Posts from hacking healthcare

Video Of The Week: Why Ida Tin Started Clue

I’m a big fan of our portfolio company Clue which is trying to improve women’s reproductive health and planning with their super popular mobile app.

Here’s a short video (< 2 mins)  that was posted a couple days ago where founder Ida Tin explains why she started Clue.

23 And Me

A month or two ago our daughter Jessica asked us to get 23andMe kits and get our genes sequenced. Jessica wants to add some information from our results to hers so she can better understand her own genetic makeup. So the Gotham Gal and I did it a few weeks ago and we are now awaiting the results.

The 23andMe process requires that you set up a profile on their web service and answer some questions about yourself before submitting the saliva sample for processing. If you wish, you can give them a full health care profile which is almost exactly identical to the interview a new doctor will give you on your first visit (do you/did you smoke, do you/did you drink, are your parents alive, are they healthy, are you allergic to this and that, etc, etc). I went through the entire process and shared all of my medical history with 23andMe in great detail.

So now 23andMe will have a full medical history/profile of me plus my genetic makeup. That’s pretty cool.

I have some suggestions for them as a user.

First, I wish that I could connect my profile on 23andMe with Jessica’s profile on 23andMe as her father. And I wish that I could connect my profile to the Gotham Gal as her husband. In summary, I would like for us to build a family tree on their service so that the work Jessica wants to do can be done automatically by their software. That seems like an obvious thing to do in a service like 23andMe, but I looked around pretty hard and could not figure out how to do that.

Second, I would like to be able to authorize third party services (starting with my doctor’s Patient Fusion service) to access all of this genetic and medical information I have stored at 23andMe. I found the 23andMe API so that’s a good thing. But I could not find a marketplace of third party apps that connect to 23andMe via its API. That would be really useful.

Another thing I would like to be able to do is sync my 23andMe data with my mom’s genealogy data that she keeps on Ancestry.com. I believe she has some basic genetic information there on herself. That would inform my profile in the same way that my data informs Jessica’s profile.

The bottom line for me is that this data (genetic information and medical history) is really powerful stuff. It should not be held in silos. Users should have the power to move it around, connect it up, and share it with their medical providers, family members, and others who can benefit from this data.

This is a big part of our thesis in health care. Users are starting to get control of their own medical data and decide how it will be used and by whom. That will lead to better outcomes for everyone. I am very excited by the potential of what can happen when this is really happening at scale. And that feels like it is right around the corner now.

If you want to get a 23andMe kit, you can do that here.

What Happened In 2015

Last year in my What Just Happened post, I said:

the social media phase of the Internet ended

I think we can go further than that now and say that sometime in the past year or two the consumer internet/social/mobile gold rush ended.

Look  at the top 25 apps in the US:

top 25 apps

The top 6 mobile apps and 8 of the top 9 are owned by Facebook and Google. 10 of the top 12 mobile apps are owned by Apple, Facebook, and Google.

There isn’t a single “startup” on that list and the youngest company on that list is Snapchat which is now over four years old.

We are now well into a consolidation phase where the strong are getting stronger and it is harder than ever to build a large consumer user base. It is reminiscent of the late 80s/early 90s after Windows emerged as the dominant desktop environment and Microsoft started to use that dominant market position to move up the stack and take share in all of the important application categories. Apple and Google are doing that now in mobile, along with Facebook which figured out how to be as critical on your phone as your operating system.

I am certain that something will come along, like the Internet did in the mid 90s, to bust up this oligopoly (which is way better than a monopoly). But it is not yet clear what that thing is.

2015 saw some of the candidates for the next big thing underwhelm. VR is having a hard time getting out of the gates. Wearables and IoT have yet to go mainstream. Bitcoin and the Blockchain have yet to give us a killer app. AI/machine learning has great potential but also gives incumbents with large data sets (Facebook and Google) scale advantages over newcomers.

The most exciting things that have happened in tech in 2015 are happening in verticals like transportation, hospitality, education, healthcare, and maybe more than anything else, finance, where the lessons and playbooks of the consumer gold rush are being used with great effectiveness to disrupt incumbents and shake up industries.

