Nat Turner

"(Cancer) Patients today walk in the office and they have no idea that the therapy being chosen is..."

Sat, 30 Mar 2013 21:18:00 -0400

“

(Cancer) Patients today walk in the office and they have no idea that the therapy being chosen is usually the one that offers the greatest return to the oncologist. Today in that interaction there is information that isn’t being shared.

I have no problem with the oncologist saying we’re picking this regimen because it’s also the most cost-effective. But we have to emphasize the other point time and time and time again: The treatment has the same result as the alternatives. We are not jeopardizing your outcome, but where we have multiple alternatives we are taking the one that is most cost-effective.

If there are multiple options available, in my mind the patient would be indifferent to which one is offered unless there was a substantial difference in side effects or results. Faced with several regimens that are basically the same, I’m going to look to my physician for what’s the right thing to do.

”

- Dr. Lee Newcomer (UnitedHealthGroup)

"(Oncologists have to be) “really good internists because you are giving people chemotherapy that may..."

Tue, 19 Feb 2013 21:41:16 -0500

“(Oncologists have to be) “really good internists because you are giving people chemotherapy that may cause side effects and you have to assess their medical condition, whether they can get their drugs, have a toxicity, and do all those things. You also have to be an oncologist and understand the drugs and write the orders. You have to be a molecular biologist now because of all the pathways and you have to read about these things and really understand them so that you know you are ordering the relevant test so that you give the right drug and not the wrong one. You have to be an informatics expert because everyone is going into electronic medical records and using pathways. You have to be a social scientist and an economist now since society has now made you responsible for the cost of care of delivery. You have to be an end-of-life specialist. You have to be a pre-certification expert and, by the way, you have to meet all of the quality standards that everyone is promoting—there are about 50 of them now. You have to take time to talk to the patient and be nice to them. And by the way, don’t make a single mistake.… And do this in 15 minutes. And do it 30 or 40 times a day.” He asked, “How can any human being do that?” Yet, this is what is being asked of physicians and he is concerned that we are continuing to add to their responsibilities.”

- The American Journal of Managed Care

Tax advice for startup employees?

Fri, 11 Jan 2013 15:22:00 -0500

We’ve had a few questions come up in the last couple of weeks at Flatiron Health from employees on what the best practices are from a tax perspective on the RSU’s or option grants they receive from our company. A lot of this stuff can be highly confusing. There are ISO’s vs. NQSO’s (each with different tax implications), 83(b)’s, options with vesting schedules, RSU’s with repurchase rights, all the while trying to set things up correctly from a tax perspective (i.e., get long-term gains treatment wherever possible as opposed to ordinary income to minimize their tax bill).

Long story short, startups in my opinion, especially in the early stage when you can actually take advantage of certain strategies due to low shares prices, should have some sort of tax advice resource available to their employees. It’s not smart for the founders or someone employed by the company to give tax advice, as that’s a whole liability on its own, and it’s also probably not realistic to expect the employee to have a family accountant who is an expert in startup options/equity and their tax implications (and optimal strategies). I know I didn’t when I got started in startups.

For example - it seems pretty obvious (and I’m no accountant) that employees at super early stage companies when their stock is worth pennies should “early exercise” their options and get RSU’s with repurchase rights, which starts the long-term gains clock (but only if you file an 83(b)). I wish I knew that was an option. If so, I would have recommended it to folks at Invite who came on early and received option grants.

I don’t know the right solution yet. But it would be great for startups to have some sort of centralized but third-party resource to point their employees to when it comes to best practices related to the stock or option grants we give them. It doesn’t feel like something the general counsel should do, or the PEO/HR company (ex. Trinet, Ambrose, etc.) should do, or even the CFO/accountant of the company, so I’m not sure what the best strategy is.

Any ideas?

