GUEST POST from Arlen Meyers

Do you wonder why some innovations diffuse, while others don’t? These days, we like to use trendy buzz words like scaling, getting traction and going viral, but the meaning is the same. But, there are many terms and concepts that are being used that are confusing , so here are some basics to set you straight:

1. Who, when, why and how people adopt new ideas goes back to Everett Rogers and his book, Diffusion of Innovations
2. Implementation science is the systematic study of strategies and factors associated with the successful integration of evidence-based interventions and policies into practice (and de-implementation of wasteful and ineffective programs). Adoption is another term describing the same thing.
3. Dissemination research involves the study mechanisms and approaches to communicate and spread information targeted to potential users to accelerate adoption and implementation (going to scale). Another term for it is penetration.

4. The five stages of the adoption process are:

1. Knowledge (Awareness): In this stage the individual is first exposed to an innovation but lacks information about the innovation. During this stage of the process the individual has not been inspired to find more information about the innovation. Hint: How can social media drive curiosity?
2. Persuasion/ Intention: In this stage the individual is interested in the innovation and actively seeks information/detail about the innovation. Hint: How can smart website content on the Google search results page help educate this potential user?
3. Decision: In this stage the individual takes the concept of the change and weighs the advantages/disadvantages of using the innovation and decides whether to adopt or reject the innovation. Due to the individualistic nature of this stage Rogers notes that it is the most difficult stage to acquire empirical evidence (Rogers 1964, p. 83). Hint: How can you make the first digital experiences with the brand enjoyable and useful?
4. Implementation/Action: In this stage the individual employs the innovation to a varying degree depending on the situation. During this stage the individual determines the usefulness of the innovation and may search for further information about it. Hint: How can you build an online community to help new users get up to speed on using your product or service? Can you craft content such as a “Beginner’s Guide with FAQ’s”?
5. Confirmation/Validation: Although the name of this stage may be misleading, in this stage the individual finalizes his/her decision to continue using the innovation and may use the innovation to its fullest potential or abandon it altogether. Hint: How can you reassure a user in real-time they made the right decision?

Here are the five customer segments by rates of adoption:

Innovators (2.5%) – Innovators are the first individuals to adopt an innovation. Innovators are willing to take risks, youngest in age, have the highest social class, have great financial lucidity, very social and have closest contact to scientific sources and interaction with other innovators. Risk tolerance has them adopting technologies which may ultimately fail. Financial resources help absorb these failures. (Rogers 1962 5th ed, p. 282)

Early Adopters (13.5%) – This is the second fastest category of individuals who adopt an innovation. These individuals have the highest degree of opinion leadership among the other adopter categories. Early adopters are typically younger in age, have a higher social status, have more financial lucidity, advanced education, and are more socially forward than late adopters. More discrete in adoption choices than innovators. Realize judicious choice of adoption will help them maintain central communication position (Rogers 1962 5th ed, p. 283).

Early Majority (34%) – Individuals in this category adopt an innovation after a varying degree of time. This time of adoption is significantly longer than the innovators and early adopters. Early Majority tend to be slower in the adoption process, have above average social status, contact with early adopters, and seldom hold positions of opinion leadership in a system (Rogers 1962 5th ed, p. 283)

Late Majority (34%) – Individuals in this category will adopt an innovation after the average member of the society. These individuals approach an innovation with a high degree of skepticism and after the majority of society has adopted the innovation. Late Majority are typically skeptical about an innovation, have below average social status, very little financial lucidity, in contact with others in late majority and early majority, very little opinion leadership.

Laggards (16%) – Individuals in this category are the last to adopt an innovation. Unlike some of the previous categories, individuals in this category show little to no opinion leadership. These individuals typically have an aversion to change-agents and tend to be advanced in age. Laggards typically tend to be focused on “traditions”, likely to have lowest social status, lowest financial fluidity, be oldest of all other adopters, in contact with only family and close friends, very little to no opinion leadership.

5. Most of us buy emotionally and justify rationally.

6. Here are the ABCDEs of technology adoption and errors.

7. As a digital marketer, you have the unique first-time opportunity to touch a consumer across all five steps of this process.

8. Here’s where crossing the chasm meets the lean startup in digital health

9. Here are the 6 dysfunctions of engaged communities

10. Here are some reasons why doctors don’t care about customer service and why they won’t text you

Here are some things innovators can learn from failed innovation efforts in sick care.

A major challenge in sickcare is the amount of time it takes for an evidence based innovation to disseminate into clinical practice. AI aggregation of scientific information might help. New D/I techniques might help. Behavioral economic and social psychologic techniques might help.

The next time the dog won’t eat your food, think about why. The answer is somewhere above.

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GUEST POST from Arlen Meyers

Victor Fuchs and Mark Cullen published an article in JAMA questioning the impact of health systems change on doctors and how the medical educational establishment should respond with curriculum reform that includes, among other things, health economics and population health.

They further provide a short history of healthcare policy and structure and how it has evolved from an unregulated industry to one that has become increasingly corporatized. They note the rise in employed physicians and that :

Physicians might become less professional, but their professional role could increase as their entrepreneurial role decreases

It seems to me there is confusion about physician entrepreneurship,its definition and whether it represents a threat to professionalism. I’m not alone. Is a physician entrepreneur someone who starts and runs a business, or is it something more?

