Dyer Medicine 2.0 (2012)

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Physician entrepreneurship and app development: business model lessons. First given at Medicine 2.0 Meeting at Harvard Medical School September 15, 2012.

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  • I’m going to share the lessons that I have learned about entrepreneurship and app development with respect to business models.
  • This is PJ, a fantastic kid who I diagnosed with type 1 diabetes at 15mo and was lucky enough to get to see him every 3 months for his checkups as his endocrinology doctor. Who am I? 30-something physician first, behavioralist 2 nd , and mobile health entrepreneur.
  • I have long been concerned about how I can better motivate my patients. These life saving medications do not work unless patients take them. And fear, about death, does not always work to motivate, especially teenagers.
  • To motivate teens, I began texting them weekly. It worked to improve their diabetes care but solution not scalable and effect wore off…they needed more, they needed actual rewards. So I left medical practice to build the solution.
  • This is the first app that I made. Automated personalized SMS texting conversation by doctor to teen.
  • Building upon the lessons learned from the first app, I build a self entry glucose journal with itunes rewards and motivation quotes.
  • Recently, I build further upon the lessons learned with EndoGoddess App and released the EndoGoal app with the same foundation but new rewards and a new gamification digital pet feature.
  • Before starting the talk I’d like to clarify a few definitions. B to C business model and B to B business model.
  • I’d also like to clarify 4 ways to make money in the app business. First, one can make revenue by charging consumers for the app purchase in the app store.
  • Secondly, when the app is free for the baseline features, one can make money by charging a subscription model for customized app features.
  • Thirdly, when an app is free in the app store, one can make significant revenue when the baseline features are available for functionality but desired higher-level features require an in-app purchase. This is a popular source of revenue currently for many apps.
  • Finally, once a critical base of users is established, traditional internet advertising banners can be bought for display…particularly when the app is free. This, however, is not a popular choice when the app is purchased in the app store as users expect to not be exposed to multiple advertisers.
  • As mentioned earlier, to motivate teens, I began texting them weekly. It worked to improve their diabetes care but solution not scalable and effect wore off…they needed more, they needed actual rewards. So I left medical practice to build the solution.
  • A medical student and I created our first app together that automated the texting protocol that I initially used.
  • However, the effects wore off as I continued texting the teens. They needed more than once a week reminders, they needed more motivation, and they needed more support…they felt like their parents and friends really didn’t support them because they didn’t know how much work diabetes is everyday.
  • Motivation, Ability, Trigger….engagement theory for sustained behavior change with chronic diseases
  • Startup lifestyle
  • EndoGoddess App, released September 2011: more scalable and more motivating with points game and iTunes rewards
  • We followed the money and changed customer then focused on addressing business pain point with our solution. Let me explain.
  • Following the money: where is it all going? Hospitalizations
  • And the consequences of non-adherence to diabetes medications are expensive. Let me explain with actual data:
  • Non-adherence is expensive and businesses and families are the ones who are paying most of that cost.
  • Remember, that companies and private insurance are shouldering this cost, here is an example.