The startup essentials

Thu, 10 Jan 2013 08:53:00 -0500

Mail/calendar - Google Apps. Has worked wonders for us. At Flatiron, we pretty much all use web-based mail, and it doesn’t get better than Gmail. Also great support for things like email groups.
Scheduled emails and reply alerts - Boomerang for gmail. Super useful tool. Primary use is to alert me if I don’t receive a response to an email I send within X days or weeks.
Instant messaging - Gtalk. Super easy when you use Google Apps
Video conferencing - primarily Skype, but also Google Hangouts is pretty good for this.
Common drive / file sharing - Google Drive. Honestly, we’d use Dropbox if we could, but almost everyone uses Dropbox for their personal accounts and it’s not great for running two different accounts. And we had a lot of sync and software issues with Box. Drive has been fine, and it’s convenient given we used Drive already for shared spreadsheets, docs, etc.
Screen sharing with clients - join.me. Have tried a few of them, join.me is the easiest and lightest-weight. Doesn’t require any installs for viewers, very quick to join a meeting.
Payroll and benefits administration - Ambrose. The “PEO” bucket, many players here. Ambrose seems like a good fit for small startups as they have good support via dedicated account managers for setting up new employees, answering HR questions, etc… Probably will outgrow around 20-25 employees.
Task management - Asana. We’ve tried them all. Asana is growing on us and has been the longest to stick. A few folks use Evernote for longer-form note taking and such, but company tasks all make it to Asana.
Sales CRM - we actually use Asana for this today by creating a project for each client, but at Invite and soon we’ll use Salesforce or Sugar.
Recruiting / applicant tracking - since we’re small today, we find Trello is great for managing applicants. We have a board for recruiting, with lists for things like “Active Conversation”, “Interviewing”, “Pass”, “Offer Stage”, etc… and a card for each candidate.
Private social network - we’re hoping to use Google+, but it’s basically worthless at the moment with no mobile support (so you don’t get notifications on your phone and just have to keep checking via browser). Yammer is probably still the best option here, but G+ will be great when they have mobile support and you’re also on Google Apps.
E-signing docs - Signnow. So easy to use and free.
Accounting software - Quickbooks Pro (desktop version). I tried other systems and also the Quickbooks online version, but none of them were complete other than QB Pro. Before you’re an enormous company, there’s pretty much no other option in my opinion, and it’s not that hard to use and does a decent job of automatically connecting to your banks and credit cards to pull transactions.
Banking - we use Silicon Valley Bank. Pretty decent monthly service fee (around $200), but lots of support. They saved our ass a few times at Invite Media and have flexibility because they’re small and focused on technology companies.
Credit cards - AMEX Plum. No brainer here. Pay within 10 days of your bill and get a 1.5% discount credited back (used to be 2%). We put just about everything on a credit card.
Travel booking - Kayak for flights and rental cars. Hotel Tonight when in a city they support. Priceline as a backup.
Phone system - Google Voice. We’re still small so we can get away with this.
Food for office - SeamlessWeb. In NYC, this is how you order delivery food and works great. Exploring the group ordering option soon, and also catering services (such as www.cater2.me) geared towards smaller companies now that we’re 10+ people.
Business cards - Moo.com. Awesome service and not that expensive.
Note taking - Evernote for most people’s private notes, including mine. Haven’t nailed sharing of notes here, so for a lot of joint meetings we’ll use Google Docs and create a notes doc that we can all add our notes to and collaborate.

Those are the things we use at Flatiron and we consider our essentials. If you’re curious of anything other system we use that I left out, please ask.

"The biggest obstacle” to a true war against cancer, Watson wrote, may be “the inherently..."

Wed, 09 Jan 2013 14:33:58 -0500

““The biggest obstacle” to a true war against cancer, Watson wrote, may be “the inherently conservative nature of today’s cancer research establishments.” As long as that’s so, “curing cancer will always be 10 or 20 years away.””

- DNA Pioneer James Watson

"Because of their levels of radioactivity, her papers from the 1890s are considered too dangerous to..."

Sat, 10 Nov 2012 10:25:18 -0500

“Because of their levels of radioactivity, her papers from the 1890s are considered too dangerous to handle. Even her cookbook is highly radioactive. Her papers are kept in lead-lined boxes, and those who wish to consult them must wear protective clothing.”

- In reference to some of the works of Marie Curie

In healthcare, government regulation can breed startup opportunity

Sun, 16 Sep 2012 22:36:00 -0400

Like most entrepreneurs, when I hear the words “government regulation” attached to a startup idea, my first reaction is negative. Traditionally, customers buy products and services that either generate new revenue or reduce existing costs. But in healthcare, they also buy products and services that help them meet certain government regulations. In healthcare, government regulation can breed opportunity.

For many sectors of healthcare, the government requires providers and/or payers to do something they may not normally do. For each of these requirements, the stakeholder will need a solution in order to meet that requirement. Here are a few examples in healthcare (just to name a few):

The Office of the National Coordinator (ONC) requiring provider’s to have various levels of EMR implementation (with incentives and penalties depending on your status)
The ONC requirement for providers to share medical records with an health information exchange (HIE)
Joint Commission requirements for providers to know population statistics, track patient safety metrics, etc…
Medicare and other payer requirements to maintain certain re-admission rates as a provider (which requires structured data and software to know where you stand and track cases)
Cardiovascular (and other disease) programs must report various conditions and procedures to national registries

Many businesses have been created (or accelerated) that offer solutions to meet the above requirements. Generally speaking, the best solution over time is from a company that makes that solution their core competency (as opposed to each hospital building their own solution, for instance).

So, if you’re looking for a startup opportunity to tackle in healthcare, it may be worth your time to research the (many) government regulations that are out there.

Can the healthcare industry afford a cure for cancer?

Sun, 05 Aug 2012 22:14:00 -0400

It’s hard to think about. The healthcare industry would be rocked if a cure for cancer was produced, and probably couldn’t afford it. Cancer is a huge problem for our country and world, but it’s also a huge business. From what I’ve read, it can be one of the more profitable specialities of many providers. Estimates put it at $150B in direct expenditures treating/managing cancer in the US, with an additional $100B in related costs.

Imagine if a “vaccine” for cancer was discovered tomorrow (albiet unthinkable right now). There are thousands of hospitals that make big money off of treating cancer, and many more private practices. Cancer patients create revenue for providers at nearly all levels, from labs to imaging to surgery to chemotherapy (pharmacy) to radiation therapy to post-operative care, etc… There are thousands of oncologists in this country. 40% of R&D from big pharma is dedicated to cancer. Perhaps they could re-allocate resources towards other specialities, but there are countless billion-dollar tertiary care facilities focused exclusively on cancer throughout the country.