The same is true of the enterprise which also had a great year in 2015. Slack, and Dropbox before it, shows how powerful a consumerish approach to the enterprise can be. But there aren’t many broad horizontal plays in the enterprise and verticals seems to be where most of the action was in 2015.

I’m hopeful that 2015 will also go down as the year we buried the Unicorn. The whole notion that getting a billion dollar price tag on your company was something necessary to matter, to be able to recruit, to be able to get press, etc, etc, is worshiping a false god. And we all know what happens to those who do that.

As I look back over 2014 and 2015, I feel like these two years were an inflection point, where the underlying fundamentals of opportunity in tech slowed down but the capital rushing to get invested in tech did not. That resulted in the Unicorn phase, which if it indeed is over, will be followed by an unwinding phase where the capital flows will need to line up more tightly to the opportunity curve.

I’m now moving into “What Will Happen” which is for tomorrow, so I will end this post now by saying goodbye to 2015 and hopefully to much of the nonsense that came with it.

I did not touch on the many important things that happened outside of tech in 2015, like the rise of terrorism in the western world, and the reaction of the body politic to it, particularly here in the US with the 2016 Presidential campaign getting into full swing. That certainly touches the world of tech and will touch it even more in the future. Again, something to talk about tomorrow.

I wish everyone a happy and healthy new year and we will talk about the future, not the past, tomorrow.

What Didn’t Happen

Last year, I ended 2014 with What Just Happened and started 2015 with What Is Going To Happen.

I’ll do the same tomorrow and friday, but today I’d like to talk about What Didn’t Happen, specifically which of my predictions in What Is Going To Happen did not come to be.

  1. I said that the big companies that were started in the second half of the last decade (Uber, Airbnb, Dropbox, etc) would start going public in 2015. That did not happen. Not one of them has even filed confidentially (to my knowledge). This is personally disappointing to me. I realize that every company should decide how and when and if they want to go public. But I believe the entire startup sector would benefit a lot from seeing where these big companies will trade as public companies. The VC backed companies that were started in the latter half of that last decade that did go public in 2015, like Square, Box, and Etsy (where I am on the board) trade at 2.5x to 5x revenues, a far cry from what companies get financed at in the late stage private markets. As long as the biggest venture backed companies stay private, this dichotomy in valuations may well persist and that’s unfortunate in my view.
  2. I said that we would see the big Chinese consumer electronics company Xiaomi come to the US. That also did not happen, although Xiaomi has expanded its business outside of China and I think they will enter the US at some point. I have a Xiaomi TV in my home office and it is a really good product.
  3. I predicted that asian messengers like WeChat and Line would make strong gains in the US messenger market. That most certainly did not happen. The only third party messengers (not texting apps) that seem to have taken off in the US are Facebook Messenger, WhatsApp and our portfolio company Kik. top social apps year end 2015Here’s a shot of the app store a couple days after the kids got new phones for Christmas.
  4. I said that the Republicans and Democrats would find common ground on challenging issues that impact the tech/startup sector like immigration and net neutrality. That most certainly did not happen and the two parties are as far apart as ever and now we are in an election year where nothing will get done.

So I got four out of eleven dead wrong.

Here’s what I got right:

  1. VR has hit headwinds. Oculus still has not shipped the Rift (which I predicted) and I think we will see less consumer adoption than many think when it does ship. I’m not long term bearish on VR but I think the early implementations will disappoint.
  2. The Apple Watch was a flop. This is the one I took the most heat on. So I feel a bit vindicated on this point. Interestingly another device you wear on your wrist, the Fitbit, was the real story in wearables in 2015. In full disclosure own a lot of Fitbit stock via my friends at Foundry.
  3. Enterprise and Security were hot in 2015. They will continue to be hot in 2016 and as far as this eye can see.
  4. There was a flight to safety in 2015 and big tech (Google, Apple, Facebook, Amazon) are the new blue chips. Amazon was up ~125% in 2015. Google (which I own a lot of) was up ~50% in 2015. Facebook was up ~30% in 2015.  Only Apple among the big four was down in 2015 and barely so. Oil on the other hand, was down something like 30% in 2015 and gold was down something like 15-20% in 2015.

