those needs,” Gibney-Gomis notes.
Scott Barclay, Partner at P72 Ventures, agrees and notes that the path forward to fixing our healthcare system is unlikely to be solved by technology or top-down policy alone. “To solve our thorniest healthcare challenges, we need to have not just technology but empathy to the patients and providers involved,” Barclay says.
Disruption: “If Your Challenge Is To Disrupt The Status Quo, Hiring 20 Ex-Epic Developers Isn’t Super Helpful”
One of the clear winners from the Meaningful Use program is Epic Systems Corporation. Based in Verona, Wisconsin, the privately held company has been around for decades but became an industry powerhouse in large part thanks to helping hospitals achieve Meaningful Use; it now holds an estimated 29% market share.
As an engineer at Epic, James Lloyd knew about Epic’s capabilities, as well as the areas it wasn’t interested in focusing on. In 2014, Lloyd and two friends founded Redox to help pave the way for the next generation of healthcare innovators by creating an EHR-agnostic platform that helps digital health companies quickly and efficiently technically integrate with any EHR. Starting out, Lloyd and his cofounders naturally looked to their friends and former colleagues to help.
Diversity wasn’t something the three cofounders started out thinking about, but they quickly realized that their network limited their thinking. “If your desire is to challenge the status quo, hiring 20 ex-Epic developers isn’t super helpful,” Lloyd says. Beyond talking about and engaging in efforts to diversify its staff, Redox also holds itself accountable, making its own diversity statistics available for all.
The reliance on existing professional relationships to address these issues is a challenge not just for entrepreneurs but investors as well. For venture capitalists in particular, who invest in high potential early stage companies that have a high rate of failure, relying on colleagues who refer in potential investments can be a time saver. However, there can be a hidden downside: limiting one’s openness to new ideas and limiting opportunities for unconnected entrepreneurs. Barclay of P72 Ventures, says “Many great VCs look for a ‘signal’ – a referral from a top founder or another trusted source – before taking a meeting with an entrepreneur. That creates a gatekeeper effect.”
Helpful Lessons: Caring Isn’t Enough
For entrepreneurs building out teams in digital health, the consensus seems to be that if you want to advance diversity, caring about the matter alone is not enough. Addo, for one, notes he talks with other founders who value diversity, but have trouble figuring out how to be productive. One easy way to get started: simply talking about it. “People listen, and your staff assume the things you talk about matter. If the only thing you talk about is EBITDA, that is what your team will focus on,” he says.
Both Addo and Lloyd also talked about putting systems in place to back up their words. At Redox, that has included reviews of processes and systems, down to how they write job descriptions. “Something as simple as changing language from ‘job requirements’ to ‘things we look for’ can help create a more inclusive and expansive pool of candidates,” Lloyd notes.
Gibney-Gomis from Swift Medical agrees, and suggests that commitments to diversity and openness are more likely to succeed if they are part of everyone’s role, not just humnan resources. Beyond this, she notes a benefit to team cohesion and culture from being willing to tackle difficult subjects, including racial injustice and social unrest. Ground rules can help, she says: ‘“We developed three ground rules that really helped us. The first was empathy, being empathetic to the fact that someone may have experienced racism or bias but also empathetic to the idea that someone else may have no exposure. The second was openness – to learning, to expressing empathy, and also to being guided. The third was that our discussions were truly voluntary; it’s great if someone can make it to every meeting, but some nights a person might be solo parenting, or have other plans. We didn’t want anybody to feel judged for not coming.”
Lloyd from Redox reiterated the benefits of taking steps to promote company resource groups and discussions on tough subjects. Doing so improves staff sense of belonging, which he suggests helps people feel more comfortable being creative and willing to take risks.
Reasons For Optimism?
Is there reason to believe things can improve? And beyond improving in the aggregate, is there reason to believe that we can specifically improve outcomes for the underserved and reduce disparities?
If increasing levels of diversity and representation across and at all levels of organizations helps to raise awareness of and to address these disparities, there is reason for optimism. Not just because this is the right thing to do, says Addo (although he notes it is), but because there is increasingly a strong business case for it. “Teams with a diversity of experience and perspectives create a competitive advantage for your organization,” Addo says, pointing to an emerging consensus of business research that suggests that diverse teams yield superior results when compared with uniform teams.
Venture capitalist Barclay seems to agree, “In building our team and meeting founders we have to be intentional with our pipeline from the beginning. For example, instead of requiring a warm intro, I work tirelessly to try to respond to any founder with a pitch that is in scope- cold emails, twitter DMs, LinkedIn.”
In addition to believing that promoting diversity of experience and thought creates a benefit to his own company, Lloyd is also optimistic about the longer term trend of innovation in healthcare. He notes that today’s solutions are limited by the creativity and experiences of those developers who are working on them, but there is a positive feedback loop at play. “The more we can remove friction from the process and bring costs down, the lower the barriers to entry are and the more opportunity there is to expand the pool of developers.”
Others agree. Mount Sinai health system has created a Diversity Innovation Hub to work with entrepreneurs and other to develop solutions that address social determinants of health, while Novartis recently announced a $25M fund to reduce health disparities.
Gibney-Gomis is hopeful. Based on her own experience, the conversations have only just begun, and seem to be building momentum. Likewise, Lloyd, Addo, Perez and Barclay are focused not just on their own ventures, but on working with others to build the next generation of leaders who will help build a smarter, more equitable health care system.
The author works with Swift Medical in a consulting capacity.