This fragmentation is certainly the least appealing facet of the mobile application market.  The investment in the construction of a mobile application is staggering.  Tomi Ahonen (author of Communities Dominate Brands) did a recent breakdown of the economics of the iTunes App Store and concluded that on average it costs over $35,000 USD to build the typical iPhone application.  But that same average application will only net $682 USD in revenues per year.  Compare that with the cost of developing a web application targeted at mobile devices – about 1/10th that cost.

Now think about developing an Android, Windows, Blackberry, and iPhone port of your mobile application.  The numbers are as prohibitive as they come.

The high stakes here are incentivizing bad behavior: Apple’s license agreement for iOS development being the prime example of defensive maneuvering in the fragmented market.  Not only are we being cornered into repetitive development for multiple platforms – but now extra steps are being taken to ensure that we have to.  Adobe’s model to metacompile flash applications for iPhone deployment became a lightning rod for Apple this past spring.  PhoneGap skirts metacompilation by providing a development toolkit more akin to a scaffold, but consistently lags behind in support for more recent device features.

Fragmentation of desktop platforms has always been a far less limiting problem. Virtualization and tools for cross-platform compilation has enabled developers to target a ubiquitous number of platforms or more often than not, simply disregard the problem.  Furthermore, the development of rich internet applications delivered by the browser has provided a natural cross-platform channel.  With the evolution of the HTML5 standard and it’s continued support by big players like Google and Apple – the ability to take a “write once, run anywhere” mentality to application development via the web browser will continue to be the disruptive force in software delivery as deployment costs continue to be pushed down.

The most ubiquitous mobile browsers – Safari and Chrome, both support much of HTML5 for their host devices.  So why haven’t developers turned to the browser to solve the problem of mobile deployment in the same way they have for desktop applications?  As big as the promise that have been delivered by RIA development has been, there have always been significant limitations – ones that mobile environments exacerbate:

• Connectivity:  Browser-based applications have long required that internet access be reliable.  Browser security prevents access to a users local storage (with Google Gears innovating around this limitation, though at the cost of a plug-in), and thus a lack of connectivity meant a lack of access.  In mobile development, this is a consistent concern.  HTML5’s native features for controlled local storage will solve this;
• Access to native environment:  Likewise with connectivity, the browser has always been severely restrictive (in fact, entirely restrictive) of access to local hardware like built-in cameras, microphones, or external peripherals.  The compact and feature rich accessories in the modern smart phone are a particularly high-value draw to mobile application developers who can only access these features through the native APIs.  Not having access to this from the web environment is certainly secure, but it completely removes some of the value of developing mobile web applications;
• Performance:  While this has improved, web applications are powered by inherently slow JavaScript.  Google’s Joel Weber compared noted in 2008 that the web application is to a native desktop app as a Commodore 64 is to today’s PC.  And while the processing power of the smartphone is leaps and bounds better today than it even was 3 years ago, it still is extremely limited;
• Commercial viability: The most important limitation is also the business problem – how do you monetize web applications?  It’s certainly something that has been done – otherwise the growth of web applications targeted at desktop users would not have exploded as it has.  But it has proven tricky in the mobile space.  The various App stores have proven effective in creating a marketplace for native applications by providing a simple deployment and distribution model.  This channel has allowed mobile devices to put apps at the user’s fingertips, something unmatched by web applications.

Until these limitations are addressed, mobile applications will continue to be loss centers or complimentary pieces of larger application ecosystems.  If mobile deployment is ever to replace or even rival the ubiquity of desktops, they will need to take the human factors learning’s of the past years that have enabled such rich mobile applications and apply them to a deployment and commercial model that enables platforms solely targeted at mobile to exist profitably on their own

Yet for all its promise, the adoption of healthcare technology by providers has been impeded by other factors. One such factor is the generally acknowledged resistance by care providers to information technology changes. To a degree, this resistance is due to two main challenges: the loss of productivity when changes are implemented and the often high capital costs for some enterprise information technology solutions that smaller or mid-sized practices are unable to shoulder or stomach. SaaS solutions have met the latter challenge by lowering the costs that have been one barrier to entry by not requiring separate and costly individual installations of solutions for each care provider or practice. Some reports suggest that such SaaS solutions are already reducing this provider resistance to technology adoption. The former challenge is being addressed more gradually by improved workflow and user experience design. These growing disciplines are delivering better solutions whose improved design minimizes the inevitable loss of productivity experienced while care providers, like adopters, are learning to use a new workflow or tool.

