Wayne Guerra M.D. MBA is the Chief Medical Officer of iTriage. Dr. Guerra has over 20 years experience as a practicing Emergency Physician. He earned his medical and undergraduate degrees from UCLA and his MBA from the University of Denver. In 2008 he co-founded iTriage with his colleague, Peter Hudson M.D, also an emergency physician. He is based in Denver, Colorado, where the company is headquartered.
March 2013
iTriage provides users with a symptom to provider pathway, giving them information on thousands of symptoms, diseases and medical procedures and directing them to the correct provider whatever their problem. We’re primarily a mobile app – we have apple and android apps – but we’re also on the web and we have microsites on other portals. Our users can check in to ERs and see the waiting times, which are fed to us via an RSS feed every 30 minutes so they’re kept updated. They can also make appointments. We also have a big database of medications. Users can look at side effects, doses, who prescribes those meds… and find out information such as side effects. We also have a pharmacy discount card. Now we make it possible for users to create a profile and log in and save their information to the cloud. It’s HIPAA secure, just like a personal health record. When users log in, based on their personal information, including their insurance company, the datasets change. It can tell you if you’re in or out of network and whether you should be pointed to a particular nurse advice line for example.
So what led you to found the company?
I co-founded the company with Peter Hudson. We were both physicians working in the ER at the time. We had extensive experience as emergency doctors and were frustrated that patients didn’t have the information they needed to make the best decisions for themselves. We saw a way to empower patients and make the system more efficient, leading the patient to the right care for both treatment and follow up.
We saw a real need to provide a symptom to provider pathway – based on the symptoms and causes we wanted to help people learn where’s the best place to go to seek care. The truth is, 20-70% of ER visits could be dealt with in a lower level of care. For the payer and employers this is costly. On the other hand, we knew that some things, like an MI or stroke, were going to a lower level of care than they should. I had friends who were smart people but didn’t know where to go and they would ask me, “Can I go to an urgent care center for this?” or “Can I go to a retail clinic?” They don’t know the answer. Again, after being seen in the ER, patients would often say to me “Doctor, could I have gone to an urgent care clinic for this?” There was a need for this information from multiple side – patients, providers, payers and employers. There’s an information gap that we’re trying to close.
How did you get started – did you launch the company whilst still practising as physicians?
We started in September 2008. We got things off the ground by writing our own information for the app – just enough for users of the app to make the next best decision. At the time we were ER doctors. Over here, a full time post in the ER is 14 to 16 days per month so we had time outside our shifts to do it. But yes, we were still were working while doing this.
How about fundraising – how much did you have to raise and at what points along the way?
We raised enough money in 10 days to give us a 9-12 month runway. We had previous business experience in a range of areas and our investors knew us and things we had done before so they had faith in us and liked what we were doing and believed we could achieve the goal. Then we brought on more money at different stages. We always used the money well, had milestones we planned to reach and could show our investors we had reached them. We went to them with more milestones and a plan. Over 3 rounds we raised a total of around $4m. We had angels and high net worth individuals come on board with amounts of $25,000 to $50,000. We then had strategic investors and sophisticated NYC angels and we were then bought by Aetna.
What’s your business model?
We partner with providers – health care organisations. Our provider partners pay an annual fee and we list ERs, urgent care centres, retail clinics and so forth. Physicians also pay a fee to be listed. The providers might be a specialist provider in specific fields – trauma care for example – and it’s really good for them to be able to reach potetntial customers looking for the expertise they can provide. Nowadays an ACO might come on board and make a thousand listings at a time. We also work with health plans. We’re free to the consumer though – our apps are free to download and we’ve had 8 and a half million downloads to date and we have 3-4 million active users each month.
What’s been the biggest challenge for you as a company?
The biggest challenge has been finding good people. We don’t code. We wish we did! Also, building awareness and marketing. In the early stages, trying to create a market and recognition of the need. We had to create a whole new market. It was tough convincing providers they could bring in new patients using a mobile app – we had to create that need and then sell the product as a solution to that need. So that was an uphill struggle from the beginning. It’s much easier now though because every single report on mobile shows you have to do mobile. That was not true back in 2009.
What do you feel have been some of the key factors in your success as a company?
In the design of any product the user always has to come first. So we only show people in context, whether a spinal surgeon or a medical device company, we only show you that information if you’ve asked for it. We defend that user experience tooth and nail and we’ve done that from the very beginning, that’s sort of my job and that’s continued to be really really fruitful for us.
In the beginning we created some personas. We thought to ourselves, “Who is going to use iTriage?”. So we thought business travellers would, we thought busy moms would, we thought the invincibles would (our name for the millennials), the people that were very under-insured, young, tended to have smartphones, maybe even had no insurance so they wanted to find an urgent care if they could as they’re maybe paying all their healthcare expenses out of pocket. Also, people who are interested in patient empowerment and consumer engagement. So then we found a list of blogs, about 300 bloggers, blogging on this, and we would comment on articles. We would spend time and do it in a very thoughtful way and mention iTriage. And we had about a 10% pickup rate where the authors wrote back and were interested in reviewing the product and we would do a demo for them. So that was really great for us. It doesn’t cost you any money. It’s a lot of work but worth it. We were once in the first couple of comments in a New York Times article that was shared many many times and we got a lot of press for that. We reached out to reporters and befriended them. From very early on those people started writing about us, as a nascent company, so we built up those relationships. We made good relationships with Apple and Android and showed them, hey, this isn’t a game. This is something people are using to make healthcare decisions. We’ve been featured in those markets and that’s been great. We look forward to continuing to have those relationships.