1. Entrepreneurship is the pursuit of opportunity with scarce, uncontrolled resources. The goal of all entrepreneurs, including physician entrepreneurs, is to create user defined value through the deployment of innovation using a VAST business model

2. Innovation has both a qualitative and quantitative component. It refers to doing something new or something old in a new way that creates user defined value that is a significant multiple of the competitive offering. Sick care sorely needs innovation that is not incremental or sustaining, but rather significantly adds at least 10x the present value to have an impact.

3. Physician entrepreneurship is not the same things as private practice nor is it fundamentally about practice management. The increasing rate of employed physicians should not be interpreted, as Prof. Fuchs implies, as decreasing entrepreneurial role of doctors and its consequent impact on medical professionalism. To the contrary, when done properly, it enhances medical professionalism.

4. There are many different goals and roles for physician entrepreneurs as small to medium sized business owners in private practice, technopreneurs, social entrepreneurs, intrapreneurs i.e.employed physicians acting like entrepreneurs, freelancers and consultants, and physician investors. Social entrepreneurship has a long history of physician involvement and business school courses in social entrepreneurship and impact investing are expanding.Here is a recent example of how one doctor is making a difference.

Roles can vary as well. Some physician entrepreneurs are problem seekers, others problem solvers. There are also story tellers, money finders, score keepers, social connectors, risk managers and business developers.

5. Employed physicians, whether academic or non-academic, have the potential to be no less entrepreneurial than their colleagues who are in independent practices.

6. While medical educational reform is necessary, expecting medical students to master health economics and population health is an unrealistic expectation. Medical schools need to be part of entrepreneurial universities with the goal of instilling an entrepreneurial mindset in all graduates, including health professionals. To that end, medical schools and their graduates schools should rethink how they teach and practice technology transfer and commercialization and how they give faculty innovators the tools, incentive and recognition for the scholarship of innovation they deserve.

7. Physician entrepreneurship enhances medical professionalism, it does not degrade it, as long its practitioners understand and resolve the conflicts between the ethics of medicine and the ethics of business. Violating the patient or public trust by self dealing or undisclosed conflicts of interest degrades any profession that has a fiduciary relationship with its customers or clients.

8. Physician entrepreneurs create value for patients in many ways other than seeing them face to face for an entire professional career. The upcoming generation of medical students and residents and scientists and engineers in graduate school understand that better than their school’s faculty and administrators and they have engaged in bottom up efforts to fill the gaps in their education and experiences.

9. Every threat to the existing practice of medicine, whether, as noted, it be acute care to chronic care, face to face care to digical care, or corporate care evolving into more patient centered care, represents an opportunity for physician entrepreneurs to help patients by adding value.

10. Every industrialized country is facing the issue of how to provide their citizens with health services with scarce resources. Innovation and entrepreneurship , fostered by rules that catalyze them, will be the solution.

Physician entrepreneurs whether as technopreneurs, medical practice entrepreneurs, intrapreneurs or international social entrepreneurs are making a difference. This non-profit group is trying to eliminate the stigma of mental illness in Nigeria.

The “golden age” of medical practice is being replaced by the “golden age” of physician entrepreneurship since there has been, arguably, no better time to be a doctor who sees the business of medicine as creating value on par with the practice of medicine as another way to help patients.

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GUEST POST from Arlen Meyers

Raising money is hard, whether it be for a for profit or not for profit. You will need a plan and the right people to do it. For most entrepreneurs, it is a full time consideration.

If you plan to raise money, here are some mistakes to avoid:

1. Not having a capital raising plan
2. Not learning how to tell your story or finding someone who can
3. Focusing on features and not benefits
4. A product or service that is not ready for investor prime time
5. A product or service that is not ready for health system prime time
6. Wrong people on your team
7. You suffer from Founder’s Syndrome
8. You suffer from Craniorectal Inversion Syndrome
9. You make too many rookie mindset mistakes
10. You don’t have a VAST business model that is evidence based
11. You have not mastered the fundamentals of entrepreneurship
12. You haven’t navigated the bumps in the road
13. Not paying attention to new trends in financing ventures
14. You are Linkedout and have limited networks
15. Your website is all about you. I’ll bet you think this blog is about you, don’t you.

Here is why your startup will fail, and , more specifically, why your digital health startup will fail.

Raising money, like all business, is about developing relationships with the right people at the right time. Re-read How to Win Friends and Influence People.

Better yet, I know you won’t take my advice since that will take more time than watching a 3 minute You Tube video, so here is a summary. OK. Here’s the You Tube video too.

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GUEST POST from Arlen Meyers

Here were my entrepreneural goals for 2018 which, I suspect, won’t change much from year to year. The good news is I still make my bed every morning.

If you are are a physician entrepreneur, 2019 will be another year of opportunity. In order to create user defined value through the discovery, development and deployment of innovation, you will need to continue lifelong learning, find the resources, build robust internal and external networks, work with mentors and mentees, get peer to peer support and continue working on your personal and professional talent development plan.

Here are five trends that are sources of innovation.

Here are some articles from this year that might help you find your way:

1. How to be a physician entrepreneur despite your MBA I graduated Jefferson Medical College in 1972. I graduated with an MBA from the University of Colorado in 1984. Given my interests in biomedical and clinical innovation and entrepreneurship, it seemed like a good idea at the time. So much so, in fact, that I led the initiative on campus to create our own MD/MBA program. Over half of US medical schools now offer the dual degree programs.

