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The pathway to high-quality care with clinical leaders from Carbon Health, Ro, Midi Health and Doctoora
How do you build and maintain a care team that drives better outcomes?
Driving better clinical outcomes and selling high-quality care is a unique selling proposition in healthcare. The question is, how do you create an organization that facilitates this mindset? And how do you make sure that the care team delivering such outcomes stays with you? To answer that question I sat down with Dr. Arpan Parikh (Senior Director of Clinical Excellence at Ro), Joanna Strober (Founder of Midi Health), Dr. Debo Odulana (Founder of Doctoora Health) and Dr. Ayòbámi Olúfadéj (Sr. Director, Program Development at Carbon Health).
The role of a clinical leader
A clinical leader is vital if you want to build and keep a care team that continuously drives the best outcomes. The role and responsibilities of such a clinical leader evolve when the company grows. Let’s take a look at how exactly.
At an early-stage company
It will be unlikely that you’ll find a Chief Medical Officer (CMO) at an early-stage company. Common titles you will find are Clinical Lead, Head of Clinical or VP Clinical.
Regardless of the title, it’s crucial that a care delivery company has a clinical leader from the start. Preferably in a founding role. If you don’t have such a role from the start, chances are high you’ll get into a lot of trouble later on (eg no clinical strategy, not able to sell to payors/health systems, solving the wrong problem). The vast majority of clinical leaders at early-stage companies are also actively practising medicine in the subspeciality that aligns with the company they are working for. The main reason for this is because those clinical leaders are oftentimes the first person who’s delivering care on the platform. This is particularly useful because by providing care the clinical leader will learn the needs and questions their patients have. Information that then can be used when defining product features, care protocols and even training material.
The role of a clinical leader doesn’t stop at providing care. The overarching goal of the clinical leader is to become the thought partner to the executive leadership team and provide a clinical lens to every early decision that the company makes. This lens is important on all levels:
Product: You need someone who understands the disease clinically to design a disease-specific patient app
Marketing: You need to advertise in a way that is clinically and ethically appropriate
Regulations: You need someone that understands the regulatory requirements for delivering care
While MBAs would probably like to put “Move fast and break things” on the wall of their fresh office, the role of a clinical leader is to put “Move fast, don’t break things. They are patients for fucks sake” on that same wall.
Besides building the guardrails in terms of what the business can and cannot do, another key aspect for a clinical leader is business development. I hate to break it to you but health systems and payors don’t care about your fancy-looking pitch deck. What they need is someone they can talk to that understands the disease. That understands the clinical language they speak. If you don’t have a clinical leader that can explain the clinical efficacy (aka how much $$ are you going to save by reducing complications) and safety of your product it will be nearly impossible to sign a deal.
At a late-stage company
In the later stages, the title will change from Clinical Lead to CMO. And with a new title, also come new responsibilities. A CMO is less of an internal role and more of an external one. This means less product involvement, no longer providing care and no longer giving input to the marketing team.
So what do they do? We can divide their role into four major pieces.
We first have the regulatory piece. CMOs need to be aware of the evolving regulatory landscape. Based on these evolutions they need to assist the leadership team and the legal team in making sure the business is adapting based on those changes.
Secondly, we have the fundraising and partnerships piece. At early stage the focus was mainly on answering, building trust and closing deals with payors and health systems. A CMO goes one step deeper and needs to strategically think about new partnerships from two perspectives:
Sales: In which states do we want to be active in the next six to twelve months? Who are the key health players in this state and how do we connect with them?
Acquisition: What tools and capabilities do we need that we can’t build in-house? How are we going to get those things? (I wrote an article on buy vs build here)
Third is the fact that they will need to become the external face of the care organization. They need to build a brand for the company and for themselves. This means they need to speak at conferences, go to hosted dinners, publish research and just be wherever the key decision makers are.
Finally, they need to build a clinical leadership team that can take over their previous responsibilities. Because you still need someone that oversees the care team or someone that makes sure all advertisements are clinically (and ethically) validated. But this will not be done by the CMO. It’s the CMOs job to build specific “verticals” for these previous responsibilities.
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How do you ensure that your clinical team delivers high-quality care?
Now that you understand the role of a clinical leader, the next thing to understand is how you can build a care team that drives better outcomes.
Pathways, Protocols & Clinical Guidelines
The first thing you need to have in place to ensure clinical quality is to have well-defined care protocols and clinical guidelines.