Atop these shifts in healthcare empowered by information technology, mobile health applications promise to be great catalysts for increased adoption and impact. With people being increasingly comfortable using smartphones for data applications and not just voice, it makes the adoption of information technology in general and mobile technology in particular easier in the healthcare industry. Mobile technology is particularly applicable to healthcare due to the significant cost, time, and inconvenience that are incurred in just transporting patients to doctors for those consultations that do not need to be in-person. Research by TripleTree presents a good analysis of the market and opportunities in mHealth. Technology and wireless phone companies also see the posibilities for healthcare and are now beginning to move to deliver solutions. For those whom might resist adopting health information technology, mHealth promises to bring health information technology to them.

Along the way we are seeing a dramatic change in the channels through which these offerings can be delivered:  It started out via face to face interactions between consumers and health providers.  Next was the capability for phone interactions with wellness coaches or clinicians.  Soon, there was access to tools and content at the job site through personal computers or kiosks.  Before long, access to these tools was extended to the home through laptops and high-speed internet.  Remote monitoring has long been a staple for the sickest among us, but at long last we are seeing a massive upsurge in the ability for mobile telephones to deliver high quality data and user experiences on the go for ALL healthcare consumers.

Combined with the relentless focus on moderating the healthcare cost trend, the incredible growth in the capability of mobile devices – devices which have permeated the population much more extensively than computers, and which users tend to carry with them everywhere – will certainly improve the business case for the next generation of innovative mobile products and services to help people manage their own health and – overall – to be healthier.  Early adopters have been using commercially available mobile activity tracking applications and nutrition tracking applications for over a year.  As these investments start to show a return – either by helping people stay fit and thereby gaining credibility and creating customer loyalty (not to mention winning more customers through word of mouth), or by demonstrating a return on investment to health plans or employers – more innovations will come.

The key to creating products and services that will provide the biggest return on investment is not to simply create a mobile app for the iPhone in a “me too” strategy.  Rather, businesses must take a step back and understand what tasks your customers really want to be able to conduct via a mobile platform.

The end result is a win-win for customers and health providers – more choice of tools to help customers to manage their health (with more access through more channels), and more engaged and loyal customers.

The key to creating products and services that will provide the biggest return on investment is not to simply create a mobile app for the iPhone in a “me too” strategy.  Rather, businesses must take a step back and understand what tasks your customers really want to be able to conduct via a mobile platform, to understand how those needs reflect your business’ current capabilities, and what existing capabilities can be extended (or what new capabilities can be created) to the mobile channel.

For those who do this well, the mobile channel will open opportunities to capture large numbers of new customers.

First, Dr. Ron Goetzel notes that one of the largest sources of the escalating cost of health care is innovation itself – new prescription drugs and new technology. This backwards incentive is fueled by a complete lack of top down pressure for cost reduction. Innovation has no need to be aimed at reducing costs – and instead seems aimed at increasing care options at additional cost. Until we can provide incentives for innovation of cheaper alternative products and process, the unchecked increases in costs will just fuel innovation not aimed at efficiency.

Second, a great presentation from Goetzel on case studies of employer organized health promotion plans, but sadly the focus was on large American companies with predominantly US-based employee bases. Justifiably, the buzz among attendees turned to how all of these good ideas could practically be applied to small business. The suggestion was made by Goetzel that the same approach used in Massachusetts to service fully insured small businesses for the individual mandate (the Health Connector) could be used to aggregate firms around wellness.