2. The pros and cons of medical experience. Medical education is an apprenticeship and has been so for thousands of years. It is unlikely to change in the near future. Consequently, the model reveres the teacher and places obligations to the student, even by taking an oath.

3. How do I know whether my surgeon is doing unnecessary surgery? Unnecessary surgery is a big problem. Here is an article that describes the problem and its size.The fact is that any doctor has a fiduciary responsibility to do what’s right for the patient. However, as long as proceduralists (not just surgeons) get paid to do procedures (regardless of FFS or bundled payment), there will be an inherent conflict of interest. I don’t think it will ever be eliminated, but there are steps we can take to mitigate it.

4. How to create more physician pharma-technopreneurs Most physician entrepreneurs, particularly those still in clinical practice, are more interested in devices, digital health and care channel, process and model improvement or innovation. For the drug industry, that is a problem since there are many exciting opportunities.. Given the escalating costs and decrease in new drug research productivity, we need to do a better job of getting physician entrepreneurs engaged in the early stages of drug discovery, development and commercialization.

5. Virtuous entrepreneurship The evolution of the cyberintelligence driven economy-the fourth industrial revolution-is forcing everyone, including entrepreneurs, to answer some tough questions.

6. Barriers to digital health physician entrepreneurship It seems that almost everyone who has anything to do with sick care is trying to innovate, move the needle, disrupt, create game changers and win the 4th industrial revolution. It could be a case of too many cooks spoiling the broth.

7. Rookie entrepreneur mindset mistakes. Innovation starts with the right mindset. Doctors who are considering a side gig or an alternative non-clinical career, have a hard time getting their heads around the entrepreneurial mindset. There is a difference between the clinical mindset and the entrepreneurial mindset.

8. How to fake it ’till you make it. The overwhelming number of doctors, engineers and scientists don’t have an entrepreneurial mindset. What’s more, when they have an idea, they don’t know what to do with it since they will not learn those competencies in their formal training. They just don’t know how to innovate their way out of our sick care mess.

9. The myth of patient consumerism The newest mantra in sick care is patient empowerment to make them effective consumers of care. The underlying assumption seems to be that by giving them the information they need, patients will make sick care decisions, and even health care decisions, that are not only in their own best interests, but, in so doing, in the interests of the society at large. Doctors are being asked to do the same thing. Unfortunately, it is virtually impossible to serve three or four masters. The problem is that asking patients to shop for care does not work.

10. Digital health: Stop frying doctors. Another survey showed that doctors are burning out in big numbers, but that some specialties are worse than others. The survey asked about the prevalence of burnout factors and how they affect physicians’ lives. Overall, 42 percent of respondents were burned out—down from 51 percent last year—and 15 percent admitted to experiencing either clinical or colloquial forms of depression.

11. Side gig doctors These days more and more doctors have a side hustle, whether it be a way to earn more money, recovering from a disability, disciplinary action, disqualification, disaster or divorce, or as a pathway to exiting clinical medicine altogether. There are many side gig possibilities.

12. How to pick a residency if you are interested in entrepreneurship Applying for and being accepted to a residency after medical school is a complex, important decision. There are several factors to consider including the reputation of the place, the likelihood you will be accepted, the culture, whether it is a “good fit”, your performance in medical school,where you went to medical school and undergrad, bias,whether you are applying as a couple, the local cost of living, and, the location and lifestyle amenities it offers and how much it pays.

13. So, if patients are customers, how do you sell to them? Consumerization of sick care is on everyone’s lips. I think patient consumerism, i.e. the belief that if given the right information, patient-consumers will make smart sick care choices based on value , is a myth.

14. Why do people still say doctors are lousy business people Despite the many doctors creating user defined value through the deployment of innovation, people still insist doctors are lousy business people.

15. Data competency is the new black Many are predicting the jobs of the future, how to robot proof your kids and what knowledge, skills, abilities and competencies will be key to avoid your white coat getting the pink slip. Communication, creativity, complex problem solving and collaboration are usually on the list. Now we need to add another “C”: healthcare data competency

Here are some other stocking stuffers:

1. Advice to a medical student entrepreneur Congratulations on your recent graduation. I’m sure you are thrilled to start medical school in August and are looking forward to taking a break this summer.
2. Advice to a premed Thank you for inviting me to address your graduating class. I know it’s hot out there sitting in those folding chairs and the pot is kicking in, so I’ll keep this short.
3. The five phases of physician entrepreneurship development Physician entrepreneurship describes the pursuit of opportunity under conditions of uncertainty using scarce resources with the goal of creating significant multiples of user defined value through the deployment and harvesting of biomedical and care innovation. Clinicians are becoming interested for many reasons and they characteristically go through defined stages of their physician entrepreneurship career progression.
4. Fundamentals of edupreneurship Entrepreneurship means many things to many people. Perhaps the biggest misconception is that entrepreneurship refers, exclusively, to starting businesses. In fact, if we use the definition that entrepreneurship is the pursuit of opportunity with scarce or uncontrolled resources with the goal of creating user defined value through the deployment of innovation, then it means much more. In fact, there are many ways to innovate and create user defined value, whether it be in sick care or education, other than taking care of patients, starting a business or teaching students.
5. A boomer’s guide to teaching millennials My parents were traditionalists. I’m a boomer. I work with a lot of Gen-Xers. I teach a lot of millennials. We are all trying to understand each other and adapt to how we teach and learn.
6. Posts on Innovation Excellence

Happy New Year and good luck!

