Category: Entrepreneurs

Interview with Steve Harden, President of LifeWings (transcript)

published date
October 19th, 2007 by
This is the transcript of my recent podcast interview with Steve Harden, President of LifeWings.

David Williams: This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog. Steve Harden started his career as a Navy pilot with more than 300 aircraft carrier landings. Steve eventually co-founded Crew Training International where he brought crew resource management training, sometimes called CRM, to US and overseas air forces and commercial fleets.

More recently, Steve founded LifeWings to bring CRM to health care. Steve spoke with me today about what hospitals can learn from guerilla warfare tactics, how landing on an aircraft carrier compares with his current work, and the importance of bringing a wing man with you to the hospital. Steve, thanks for your time today.

Steve Harden: You’re welcome. Glad to do it.

David: Steve, what is LifeWings?

Steve: LifeWings is a team of pilots, former NASA astronauts, physicians, nurses and risk managers that provide the same teamwork, training and safety tools for health care that have made commercial aviation so safe and reliable. LifeWings is actually an offshoot of Crew Training International. Crew Training International was a company that myself and another FedEx pilot started in 1991 to provide teamwork training, commonly referred to in the aviation world as Crew Resource Management (CRM) training, to military organizations.

And about seven years ago, it became apparent to us that there was beginning to be a little bit of an appetite for it within health care. So we dabbled at it for several years trying to develop a practice of providing CRM training for health care organizations. In 2005, it had grown such that we felt like we needed to split it off and concentrate on it solely. So we actually spun that part of the business off into LifeWings Partners, LLC, and it’s really taken off from there.

David: And if you compare medicine with either commercial or military aviation, how does medicine rank from a safety standpoint?

Steve: I think health care is probably somewhere around 15-20 years behind commercial aviation in its systems for safety, and its culture of safety. I don’t know that it will take 15-20 years for them to catch up; I think that health care is learning very rapidly from the best practices of aviation.

David: What is required to take the CRM techniques from aviation and apply them to health care? How directly do they translate?

Steve: The short answer is that there’s almost a direct application. The underlying bones of a CRM program, the basic training that you do in terms of skills improvement, teamwork skills, communication skills, is pretty much identical in both industries. The safety tools that you try to implement, things like checklists, standard operating procedures, communication protocols, are very similar as well. So the bones are the same. The skin and the muscle that you put on top of those bones clearly have to be a little bit different.

David: How widely can you apply these techniques within health care? I can see a very direct translation to something like doing surgical procedures. How about monitoring patients in an ICU or patients coming into an emergency room? Does it also translate very directly there?

Steve: Actually I think the most successful program we’ve ever had was in an inner-city clinic. And it was a clinic staffed by licensed practical nurses, not many physicians, and lots of turnover among the medical staff. The patient population had a low health IQ, and was mostly a minority population. Not many resources among the patients or the clinic.

They hired us to do the same program that we do for surgical services, an ICU or an ED – training and tools. And the whole intent of it was to try to improve the level of diabetes screening and care that they gave their patients, because there was a high incidence of diabetes among their patients.

We saw some remarkable results, and much better outcomes, in terms of their patients, more compliance in terms of providing the right protocols of care, reduction in turnover among the staff, less time spent per patient, in other words, they were more efficient with their patients, and less time to train new employees.

There is a formula to follow. It’s not ‘smoke and mirrors’, and it’s not hopeful thinking and wishing. There is a very specific formula to follow that can change culture. And we have worked very hard at LifeWings to decipher what that formula is and publish it with the folks that we work for, so that if you follow these instructions and do these things on this day, at this phase of the implementation, you will be successful.

David: There’s been some opposition, at least historically, or skepticism amongst physicians and perhaps surgeons, in particular to the idea of being part of the team. And I wonder whether that’s something that you still run into, and how you deal with it, and if that’s actually similar to what a pilot might feel as well?

Steve: Well in the beginning days of CRM and aviation, we had that resistance from the ‘old-line’ captain. “You’re creating a ‘monster’ first officer that’s going to try to take over that cockpit. This is not a vote mentality. It’s not a democracy. It’s a crew. It’s a team, but there’s only one team leader and that’s me, and quite frankly, I don’t want mutiny on my hands.”

We don’t hear that anymore because that obviously never happened. We were not creating the ‘monster first officer’. We were creating a better team for the captain to work with, to have more resources at his or her disposal and teaching them how to use those resources more effectively, so that they had a better place to be employed and fly airplanes, and we’re able to do a better job of it.

And so we now occasionally hear that same argument from the ‘old-line’ physicians. “I am the captain of the ship. And if I tell you to jump, then you should say how high on the way up.” We don’t really hear a lot of that now. I think there’s just a great sense that health care has gotten so complex and is changing so rapidly that unless you have the full and total support and help of all of your surgical team, that you’re probably going to miss something.

David: Are there other things that are needed besides a CRM or team training approach in order to create a safe overall environment? Are there other things that you depend on happening from a hospital standpoint so that you can walk away and expect the results that you want to see?

Steve: I think the most important is a good leadership structure. I think there is a fundamental lack, in many cases in health care, of ‘Management 101’. Aviation, both military and commercial aviation, is so chock-full of–especially from folks from the military that have been through so many different kinds of leadership and management training courses–I think the level of basic skill at management pervades to a much lower level in aviation than it does in health care.

My experience has been that a hospital will absolutely not be successful at changing their culture and really having sustained success with this program over time unless they’ve got a really good leadership structure, a really good organization in place that can foster and sustain the kinds of things that need to happen for this to work over time.

The other thing, I think, is this whole idea of getting away from blaming the individual and looking at the systems issues. You know, so much of what goes on in health care now is, “Figure out who screwed up and figure out what to do about them,” rather than figuring out the latent system problems that led to that error. I think in health care we tend to look at errors as personnel problems. You know, “That person didn’t know the right thing to do so we have to fix that person.” And really, we need to think of it in terms of what sort of system can we put into place that would either prevent that error altogether or catch the error before it caused some sort of harm to the patient.

David: What kind of role do you see the legal system playing? You hear a lot about defensive medicine and you just described a little bit about assigning blame in medicine. Does that play a role in the mentality or how you approach the training?