This seems a bit simplistic. The incentives are simply not there. You could indeed crowd-source the employment of wellness across a larger employee population through a cooperative, but you cannot expect all participants motivations to align. Perhaps a model where participation in the connector itself were tied to roll-out of a standard wellness program could work, where participants not wishing to roll out wellness across their company could pay credits to opt out and further incentivize those who do wish to participate could create some efficiencies while employing wellness across a larger but transient employee population.

As I’ve written before – the good intentions of HIPAA and the cost of compliance are undoubtedly an overhead to innovation of newer systems to better manage health information.  Massachusetts has done a fine job in increasing this burden, requiring as part of CMR 17.03 that “Every person that owns or licenses personal information about a resident of the Commonwealth shall develop, implement, and maintain a comprehensive information security program that is written in one or more readily accessible parts and contains administrative, technical, and physical safeguards [sic].”  Now, in addition to creating auditable systems that can abscond identity and protect personal information, innovators will now have to contend with the development of a document that will outline their strategy for securing information and guarding its transport.

So, will consumers ultimately benefit from increased regulation of data security and harsher penalties for policies that don’t go far enough to prevent a breach?  Benjamin Franklin is noted as saying “They who can give up essential liberty to obtain a little temporary safety, deserve neither liberty nor safety.”  Applied to innovation and data security, consumers have to decide whether the promise of technology carries with it enough value to compensate for what may initially be a less than perfect standard for security of information.  The teeth of any legislation that aims to ensure consumer trust in the storage and transport of personal information should be tooled towards ensuring transparency.  The creep of regulation driven requirements for encryption and de-identification, with penalties imposed only upon the incident of data breach only delays time to market with no additional trust from the consumer.  However, clear and published documentation of steps taken to secure information creates valuable transparency in the marketplace and allows consumers to select those providers that offer the most transparent and most comprehensive strategies for data security.

Whether or not regulation is a valuable tool is a more political issue.  The real challenge for businesses and consumers in the future will be how to evaluate the cost of data security against the opportunity cost created by the accompanying delay in time to market.  If consumers decide that the delayed arrival of new technologies are worth the increase in data security, the role of regulation will be determined by how service providers respond to this demand by the market.

Given the relationship between obesity and other chronic health conditions like diabetes, high blood pressure, and heart failure, these rates are indeed frightening to consider.  It’s been widely acknowledged that today’s generation of children are poised to be the first in a long time to have a shorter average lifespan than their parents.

Clearly, there’s a lot of bad press about obesity.  So much so that it’s not even ‘news’ anymore.  However, there is good news: there’s no shortage of attention being paid to the subject.  Many people and many organizations have taken it upon themselves to address the rising tide of obesity.  Consumer empowerment is on the rise; for example there have been laws passed to make caloric information available to consumers at the point of decision-making.  Attention to the fact that people aren’t getting the proper level of activity is also on the rise.  As just one example, the First Lady has made it a personal mission to address obesity by getting kids moving.  After decades of budget cuts to school sports programs, physical education, the elimination of school recess, even things like unsafe neighborhoods for kids – we have a lot of ground to make up.  But at least there are signs of progress.   This must continue to accelerate – otherwise our notoriously short attention span as Americans will be a death knell for the little process that has been made.

Where I personally would like to see more attention paid to address the obesity epidemic is on the topic of nutrition.  After all, we ‘are what we eat’, and getting people to be less sedentary is only addressing half of the problem.  The other half of the problem is that the food industry has realized that there is a large portion of the population who will gladly spend their money on nutritionally deficient, yet calorie (and sodium!) dense “convenience foods” in lieu of fresh, nutritious, natural foods.  As a society, we have become dependent upon convenience in all areas, and our food has become no exception.  Our ‘nutrition/value’ barometer is all out of whack.  After all, how can we honestly expect to pay $1 for a nutritious hamburger?