While we all want cancer to be cured, one has to think, with cancer being such a big business, how bad do the big providers also want it cured? I’m not talking about the brilliant and talented physicians and researchers tirelessly working for their patients and institutions towards a cure, but the business operations at a higher-level.

If anyone has any anecdotes / history lessons on how our healthcare system has reacted to a major disease being cured (ex. Polio?), I’d love to hear it.

Healthcare vs. online advertising

Thu, 12 Jul 2012 23:31:00 -0400

I was talking to a few folks today looking to get into healthcare, and a good analogy for a big trend happening in healthcare occurred to me. In short, healthcare providers are being forced to take on more and more risk for the quality of the care they provide, and that closely mirrors what happened in online advertising with advertisers vs. publishers.

Just like in advertising, in healthcare there is a spectrum of risk shifting. The poster child is the so called accountable care organization (ACO), whereby the provider’s fee reimbursement is tied to certain performance and quality metrics. Another example is bulk payment, where the hospital is given a flat price for a population, say a group of CHF patients, and based on data the payer expects each to cost $5,000 to care for, and that’s the amount the provider gets regardless of services done. Any dollar below that level that the provider spends to get that person up to the agreed-upon metrics they are allowed to keep, any dollar over the provider eats. So then, things like double ordering MRI’s and hospital re-admission rates become really important, as it’s pure financial loss.

So, back to advertising. If you look ad ad-tech, over the last 15 years there has also been a shift of risk from publishers to advertisers. When an advertiser pays a publisher on a CPM basis (forgetting the countless middlemen in between), the advertiser is essentially taking on all of the risk for that campaign. If no conversions are generated from the media, the publisher still made their money and the advertiser had a negative ROI. Of course advertisers started wanting to shift risk to the publisher, saying things like “I want to pay you Mr. Publisher only when you generate a sale for me.” Then, companies like Ad.com and others popped up (not the publishers themselves of course, as very few of them are large enough individually to gain attention from a busy ad buyer) who allowed advertisers to pay out on CPA and thus pay for media only when that media generates a sale for them. That created a full risk shift to the publisher, which made them accountable for the performance of the media and in theory aligned the industry.

The similarities are quite similar to healthcare. Industries in free markets will in theory evolve towards alignment, unless outside forces like government keep them from doing so. Healthcare right now is unaligned, whereby the payers / insurance companies (in the analogy, the advertisers) are paying their providers (the publishers) in their network for every service the provider does, and nobody wins. Every time the hospital does a heart surgery, they get to charge the insurance company for doing so, just like how a publisher in advertising gets to charge the advertiser a CPM for the impressions they just served for them. In this new world, if the heart patient comes back into the hospital two days later because that last operation didn’t get the job done and symptoms were missed or mis-treated, the hospital gets dinked and loses money, much like how a publisher on a CPA basis eats inventory they serve that doesn’t generate a conversion for the campaign. Oh, and the patient was a victim of the cycle.

Personally, I think the much-talked about risk shifting happening in healthcare right now couldn’t be more opportune. Financial alignment is the only way to curb our healthcare spending in my very naive opinion, as it very much still is a business. Of course it’s still very early in this process and very few providers in the grand scheme of things are actually on the hook right now for the quality of their care from a reimbursement perspective, but change is coming and it can’t come fast enough.

"Steward is also positioning itself to take advantage of a shift by insurers toward paying health..."

Thu, 12 Jul 2012 09:10:23 -0400

“Steward is also positioning itself to take advantage of a shift by insurers toward paying health care providers based on patient outcomes rather than the individual services they provide. More than 80 percent of Steward’s patients are currently under so-called global budgets, where Steward receives a fixed amount of money per patient to provide care. Under these contracts, Steward makes more money the more efficient it is in caring for patients. Wherever possible, company officials say, they are shifting treatment to lower-cost settings, such as a doctor’s office or a patient’s home.”

- http://www.commonwealthmagazine.org/News-and-Features/Features/2012/Summer/001-Cerberuss-health-care-play.aspx

Recruiting tip: look at acquired companies and follow-up in two years

Wed, 27 Jun 2012 09:57:36 -0400

Recruiting engineers is hard. It’s one of those things that you also just have to get done if you’re a technology startup. Some of the best engineers in the world who think dynamically and work hard to make something happen work at startups. If you’re a startup, those are the kind of people you want (as opposed to 9 to 5’ers at large companies).

A good way to find these folks is to get organized and start tracking startups or companies that get acquired, track the date of those events, and then set your self reminders to talk with those folks around the two and three year anniversary of those deals.

In general, it’s good practice to meet engineers at startups that get acquired pretty much the day after so as to get a jump start and build a relationship, but realistically if the acquirer is smart the best engineers will be incentivized to stick around for 2 or 3 years. Many will leave sooner, few will stay forever. The same goes for potential candidates in other areas such as sales. I’ve noticed scrappy contingency recruiters do this in the past informally, whereby they’ll say things like “I think folks at company X are probably ready to leave, so we’ll focus on them.”

How many co-founders is right? And other related topics.