Here’s what is less clear:

  1. Bitcoin had a big comeback in 2015. If you look at the price of Bitcoin as one measure, it was up almost 40% in 2015. However, we still have not see the “real decentralized applications” of Bitcoin and its blockchain emerge, as I predicted a year ago, so I’m not entirely sure what to make of this one. And to make matters worse, we now seem to be in a phase where investors believe you can have blockchain without Bitcoin, which to my mind is nonsense.
  2. Healthcare is, slowly, emerging as the next big sector to be disrupted by tech. The “trifecta” I predict will usher in an entirely new healthcare system (smartphone becomes the EMR, p2p medicine, and a market economy in healthcare) has not yet arrived in full force. But it will. It’s only a matter and question of when.

So, I feel like I hit .500 for the year. Not bad, but not particularly impressive either. But when you are investing, batting .500 is great because you can double down on your winners and stop out your losers. That’s why it is important to have a point of view, ideally one that is not shared by others, and to put money where your mouth is.

Clue

Last week, our newest portfolio company Clue announced that it had raised a Series A round from USV and Mosaic. Co-Founder and CEO Ida Tin‘s blog post is here. My partner Albert’s post on why we invested in Clue is here.

There’s an interesting backstory here and I thought it might be useful to tell it.

A few years ago our oldest daughter told the Gotham Gal that she was using this mobile app called Clue to track her cycle and related health data and she loved it. She recommended it to her.  So the Gotham Gal took notice and ended up participating in Clue’s angel round. So our family has been a user (first) and then an investor in Clue for a few years now.

I got wind of this sometime later and asked the Gotham Gal why she picked Clue in a field with a number of strong competitors. She responded “in this market I’m backing a woman and Ida is exactly they kind of person who should be running a company like this.” That shut me up and ever since then I’ve been rooting for Clue.

Earlier this year USV did a roundup of all the interesting things we’ve seen in health care apps and Clue was on the list. I was mindful of my conflict of interest but did mention that I thought Clue would be raising a Series A this summer. Albert jumped on that and the result was our investment in Clue’s Series A.

If you believe, as I do and as USV does, that the mobile phone is the new EMR, then I can’t think of any better example of that than Clue. Women use it to track their cycle and their fertility and a whole lot more. I have not yet met a woman who uses Clue that doesn’t love it.

Ida says it best in her post:

Millions of people across all cultures are using Clue. With every single data point a user enters, we are moving the world toward an educated, informed and empowered future – for our users and their partners and families, for mothers and daughters and sisters, for doctors and patients.

I am super excited that USV and that our family are investors in (and users of) Clue. It’s a great app and a great company.

On Digital Healthcare

At USV, we are big believers in being public about our investment thesis and the work we do to arrive at them. We are also big believers in working with like minded VCs on our investments. A few years we decided to merge the two. My partners Albert and Andy started collaborating with Boris Wertz at Version Ventures on developing investment theses in the digital healthcare sector. They roped in two analysts, Zander and Angela and off they went. When Zander’s two year stint at USV ended, Jonathan replaced him on the effort.

For several years, this group has shared investment opportunities, research, and insights with each other. They have a shared database of startup companies and a shared market map. They have collaborated on one investment, Figure1, and thought seriously about a bunch more.

Yesterday, they started to share their learnings and, more importantly, their questions and concerns. It is called OnDigitalHealthCare and as it is currently conceived, it is a six part series on what they have learned and where they are going with all of those learnings. They are two parts into it right now.

I hope they don’t limit this to six parts and would love to see them continue to update this blog from time to time with additional learnings, questions, concerns, and insights. I think most everyone realizes that a computer in everyone’s pocket (and possibly elsewhere on their bodies) is going to massively impact healthcare over time. But how, when, and why is a lot less obvious to us, and I suspect everyone else. So we are trying to figure it out and sharing that process publicly in the belief that the more eyes and ears on our process the better outcomes for us and everyone else.