We need to re-educate people that good nutrition doesn’t necessarily have to come at the expense of convenience.  Until we break the trend of reliance upon convenience foods, obesity will continue to be a problem that we address after it has arrived.  We need to stop treating the symptom and treat the cause.

Based upon the various amalgamations of the data, the conclusion I have reached is that the health reform bill focuses largely on “access” through things such as:

• covering the currently uninsured by requiring (and where necessary, subsidizing) all Americans to purchase insurance,
• removing the ability of insurers to deny coverage based upon pre-existing conditions,
• removing the limits that insurers can place on members through ‘lifetime maximums’ that limit the total amount of money the insurance company spends on any member’s care
• extending the age limit for children to remain on their parents’ policy

I applaud these actions, and recognize that they are an important element of reforming the way we deliver healthcare by ensuring that people have access to care. That said, increasing access alone will not only fail to moderate the cost trend – it is likely to exacerbate it. So what’s missing?

1. Payment reform – much has already been said about the perverse incentives created by the fee-for-service reimbursement model. True health reform must include payment reform that puts the incentive on delivering better outcomes, not simply delivering more care.
2. Limits on litigation – another incentive that doctors have to prescribe care that doesn’t directly correlate to better outcomes is the fear of litigation. True health reform needs to address our litigious nature as a society, and protect doctors from frivolous lawsuits.
3. Patient behavior reform – despite plenty of evidence to the contrary, the predominant mindset among patients is that more care is better care, and that more expensive care is better care. In order to moderate the healthcare cost trend, there will need to be less consumption of healthcare and a shift from late stage medical care to more preventative medicine. Increased access to care will certainly help, but more will need to be done than to simply provide people with the ability to see a doctor – they will need incentives that actually change behavior.
4. Eliminating waste due to fraud and overuse – an obvious way to reduce healthcare spending is by eliminating the 30% that is estimated to go to waste or fraud. Advantages of health IT are that it can limit duplication of healthcare (waste), increase efficiency of the care currently being applied (efficiency) and apply controls to prevent or detect outliers (fraud protection).
5. Reforming the system itself – largely overlooked is the idea of reforming entirely the system of how insurers, patients and providers work together. True Healthcare reform would enable more disruptive innovation in the market – such as allowing members to select whatever combination of wellness and health insurance they like (even across state lines) rather than limiting to 2 or 3 choices by their employer, or allowing members to carry their plan with them for as long as they like, even if they change employers. There are limitless possibilities for new and unique business models that will provide better value at lower cost.

The reform bill that was signed into law this week is a start, but to really change the healthcare landscape in America, we will need to address many (if not all) of the items above as well.

What do you think?

It’s evident that the average person doesn’t feel like they pay for the difference between a medical procedure that costs $15,000 at one hospital versus the same procedure that costs $7,500 at another hospital.  In fact, when faced with price information, many healthcare consumers actually trend towards the higher cost option.  The predominant mindset is that higher cost means higher quality.   That, combined with the idea that “the insurance company is paying for it, not [the patient]”, then why take the risk that the lower cost option might be lower quality?

How did we get here?

One contributor to this mindset clearly is that the employer-sponsored health plans have bred all the cost-consciousness out of the healthcare consumer.  The reason for this is because the cost of healthcare is virtually invisible to employee subscribers.  If you ask anyone who has employer-sponsored health coverage what they pay for health insurance, a minority may be able to quote how much of the money comes out of their paycheck each month (e.g. their out of pocket contribution for healthcare premiums), but virtually no one knows how much their company is paying for insurance on their behalf.  The thing no employees seem to think about is the fact that employers would be happier to take the money that they currently contribute to subsidize employees’ healthcare premiums and instead put it into the employees’ paychecks.   Since most companies subsidize at least half of the cost of health insurance (with some paying two thirds or even 75%), the opportunity cost for health insurance is at least twice (if not 3x or more) higher than what people recognize as their “cost” for health insurance.