Tue, 26 Jun 2012 09:53:00 -0400

A couple students starting a company recently asked me if they had too many co-founders and if their equity arrangement made sense. When you’re in college, it’s not too uncommon to have a semi-large group of friends working together on the same project which sometimes leads to a formal company starting. It could be 2-5, and I saw one recently where there were 6 classmates all coding and designing a new mobile app concept together. When we were starting Invite, there were four of us there at the beginning.

The interesting step to figure out, and take seriously, is how you setup the co-founding group both in terms of number of co-founders, titles and equity allocations. My friend Chris Dixon wrote a good post related to this, and I’m sure there are many other posts on the topic. It’s something you need to take seriously, as it sets the trajectory of the company for better or worse. It’s all too common for startups to blow up before they’ve left the launchpad due to disagreements and poor arrangements among the initial team. Here are some “best practices” if they can be called such in my opinion related to the founding team:

First off, do what it takes to get things started. If you absolutely need your semi-large group of friends working together to get something off the ground even if it means impending confusion, then by all means do it. I’m never a fan of stopping something before it starts and am a huge supporter of things just getting done and figuring things out later. That doesn’t mean you can’t be thoughtful and look ahead to how you’ll need to structure things if something clicks though.
Second, co-founders are great. I am a huge skeptic of single-founder companies. I probably wouldn’t invest in one. I truly believe it’s a great thing to have a partner (or two) in the trenches together, second guessing each other, etc… I’m personally most enthusiastic about a two primary co-founder structure, with potentially 1-2 other secondary co-founders. It’s fine if they all have the co-founder title, but in terms of equity the 2 primary co-founders should own a significant portion and any secondary co-founders own a minority share. Startups work as dictatorships for a reason, and group-think and consensus decision making is for big companies. I’m never a fan of seeing three or more equal partners, for reasons explained later.
Every founder’s shares should be subject to vesting. Your founding shares should vest. Whether you do this day 1 or as part of your first funding round is up to you, but I think it should happen. I think it’s bullshit for an entrepreneur to claim “oh well I started the company, my shares should never be able to be taken away”. Sure, maybe some portion of them can be vested day one thanks to your effort and time spent, but in no world do I see it being fair to the company and it’s shareholders for a founder to not be subject to vesting, especially if you own a significant portion. It also helps with recruiting employees if you’re able to tell them you’re vesting on the same terms as they are.
Minimize “dead equity” in the future. Equity is precious, and in general one of the goals of a company CEO is to maximize the % of shares that are still actively at work for the company. In other words, the higher % of shares that are held (or are vesting) by an active employee building value the better. Conversely, someone owning a significant stake in the company who is no longer working on building value is “dead equity” (dead wood if you will). There’s no doubt a portion of the company that ultimately will be held by people who are no longer active, or you may have given out equity in exchange for short-term services to conserve cash. But in my experience, one of the most significant sources of dead equity is a co-founder initially getting a big chunk of equity, wasn’t vesting, and then before you know it the co-founder didn’t work out. Investors love to see active co-founders and critical employees owning as much equity as possible (the more the better).
Engage advisors. In my experience and observation, as a company matures, no more than two co-founders will ultimately be super critical to the business, and many times it can be none. This is important to accept as you go about planning your equity arrangements. If you have three co-founders and you split things 1/3rd all the way around, it’s likely that 1 or 2 of those holders will ultimately not be with the company after 3-5 years (thus creating dead equity). Sometimes this is unavoidable, other times it’s not. So how do you plan for that? Get outside help to verify that what people are bringing to the table and if the equal arrangement makes sense. Utilize advisors to help identify the strengths and weaknesses of the team. If there’s a clear person in the group who will grow into the CEO spot or fill it from day 1, and one person who is wavering on wanting to be an entrepreneur longer-term or who’s skills won’t scale with the company, better to know that (or think about it at least) early on.
Have the conversation early. Sometimes it’s worth it to have those serious conversations early to figure things out. Trust me, I wish I had done that in some previous companies before things got rolling. Sitting down as a team and figuring these things out early is important to ensure things don’t blow up. Call it a preventative measure or management debt or whatever you want, it will pay dividends in the future by taking care of it early.

Lastly, I wish there was (or if there is, I want it) data around co-founding groups and eventual outcomes. If you know of anything like that, please let me know. My gut tells me two primary co-founder teams have a high percentage of success, at least when I look at all the startups who have crossed the line into profitable companies or successful acquisitions.

Treatment by anecdote (and not data)

Sat, 23 Jun 2012 20:17:35 -0400

In my brief time in the healthcare industry, one thing I’ve noticed is that doctors treat by anecdote and not by data. They make treatment decisions for the patient sitting in front of them based on something that happened to a patient they treated in the past and their perceived outcome of that treatment. Or they make treatment decisions based on some agreed upon “best practice” (as decided by a group of like-minded physicians going off of experience).

For the best doctors in the world at large academic centers, such as top oncologists or cardiologists, this is probably fine and works well. A large part of medicine is artistic, with the top physicians reacting and making educated judgements dynamically to help their patient (and doing a great job). But in oncology, for example, around 80% of patients with cancer are treated in community hospitals where they are largely given “one size fits all” treatment off of national guidelines. These centers just don’t have the same resources as the big guys to do anything different, and can’t attract the nation’s best doctors or even install an electronic medical record system.