Steve: Well, it really doesn’t. You know, we’re not conscious of that, of the legal system or defensive medicine when we’re doing our teamwork training or trying to put our systems in place. The healthcare organization itself may be conscious of it, but if they are they rarely ever mention it.

It is helpful to us, kind of in a perverse way, in the sense that folks make the connection that, if I have better teamwork and better processes, I’m going to make fewer errors, and if I make fewer errors, then I’m going to have less exposure to risk, and therefore less exposure to the legal system.

David: I know there’s been some debate recently I think between Dr. Sachs and Dr. Gaba about the necessity of using real kind of medical simulators in doing the training or whether the training can be done in a classroom environment. Do you have a view on that?

Steve: I think it takes both. I think you need an underlying level of expertise that you can get from the classroom before you go into the simulator, which is the classic aviation model. I mean, you’re going to do some classroom training before you get into the simulator, so that the time spent in the simulator makes sense for you and you can tie together what you’ve learned in the classroom. So, I don’t think you can actually do one without the other.

I do agree that simulation is the best place to teach teamwork training. I think the aviation experience would bear that out. But I don’t think you can just jump into a simulator without doing any sort of pre-work in the classroom and make the best use of your simulator training time. So I’d say you have to have both.

David: As you look around health care, you mentioned the field being 15 or 20 years behind aviation. I’m guessing you’re being charitable about that. But do you see examples, either in particular specialties or hospitals or particular countries, that are maybe a little bit ahead of the curve and, if so, how did they get there?

Steve: Anesthesia is clearly ahead of the curve. And I think they got there because they realized the extent of their errors and the effect of that upon their patients long before the rest of the other specialties did. And I think they took lessons out of the aviation play book a long time ago. So, they’re clearly ahead of the other specialties. And, quite frankly, most of the time when we go into a hospital, it seems that someone from anesthesia always ends up being one of our champions, you know, to help us implement the program in other specialties, especially in surgical services.

Recently, many of our clients are actually starting out in labor and delivery. And I think that’s a function more of need as they have the highest exposure to risk and the highest claims history. But I fully expect that the OB area or the labor-delivery area will catch up pretty rapidly as well.

And other areas that we are gaining a lot of traction in are emergency departments and ICUs. Especially since intensive care is becoming so specialized and so teamwork-dependent, I think they’re going to see the need for it.

I just spent quite a bit of time at the Annual Conference for the Extracorporeal Life Support Organization. So, it’s the profusionists and the physicians and staff that basically run the heart-lung machines, mostly in neo-natal intensive care units for preemies. And they’re really rapidly catching onto this whole, “We’re a team. It takes a huge team to do this well. We’ve really got to get this whole teamwork training and communication thing down and put systems in place that ensure that the teamwork happens.”

David: When a hospital decides that they want to bring LifeWings in, what kind of a commitment is it for them, either in terms of costs or time or commitment on the part of the staff?

Steve: Clearly, there is a financial commitment, because they have to pay for our services. And clearly there is a time commitment, because you have to spend some time doing the training. And you have to spend some time doing the process engineering to put the tools in place. And then there is a time commitment to manage all the moving parts.

I tell our clients that, “You don’t need the support of the entire population to get moving.” To use a risky analogy here, it’s really kind of like conducting a guerilla warfare campaign. You need about three things to get started. You need the support of about 15 percent of the population. You don’t need the support of every nurse and every physician and every staff member and every administrator to get started. You just need the support of some key people.

You need a secure base of operations. And, in this case, a “secure base of operations” means you are under the cover of the support of the highest level of administration, which means your board is supportive of it and your executive suite is supportive of it. Then you need the support of essentially a strong government. And that again is the support of your key administrators.

So, if you’ve got those three things, you can be successful. And then each piece builds on itself going forward.

So, who do you really need to get started? You need the support of someone from the Chief Executive Office and that’s generally the President or the CEO and quite frankly they wouldn’t have funded it if they weren’t supportive of it. And you really need the support of the Chief Medical Officer or the VP of Medical Affairs, and obviously the support of the Chief Nursing Officer. And then in whichever department you start in, you need the support of the Chair of Surgery or the Chief of Surgery or the support of the Chief of ICU, whoever the key medical director is of that particular department. You obviously need his or her support. Then you need the support of your director or your manager, like your Director of Surgical Services.

On top of that, you need one physician champion who does not hold a title or a position, they’re just a physician that works there in that department who can really champion the cause. And, if it’s in surgery, you need the support of one anesthesia champion. So a surgical champion and an anesthesia champion. But, generally, if you have two physician champions, you’ve got enough to get this started.

So you count that up. That’s the support of six, seven, maybe eight people at the most and if they’re supportive and follow the process, then they’ll generate the support among the additional 15 percent and then that 15 percent will generate the support among the rest of the population. And then you’ll end up being successful.

David: As the concept of patient safety has become better known with the IOM reports and then just more of an awareness in the general press, I’ve started to see articles that are recommendations to patients about what they should do to protect themselves in the hospital. And I’ve seen things like advocacy; that patients should make sure to tell physicians to wash their hands and to ask the nurses if the right antibiotics have been started, or whether a particular line can be removed.

And when I said I thought you were charitable with the aviation thing. It’s 15 or 20 years ahead. I’m just wondering, thinking back 15 or 20 years ago, I don’t remember asking if the flight attendant had closed the door, or if the pilot had taken fuel on or if they had their glasses. Is this being unfair, is it more complicated, are there some other pieces, or do people have a right to be upset about the current state of affairs in medicine?

Steve: Well, I think they are. I don’t know if “upset” is the right word. I think “vigilant” is the right word. And I absolutely believe that patients should be vigilant. Absolutely do.

I still fly for FedEx and a lot of my peers know what I do for health care and it always seems to come up in conversation with my piloting peers. And that conversation never starts without them telling me a story about what’s happened to them or what’s happened to their family. It seems like everybody has a story of some sort of huge mistake or difficulty that they’ve had with the healthcare system.