Figure1

Last week I wrote the Dentist Office Software Story and the top comment on that post was this from LIAD:

….along comes Sevin Kystrom, he only cares about looking at photos of teeth. he unbundles photos from denstry.com by creating a standalone app called teethagram. users love it. he sells it back to dentistry.com for $1bn

I kind of flipped out when I saw that comment because it describes our most recent investment, Figure1, which my partner Andy blogged about at usv.com yesterday. We had closed but had not yet announced the Figure1 investment when LIAD made that comment.

Figure1 is “instagram for doctors.” It’s not for dentists, as LIAD’s fictional company teethagram is, but other than that, and the sale for $1bn, the story is pretty much the same.

We have believed that simple, easy to use, photo centric apps on mobile have the potential to become very large businesses for a host of reasons. First and foremost, as Brian Watson taught me, photos are the atomic unit of mobile. It’s easier to snap a photo and post it/send it, than it is to do anything else, including write something. And, as the old adage explains, a picture tells a thousand words.

A doctor can say “I’ve got a patient with a very rapid A-fib” or she can send this to her colleagues:

A-fib

There’s a hell of a lot more info in that EKG than a doctor could type into a text message or email.

But the even better thing is the conversations that instantly develop around these images, like this one:

I think it’s rapid a-fib. I think the ischemic changes are due to the rate. Give them some #Amiodarone and see what happens when the rate sloes down.

Instagram is a powerful product. And most people know how to use it and the value of the interactions around photos that it produces. Like our portfolio company Edmodo, which took the Facebook UI and applied it to teachers and students in K-12 education, Figure1 takes a popular and effective UI and applies it to an industry in desperate need of change.

I’m super excited about the value Figure1 provides to doctors and their patients and I am really pleased that the Figure1 team agreed to work with USV as they build their business.

iOS8, Health Data, and Open Data

News is leaking out of Apple that iOS8’s primary feature will be health and fitness data. Rumors are that there will be a new app called Healthbook that will track a plethora of health and fitness data that iPhones and related devices (iWatch?) will be able to collect on the person carrying the devices.

This is interesting to me on a number of levels. We have been looking at this sector for a while and one of the things that has kept us (USV) from making investments in this space is the sense that all of this data capture is soon going to happen in the phone itself.

Once that happens, things can change pretty rapidly. The key will be APIs. And my big question is whether Apple will give its users an open API to send their health and fitness data to third parties they authorize.

I can see a button that says “auth with Healthbook” in my doctor’s office, my gym’s mobile app, my health insurers’s web app, and a host of other places.

So to my mind, the big question is not what Healthbook will look like but whether Apple will make it easy to get our data out of it. If they do, this will be a massive game changer for the quantified self, health, and wellness markets.

Large Networks, Big Data, And Healthcare

Zander posted this NY Times opinion piece to usv.com yesterday and it's been rattling around in my head since then. The author suggests that big data is coming to health care and bringing with it many issues that will have to be resolved. I am sure that is so. But I also think the intersection of big data and health care and our large networks thesis is likely to produce some interesting investment opportunities for us and some valuable health care services for consumers.

Jason Karlawish, the author of the NY Times opinion piece, writes:

This is a revolutionary shift. Once upon a time, medicine was a discipline based on the nuanced diagnosis and treatment of sick patients. Now, Big Data, networked computers and a culture obsessed with knowing its numbers have moved medicine from the bedside to the desktop (or laptop). The art of medicine is becoming the science of an insurance actuary.

The question is who will control the input of the patient data, the aggregated data sets, and the results the data science produces. If the answer is the current healthcare system; the insurance companies, the hospitals, and the doctors, then we will have missed a big opportunity to reshape healthcare. If, on the other hand, the data is entered by patients, controlled by patients, and benefits patients, then we would have something new, different, and disruptive.

Large networks of patients coming together to do this data science together and benefit together feels like its around the corner and coming fast.  Maybe some enterprising entepreneur will take this "Omnibus Risk Calculator" put it into a clean and simple web service, allow us to connect our phones and connected devices to it, and peer produce a service that we can, together, use to manage our cardiovascular health. Maybe someone has already done that.