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GUEST POST from Arlen Meyers

The 12 steps to biomedical innovation starts with being a problem seeker, not a problem solver. Eventually, to be successful, customer problems and solutions need to meld around a VAST business model i.e. one that is not just profitable, but that demonstrates:

1. Validity Regardless or which elements of your model you choose, they have to be valid. In other words, the dogs have to eat the food. When the dog won’t eat the food, you’ll have to change your approach and try again.

2. Automaticity At the very start of planning your venture, you should think about how you are going to work on your business, not in it. Reducing hands on time to manage operations will give you more time to lead the company and create strategies for growth and give you more personal time to enjoy the fruits of your success. Outsourcing, automating or using technologies to ramp up operations, sourcing and distribution is a key part of scaling, and something that investors want to see…which brings us to the next piece.

3. Scalability Your business model is primarily a way to create a business machine that can produce an infinite number of products. Think of it as a device that takes in customers and creates profits out the other end and can do so at quicker and quicker speeds.

4. Time and Traction Finally, your model need to create as much profit as quickly as possible with a growing customer base that is loyal to your brand.

Many doctors, scientists and engineers start with solutions looking for a problem. Some find it or, eventually, as their inventions or technology evolves, markets appear to those who have the talent to see them. The more typical model, and one that is more common among the startup community, is to find a problem and devise a solution.

But, how do you pick the IDEAL opportunity given the almost infinite possibilities? Here are some tips:

I Identify the problem: Seeing a problem is an important skill and core competency of savvy entrepreneurs. It typically is the result of personal experience, primary research talking or watching others or secondary research. Whichever problem you pick, look for ones that:

1. Will make a very big difference in people’s lives if you solve it
2. Has the potential to be very profitable or create lots of user defined value, typically at least 10x the value compared to existing offerings or the status quo.
3. Is something that taps into your passion or satisfies your psychic need
4. Anticipates future customer/stakeholder wants and needs
5. Has an extremely high level of market pain and frustration, where customers know they have a problem and have unsuccessfully and repeatedly tried to solve it
6. Has limited barriers to entry
7. Has the right potential risk-return profile that matches yours
8. Is not one dominated by incumbents
9. Is easy to explain and understand
10. Someone is willing to pay enough for your solution so that you can make it profitably

Where massive success comes – where a good idea becomes great – is when it meets five simple criteria:

1. It is the first solution to a problem or gap (it is “innovative”)
2. It is the first WORKING solution to a problem or gap (it is “innovative and effective”)
3. It is the most affordable, comparable, option for its market (it is “innovative, effective and affordable”)
4. It consistently examines its effectiveness and seeks to improve (it is “innovative, effective, affordableand adaptive”)
5. It is powerful enough to create a loyal following that naturally wants to – and does – share the idea with others (it is “innovative, effective, affordable, adaptive and influential”)

How do you find problems worth solving?

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GUEST POST from Arlen Meyers

There are three basic ways to establish or TEE up a competitive advantage: Technological excellence, Execution/operational excellence and customer Experience excellence e.g speed, convenience, service and high touch. You must dominate on one, but be equally competitive on the others. Here is how to measure them.

While policy makers are pushing value based care, convenience care is more important to patients. In addition, the poor doctor experience is causing burnout and career dissatisfaction. Sick care delivery is presently organized for the convenience of the doctor, not the patient. Changing that model by “democratizing” care or consumerizing it causes workflow disruption and resistance.

Consequently, many sick care entrepreneurs are trying to improve the doctor and patient experience. Several companies are using AI and machine learning to do so using apps and mobile platforms, voice to text technologies and products designed to work around the lack of EMR interoperability. However, whether successful improvements in patient and doctor experience translates into higher value, i.e. quality per unit cost or significant reductions in waste and unnecessary patient visits, is difficult to measure.

Examples include doc-on-demand (Healthtap), patient reported outcomes (Cliexa), distributed care coordination documentation (mCHarts) and symptom checker (WebMD)

Hospitals with high patient experience scores performed better on a number of clinical quality measures, further evidence that such efforts provide a clinical return on investment. Demonstrate a correlation does not mean causation, though.

Researchers at Deloitte compared patient experience scores from Hospital Compare to quality measures that looked at both the point of care and outcomes, including emergency department wait times, readmission and mortality rates and hospital acquired infection rates.

They found that hospitals with “excellent” ratings (a 9 or 10 out of 10) for patient experience performed better on many of the 18 included clinical quality measures when compared to those with “low” (a zero to 6 out of 10) scores for experience.

However, several studies have failed to correlate patient satisfaction scores with quality scores.

The challenge, then, is to translate data to experience to measurable value. Here are some of the problems and challenges with data, data everywhere. Here are some solutions.

In order to reduce spending, the Institute of Medicine suggested attaching incentive payments to high patient satisfaction scores, ideally driving providers to deliver high quality healthcare. The Affordable Care Act also established a provision for value-based purchasing, which created a set of quality measures that included patient satisfaction scores.