The other area of conversation is always, “Hey, you know, my mom’s got to go in for surgery. What should I tell her?” Or, “I’ve got to take my son in to see a specialist. What should I be looking for?” And my first piece of advice to my friends and peers is, “Never go to a hospital for an invasive procedure without 1: doing your due diligence and, 2: having a wing man. Always have a wing man.”

And the wing man could be your spouse or your parents. Somebody to look out for your interests when you’re under anesthesia or groggy from medicines or recovering. And by that I mean cross-checking medicines, making sure that when folks come in they do wash their hands. All of those things, I think, you have to have a wing man if you can’t do it yourself. And you need to be hyper-vigilant that basic blocking and tackling is done correctly in terms of hygiene and cleanliness and double-checking the meds and all of those sorts of things.

And quite frankly, my most successful clients take to heart our message that the team to provide care doesn’t only consist of the healthcare team. It also includes the patient and the patient’s family. And my best clients actively recruit patients and patients’ family members to be part of the team and to be part of the cross-check.

David: I notice on your bio that you have over 300 aircraft carrier landings. And I have to ask: Is that harder, or is it harder to change the culture in some of the hospitals that you work in?”

Steve: Both are very, very challenging and both have different rewards. In performing a landing on an aircraft carrier, the penalty for failure is most likely my own personal death. And if I’m truly unfortunate, I might take some of the crewmen on board the aircraft carrier’s deck with me. It is a very unforgiving task. Unforgiving of failure.

Now the failure for not being able to help a hospital change its culture is not my personal death, but it is most likely the unnecessary death of many patients who probably would have survived their care had the culture been different. So there are different risks and different rewards.

Quite frankly, I would never trade the ability to do what I’m doing now to go back and be able to do some more aircraft carrier landings. It was a challenge. I’m very glad that I can say that I did that. I’m glad that I survived it. I’m glad that I did it well.

But in terms of leaving the earth in a better state than I found it, this is truly the highest and best use of my time and I really feel like I, and all the people that work with me on this task, are making a difference. And so the intrinsic reward for changing the culture is way better than the intrinsic reward of just being good at aircraft carrier landings.

David: I’ve been a little harsh on the healthcare system and medicine during in this interview. I was wondering if there is anything that you see in medicine that you’ve been able to bring back into the world of aviation.

Steve: Well, I’m always struck, everywhere we go, with the incredible passion and care and concern that physicians and nurses and staff have for their patients, in spite of the fact it’s just an unrelenting stream of people that need help. And, you know, to be able to, day in and day out, carry that level of care and enthusiasm and passion for what you do is something that I have brought back to aviation because, quite frankly, aviation can be, in terms of transport aviation, moving from point A to point B, can be pretty routine.

You know, I do think about that. I do think about what an incredible group of people that are attracted to healthcare and they don’t seem to take their position for granted. So, it reminds me not to take the profession that I love for granted.

David: I’ve been speaking today with Steve Harden, President of LifeWings Partners and co-founder of Crew Training International. Steve, thanks very much for your time today.

Steve: I’ve really enjoyed answering your questions.

Interview with MedHelp CEO, John de Souza (transcript)

published date
October 17th, 2007 by
This is a transcript of my podcast interview with MedHelp’s CEO, John de Souza.

David Williams: This is David Williams, co-founder of MedPharma Partners, and author of the Health Business Blog. I spoke today with John de Souza, CEO of MedHelp, a popular website where patients can post questions about their health and receive answers from leading doctors.

The service is advertising supported, and attracts about four million visitors a month. Although MedHelp fits into the Health 2.0 bucket, the company’s actually been around since 1994. John and I spoke about how patients use the site, why physicians and hospitals participate, and MedHelp’s plans for growth.

John, thanks for being with me today.

John de Souza: Thank you for having me.

David: John, tell me a little bit about the story behind MedHelp. The company’s not brand new, and I’m interested to hear how it’s evolved over time.

John: MedHelp has been around for a long time now. The company started back in 1994. It was actually started by two people, Cindy Thompson and Phil Garfinkel. Cindy, at the time, was searching for a lot of medical information. Her mother had been ill and they were unable to diagnose what exactly her condition was.

She went for several years before eventually she came across a physician who went to her and said, “You have systemic mastocytosis“, and was able to get her on medication. But in the process her body weight had dropped to about 70 lbs.

It was two years later that she met the doctor at the NIH and was able to get the right combination of drugs to help her improve her body weight. But unfortunately, at that point, she lost a lot of weight and wasn’t doing well, and then she passed away. But that drove a mission for Cindy to help people get to really good doctors.

Phil’s daughter, at the age of two, and right around the same time, was diagnosed with a malignant brain tumor. And two different brain surgeons came up and told him, “You’ve got to choose between different courses of action here. You need to tell us what to do.” And he wasn’t sure, and he was out trying to reach doctors for information to find out what’s the best course.

So the two of them got together. They met actually while they were searching for information and said, “Wouldn’t it be great to create a resource whereby people can go and find out the best doctors in the world and pose their questions to them?” I think a lot of us, being in large cities, forget that a lot of people don’t have access to really good doctors.

So they actually set this up back in 1994 with the mission to be the largest, most trusted health care community in the world. Largest, because they realized that for this to be useful for health care, you need to be able to deal with a lot of conditions.

No matter how rare your condition, it’s very important to you. And the only way you do that is by having a large number of people working with the best doctors.

David: And was the website similar to what it is today? Was it fundamentally the same sort of idea?

John: It started similar. There’s a lot more functionality now that incorporates a lot of new technologies. But the heart of it was similar back then. They said let’s go out and get the best doctors, make their questions available to users, and people can go and work with them.

So they’ve been working with a lot of these hospitals for over a decade now. And when you look at the hospitals, they’ve done a great job of going out and working with many of the top hospitals: Cleveland Clinic, Mass. General, University of Washington, Brigham & Women’s, and the list goes on.

David: And so it sounds like Cindy and Phil built the company up. Are they still active? And where did you come into the picture?

John: Yes, they’re very, very active. I think for a company to be really successful, you need a real passion. This was born out of a real need, and so they’re very active. They’re committed to this and keep on pushing it.

My interest in this has also been a personal journey. I was originally born in Ethiopia. I eventually came to the US to get an education and went to MIT.