To make matters worse, when something goes off course and doesn’t work, which happens about 50% of the time in cancer, doctors are basically flying on instruments and making decisions such as experimental clinical trials or off-label use of drugs based on their knowledge and experience.

Wouldn’t it be useful to the physician treating your cancer if he/she was able to compare the genomic information of your tumor, your cancer type/stage/size, your various bio-markers, your age/gender and other demographic data, etc… against past patients and the treatment they received, and then those patient’s outcomes? The output of this could be “175 patients with similar demographics who received XYZ treatment lived 4.2 years longer than those who received NMO treatment”. We call this “data-driven clinical recommendations.” We’re not talking about replacing the doctor with a computer, but simply aiding their decision making with surfaced data.

Fortunately, a lot of people see this problem in the healthcare industry as well. The problem is that we’re still a long way from making this a reality. And there are a ton of reasons. The most obvious is the lack of usable data. A scary percentage of hospitals still take records with pen and paper, and others who have implemented EMR’s are still a long way off from using them correctly (and many EMR’s aren’t great to begin with). And even if data is being collected, much of it is free text from physicians that isn’t easily searchable or structured for comparison.

On the genomics front, it’s often said that the most over-hyped phrase in medicine right now is “personalized medicine,” both because of the lack of clinical utility on running genetic sequencing for the purposes of treatment decisions and also the “all-in” cost. Perhaps a more fundamental roadblock is physicians themselves who are historically resistant to change and protective of their domain. And the best institutions probably don’t want their bleeding edge treatments and data being shared by other hospitals in their area (this is a business after all).

Whatever it is, change is afoot in the industry. Hospitals are obviously collecting more and more data electronically as opposed to pen and paper. Physicians graduating medical school and residency are finally of the same generation that grew up with computers their whole life. And closest to my heart, more and more startups are tackling problems in the healthcare industry that are worth solving thanks to movements like the Community Health Data Initiative. It just can’t happen fast enough.

Don't ask me if I know any engineers you can hire

Wed, 20 Jun 2012 15:33:11 -0400

If only I had a quarter for every time I’ve been asked that question. Most often it comes from a first time entrepreneur who doesn’t know any better yet. Engineering talent is one of the most sacred and rare resources our industry has and is often times the difference between success and failure. As such, it’s not something you should ever expect to be handed, if that’s even possible. Entrepreneurs who know engineers worth bringing on to a team recognize the value, and great engineers know that they’re valuable and could work just about anywhere they want. My typical response to the question is “if I knew any engineers looking for a job I would hire them.” So you get the point.

I get why entrepreneurs ask the question though, it’s a critical part of the team that is never big enough. And if you’re just starting up and can’t code or design yourself, then you pretty much can’t do anything without them. So what do you do? Plenty of people have written posts about how to recruit and attractive engineering talent (I’ve even seen a few engineering recruiting startups recently), but at a high level you just need to be super scrappy and dedicate a ton of time to it. Network with people you went to school with. Then network with those people. Ask your current or former classmates who aren’t tech entrepreneurs if they know anyone who codes, even if your friend is a lawyer or doctor. The best startups I work with just seem to get it done, and the path is always different and serendipitous. It was through a friend of a friend of a family member. It was from a LinkedIn blind message. Once it was that the founder’s struck up a conversation with the guy sitting next to him on plane.

No matter how you do it, hiring engineering talent as an entrepreneur is totally up to you and is gonna be hard. You have to not ony convince the person your startup is better than the
1,000 others out there (not to mention the option of the engineer starting his or her own startup), but you need to find the person in the first place to talk to. But it’s one of those things that sets entrepreneurs apart, like being able to sell customers or raise money, or yes, code. So get after it.

Leaderboards and getting new users motivated

Wed, 06 Jun 2012 18:53:15 -0400

One of my biggest problems with Foursquare a bunch of other gaming-type of apps that have leaderboards or things like mayorships is that they’re calculated as “all-time” stats and provide less and less opportunity for new users to compete. That’s a big problem when you need to get new folks excited and motivated to use your application.

For example, let’s say you just now joined Foursquare or just now start using it. From what I understand, the mayor of your local coffee shop got that title based on being the person who has checked in there the most. Therefor, over time, as that person continues to check in and accumulate check-ins to that location, there’s less and less of an incentive for someone new to the system to check-in as it’s hard to compete and catch-up. Same problem goes for games that have points leaderboards. If all you provide to users is a “Top 100” users and it’s based on all-time points, it’s very hard to incentivize a new user to care about that leaderboard since they’re out of the race the second they start.

I’m by no means an expert on B2C startups and gaming mechanics, but I much prefer approaches that utilize things like “player of the week/month” or other mechanisms that level and refresh the playing field and make it more continuous. If you do that, you have a much better chance of giving new users a reason to compete and get them hooked.

On to the next one...

Tue, 05 Jun 2012 16:04:00 -0400

This Friday will be my last day at Invite Media / Google. Five years ago to the day, Zach, Scott, Michael and I started working in a apartment-turned office with no AC or internet (we used Sprint wireless internet cards for the first month) in Northern Liberties in Philadelphia. Three years and two days later we were officially acquired by Google.