But those scores have been ineffective in actually improving quality healthcare, these authors said, influencing the way physicians deliver treatment potentially for the worse. In an attempt to avoid penalizations for low patient satisfaction scores, many physicians alter their practice in ways that don’t improve patient wellness and outcomes.

Doctors are increasingly being disintermediated in every phase of care, including DIY initial diagnosis, clinical decision support and computer vision assisted diagnosis, treatment, and post treatment follow up and chronic disease management.

AIntrepreneurs should keep their I’s on the prize and demonstrate D2E2V (data to experience to value). The Apple Watch detecting atrial fibrillation is already getting push back from cardiologists overwhelmed by messages in their inbox. Thirty teams are advancing in IBM Watson’s international AI competition, with healthcare startups making up more than half of the top 10 finalists.

Digitizing the patient and doctor experience and translating it into value requires changing your business model, not your technology. In sick care, that will require changing some rules since rules drive ecosystems that create business models that drive or inhibit innovation.Primary care physicians, for example, do not routinely put patient-reported symptoms regarding sleep, pain, anxiety, depression and low energy or fatigue into electronic health record systems. At the same time simply putting patient symptoms—which often go unrecognized and undertreated by busy clinicians—into the EHR won’t address the problem by itself. The key is making the information actionable in the context of a primary care physician visit.

Anything short of delivering multiples of value that does not disrupt workflow or improves workflow is technoinnovation hype and theater that misses the mark, and, quite conceivably, adds cost and workflow disruption that makes the doctor and patient experience worse, not better and has little, if any, favorable impact on quality or cost.

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GUEST POST from Arlen Meyers

In defining primary care, it is necessary to describe the nature of services provided to patients, as well as to identify who are the primary care providers. The domain of primary care includes the primary care physician, other physicians who include some primary care services in their practices, and some non-physician providers. However, central to the concept of primary care is the patient. Therefore, such definitions are incomplete without including a description of the primary care practice. Here are some definitions concerning the different parts of primary care.

Digital medicine, the use of information and communications (ICT) technologies to exchange medical information, is being promoted as the salvation of our sick, sick care system. Here are some takeaways from a recent conference, for example:

• Key Takeaways
• Creating a digital medicine toolkit becomes more relevant as we transition away from fee-for-service and into value based reimbursement.
• But it is very important to note that in healthcare the biggest ROI for any investment is to invest in primary care. Tools to assist, complement, and support the primary care physicians can potentially of most value.
• High priority items to invest in – telemedicine, data analytics, behavioral health.
• Incentive structures from payers or employers are necessary components to the success of a digital intervention

Consequently, primary care is changing in response to many factors, including consumerization and the hightened patient and care community service, cost and quality expectations.

With all this change, as always, comes opportunities for primary care entrepreneurs interested in creating multiples of user defined value through the deployment of innovation.

1. Digital health development, dissemination and implementation
2. Office based clinical research using digital tools
3. Edupreneurship opportunities
4. Business model innovation
5. Patient experience innovation
6. Doctor experience innovation
7. Working with patient entrepreneurs and prosumers
8. Non-clinical physician entrepreneurship career opportunities
9. Care coordination tools
10. Participation in early stage drug, device, digital health and care delivery product design and development
11. Intrapreneurial leadership as an employed physician or health professional
12. Social entrepreneurship
13. Physician investing
14. Mentoring
15. Transforming medical education
16. Interprofessional entrepreneurship
17. Building community based biomedical and clinical innovation networks
18. Encouraging medical societies to offer biomedical entrepreneurship education and training
19. Building and participating in accelerators, scalerators and other regional innovation ecosystems
20. Expanding your internal and external networks.

While the opportunities are great, so are the barriers to physician entrepreneurship. Here are some ways to overcome them. Here are some ways to get started.

There are three basic ways for primary care docs to innovate their way out of the mess we’ve caused: technology, execution and customer/patient experience.

Physician entrepreneurship is the pursuit of opportunity under conditions of uncertainty with the goal of creating multples of user defined value throught he development, deployment and dissemination of biomedical and clinical innovation. As you can see, their are many ways to do that other than creating your own company.

Primary care is under stress and needs to be unbundled. It is getting harder to save private practice. The only way to transform it is to embrace an entrepreneurial mindset and follow the rules of Othercare. Or, you can just fake it ’till you make it.

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GUEST POST from Arlen Meyers

The 2016 election revealed a dramatic gap between two Americas—one based in large, diverse, thriving metropolitan regions; the other found in more homogeneous small towns and rural areas struggling under the weight of economic stagnation and social decline. Amazon choosing NY and Washington to build headquarters is an example.

Economic development experts agree that regional economic development depends on creating ecosystems that support entrepreneurs and new value creation. However, the assets, culture and needs of one community differs substantially from the next, particularly those smaller sized or rural communities that face demographic, infrastructure, capital formation and housings challenges unlike those in major metropolitan areas.