I loved medicine, did medical robotics. And eventually for me, the highlight of my educational career was getting into Harvard Medical School. But at the time, I found out, being from Africa, that the US government required me to leave the US upon getting my medical degree.

They required me to go back to Africa. We had left during the revolution. I didn’t really have a place to go back to.

David: Right.

John: And so the only way for me to go through and do it was to go and get a green card, get my permanent residency and come back. That journey took me a long time. It took actually nearly 15 years to get it, and I never actually got my M.D.

I’ve always had this interest in medicine. So I actually got to know Cindy and Phil way back in 1995. I have a background in technology and startups, and was sort of advising them since 1995, and then got actively involved about a year and a half ago.

David: There are questions that are on the forums that patients submit, and then either individual doctors, or some doctors from these major medical centers that you described answer those questions. How does that work? And why is it that the doctors, or these medical institutions actually participate at MedHelp?

John: We spent a lot of time wondering do we pick questions and answer only selected questions. And in the end, we really believed that in health care, if you have a question, it means a lot to you.

Even though to somebody else, it’s not as significant as a different question, we decided that everybody who has a question needs to try to get it answered. So we go through and we answer most of the questions that come. It’s on a first come, first serve basis.

In terms of the institutions, I was actually delighted going in and speaking at institutions because a lot of them are looking for ways to reach out to the consumer. For them, this is a great way for them to say, “Look we’re looking for different ways to reach out. You have a large number of people.”

We have about 4.5 million that come to our site every month. So it’s a great way for them to do it, and not have to worry about interface, how do you build traffic, what do you do.

All that’s taken away from them. They inform us on what they do well, which is their medical specialty. And they get a tremendous amount of people that see the work they do.

In addition to responding to that one question, that one question answered gets viewed thousands of times by other people. For them, it’s a great amount of visibility, and it showcases what they do really well, which is helping people with medical questions.

David: I noticed that in addition to being able to raise the profile for some of these individual physicians and institutions, that in some cases, there’s a ‘Request an Appointment’ button on the form that allows a patient to actually click and request an in-person appointment.

Is that a popular service? Do people actually do that? And do they follow through, and cut and paste in the URL that refers to their specific discussion?

John: We’ve put that out there for a variety of reasons. They actually had a lot of people coming to us and asking us to coordinate meetings with the institutes we work with; so we’ve done that.

And after working with those institutes, they’ve actually gone out and set up these e-conference services to help deal with that traffic. We get both domestic people and international people who want to do it.

They also have, across almost all institutes, people who show up with print-outs from our site, and they say, “This is the doctor I want to see.” And when you think about it, what is unique about the experience you have on our site is that you have a chance to sit in on a doctor-patient interaction. You get a feeling for what kind of doctor this is, what sort of temperament he has, and does that work well with you.

Normally you don’t have that. Normally, when you go in to see a doctor, you don’t know what you’re in for. You don’t usually have much say. And so I think people really like it. They get very comfortable with the doctors.

And once they do and they build that rapport with the doctor, they want to go in and see that doctor. So it’s been very common for people to go in with a printout and say, look, this is exactly the doctor I want to see. I want to go on. And we get a lot of activity on that. A lot of people do click on that and we do send a lot of referrals back.

David: Well, it sounds very useful because I know that it’s often the case that when people go to these very esteemed institutions, traveling a long distance to get there, the service they receive is not always so good. They have to bring a lot of their own medical records, and you’ve got somebody taking a look at something for the first time. So to me it would make a lot of sense if somebody can actually continue the online discussion.

There are different types of forums on MedHelp. I notice you have some forums where it’s what we’ve been describing, where the patient’s asking a doctor a question. But then there are some other forums that are patient-to-patient forums, and then there are forums about pets.

But leaving the pets aside for a minute, what’s the difference between the doctor-patient forum and a patient-to-patient forum? Because I do notice on the doctor-patient forum, sometimes patients also comment, people who are not the original person asking the question, but somebody may offer some kind of a hint or a tip.

John: Yes, we do have different forums, and these serve the different needs you see out there. So the first one was for people to go and get access to these experts. And if you have a question that you have simply for a doctor, you go through the doctor-patient forum and ask the question there. Actually to step back, when you look at how people fish for information, often what they do, the first one is they want to go out there and they want to understand the disease, read general information.

But the second phase of that is they want something personalized. They now have a question specific to them and that’s when they will go to the doctor-patient forums, pose the question there, and get a response that’s tailored to what they need.

There are two other needs that we try to meet. One is the value of shared experiences. If you have a specific condition, you go through and see almost anything. You put it into search and you go through and find a large number of people who have very similar conditions. And you can read their questions, the responses, and you learn through that.

So the shared experience is very, very important and the patient-to-patient forums definitely help with that, but also they are used for support. As you’re going through it, sometimes all you need is for other people to help support you through the experience. And so you see a lot of that in the patient-to-patient forums as well.

Beyond just the forums, we also do have all the other community aspects. You do have people that create journals. You can go and see people, as they’re going through therapy for different illnesses, they’re keeping journals. So you can read their journals, you can see what they’re going through.

We do have a way for people to do messaging between each other. And we have a lot of those community aspects as well to help build a community. A lot of people just share their experiences and gain support.

David: And then on the doctor-patient ones, I was intrigued. I saw an example of a woman asking about congestive heart failure. And she said she’d had this, that, and the other test done. And she was asking the physician whether that could rule out CHF or if she had to look into it further. And the physician responded with some tests that the woman should ask her doctor about.

And then I thought it was interesting that a patient commented to say, hey, this sounds like it could possibly be sleep apnea, and you might want to check into that. And it seemed to me to be very valuable, because you had both the strict clinical answer and then you had a patient who may or may not have been right, but suggesting something that might short-cut somebody who might have been in a similar situation to someone like Cindy or Phil, actually trying to find the shortest path to what their actual diagnosis is.

John: It’s actually multi-leveled. The one which you are describing is a very common occurrence. We actually had this lady who wrote to us recently saying that she was having trouble with her pacemaker. And she kept on describing it to her local physician. The local physician said, I don’t think there’s anything wrong, you’re fine.