At Midi Health they hired two clinical leaders that spent six months writing their clinical protocols. They reached out to experts in different fields, ranging from bone health to cardiovascular health to mental health. They then integrated all of this material into clinical protocols. They ended up with books of protocols ready to be used when they launched the company.
While every doctor is used to a certain way of doing things, one of the requirements of working for Doctoora Health is that clinicians need to follow their evidence-based care pathways. They currently have over 600 care pathways ranging from depression to endometriosis or erectile dysfunction. They have a fascinating process on how they define such care pathways (the process Carbon is following for designing care pathways is almost identical).
So let’s imagine Doctoora wants to design a care pathway for depression. What they will first do is an initial brainstorming with mental health professionals (therapists, psychiatric. psychologists...). During this brainstorming, they first discuss existing evidence-based guidelines and then try to visualize the full patient journey. Starting from diagnosis to treatment and (hopefully) all the way to a cure. For each touch-point, they define what the most important outcomes (e.g PHQ-9, GAD-7, PROMIS-10) are and how they can track them.
At the end of this brainstorming, they have care pathways defined. Then it’s the responsibility of the product manager to define what needs to happen at each encounter:
Are we doing a paper questionnaire where the patient needs to come to the hospital to fill in the questionnaire (e.g if the patient population is old, they might need assistance)? Or are we making it digital so we can send it to the patient before the consultation?
Is the first consultation going to be virtual or is it going to be physical?
How can we incorporate this care pathway into our EMR?
Once that’s cleared out, the next step is setting up a cohort of ten patients that give feedback on areas of improvement. Based on that the final adjustments are made and the first version of the care pathway is used in clinical practice. “First version” is important here because at Doctoora a care pathway is never finished. Every six months they look at their existing care pathway, organize another brainstorming session, discuss the current outcomes they have and how they can improve them further. They are creating a continuous loop of improvements. The same is true for Midi Health, by the way, they iterate and improve their protocols every week.
Why are companies such as Midi Health, Carbon Health or Doctoora putting so much time and resources into developing their care protocols? This has three main reasons:
Scaling: Once you have your protocols defined you can (more) easily train new care team members and get them up to speed quicker.
Standardization: The one thing you don’t want at your care providing company is variability in outcomes. The only way to prevent this is by having a standardized way of delivering care.
Quality of care: Changing behaviour is challenging. Changing doctors’ behaviour is even more challenging. That’s why it takes hospitals and clinics about 17 years to adopt a practice or treatment after the first systematic evidence shows it helps patients. To make sure your care team follows the latest evidence, you need to have clinical protocols in place. This will ultimately lead to better outcomes.
To conclude this first part: please make sure your clinical leader spends a lot of time developing well-thought-out and rigorous guardrails, protocols, pathways and guidelines (these are +- the same thing) for the clinical practice.
Training the care team
A second important aspect of maintaining clinical quality is training your care team. They need to become (or maybe already are) experts in the medical condition(s) you’re treating.
At Midi Health they created a, mostly asynchronous, care training curriculum. This curriculum consists of two things:
Videos (e.g information about hot flashes)
Quiz (e.g set of questions about hot flashes)
The goal of the curriculum is to make sure that what they’ve learned, they also understand. If they want to work for Midi Health, they need to score 100% on these tests. You could argue that this is a pretty serious commitment, but that’s the purpose of it. Midi Health is selling high-quality care that you wouldn’t get elsewhere. So therefore they need to make sure that their care team is also high quality. And that’s why scoring 100% on the tests is important (they can take a test twice if needed).
In addition to this training curriculum, Midi also organizes monthly talks where they invite an expert to talk about specific medical conditions that are related to women’s health (e.g non-hormonal solutions for menopause). They also have an active Slack group where the care team can ask real-time questions to specialists.
Besides training their practitioners in medical skills, they also train them in soft skills. They have classes on listening, building trust with patients and much more.
Carbon takes a similar approach as Midi. They have three major ways of training their care team:
Learning Management Solution (LMS): Video courses on operational (e.g how medical coding works) and clinical aspects (similar to Midi Health)
Internal wiki: Place where they explain care pathways/protocols
Quality rounds: Each month they remind their care team of a protocol (e.g bronchitis) and share data on that specific disease (e.g # patients treated, # antibiotics prescribed). Then they ask for feedback or group together to talk about things like “What are the gaps?”, “Why are we having trouble with meeting this requirement?” or “How can we improve?”