  • The Benfield Group LLC. Rememberitnow email reminder employee wellness program which started in 2010 may work for conditions where forgetfulness is a primary reason for nonadherence but this doesn’t work for diabetes. Employers motivated to decrease healthcare costs thus explains large increase in wellness programs over past several years. Sources: http://insight.milliman.com/article.php?cntid=7628?&utm_campaign=Milliman%20Homepage&utm_source=milliman&utm_medium=web&utm_term=home%20banner&utm_content=MMI http://www.huffingtonpost.com/2012/06/25/employee-health-incentive-benefit-survey-society-for-human-resource-management_n_1625978.html
  • Glucose checks alone correlate with good diabetes control (and insulin adherence). Glucose checks mean engagement. Given that glucose checks are a strong predictor for insulin non-adherence, improving this rate by X% is the core of the business model and we believe this will reduce hospital visits and reduce health care costs by Y%. The value of SMBG in insulin-treated patients with type 2 diabetes is unknown. Most observational studies and randomized trials have focused on patients treated with oral agents and have led to conflicting results ( 4 – 15 ). Despite the absence of consistent data, the American Diabetes Association recommends SMBG for “all insulin-treated patients with diabetes” ( 27 ). We conducted one of the few longitudinal studies that prospectively measured HbA 1c at different times after starting an intensified protocol, precisely ascertained compliance, and controlled for the effect of other variables affecting glycemic control. Our results support the American Diabetes Association monitoring recommendation because we found that intensified blood glucose monitoring resulted in significant and sustained reductions in HbA 1c in stable, insulin-treated subjects. This change was remarkable because study investigators did not provide subjects with any self-care recommendations, referrals, or treatment modifications. In fact, parallel changes were detected in prelunch and bedtime blood glucose readings even before subjects returned to download data from their blood glucose meters and first received summary time-of-day readings and interpretations.
  • We provide an effective solution designed by a doctor and behavioral research who knows diabetes and the importance of glucose checks: turnkey apple/android mobile insulin adherence/glucose checking engagement and rewards program specific for adults or children.
  • Maintaining BJ’s health behavior model principles but improving rewards to health savings accounts.
  • We provide an effective solution designed by a doctor and behavioral research who knows diabetes and the importance of glucose checks: turnkey apple/android mobile insulin adherence/glucose checking engagement and rewards program specific for adults or children.
  • Real rewards. Not only do you feed yourself but you feed Cooper too. Cooper is along for the journey. Your diabetes dog. Everytime you take of yourself you take care of Cooper. Engagement.
  • Nationwide would pay initiation fee then monthly user fee based on the number of users. They would also offer health savings account payment based on user engagement and adherence.
  • Long term focus for exit strategy: with revenues, crowdfunding, and angel investment we are planning to complete clinical trial testing of the app to prove beyond pilot studies that apps provide excellent platforms for behavior change that should be part of the healthcare ecosystem: both by doctor prescription and by insurance cost containment strategies. The only way to enter this arena is with evidence.
  • Growth: advertising
  • Growth: in app pharma purchases
  • Growth: increasing platforms with smart apps on dumb phones
  •   Integration beyond web-based software.
  • Based on past experience with EndoGoddess App, developed EndoGoal. We provide an effective solution designed by a doctor and behavioral research who knows diabetes and the importance of glucose checks: turnkey apple/android mobile insulin adherence/glucose checking engagement and rewards program specific for adults or children.
  • Being a 30 something technology entrepreneur, I never went to school specifically for app making but find myself here solving human problems with human methods just by watching how technology integrates into mine and my patients lives…and you can and should do it too! 
  • Dyer Medicine 2.0 (2012)