Some experts point to 4 foundations of a thriving technology based innovation ecosystem, like Austin, Denver-Boulder and Silicon Valley:

1. Well funded basic research at universities and government labs
2. Local assets, like outdoor recreation, quality of life and amenities
3. Leadership from the ground up
4. Infrastructure

A recent review suggests some approaches to building mid-tier entrepreneurial ecosystems:

1. Favor incumbents less. Policies and regulations that favor incumbents—existing, dominant companies—create barriers to entry by new firms and restrict competition.
2.  Listen to entrepreneurs. Rather than develop policies abstractly intended to correct “market failures,” policymakers should engage local entrepreneurs in person to develop and implement practically focused policies intended to encourage dynamism, increase diversity, and stimulate “metabolic” activity such as idea exploration, product development, and increased rates of deal flow. •
3. Map the ecosystem. Create an inventory or graph that indicates who the participants in the ecosystem are and how they are connected. More ambitiously, map roles and differentiate relationships by type, direction, and magnitude of interaction. Once validated by the entrepreneurs and community members, ecosystem maps can become valuable tools in developing strategies for engagement. •
4. Think big, start small, move fast. This simple rule, which applies to entrepreneurial ventures, also holds true for strategies to enable local entrepreneurial ecosystems. To be effective, such strategies should seek domains for early success and rapidly iterate forward
5. Avoid artificially segmenting your community or your strategies. Entrepreneurs and members of entrepreneurial communities are not potted plants: they are active participants in a range of activities, such as creating new compd from there to build well-grounded programs at scale.
6. Prepare to capitalize on crises. Much like a rotting trunk of a fallen tree feeds the growth of new saplings, economic disruption creates entrepreneurial opportunities. Because experiencing disruptions is an inevitable part of economic and social life, those involved in enabling entrepreneurial ecosystems should anticipate them and prepare to make the most of the opportunities they create.

When it comes to creating digital health or clinical innovation ecosystems in rural or smaller regions, I would add using local assets that are more nimble to:

7. Create digital health human subject trial infrastructure

8. Take advantage of remote patient monitoring, sensing and patient reported outcomes measurement information systems to overcomes geographic boundaries and geographic barriers

9. Integrate as a spoke to larger sized innovation hubs using information and communications technologies

10. Create ways to simplify the process of testing and piloting digital health solutions in smaller sized hospitals. using them as experimental laboratories for larger hospital, mother ship integrated systems

11. Create Collaborative Open Innovation Networks

12. Expand education programs at community colleges and universities serving the community offering nano and online coursed and degrees. Rethink higher ed now that the differential between the costs and benefits of a bachelor’s degree is narrowing and many colleges are not meeting enrollment targets.

13. Create knowledge exchange programs with the closest innovation hub

14. Avoid the 6 dysfunctions of engaged communities

15. Mix the creative class with the technical class including interface industries like aerospace, energy, IT technologies, photonics, media and communications and outdoor recreation.

16. Define entrepreneurship as something other than creating a business

17. Create and empower patient entrepreneurs

18. Offer fellowships to physician entrepreneurs in residence

19. Win the war for talent, particularly for those working in the gig economy

20. Maximize information rheology i.e the flow of information

Here’s a short checklist to measure the health of your cluster:

1. The extensiveness of your internal and external networks and the flow and pressure of information through them.

2. Churn. How many companies are being created and then new ones procreated by the founders?

3. Value creation at the level of the patient, enterprise, regional economy and national competitiveness.

4. Educational program graduates and short and long term contributions.

5. The participants in the cluster and gaps that need to be filled.

6. The regulatory, IP and business environment that facilitiates or interferes with innovation.

7. The level of integration with decentralized, participatory , community based innovation networks

8. Seed stage funding levels and incentives

9. Risk tolerance and the pervasiveness of an entrepreneurial mindset.

10. Tolerance for failure.

Here is how Georgia is building statewide innovation centers and connecting them.

Another prescription to close the rural-urban divide has these active ingredients:

• Boost the digital skills of left behind places. The workers, industries, and places that possess strong digital skills have enjoyed distinct economic rewards. To push back against this winner-take-all dynamic of today’s tech economy, every region’s workforce should be prepared to participate in the digital economy.
• Ensure businesses in lagging regions have access to capital. The pullback in small business lending following the financial crisis has hit less densely populated parts of the country
• particularly hard. Efforts to improve data on small business performance can help banks lower the transaction costs of extending small loans while innovations in financial technology can help create a secondary market for them and reduce risk. Boosting alternative, non-bank sources of capital, such as venture capital funding, can also help support regional economic growth.
• Reduce gaps in broadband. Large gaps in broadband service and subscriptions have put businesses and workers in less densely populated areas at a huge disadvantage. Policy proposals should focus on connecting more people and encouraging greater subscription rates in places already endowed with broadband.
• Identify “growth poles” that can support regional growth. While it may be inefficient to “save” every left-behind small city or rural community in the U.S., targeted federal policy aimed at strengthening 10 or so promising mid-sized centers of advanced industry activity would bring more growth to some communities adjacent to many more lagging towns and rural areas. Federal investment in these “
• growth poles” will put more communities on a path toward self-sustaining economic growth.
• Help Americans move to opportunity. The federal government should expand the availability of financial support for individuals who want to make
• long-distance moves to places promising greater economic opportunity. At the same time, federal policy should encourage states and localities to relax zoning restrictions and construct new housing units to increase the supply of affordable housing. For those who wish to stay in their communities to live but not necessarily to work, state and local governments could provide a subsidy for workers commuting to adjacent communities.

Communities should strive to be part of the BIG FIX, moving sick care to health care. It will take rethinking community level education, sick care process re-engineering, community engagement and building entrepreneurial ecosystems.