So through the online discussion she met another lady that was in a similar situation. The other lady said, at a certain point I switched to a dual-chamber pacemaker and it completely solved my issue. This lady then did get a change to a dual-chamber pacemaker and it completely resolved her issue as well.

So it is a common experience. It helps direct them. And often, depending on the type of physician you go through, this really provides them with a clue as to one more thing for them to check to see if it makes sense or not. But again from a physician’s perspective, according to a cardiac surgeon at the Cleveland Clinic, and he was saying, what I like about this site is I learn things from your site.

And I was surprised about that. And he said, you know, he was answering all these questions to people about heart palpitations, and he realized after a while that there must be a link between the heart palpitations and the menstrual cycle because a lot of people were asking about that. He did the research on it, and sure enough, there is a link.

David: One of the things about medicine that always strikes me is that it’s not particularly systematic in how diagnoses are done. So when you have somebody presenting with symptoms and you’ve got a doctor giving some answers and patients chipping in, it’s great that you’ve got millions of visitors and excellent physicians who can help out.

But there are some more systematic approaches that are being developed. And I wonder if you’ve thought about marrying those up. I’m thinking about computer-aided decision support, for example, that might help elicit the symptoms that somebody might actually need to check to see whether sleep apnea or in fact something else might be also worth looking into.

Have you thought about incorporating those kinds of tools? Or how do you think about it?

John: We have spent a lot of time thinking about that, and especially because we have probably the largest archive of questions and answers. You know, for 14 years we’ve been doing this. There are millions of posts that we have. And just going through all of these archives has led to incredible insights as to what people are asking, what works or doesn’t work.

And so we are looking to that to say, since we have this incredible resource here, how can we help mine it in different ways to provide those sort of connections between the different diseases and do exactly what you’re talking about.

David: And then so there would be a kind of a research aspect to that, and you’d also maybe present information to patients to say, well, based on what you’re describing, maybe these are some other things that you might want to also be considering. You wouldn’t be just giving the diagnosis but it would be to help to steer people into the right sort of directions and questions that they should be asking. Is that the idea?

John: Exactly. So we have the ability to go through all this and find out exactly what all the related conditions are based on all the archives of questions, and use that to say here are a bunch of things you should look at as well. And hopefully this will help. If nothing else it will provide you with a lot more knowledge going in to speak with your doctor.

David: I guess another piece beyond understanding from some of the symptoms and other aspects, what are the questions that people should be asking: if you had access to a person’s personal information, like a personal health record, it seems like that might also help.

I know that it’s an anonymous site, but is there any way to think about linking with a patient’s personal health record so that the questions that they are providing are more on target, or the answers can be recorded by them in a systematic way?

John: We’ve been spending a lot of time with our users to understand how we can serve them better on that front. We want to do this in conjunction with them. And we want to make sure that we have their trust. So I think over the years we’ve built the trust of our users. And so we want to make sure that as we do accept more information, that they are comfortable with how it’s being used.

So, we were spending time with them and said, we want to keep this anonymous. I think that it’s important to make sure we relate that the information we share here is not going to go back and be connected to you. But at the same time we want to make sure that you can ask questions and provide the relevant information to get the best response back.

We spend time with them to understand – how do we provide more information while at the same time maintaining trust and anonymity of the users.

David: You described before how you had patients who were going and getting, in-person, second opinions after they’d had conversations on MedHelp. Can you describe a little bit what the demographics might be of a typical user. I’m sure with four million people, you’ve got all types. But are there any particular types of users that are worth talking about?

John: Well, you know one thing that has been unique is – I know a lot of these sites that talk about having online communities. A lot of them tend to be heavily skewed towards women. They have 80 percent women or 85 percent women. I think we are surprisingly balanced from that perspective. For whatever reason the men seem comfortable coming online, as well, on our site and we tend to have a very good balance.

We tend to also reach, I think, older people as well. Whereas a typical demographic of an online health community would be primarily younger women. Since we tend to be balanced by age, balanced by sex and so we have a large audience.

I remember when I was traveling in India over Christmas. When we got there, I was in this rickshaw and asked the rickshaw driver as he was talking to me and he asked me, “what do you do?” and I say that I work for MedHelp and he said, “MedHelp, I go to your site to ask questions.” I go, “What do you mean?” He goes, “Well, I have a cellular phone and on my cellular phone I can access your site.” And he showed it to me and he said, “I’ve gone there and I’ve read the questions and answers and it’s really useful.”

And so, I think when you look at our site, a large portion, we have information that is accessible to everybody: the young, the old, people with broadband, people with dial-up. Maintaining that accessibility has been key to the site.

David: Tell me a little bit about the business model, because you have described a lot of activities that are going on and it sounds like it’s a very valuable service, but I haven’t heard yet about what the revenue generation model is.

John: We do have advertising on the site. Before we actually did a lot of that, we reached out to the users and we played with different models. Advertising has worked very well for us. For the users, they were happy to have the advertising there. So, if it makes sense to them, they do click on it. The advertising tends to be very relevant. If they’re in a specific forum, the advertising is definitely targeted to that condition.

From the users, they see relevant ads. From the advertisers, they’re happy because they get in front of the people that it makes sense. So, it was a very nice marriage between the different parties.

David: It does seem to make sense because people are really segmenting themselves based on the specific forum that they’re visiting. I did notice that a lot of the ads, and this is probably not a surprise, are for prescription drugs and even for some of the blockbuster drugs. There would be blockbusters – I noticed that an Exubera ad followed me around from forum to forum, probably because a lot of people have diabetes and advertisers are paying top dollar to get that kind of ad placement.

I’m wondering what you think about the sustainability of that model and if that’s the kind of model that you think you’ll, if we have this conversation again in a couple of years, will it be more or less similar to what you’ve done now or are there other sorts of avenues for revenue opportunities?

John: We definitely are interested in working with different hospitals, with other companies on doing surveys. I think that if people are interested in getting surveys of users and willing to pay the users to do it, I think we can find ways to do that to benefit the users as well. We would embrace that.

We want to keep it, part and parcel, from a users perspective to make sure that we’re not putting up unnecessary barriers or making an unpleasant experience. So, we want to do that and we have all these hospitals that we partner with and whatever we can do to help them as well, we’d love to do.