    1. 1. Physician Entrepreneurship and App Development: How Did I Do It? Medicine 2.0, September 15th 2012 Jennifer Shine Dyer MD, MPH Physician, Mobile Health Entrepreneur Duet Health LLC EndoGoddess LLC Columbus, Ohio
    2. 2. • Pediatric Endocrinologist• Health Behavioralist (MPH)• Problem-solving technology entrepreneur• Social media enthusiast (@EndoGoddess)
    3. 3. Problem: Adherence
    4. 4. Not scalableNeed moremotivation
    5. 5. Bolus Reminder App, 2010 Automated, personalized SMS texting conversation by doctor to teen
    6. 6. EndoGoddess App, 2011 Self-entry glucose journal: - iTunes rewards - motivating quotes
    7. 7. EndoGoal App, 2012 Self-entry glucose journal: - real $ rewards - digital pet rewards - company wellness
    8. 8. Definitions: Business Models• B to C• B to B
    9. 9. Definitions: How Apps Make Money App Store purchase
    10. 10. Definitions: How Apps Make Money Subscription Model
    11. 11. Definitions: How Apps Make Money In App Purchases
    12. 12. Definitions: How Apps Make Money Advertisement Banners
    13. 13. Example #1• B to C• App store purchase
    14. 14. Bolus Reminder App, 2010 Automated, personalized SMS texting conversation by doctor to teen
    15. 15. Bolus adherence improvementsdecreased over time • Needed more reminders • Needed motivation • Needed more support
    16. 16. BJ Fogg’s Health Behavior Model
    17. 17. Networking
    18. 18. LLC Formation,Duet Health Partnership
    19. 19. EndoGoddess App, 2011 Self-entry glucose journal: - iTunes rewards - motivating quotes
    20. 20. +1000 users
    21. 21. Duet Health:Proprietary Revenue
    22. 22. +6,000,000 users
    23. 23. Investment Funding, Mentorship
    24. 24. Example #2• B to B• App subscription model
    25. 25. B to B Pivot:Follow The Money
    26. 26. Nationwide Children’s Hospital, 2009 80% of hospitalizationsdue to insulin non-adherence (140 total)$10,000 each hospitalization $1.4 million total cost
    27. 27. Who is paying? Employers
    28. 28. Fifth Third Bank: Diabetes 21,000 employees 30 kids with type 1 diabetes 420 adults with diabetes on insulin $450,000/year extra annual costs due to non-adherence Adults with insulin-dependent diabetes (2% of total population) Kids with type 1 diabetes (0.15% of total population)10% of those on insulin therapy will have hospitalization ($10000 each) due to non-adherence Sources: CDC, NIH, Fifth Third Annual Report
    29. 29. Adherence Programs: Email Reminders Ineffective Not specific for diabetes Wrong target behavior
    30. 30. Correct target behavior: glucose checks Diabetes Care :June 2003, vol. 26, no. 6, 1759-1763.
    31. 31. Record Glucose Earn Points Get Rewarded
    32. 32. Amazon.com DepositsHealth Savings Account Deposits
    33. 33. Social Business Model:Peer & FamilyReinforcement/Motivation Motivation from Support •Amazon account deposits •Social network support
    34. 34. EducationEE
    35. 35. Reminders/Triggers
    36. 36. RewardsHealth Savings AccountAmazon.com
    37. 37. 105 30 310:00 pm
    38. 38. Subscription Payment Model (Corporate Program) - Initiation/Configuration Fee - Monthly User Fee
    39. 39. Competitive Analysis (US) AgaMatri iGlucose Glooko Telcare WellDoc EndoGoal x DataManagement X X X X X X DeviceConnectivity X X X X Guidance X X Corporate Wellness X XAdherence X Rewards X
    40. 40. Corporate Case Studies: Revenue
    41. 41. Crowdfunding
    42. 42. Growth: Angel/VC Investments Expand corporate clients (sales force) Expand consumer users (exposure) Reach critical number of users Data Sales, Advertising Device Connectivity, Platform Expansion Pharma Partnerships
    43. 43. Advertisement Banners
    44. 44. In AppPurchases(Pharma)
    45. 45. Jennifer Jeff Ivan ShawnFounder,Partners Dyer Harper Harper O’Reilly (EndoGoddess (Duet Health) (Duet Health) (Advisor) )Clients, Fifth Third Huntington Nationwide CardinalRevenue (pending) (pending) (pending) (pending) JP Morgan Crowd- Ohio State Chase Scotts funding (pending) (pending) (pending) (MedStartr) FoundersInvestors Factory 10X
    46. 46. Jennifer Jeff Ivan ShawnFounder,Partners Dyer Harper Harper O’Reilly (EndoGoddess (Duet Health) (Duet Health) (Advisor) )Clients, Fifth Third Huntington Nationwide CardinalRevenue (pending) (pending) (pending) (pending) JP Morgan Crowd- Ohio State Chase Donatos funding (pending) (pending) (pending) (MedStartr) FoundersInvestors Factory 10X
    47. 47. Real rewards. Real results. endogoal.com
    48. 48. Thank You!jennifer.dyer@duethealth.com

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