If you find that there are opportunities for improvement, then try using some of the strategies to fill the gaps and reap the rewards, no matter where you live.

Image credit: Tehran Times

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GUEST POST from Arlen Meyers

In my role as the President and CEO of the Society of Physician Entrepreneurs (SoPE), I sometimes receive inquiries like this: “Hi, Dr. Meyers. I was reading some of your posts on the SoPE website and social media, and was wondering if you wouldn’t mind taking time to read the enclosed business plan for an idea I have and whether you could give me some advice on where to find investors.” In most instances, the information that I receive is not investor-ready and typically contains the following errors written by biomedical and health entrepreneurs trying to commercialize an idea, invention or discovery. They are:

1. People describe ideas that have not been reduced to practice. There is a big difference between an idea, an invention and an innovation. An idea is something that pops into your mind and stays there. It is a prisoner, never to escape or otherwise see the light of day, let alone a customer. An invention, on the other hand, is an idea reduced to practice. It can be sketched on the back of a napkin, a prototype made of Styrofoam and duct tape or a YouTube video describing your digital health product. An innovation has both a qualitative and quantitative component. It is a new way of doing something, possibly using old things in a new way that result in at least ten times the value of existing competitive offerings. Anything short of that is an improvement or, worse case, a solution looking for a problem.

2. They are not clear whether they have a technology, a product or a business. A product is something customers will buy that solves their problem. A start-up is an entity looking for a scalable and profitable business model. Like a child is not a small adult, a start-up is not a smaller version of an ongoing business.

3. They ask for money to make a product or do research. Investors give money to make money as soon and as risk-free as possible. They are not interested in giving you money to do research, pay your salary or buy an office. They want you to use their money to validate a business model that can be scaled to create profits as quickly as possible. They don’t support science projects.

4. They do not have a business, let alone a business model. A for-profit business is an organizational entity designed to offer products at a profit. The business model describes how the business will create, deploy and harvest value. Several businesses sell one or a few products; however, there are not many. Most have to expand their product lines eventually, capture new markets and adapt to change to sustain their growth.

5. Most don’t have a validated business model, i.e., early adopters or customers. Technological products require not just technical validation (Will it work the way it should and the way customers want it to?), but clinical validation (Will it do what we say it will do and be safe?) and ultimately commercial validation (Will the dog eat the food?).

6. Their proposal is not investor ready. Less than 0.5 percent of venture pitches will get funded because the presentation is not formatted correctly, the information is not appropriate or focuses on the wrong things, the opportunity is not big enough or profitable enough or, quite simply, what is being proposed is not technically feasible, believable or based upon valid marketing and revenue assumptions.

7. They spend 80 percent of the time talking (usually in arcane language with lots of jargon) about their solution, 15 percent of the time talking about themselves and five percent talking about the problem to be solved or the job to be done. Most doctors, engineers and scientists are preoccupied with their solution. Investors are interested in the market pain, how big it is and how much the market is likely to grow if you fill the product/market gap. In short, at this stage, you need to be a problem seeker, not a problem solver.

8. They don’t listen. If you listen long enough, patients will tell you their diagnosis. The same is true for customers. They will describe or demonstrate their pain and ask you for a solution. Don’t miss the diagnosis by listening to their chief complaint.

9. They insist they are right and are usually looking for validation of their ideas. What you think is valuable is irrelevant. The only thing that matters is what the customer values, and they vote with their wallets.

10. They have poor interpersonal, communication and selling skills. Investors bet on the jockey, not the horse. Act like you’ve been in the end zone before.

Here are 10 more turn-offs.

Before you ask for money, be sure you have:

1. A product

2. A patent

3. A team

4. A customer

5. A validated plan

6. A website

7. A story

8. A company

9. An executive summary

10. An exit strategy

Here are 50 questions angel investors will ask you when you make your pitch. Be sure you are ready to answer them. Also, you should do these things before announcing your fundraising round.

The information that potential investors will be answered by these questions:

• Who are you and your team and why should investors have confidence that you will succeed?
• What problem are you solving and how significant is the problem to all the stakeholders? (Use market data to develop a market model and illustrations showing the opportunity.)
• What is your solution to the problem and how will you sell it? (Describe the user experience and bring a prototype.)
• What are your clinical, regulatory, economic value and reimbursement pathway plans, if applicable?
• How is your approach creative or original vs. competition and how will it be protected by intellectual property?
• How will you grow the venture and value vs competition over the long term?
• What is your exit strategy?
• What funding are you seeking?

The bottom line IS the bottom line. For investors, and for your sake and the people you hire, you need to answer three basic questions about revenue and profit:

1. How? HINT: By creating the right product-market mix
2. How much? HINT: By sizing the market
3. How soon? HINT: By creating a high revenue, low cost business model canvas and scaling it

Do me a favor, please. Before you send your idea to someone for input, be sure you’ve done your homework and have a proposal that is ready for prime time. Focus on the problem, not the solution. Create a business model that you can test and then validate. Don’t ask for money too soon. Practice your communication skills in order to tell your story in as short a period of time as possible, using language that a sixth grader could understand. (The Wall Street Journal uses language at a sixth grade reading level.)

Finding startup money is painful. So, take these pain relievers and use your patient portal to send me an mail in the morning.