David: Now, the company’s been around quite awhile, as you described early on, and lately in the last year or so there’s been a lot of talk about Health 2.0. I know there was just a conference on that topic. If I look at your site, it has a lot of elements that you describe as Health 2.0. What’s your impression about Health 2.0? Do you consider yourself in that space? Do you think that the hype is justified? Are there any aspects of it that are important for MedHelp as you think about your next steps?

John: I think the user need has been around for a very long time. For the last fourteen years people have been clamoring for better access to doctors, for better communities to discuss stuff with other patients. The path has been there. I think the doctors also have been willing to do the outreach. I think that aspect of it has been around for a long time and that’s not new. We do have a lot of interesting technologies that are coming out that are helping, facilitating, this sort of interaction.

Back when we had the previous bubble, there was a lot of buzz around this as well and I think a lot of people –rather than really thinking at the needs of the patients– get caught up in the hype and the Health 2.0… A lot of them disappeared. I think almost all of them after a while went away.

So, for us the question is, we’d love to see this interest in it. I hope it’s a sustained interest. This is a field where I want a lot of people to succeed because they’re all serving a very important need.

David: Does the company have external investors? Are you looking at that, either partnerships or more traditional kinds of financial players?

John: We have been internally financed. We’ve pushed a lot to keep the company profitable. Rather than the money it’s the partners you work with. We have always been looking to work with the right partners and I think with the right partners you can grow a very big, very successful company. So the thing, our approach to any of the financing will be let’s understand who’re the partners you’re working with. If that makes sense then everything will fall into place.

You need to find an investor that understands the space, what the needs are. Because the danger is that if they don’t understand the space, they come in and then money can make you do very unnatural things very quickly. I think with the right partners you can do a tremendous amount. There is a lot that has to be done in this space and we have four and one-half million users. We are very proud of that.

But I think there is an opportunity here to easily get to 10, 15 million users a month. I think that there is a tremendous amount that can be done. We’d love to get there. So, if we could find the right partner, we’d love to work with them to sort of accelerate that and get there and to help as many people as we can.

David: I’ve been speaking today with John de Souza, CEO of MedHelp. John, thanks very much for your time.

John: Thank you very much for having me.

Interview with Steve Harden, President of LifeWings

published date
September 28th, 2007 by

Steve Harden started his career as a Navy pilot, with more than 300 aircraft carrier landings. Steve eventually co-founded Crew Training International, where he brought Crew Resource Management training (or CRM) to US and overseas air forces and commercial fleets.

More recently Steve founded LifeWings to bring CRM to health care. Steve spoke with me today about what hospitals can learn from guerrilla warfare tactics, how landing on an aircraft carrier compares with his current work, and the importance of bringing a wingman with you to the hospital.

Interview with Medical Tourism Association Founder Jonathan Edelheit

published date
September 27th, 2007 by

This is the transcript of my podcast interview with Jonathan Edelheit.

David Williams: This is David Williams, CEO of Jonathan Edelheit is an executive at a company that sells limited benefit health plans, which are sometimes called Mini Meds. These plans cover day-to-day expenses but they don’t cover major surgery. Jonathan’s involvement in medical tourism began as a way to add affordable major medical coverage to Mini Med Plans. But now, he’s going a step beyond, by founding the Medical Tourism Association.
I spoke with Jonathan about the future of medical tourism as an insurance benefit and his plans for the Association.
I’m speaking today with Jonathan Edelheit, Vice President of OptiMed Health/United Group Programs. Jonathan, thanks for being with me today.

Jonathan Edelheit: Oh, it’s my pleasure. I appreciate you having me.

David: Jonathan, what is OptiMed Health and United Group Programs. Can you tell me a little bit about the company?

Jonathan: OptiMed Health Plans is a subsidiary of United Group Programs and it’s a special arm of our company that we have that offers low-cost health care to part-time and hourly employees, 1099 contractors, full time employees who aren’t eligible for major medical benefits and also for individuals who are part of associations. And basically, it’s an alternative to expensive major medical insurance for people who need low cost, affordable insurance. It starts at about $50 a month and covers the day-to-day expenses like going to the doctor, getting prescription drugs, going to the ER, but not the catastrophic.

United Group Programs is the parent company. We’re a national health care company. We administer health care plans here and throughout the United States. We’ve been in business for about 40 years and we have about 4,300 corporate and governmental clients throughout the United States and we are really trying to focus on cutting-edge health care products.

David: So would that be a kind of a third party administrator business?

Jonathan: Yes, absolutely.

David: And so, with 4,300 companies, roughly how many covered lives does that represent?

Jonathan: It’s several hundred thousand.

David: You’re a major player then in that space.

Jonathan: Yes, absolutely, and we’re very well known nationally.

David: And on the low cost plans, are those plans what some people call limited benefit plans or Mini Med Plans?

Jonathan: Exactly.

David: How did you become interested in medical tourism then?

Jonathan: It kind of segues, exactly into what we’re doing with Mini Med because with our Mini Med or low cost health care plans, they don’t cover the catastrophic like major surgeries, major hospitalization. We had heard about medical tourism, people going overseas for surgical care. Basically, I think our initial thought was the same thought everybody else had, that America had the best health care and this was substandard care overseas, “health care under a hut”. I ended up talking to several people who had gone over for health care overseas and got the exact opposite impression, that they thought it blew away our American hospitals and they got great care and great service.

So we started to look into it and what we found was our initial perception, which is most Americans’ perception, was wrong and that the health care in certain countries is very advanced and in some ways, it can be more advanced than ours, but especially in the area of better service, people who need more quality time with the providers and better standards in the actual room people are staying in.

David: So it sounds like you’re well positioned to introduce a product like this into the market because unlike somebody who maybe has a comprehensive Blue Cross, Blue Shield plan, and when their insurance says they were offering this as a benefit, they get skeptical, you’re explicitly not offering major medical and this is the way to offer low cost major medical, at least a portion of it, and it’s something that your customers, your members might be paying out of pocket anyway. They might be some of those so called medical tourists who are going on their own nickel.