You’re a business where one set of users relies upon another set of users to provide value – i.e. a business with network effects – so how did you solve that chicken or egg problem?
Each health system we signed on, we’d have a marketing plan for them. We’d market the application for them. They’d embrace it as their own app. They’d do billboards showing their ER wait times. Showing they could do them on the phone. We’d get on local news as it was a really interesting topic… two doctors created this application. I still go on the news every month or so. Sometimes about medical topics like getting a flu shot, sometimes about iTriage. The more awareness the more click rates. So we would build awareness in every health system and that would bring more users to the app.
You’re currently hugely popular in the USA. How do you think iTriage will work outside the US… in the UK for example?
So we recognise that that’s something we could work more on in the future. The app has to be localised – the names of medicine have to be changed for other localities for example. We have talked to people in the UK. It’s tricky. It’s likely to be more of the fee-for-service, pay-per-user model at the outset but I think there’s a lot we could do for the NHS too. To some extent the incentives have to change. If you can shift a population from going to A&E to instead seeing their GP, that’s worthwhile. But the incentives aren’t always there. That said, even just the content we provide can help enormously. Helping people organize their thoughts around a symptom and then deciding where is the place to go. A lot of times NHS patients are going to A&E just because they don’t really know better.
If you could change one thing about how you’ve managed the business since you launched, what would it be?
Well… we’re just about ready to put out multi-symptom processors which will allow us to also get some demographic information – “I’m a male or female”, “I’m 5 years old” (if someone’s searching for a child) for example, and then add symptoms. I’m ‘Q-A’ing’ it with the medical team right now and I’m really excited about it. It’ll be out in an update really soon. We do a lot of updates – please download it and look at it, I’d love to get your opinion on it. So if I could change one thing… I would have done that a lot earlier.
What led you to make that decision – to add that update?
We have 75,000 reviews on the iPhone and Android market and we’ve used those reviews to build new features and that’s been a persistent request for a long time. But the reason we haven’t done it is that we didn’t have a framework for doing it correctly. We didn’t want to just fake it – what we’re using is CDC biosurveillance data which represents millions of visits and then using the probability of a symptom related to a disease, basing it on statistics, and its really kind of cool. We have some very very smart people that understand machine learning and statistics that are helping us build that. So, we wanted to build it correctly, but I would have done that much much earlier. I would have said, “Guys we’ve got to figure this out… we’ve got to do this right now!”
So, you’re personalizing the advice based on demographics?
Yes, but also on a couple of symptoms. Because if you have that cough, do you also have a fever? Because maybe that cough’s allergy-related or from gastro-oesophageal reflux. So whether you have a fever or not really changes the lists of things. We’re certainly not diagnosing anyone, because we don’t do that, that would take much more complex technology, a Watson-like technology.
Yes, well I work in exactly that area, diagnosis support, so its very interesting to me. It’s a challenging area though.
Yes, it is. It’s complex. Because how do you weight a symptom? What I’ll do. Well, all providers do it, is I’ll ask, if someone tells me they have a cough, and then they say they have a headache, I ask them, “Well how bad’s your headache?”. And if they say, “oh, not that bad’, well then I don’t even bring that into the calculation. That’s just a red herring. But, when you’re doing it on a machine, you could do a scale – how significant is the cough or the headache? – but then the complexity of the technology to do that, it gets interesting, but it gets very complex. The number of pathways that you have to QA for that is mind-boggling.
Anyhow… I would have loved to have done this earlier and I can’t wait for it to come out as it’s one of our biggest requests.
What would be your advice to medics who are looking into taking an entrepreneurial path?
So, I think it shouldn’t be a passing fancy. Peter and I HAD to do this. Once we got started we lived and breathed it. I couldn’t wait to wake up and look at the emails. I drove people crazy with my iPhone – I was looking at my iPhone even as I went to bed. And they were never emails saying “you’ve done a really good job Wayne, have a nice sleep”! It was always a problem. But I wanted to be able to think about it, work on it at that time. So, I think, if you have a good idea, I would do some basic analysis on it – Is it marketable? How big’s the market? And then you should do it because you have to do it. And then, be flexible, because you might have to change your path. Your business plan and ability to generate revenues will probably change, as the market changes underneath you. We went from a pure fee-for-service tool to now, our whole idea about managing populations and helping people to manage populations is becoming much more significant in the market. That’s a big change in the last 3 years, because the market’s changed, but you have to move with it.
Wayne, thanks, this has been really interesting. One last question – if you were starting another digital health company – something totally different – what other areas interest you?
I would say it would have to be analytics. Someone who understands healthcare can make huge advances in that area. Also, how do you get patients to make better decisions? The long-term goal of better health just isn’t enough for many people. How do you use technology to find people in the population who for other reasons aren’t looking after their health and help them make better decisions?
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Follow Wayne Guerra on Twitter @WayneGuerra