At Dooctora they also emphasise a lot on training. Once they hired a batch of clinicians they regularly organize focus groups of a maximum of 15 clinical people to talk about all the different kinds of patients they are going to see. So if they bring on a gynaecologist, they will talk about endometriosis, ovarian cancer and fertility. They will share experiences, best practices and what good outcomes would look like.
Working with targets
Tracking outcome metrics like PHQ-9, capacity utilization or patient satisfaction is one thing. But do you also reward or penalize your care team members if they do (or don’t) meet the targets?
The majority I have spoken to do not like to impose well-defined targets on their clinical team. The main reason is that they have trust in their people, they have trust that they hired the best nurse practitioners, doctors, dieticians… in the space and that they don’t need targets to drive better outcomes.
Early-stage companies should focus on two things when tracking outcomes:
Utilisation metrics (e.g average consultation time)
One or two clinical performance metrics (e.g NPS & PHQ-9)
Later stage companies have more targets and are almost always different for each clinical condition. At Midi Health they track a lot of different measures, but the most important indicator they track is “Are patients coming back?”. Additionally, it’s also important to know how you make people feel after they used your services, that’s why they also actually interview patients to see how their experience went. On the one hand, this gives you insight into your quality of care but on the other hand, it also gives you insights on how to improve your care protocols.
Although you don't work with targets, that doesn't mean you need to tolerate poor care. At Doctoora they put in place a “physician evaluation process”. After each session, the patients have to rate the doctor on different aspects (e.g communication, friendliness…). This ensures that each physician has an average satisfaction score. If the satisfaction score is too low, they have two meetings with that physician. The first meeting is used to try and help them improve the care they provide. They will look at what’s going wrong and how can they do this. If there is no positive evaluation in the next months, they have a second meeting to inform the physician that they can no longer work for Doctoora’s customers.
Both Midi Health & Doctoora don’t penalize their care team immediately if they don’t meet specific targets. Evaluations are always done by looking at things from a holistic view. Besides not penalizing their care team, they also don’t reward them yet. Dooctora has been trying to figure out a “rewarding system”, but it’s more challenging than you think. Patient satisfaction is for them not enough, they want to work with tailored outcomes for each and every disease (e.g can the doctor keeps the glucose levels of his diabetes patients within a specific range?). So if you have a good rewarding system put in place that goes beyond “doctor satisfaction”, please reach out!
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Building a care team in-house or using staffing agencies
The first question that pops-up, when you’re building a care team, is: do I work with staffing agencies (e.g Wheel, Openloop, SteadyMD) or do I build my care team in-house? The answer, like all in life, is: it depends.
Some care providers are treating such complex medical conditions that they need well-trained clinicians that are experts in that specific condition. Some have such complicated protocols, protocols that you’re not learning in nursing school, that it’s almost impossible to outsource them to a staffing agency. This is true for Midi Health and that’s why they are building their care team in-house. In the beginning, they hired care team members who worked 10 hours or sometimes even less per week for them. They quickly moved away from this and now everyone needs to work at least 20 hours a week for the company. The reason for this is that they expect commitment from their care team and if they are only working for a few hours per week they are not dedicated to the company and its mission.
Another problem with staffing agencies is that you lose two crucial things:
You lose insights into the clinical practice
You lose levers to influence quality & outcomes
The physicians working for such agencies will not see you as their supervisor. They will not feel the same camaraderie with your employees. And because of this incentive misalignment, I personally think that it will have a negative impact on outcomes.
One last point I want to make, before giving you another view on the same thing, is that with the rise of staffing agencies we will see more and more Linkedin pages turn into this:
When seeing such profiles, I wonder: can care providers still differentiate themself from the competition if your competition is using the same clinicians? You could argue: yes because each company has different protocols. But can you ensure that your clinicians are using your protocol and not the protocol from Teladoc for example? Jay Parkinson made a similar point here:
But are staffing agencies useless then? Not at all! In some cases it makes total sense to use a staffing agency. Companies like OpenLoop have great customer cases that showcase this. Where I see value for staffing agencies:
Scaling quickly: Imagine you are already active in behavioural health with 100,000 patients monthly and you want to scale to different medical conditions. Given the size of your company you want to deliver care in all 50 states. Setting this up in-house would be a pain in the a$$. That’s why you decided to partner with INSERT_STAFFING_AGENCY to scale quickly.
Low complex diseases: If you treat common diseases that have low complexity (e.g erectile dysfunction, hair loss, etc) it makes sense to use a staffing agency. Their team could easily be trained to follow your protocols and the impact on outcomes of having an in-house care team will probably be small.