Jonathan: Oh, absolutely. Now, we’re able to give them the option to say, “Hey, you really don’t have coverage for surgery here in the US and we know you can’t afford it. So now, here’s an option to go overseas for surgery at an international hospital for 80% less than in the United States.”

David: If you look at introducing medical tourism as a benefit, what sort of hurdles do you need to overcome beyond the initial one that you described upfront about people assuming the US health care is the best and if you go overseas, it’s going to be dirty and nasty? Are there other sorts of hurdles and how have you been addressing them?

Jonathan: I think the first hurdle that we have is just convincing employers of the quality of the health care over there and the cost savings, and that’s not very hard. Usually in one meeting, we can convince them and they’re ready to sign up on the project.

The next major phase is actually communicating it to the employee and that’s where I think most people in the industry are completely lost because they’re not focusing on that. You really have to focus on educating the employee and making them feel totally comfortable with the opportunity to go overseas for health care.

David: Are there certain mechanisms that you would use to do that? As I had said up front about Blue Cross telling me all of a sudden it’s a good idea to go overseas, even if it is a good idea, I’m going to be worried, I’m going to take a second or third look at it, to see, “Why are they trying to send me away?”

Jonathan: The key is finding the right partner to go overseas. You’ve got to do your research, you’ve got to do your due diligence to make sure you’re going to a quality hospital by the provider that’s helping you get over there and actually has the experience. I think people will be skeptical at first and we look at it as a long-term project where we educate the employees. We know we have to wait for the first employee who needs a surgery and is willing to go overseas to do it. And when he comes back or she comes back, all the employees at the company are basically going to be waiting there anxiously to find out the stories, whether positive or negative. What our experience shows is that the employee will come back, talk about what an amazing experience they had and how they had a free vacation, and then all of a sudden the other employees at the workplace will start thinking about, “Well, why am I going to, you know, my local hospital when the care isn’t as good and the service is not as good when I can go overseas and get better service and care and actually get a free vacation, too?” Then you’ve changed the corporate climate and attitude at that employer.

David: I’m sure we’re early in that process so far. About how many people have actually gone overseas and have been able to come back and tell the stories around the break room?

Jonathan: We’ve had several. It’s a very long process that I think that most people do not understand or appreciate. What I mean by that is, after you explain to the employer the whole concept of medical tourism, and after that employer signs off on it, it could be six months to a year before you really have a taker on medical tourism, because it’s not just signing someone who needs a surgery, it’s signing that person that’s willing to go overseas. So it’s a very long-term approach, and the idea is that an employer has to buy into it and know that it’s going to take a couple of years for the program to be fully in swing, where they’ll have a change in corporate climate.

So we’ve sent less than 10 people overseas for surgery, and everyone who’s gone over has been very satisfied with their experience. We have a lot more that are in the pipeline of who’s going over, but we’ve been focusing very strongly on the whole concept of educating the employees to the point that we’re going to be getting a lot of them to go over, not just one or two each year.

David: What is the potential overall impact? I understand that for an individual surgery, you could have a major impact, maybe 75, 80 percent, or perhaps even more, on a given surgery. If I’m an employer, and I looked at all the things that I’m trying to do to reduce health care costs or improve benefits, how big of a difference does this make, overall? In other words, those expensive surgeries, how much is that really costing me today?

Jonathan: It can actually make a very significant savings, for everyone they’re going to send overseas, they could save up to 80 percent on the cost of the surgery. So, a surgery that costs $100,000, with airfare and other expenses, the surgery might cost $10,000; it might add up to about $20,000 in costs. For the employers, it’s going to be an immediate, direct savings. We actually believe if an employer gets a lot of their employees to go overseas for major surgeries when they’re needed, an employer can easily see a savings in their health care from anywhere from 20 to 50 percent. But that requires not just one employee to buy into it, but a lot of employees.

So if the employer believes in it, and what will end up happening is the employees will begin to believe in it. When their health care costs actually don’t go up each year, but start going down, then everyone at the company is going to have a significant interest in trying to work with medical tourism to keep their costs down, because everybody knows their contributions towards health care aren’t going up and the benefits are not being reduced by giving higher deductibles and co-insurance, and that’s because the employees are utilizing medical tourism, which saves the company money.

David: I know you’ve been doing a lot of international travel these days, in order to see some of these different destinations. Can you tell me about some of the places you’ve been and maybe some of those that you’re most impressed with?

Jonathan: I’ve been to Costa Rica. And I just got back from there, and it was a very nice trip. It’s a great location if people actually want to do the tourism part, along with the medical care. I was very, very impressed with the hospitals. I actually felt they were equal to or better than United States’ hospitals. And it was just a very big difference. The level of the care and the service you get definitely, tremendously surpasses the United States.

What I mean by that is the nurses, the doctors, it’s all about being polite to the patient, helping the patient, taking as long as the patient needs. It’s not with the mentality that we have here in the United States, which is you have three to four minutes and then you have to leave the doctor’s office. I spent about 40 minutes with my doctor there, and that’s unheard of here in the United States. It was just a great feeling to have communication and feedback and just kind of go over everything with the doctor, without feeling pressured or raced. The same thing with the nurses, is it’s all about service. Everybody’s there to help you, to make sure you have just a great experience.

To give you a crazy example about it, I had some people I was down there with who actually went ahead and had breakfast at Denny’s, which happens to be one of the most popular restaurants in San Jose, Costa Rica. They were just shocked and surprised, and they were telling us a story with extreme enthusiasm that they went into this Denny’s and they could not believe the level of service they had, how polite the people were, how clean the restaurant was, and how much these employees really cared about the customers. They thought maybe they were in the wrong restaurant. That equates to everything in the culture of Costa Rica; it’s just very high-quality care. Someone that I went down there with got an ultrasound, and it only cost $70. Their prescription drugs that they picked up at a pharmacy down there cost less than their co-pay with Blue Cross Blue Shield here in the United States, and the government doesn’t subsidize prescription drugs, so it’s a very different culture there.

In a couple months I’ll be going to India and also the Philippines to go visit all their hospitals. Then next month, the Medical Tourism Association has a couple board members who are going over to South Korea to inspect the South Korean hospitals, because they’re launching a big initiative for medical tourism.