Imagine if you were paying for mobile phone service each month but had no idea what it cost?  Would it be realistic not to expect monthly phone subscription prices to rise?  One of the main tenets of a competitive economy is that competition drives prices down, but this is only possible when people actually compare the prices of like products and choose the cheaper alternative.  This is impossible if the consumer doesn’t know the price.  This is one of the fundamental issues behind the rising cost of healthcare – ignorance on behalf of consumers for the actual cost of healthcare – and yet it’s one issue regarding which I’ve heard very little discussion as the health reform debate wages in Washington.

What if…?

What if we had a world where health insurance was no longer predominantly employer sponsored?  What if instead, employers put the money that they currently use to subsidize health insurance into the employee’s paycheck every month, and the insurance company billed the employee for the full amount of their health insurance coverage?  The government could still give healthcare insurance consumers the tax break that we get today so there would be no increase from what a subscriber pays now to what they would  pay under this new model – but consumer awareness (and sensitivity) to the full cost of healthcare would skyrocket.

Suddenly, health insurance consumers would be much more likely to become discerning consumers of health insurance (and healthcare services).  Combine this with the concept that in this model, health insurance subscribers become the decision makers regarding which insurance they buy (instead of being limited to the options that their employer offered).  This new price awareness plus decision making power would lead to a new competitive environment among the health plans, where plans would innovate and compete to provide higher value options for consumers.  Decoupling plans from employers would also entice health plans to focus on ways to enable their subscribers be healthier.  The plans would be able to see a much larger return on each dollar of investment made in a subscribers health today, since there would be a much larger possibility that the subscriber would still be in that plan many years from now.

It’s unrealistic to expect that we can address the cost trend without addressing the lack of cost sensitivity on behalf of the ultimate consumer of healthcare services – the patient.

Rep. Charles Boustany, a third-term Louisiana congressman and retired surgeon, has been busy on the health care issue, voting against the State Children’s Health Insurance Program (SCHIP), against flu pandemic preparedness and response bills, and against expanding COBRA coverage.

Recently interviewed on CNN, he showed a softer side:

“We do believe that we have to provide a system that creates access to a doctor-patient relationship first and foremost for all Americans.”  (link)

At least there’s something everyone can agree on …

]]> http://reach.medullan.com/2009/09/09/louisana-surgeon-giving-gop-rebuttal-obamas-health-care-speech-tonight/feed/ 0 http://reach.medullan.com/2009/06/16/the-value-of-workshops/ http://reach.medullan.com/2009/06/16/the-value-of-workshops/#comments Tue, 16 Jun 2009 19:05:05 +0000 Wesley Boland http://reach.medullan.com/?p=354 Most organizations insulate their developers from requirements gathering activities.  They prefer to pass one or many documents specifying all application functions to the implementation team to act upon. Medullan prefers to integrate developers into projects as early as possible – even having them participate in the workshop as note taker or even facilitator. As a developer, I feel like I add a unique perspective to the workshop team that would otherwise be missing.

By gathering all the key stakeholders in one room, Medullan’s workshop team can let everyone at anytime know what is possible, what is costly and what is impossible. In a sense, we developers are the realists in a workshop; we have the implementation know-how to realize that some things are not worth chasing and the experience to say that it will take 1 week or 4 weeks.  We are also able to create a quick prototype of an idea to prove or disprove ideas generated in the sessions.

More importantly, by participating in the workshop, we too, can build strong relationships with the client that will be valuable throughout the project’s lifecycle.

In a workshop, the common language of the application is created by all participants. System modules and concepts are created and named and for all future communication with the clients, this language must be known and understood. With the relationship established and the common language understood, the project leadership no longer need be gate-keepers or bottle-necks when implementation issues arise.

While unorthodox, Medullan’s approach of including a developer in the workshop has proven to be valuable for both the developer and the client.  By keeping the team grounded in reality and opening the channels for future communication, the developer role in a workshop is essential.