If you can’t, then kill the idea, save us both time and move on to the next. Good luck with your new venture.

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GUEST POST from Arlen Meyers

Creating corporate innovation is never easy and takes several steps. Carlson and Wilmot mention five disciplines:

Important Needs: Work on important customer and market needs, not just what is interesting to you.

Value Creation: Use the tools of value creation to create customer value fast.

Innovation Champions: Be an innovation champion to drive the value-creation process.

Innovation Teams: Use a multidisciplinary, team-based approach to innovation to create a collective, genius-level IQ.

Organizational Alignment: Get your team and enterprise aligned to systematically produce high-value innovations

Identifying innovation champions within your organization is not always easy. Appealing to self interest is one tip and there are many more. However, when it comes to identifying internal champions from the outside in, it is even harder to penetrate the internal firewalls. For example, suppose you have a digital health product that you want to develop and test with a hospital or physician provider? How and where do you find those people interested in innovating who are earlyvangelists and adoptors?

What are early adoptors?

Here are some ways to find them:

1. Create a free to the customer model so they don’t have to pay for it

2.Make it painless. Be sure to make your product as easy to buy and use as possible so that you do most of the work and they client gets most of the value.

3. Find an internal mole, connector, maven, salesperson or doer who knows the landmines and knows how to remove the gatekeepers.

4. Be sure you know your potential target pain, who it affects and how your solution aligns with their strategy.

5. Find a third party advocate or ex-employees who can provide you with the necessary support and business intelligence.

6. Ask the grunts in the trenches . They know the leaders, who does what and who can get things done.

7. Contact those with a track record. While past accomplishes are no guarantee of future accomplishments, nor, as they say, if you want to get something done talk to someone who is busy always work, at least it will give you some warm leads. If they say no, ask “Who else should I talk to?”. Doers know other doers.

8.Social media tracking is a great place to listen. Most use it to shout.

9. Find disproportionate pain points and who has the most to gain from treating them.

10. Go big or go home. Focus on big market opportunities, or particularly painful problems for a hospital ,not tinkering. Here is the case for improvement, not innovation.

11. Bring money to the table to help offset the costs of a pilot

12. Be sure you don’t expect too much from your provider development partner

13. Don’t disrupt existing workflow or systems to implement or test the product

14. Have a legacy EMR integration plan or find a third party who can help you do it

15. Come to the table with an experienced team that can execute your pilot project plan on time and under budget.

16. Be willing to engage in revenue or equity sharing if warranted from the results of your pilot.

17. Contact the increasing numbers of hospital innovation centers

18. Join your local innovation ecosystem

19. Join the AMA physicians innovation network or the Society of Physician Entrepreneurs and chapter meetings.

20. Be sure you are able to comply with legacy EMR, WiFi and security requirements

Finally, another factor in finding champions from outside in is to tell your story and create enough buzz so they can find you. Once you have found your champion, here are some ways to sell to doctors and small medical practices.

Innovation champions are :

• Builders
• Passionate, committed and curious
• From all disciplines
• Synthesizers
• Team and partnership creators
• Helpers who seek help from others
• Organizationally responsible

Crashing the gates is getting harder. Value added committees are piling on the paperwork. More and more digital health entrepreneurs are knocking on the doors. Health IT security risk has substantially increased. In addition, with so many hospital systems creating innovation centers, ideas are being funneled to Chief Innovation Gatekeepers.

Finding an internal clinical champion starts with understanding what role you’re looking the clinical champion to play. It’s comes down to one or a combination one of the 7 M’s:

1. Money is I want you to find rich doctors who will invest in my product, or angel networks or high net worth individuals.
2. Marketing is I want you to eliminate the gatekeepers, connect me to your network and get me through the door.
3. Making Something is I want you help me develop this product based on your domain expertise.
4. Management is I want you to be a member of my company board of advisors, directors or officers. I want you to provide management expertise based on what I’ve read about you.
5. Manpower is I need data scientist who can help me solve a technical problem, and you have academic resources or students who can help.
6. Monitoring the Environment is you have a big network and a finger on the pulse of what’s happening in healthcare. I want you to keep abreast of trends. You are my eyes and ears and help me do a SWAT analysis.
7. Maturity is the clinical and business judgment derived from years of experience. While difficult to measure, instincts and that gut feeling are invaluable if they contribute to preventing the wrong move or step.

Here are some additional points to consider when looking to develop a relationship with an internal team?

As a validator, advocate or partner?

• next critical success factor
• comfort level of champion
• abilities of champion
• regulatory and ethical issues
• conflict of interest

What training should they have?

• connections
• reputation and credibility
• ability to execute, align and engage
• strategic thinking

At what point should a physician be brought in?

• As part of the initial advisory board , BoD or management team

Should they only reach out to physicians they know?

• big internal and external networks

Do they need to be using the solution?

• Depends on their role

What kind of content do they need?

• depends on stage of engagement

How do you measure success?

• inputs, processes, outputs, outcomes

How do you compensate them?

• cash/equity

Finding internal champions is a black art. It takes intelligence and the right strategy and tactics to find your champions. Realize that like every other customer, they buy emotionally and justify rationally. You are unlikely to find most of them in the C-suite, so stop wasting your time on Linkedin and coffee shops barking up the wrong trees.

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