Labour market: Hiring physicians can be extremely competitive, time-consuming and expensive. If you don’t have the time and resources to manage this, partnering with a staffing agency makes sense.
The above is just a personal opinion, there are many (much smarter) people than me that have a different opinion. See what healthcare OG Chriss Hogg thinks of staffing agencies for example:
So the conclusion to this question is that it really depends on different factors and at the end of the day you just need to treat it as another buy vs build decision.
How do you keep a rockstar care team?
The labour market is extremely competitive and finding a replacement for a care team member that left your company isn’t something that will happen in a few days. In order to be a successful care provider, it’s important that you keep your care team retention rate as high as possible (the same advice goes for your patient retention rate). There are several tactics for achieving that.
First, you need to decrease the admin burden for your doctors, nurses and other healthcare support staff. In Notable’s “State of Automation” it’s reported that 58% of staff time is currently spent on repetitive tasks such as data entry and documentation. KLAS reported that 47% of physicians think their EHR or other IT tools are a driver of burnout and 54% reported that spending too much time spent on bureaucratic tasks is driving burnout (fun fact; before joining physicians will probably ask to someone working at your team “How is the EMR?”, if it’s shit they will probably not join). There is no silver bullet for decreasing this admin burden, but smarter technology can be a big difference-maker as well as hiring clinical ops role(s) (I’ll explain this role in detail in my next article).
A second tactic is making them feel part of a community. At Midi Health they did this from day one. They created an active Slack community for their care team where they can communicate, ask questions, and help each other. They also organize monthly meetings with every one to talk about the challenges they faced in the past week. With this approach, the care team at Midi Health feels connected on another level than normal colleagues do. Joanna is convinced that this community-building is of inestimable value.
A third tactic is to manage the chaos for them and let them focus on providing care. You have two roles for that:
Clinical leader: They should shield the clinical team from organizational chaos / bureaucratic shizzle
Clinical Operations: They need to make sure that the care team can focus on providing care (I’ll explain this role in detail in my next article)
A fourth tactic is making it very obvious to your care team on how their care improves the lives of people and celebrating this (e.g via Slack). Show them the data: patient outcomes (eg PHQ-9 improvement), patient reviews (eg NPS) or cost reductions (e.g saved $ per patient).
Some other, important, tactics:
Make sure pay is competitive for full-time staff. Part-time staff, pay should be competitive with per-diem rates.
Respect their opinions and ideas. You will see a lot of clinical staff leave if they feel that they are not being heard or understood, especially if management does not have clinical care experience.
Enable participation in non-clinical projects where possible to expose them to other aspects of startup life they want to explore
Make sure that safety concerns are being heard and addressed.
Ensure they have the right tools to effectively care for patients
Ensure they have clear career pathing/growth opportunities
Give them the decision to build flexibility into their life by letting them decide when they want to work and how much they want to work
As a care provider, your clinical team is your product and your brand. So don’t underestimate the importance of training them properly and making sure they feel valued.
Long term value (LTV) >>>> Customer Acquisition Cost (CAC)
Providing care is much more than just the clinical aspect, train your care team with soft skills as well (e.g active listening, stress management, communication…)
Finish the first versions of your protocols before you start engaging with patients
If +20% of what you’re clinical team is doing has nothing to do with providing care you need to hire a clinical ops role asap
Don’t underestimate the impact of a low care team retention rate. Make sure your care team loves working for you. The digital health winners that will attract all the clinical talent will be those that create the right work environment for their care team
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Shameless plug, but in case you’re looking for a no-code tool to build, operate (this means using it in clinical practice with patients - integrated with all your systems) and improve your pathways/protocols/guidelines: this is exactly what we’ve built at Awell Health.
We’re already automating and standardizing care processes for many leading (virtual) care orgs. Feel free to ping me via firstname.lastname@example.org if you’d like to learn more.
If you want to learn more about building your care team, I highly recommend the article from Jonathan Slotkin & Christina Farr. This article where Omada Health's CMO shares his wisdom is also great (also from Christina Farr).
Thanks dr. Arpan Parikh, Joanna Strober, dr. Debo Odulana and dr. Ayòbámi Olúfadéj for sharing your wisdom.
Thank you Paulius Mui, Matt Sakumoto, David McCarthy, Rachel Menon, Phil Efstathiou and Rania Nasis for the feedback.
Thanks John Klaus, Nina Underman and Erica Webb for the input.