David: Tell me more about the Medical Travel Association, because I understand that you’ve gone well beyond looking at medical tourism for your core businesses and are instrumental in founding this association. What’s the thinking behind that?

Jonathan: The thinking, really, is that we had really gotten together with a bunch of the top leaders in medical tourism and the top hospitals, and we found that there was no forum for anyone to get feedback or information on medical tourism. Nobody knows what conventions are going on, who’s written books, what hospitals are quality, which are not, who to work with, who not to, or just to get general information on medical tourism. Then, also, there was some real concern by a lot of the hospitals of the horror stories and negative things that could happen by unscrupulous and immoral medical tourism travel companies who send people to bad hospitals or send people to countries for hospital care that don’t have the same standards as the United States, in order to generate extra fees.

There was a big concern to help promote the industry in a positive way, and also to help regulate it. So a bunch of us all came together and made the decision to form this association, to provide information. We’re launching a comprehensive website at, where people can go online and get information on hospitals, on medical tourism, and do all the research that they would want, from a non-biased, non-profit standpoint. They’ll get detailed information on the hospitals themselves and on doctors. We’re also working on launching both a magazine and a documentary, to keep the industry informed of what’s going on. We’re looking at a lot of really neat initiatives that people just don’t know of in this industry unless you’re fully involved in it, such as we’re looking at creating minimum standards and credentialing and accrediting recovery centers, because recovery centers are popping up around the world.

While there’s maybe 100 around the world right now, there’s expected, within one to two years, to be tens of thousands. Americans don’t know that these are unregulated. There’s no government regulation. There’s no standards. The industry has no standards. We want to protect people in getting the best care after they complete medical tourism, so we’re working with all the top international hospitals to come up with minimum requirements and to certify those recovery centers that meet those requirements so that American patients aren’t going to a bad facility where they might get an infection.

David: I understand you have some fairly prominent and important people that are involved. Can you tell me some names of some of the key folks that you’re working on the Tourism Association with?

Jonathan: Yeah. We have Tom Johnsrud, who works for Parkway Hospital in Singapore. And he also used to work for JCI, who accredits all the international hospitals. He’s brought a wealth of experience and knowledge, and has really helped drive a lot of this in the Association. There’s Robert Krone, who’s the president and CEO of Harvard Medical International. We have John Bridges, who’s a Johns Hopkins economics professor who’s heavily involved in medical tourism. We have Mary Ann Keough, who’s a professor at Eastern Washington University, and then Clinica Biblica at Costa Rica is a member of the association. We’ve had several other recent members who have joined. For example, one of the new board members is Ruben Toral, from Bumrungrad Hospital. There’s a couple other very important people on there, and it’ll be posted on our website in a couple days.

But it’s neat because we have the real thought leaders and the people who have really helped, been instrumental in growing this industry and establishing it, coming together to help really promote it and also provide minimum standards and information for the public.

David: You had talked about JCI, and one of the people that’s going to be involved is ex-JCI. How does JCI fit in with your thinking, in terms of minimum standards, accreditation, and rules?

Jonathan: We’re kind of reviewing the whole accreditation process for hospitals, because I don’t think that’s going to be something that we’re going to get into right away, because we’ve got JCI, who accredits hospitals, and there’s several other international accreditation agencies.

So, what we plan on doing is really giving consumers the information as to what are the standards of each accreditation agency, so consumers can be aware of the differences between the different accreditation agencies so they can determine the quality of care and level of service at specific hospitals. The areas that we might look into, regarding any kind of accreditation, might be with the recovery centers, possibly with the medical tourism, like the travel agency type companies, but that’s where it stops.

Our main purpose is to kind of inform the consumer of the differences. Most people don’t know the international accreditation forum, the Joint Commission, is actually different and has a lesser standard than the United States’ version of the Joint Commission accreditation. So our mission is to really make the public aware, so they can make more informed decisions about their health care.

David: Jonathan, what advice would you give to a consumer who, right now, is considering going abroad for a medical procedure?

Jonathan: The advice that I would give is they really need to do their due diligence. They need to make sure they’re going to a quality hospital that’s accredited, or has certain minimum standards, or might be getting accredited shortly.

They need to be very careful if they’re working with a medical tourism travel agency type company, that they choose one that has tremendous experience, knows what they’re doing, and is going to send them to a top hospital and not just send them to a hospital that they’re going to get the biggest kickback from.

You need to make sure that you’re dealing with companies that, if they’re facilitating you getting overseas to a hospital, that they know the people at the hospital, that they’ve been to the hospital, that they can actually make recommendations. Because one of the complaints we’ve gotten from a lot of the hospitals is medical tourism type travel companies misrepresenting and making fraudulent statements to consumers about knowing hospitals, being in hospitals, and recommending hospitals, when, in fact, a lot of these hospitals don’t know who these people are and have never met them before.

If they’re going with a quality source, they won’t have to do as much due diligence, but to give you an example of why it’s so important, in the country of Costa Rica, if a hospital has under 20 beds, it’s not regulated by the government. There are Americans going over to hospitals that might have less than 20 beds, and the Americans have no idea that there’s absolutely no regulation or oversight of these facilities whatsoever.

David: I’ve been speaking today with Jonathan Edelheit, Vice President of OptiMed Health and United Group Programs, and a founder of the Medical Tourism Association. Jonathan, thanks very much for your time.

Jonathan: Thank you.

Interview with MedHelp CEO, John de Souza

published date
September 25th, 2007 by
I spoke today with John de Souza, CEO of MedHelp, a popular website where patients can post questions about their health and receive answers from leading physicians. The service is advertising supported and attracts 4 million visitors a month. Although MedHelp fits into the Health 2.0 bucket, the company’s actually been around since 1994.

John and I spoke about how patients use the site, why physicians and hospitals participate, and MedHelp’s growth plans.

John was born in Ethiopia, left during the revolution and ended up at MIT where he studied medical robotics. The highlight of his academic career was getting accepted to Harvard Medical School, but he decided not to attend once he found out that US immigration rules would force him to go back to Africa before he could practice here! He’s been an adviser to MedHelp almost since its inception, and took over as CEO a little more than a year ago.