I personally never thought things would end up the way they did for Invite. In the beginning and for the first couple of years, we struggled to figure things out. Our investors called us the “idea de juor”, we had trouble working as a team, our first few products flopped, we had trouble raising money, etc… Looking back though, and comparing us to the companies I work with now as an angel investor, we were just like every startup. Then after about two years something clicked. We started working much better as a team. Our product started to scale. Customers started to call us and sales got quicker. The companies trying to acquire us got larger and larger. It was an awesome experience, and something I think about a lot and hope to be able to replicate again.

When Google called in early 2010 to “explore the DSP space”, we were nervous. We wanted to be the one picked for the dance. We used to say that “if Google was going to buy someone, we wanted it to be us”, and we meant it. We knew how synergistic it would be if a leading-edge DSP was combined with a leading-edge ad serving platform, and the culture of Google is second-to-none. We were ecstatic when Jason Harinstein (now at Groupon) called to begin negotiations, and once we agreed on terms and closed the deal we immediately got to work on the integration. Over the next two years, we worked with some amazing people as Invite continued to grow rapidly by every metric. Sure we had our integration pains like anyone, but I can honestly say I think we’ve been spoiled with the whole integration process. The last two years at Google have been great, simply put. It is very bittersweet to close that chapter of my life.

When we started Invite, we didn’t consciously chose ad-tech as our industry to focus on. I serendipitously was able to get an internship at VideoEgg (now Say Media) in 2006 and the rest was history. Sure we had fun building Invite, but quite honestly we were never really personally passionate about optimizing and buying online advertising. Now that we’ve thankfully ”got a win under our belt” and new resources, I’m excited to be able to focus on something I care deeply about. For my co-founder Zach and I, that is healthcare. So, in a couple of weeks, Zach and I will be jumping back on the saddle and starting a healthcare IT company in NYC. We don’t know exactly what we want to do yet, but we’re going to waste no time figuring that out and getting to work. I’ll most certainly post to this blog various updates along the way.

To close, I’d like to thank everyone who helped us start and build Invite over the last five years. From our amazing co-founder group, to all of our co-workers who took a risk in working with us, to our clients who stayed with us through the ups and downs, to Andy Boszhardt and the First Round Capital guys for giving us our first money, to our awesome group of advisors, to Google for making us their choice, we couldn’t have done anything without them all. Now it’s on to the next one…

"(Hank Aaron told me) ‘Don’t dig in against Bob Gibson, he’ll knock you down...."

Sun, 03 Jun 2012 22:58:01 -0400

“(Hank Aaron told me) ‘Don’t dig in against Bob Gibson, he’ll knock you down. He’d knock down his own grandmother if she dared to challenge him. Don’t stare at him, don’t smile at him, don’t talk to him. He doesn’t like it. If you happen to hit a home run, don’t run too slow, don’t run too fast. If you happen to want to celebrate, get in the tunnel first. And if he hits you, don’t charge the mound, because he’s a Gold Glove boxer.’ I’m like, ‘Damn, what about my 17-game hitting streak?’ That was the night it ended.”

- Dusty Baker on Bob Gibson

How I manage my inbox

Fri, 25 May 2012 19:00:42 -0400

A few people have asked me recently how I manage my inbox. For me, there are a two inboxes, primarily (1) email (which I use Gmail exclusively for, both personal and corporate) and (2) anything related to my phone (which I manage via Google Voice) such as texts, missed calls, voicemails, etc…. It’s a true skill to be good at managing your inbox(es), and personally I think it is very important to do it well (and I hope I do). How quickly you respond to an email or return a call reflects on your level of responsibility and productiveness. I do think it is unfortunate, however, that people (myself included) feel a sense of expectation that someone should respond to your email, however weak your connection to said person may be. For me it’s very structured now in terms of my process.

Generally, my strategy is to archive anything that does not need immediate attention so that every item in my inbox represents something that I need to do. This departs from some people’s strategy of using read vs. unread to denote items needing attention. I personally like to keep things clean and as such use the Archive function for inbox management frequently (I’d go crazy if I saw 4,300 messages in my Inbox like most people keep). I don’t like unintended uses for features like that where you mark emails unread even though you’ve read them, because for example I may re-read an email but not respond multiple times and don’t want to have to keep marking something as unread. For email, threading is great for this, as I can quick reply to someone’s message knowing I’ll need to reply more deeply later but can keep the entire thread in my inbox, and Read vs. Unread means what it means. Here’s the breakdown of what I do for email, which translates to Google Voice too:

Anything that doesn’t require any attention, Archive the thread. I do this having full confidence in being able to find things later via Search. Anything requiring long-term attention, I’ll Star it (more on this later). My email inbox becomes a relatively short list of items that require near-term action such as a thoughtful reply, follow-up, some other event (such as sending out a calendar invite post-scheduling, or calling someone back). My Google Voice inbox becomes the same, any calls I need to return, voicemails that I need to remember to listen to and/or act on, texts to reply to, etc…
I’m not a big fan of typing on a tiny mobile device, as I like to reference other things (ex. other emails, the browser, calendar, etc…) while doing so, so I mainly use my phone as a means of scanning emails and Archiving threads quickly. This is great so that when I sit down in front of a computer, my Inbox is pretty well organized and ready to go. For example, I get a bucket of emails during the night like most people. Every morning, I take 2-3 minutes on my mobile phone to quickly go through and archive things that don’t need my attention. Same goes for getting out of a meeting, I’ll spend a minute or two in the elevator or cab afterwards quickly organized it. I sometimes leave things in my inbox that I need to use my PC for mainly due to lack of feature support on mobile or a bigger screen making it easier, such as setting up a new filter for that particular type of email.
On any email I’m sending that I need a response for, I utilize Boomerang religiously to remind me if someone doesn’t reply in X days. This is great to use when, for example, scheduling something time sensitive. Boomerang automatically Stars the thread and moves it to your inbox when the deadline passes.
I use the Labs feature in Gmail for “Send and Archive”, so that when I send any email I also Archive it simultaneously.
Any item that doesn’t require immediate attention but I may need to do something in the future or reference it, I Star the thread and also Archive it so as not to clutter my inbox. The Starred folder then becomes a folder of threads that I need to keep track of for some future reason. Examples here may be needing to send someone a check after you receive something you’re expecting from them, or a legal template that you know you’ll need to use in a few weeks. There’s some redundancy built in here too, whereby I may Star something even if it’s in my Inbox still that I know is super-important not to forget.
Every so often, I make a point to go to my Starred folder and clean it up. I probably average once a week for this. I’ll Unstar threads that have became obsolete, or realize I need to follow-up with folks again to threads I’m tracking, etc…
Another critical piece to my inbox management is that it is an absolute requirement that any device I use syncs seamlessly with any other device. In other words, the status of my inbox is synced effortlessly regardless of device. This is why I exclusively now use Gmail via the browser (I used to be an Outlook guy and can’t believe I ever was). Since I’m addicted to Google products such as Gmail and Google Voice, I’m also an Android guy, both for mobile phone and tablet. This is great for me since both look and feel, syncing, and features are the same on every device I use from PC to phone to tablet.
I haven’t perfected this yet, but I utilize Labels in Gmail setup with filters. For instance, I have all of my Amazon order confirmation emails tagged as “Receipts”, or any email from American Airlines tagged as “Travel.” I have occasionally found it easier to locate a thread being able to check these Label folders. However, the main purpose is for items that don’t require immediate attention every time but I still want to receive and occasionally read. Examples here may be corporate updates or newsletters I subscribe to that are non-critical that I still want the ability to read from time to time, so I auto-Archive them and auto-Label them and can every so often go check that folder and read those emails.
I’ve played around with Priority Inbox, as I’ve found it useful to be able to prioritize emails based on who it is, but frankly I haven’t perfected it yet. I just know in my head who I respond to all the time and quickly vs. those that I don’t (and do so naturally) . For instance, any email from my family or co-founder I know what to do with, or someone I know and trust third. I don’t get absolutely inundated by random strangers who want a reply in terms of emails, but when I do get one of those emails I do my best to reply with my honest quick opinion (if asked) or go/no-go of being able to find a time to talk. Unfortunately it’s most often a “Please get an intro from someone I trust” response, as if I took 30 minutes to chat with everyone who emailed I’d be underwater time-wise which is a different issue.
Like most people, most of my work now is via the Browser. So for me, I always have two tabs pinned, one for each of my email inboxes (corporate and personal), and the auto-updated favico’s of Gmail that show # of unread messages is great. Second, my next tab open is permanently my calendar, so I can quickly cross-reference with email and vice-versa.

Anyways, that’s most of the note-worthy strategies and tactics I use to manage my inbox. I’ve been told many times that I’m unusually quick at responding and considered good at email, which I’m proud of. I’m sure I can do a lot of things better, and personally think that being “quick” at email responses isn’t as important as being “good” at responding, so there’s that to keep in mind in terms of balance. But either way, it’s important to me that my inboxes are managed and I think constant upkeep and monitoring and quick archiving is the way to do it.

Lastly, I’m always looking to improve, so if anyone has any suggestions for how I can manage my inboxes better that what I’ve laid out, I’m all ears.

Enterprise Sales: Seed your customers with the right questions

Mon, 21 May 2012 16:46:23 -0400

In enterprise sales, one of the most effective tactics I’ve learned is to put yourselves in the shoes of your customer and help them figure out what the right questions are to ask in an evaluation process. This is important because your customer is probably going to issue a request-for-proposal (RFP) that tries to standardize the evaluation process, or will at least be meeting with your competitors. What better way to ensure the process is well-run than by helping them figure out the right questions to ask you and your competitors?

We’ve all been there in enterprise sales when you receive an RFP and the questions seem like softballs or unrelated/irrelevant to the core reason they need a particular product. This sets up a messy situation where the best technology/product combined with appropriating pricing may not win the RFP. The more advanced the RFP and specific, the better (unless your product sucks and is weaker than the competition). The best situation is when you gain enough trust from your customers to the point that they literally start asking you to help them write the RFP(s). Needless to say it’s a big advantage to see the exam before you take it.

Let’s say, for example, your software system is built on cloud-computing and is horizontally scalable, and you know one of your competitor’s isn’t. A first-draft RFP from a potential customer may neglect to ask a forward-thinking question such as “If we sent you a crazy amount of traffic, could you handle it?”. A competitor that isn’t as scalable as yours may dodge a bullet if that question isn’t asked and save some points in the process.

The best enterprise sales organization recognize that there’s a lot of potential to gain competitive advantages “upstream” before an evaluation process has even begun. It also has to be an entirely honest process, whereby you help the customer ask the right questions for them, not just the right questions for you. Send them a list of questions that you recommend asking you and your competition (broken down by category or type), build a white paper describing why certain features or differentiating factors are important, etc… The goal is to help the customer be able to compare apples to apples as an outcome of their RFP process and to ensure that your company and your competitors are judged fairly.

Why aren't there more traditional tech entrepreneurs in healthcare?

Tue, 15 May 2012 21:19:00 -0400

In my brief time as an angel investor and future healthcare IT entrepreneur, I’ve noticed that there just aren’t that many true technology entrepreneurs in healthcare. It’s well known that healthcare is way behind in terms of technology innovation and adoption, so this is a problem. I know for sure it’s not because of a lack of market size. Pick just about any sub-market of the overall $2.5 TRILLION dollar healthcare industry and you’ve got a market worth tens of billions (which is bigger than most markets entrepreneurs choose to focus on these days). I’ve encountered a bunch of MD’s-turned-entrepreneurs, or MD’s doing a startup on the side, and they all know medicine well but not really technology. A few of them are able to start disruptive companies, but healthcare is noticeably missing those “garage tech startups” that shake things up and the techie entrepreneurs behind them (who are often very young). There are of course exceptions, including a few “MD/programmers” who remarkably learned how to code and also somehow managed to get their MD, but they’re rare.

So what’s behind this? Why aren’t more of the super-smart young entrepreneurs coming out of college choosing healthcare as their industry to build a startup? In my opinion, it’s because of a few reasons: (1) healthcare as an industry has a reputation for being “highly regulated”, (2) it’s really hard to learn the ropes, and (3) the key people in the industry aren’t that approachable (many of them are busy saving lives) and/or are hard to find. I’d also argue it’s unfortunately not currently “sexy” to start a healthcare IT company like it is an Instragram or Pinterest, but hopefully that changes as there are some big outcomes that don’t take 25 years to develop. I’m going to go into each of these three problems real quick based on my recent experience, as I think it is very important that we foster and encourage more tech entrepreneurs to focus on healthcare instead of building some marginally useful consumer app.

Healthcare has a bad reputation for being highly regulated. Yes, it’s true that the government regulates certain parts of the healthcare industry. And honestly, they should for certain things like drug safety, patient confidentiality, insurance providers, etc… But for the most part, these regulations either don’t apply or are easily surmountable for a healthcare IT startup. In general, all you’ll run into would be the HIPAA regulations around dealing with patient data if that’s something you have to do, but that’s a well-known and defined problem to deal with. So, I don’t buy that as an excuse unless you’re starting a new health insurance company or something like that. Perhaps there is a business opportunity in starting something like AWS for healthcare IT companies, whereby you productize the hoops a healthcare IT startup would need to jump through onto a platform that is usage-priced.

The people aren’t as approachable or easy to find. This is important to solve, as the way you learn an industry and build early partner/customer relationships is via networking. I heard this going into the industry, “when they’re not saving lives, doctors are generally too arrogant to spend time with people who aren’t doctors.” This unfortunately isn’t entirely inaccurate for many doctors, but there are some who couldn’t be more willing to spend time with prospective healthcare entrepreneurs, it’s just really hard to find them (you’re also not only going to meeting with doctors). I feel advantaged being a successful second-time entrepreneur who is able to get meetings more easily, but that’s the problem. It shouldn’t be the case that only successful second-time entrepreneurs can get the meetings, we need to lower the walls and open the doors. That’s why I like what some of the healthcare-specific incubators like Blueprint, Rock Health and HealthBox are doing to create “mentor networks” that bring key opinion leaders and industry stakeholders in the same room. I think over time it will be important to make sure the industry mentors get something out of the process too for it to persist. But we need more than incubators, we need a change in mindset of the healthcare industry stakeholders. I wish I knew how to do that quickly.

It’s really hard to learn the ropes. I’m not gonna lie, this part is hard and that’s a big problem. This isn’t about knowing medicine and needing to spend 8 more years in school, it’s about learning how the industry operates and why. The ad tech industry was generally easy to learn, either because of available blogs/online resources or people willing to walk you through things. It took about six months to get our heads around that industry at a high-level. In terms of healthcare, it’s really confusing and there’s no good place to start. There are payers, providers and patients, and multiple variations of all three. Then of course there is the government who is also a payer. Figuring out how the money flows and how all of these people interact with each other is super confusing. I’m a fan of what a few of the healthcare-specific incubators are doing with some “pre-incubator” initiatives like industry education for prospective entrepreneurs where anyone can show up and learn. I think in general, the industry needs to invest more energy into education outreach to entrepreneurs at universities, perhaps via sponsored classes or programs, or the government could create a program like what Todd Park did with opening up health data to opening up knowledge of how the system works (i.e., a more basic problem). Perhaps some successful healthcare IT entrepreneurs can teach a class online and post their notes about the industry. I know I’ll do that if we’re actually successful in this industry.