Discover what's on our minds

We like to research, think about and discuss what's going on in health care and find new ways to keep transforming it. Join the conversation!

One Coffee at a Time

The work we do is challenging and sometimes it is easy to succumb to feelings of doubt, thinking that all our hard work is in vain. However, there are examples that highlight the difference we make. One such example is one of our Health Coaches, Vero’s, most challenging patients.

She is a 23 year old patient. When she came to us it was clear that she was suffering. She has type 1 diabetes, difficult enough for a young adult to handle yet she also suffers from ulcerative colitis. After an extended hospital stay and major bowel surgery, she was left with an ostomy, a difficult situation for anyone and particularly debilitating for a 23 year old.

Her surgeon told her she would have to get her sugars under controlled before they would reverse the ostomy. Dealing with an ostomy bag was not only a hindrance on her social life, it limited her job opportunities.

Not surprisingly, she also suffered from major depression which became a compounding factor in managing her multiple medical problems. She tried talk therapy but never really felt comfortable opening up. Antidepressants didn’t make a dent. She was mired in despair and despite our efforts to engage her in managing her blood sugars, Vero’s texts often went unanswered. We knew she would spend days in her room, crying and isolating herself. She would frequently break down while at work. We begged her to come in to talk to us.

Finally, one day without prompting, she did. We could tell she was on the edge and didn’t know where to turn. She had decided to put her trust in us as a last resort. She opened up to us and all her emotional and physical traumas began to trickle out. It was a very emotional meeting and it was only the beginning. We offered more therapy from a professional, but she really just wanted to talk to her Health Coach. We decided that coffee with Vero every other week would be a start. She left that meeting only a step back from the edge but she was moving in the right direction.

And then, Vero received a gift of beautiful flowers.

One Coffee at a Time Vero

The note reads:


Over the past couple of months Vero’s coffee meetings have been a huge success. She has shared some of her deepest secrets that have clearly been weighing her down and blocking her from moving forward. She has felt comfortable enough to establish care with Nina, our social worker, so she can get the trained help she needs in dealing with her significant past traumas. From a medical standpoint we are still working on her sugars with the goal of reversing her ostomy. She is by no means a picture of health, but we are taking baby steps, in the right direction.

This patient has been a huge reminder to me that despite the monumental task we have in front of us, we do make a difference in people’s lives, everyday. Because of the unconventional resources we have to help us connect with our patients, we are able to continue to find creative ways to make breakthroughs and put our most challenging patients on the track to leading healthier and more fulfilling lives. I know that there are times we feel like no matter how much we try to help our most challenging patients, that they can’t or won’t change. It is so wonderful to be reminded that by showing our patients that we truly care about them and that we won’t give up on them, our positive attitude can have an impact. Great job Vero!

Bad Medicines

Gerardo Pis-Lopes and Eliot Kristan

Photo: Gerardo Pis-Lopez (left) and Eliot Kristan (right)

Two weeks ago, Eliot Kristan, Iora Health’s Devops and Systems Manager, was in the middle of his week-long on-call rotation when he received a support ticket from Stephen Dahmer, a physician in our Manhattan practice. Stephen wanted help querying our electronic prescription service for a list of our patients taking a specific combination of medications due to a report in the NEJM which concluded that the coadministration of trimethoprim-sulfamethoxazole and spironolactone “confers excess risk of sudden death”.

Unfortunately, the two vendors we use for electronic prescriptions do not provide a way to query a patient panel for those who have a specific combination. But the Iora practice team could go through each drug and cross reference the but that would be time consuming and error prone.

Eliot understood that this manual search was going to be a huge burden on the Manhattan team so he consulted with Gerardo Pis-Lopez, a Senior Software Engineer, who had recently been working on integrations with our electronic prescription vendors (and who happens to sit right beside Eliot). After a quick spike (that means a time-boxed experiment), Gerardo was able to download the medication history for each patient at our Manhattan practice. Eliot provisioned an Elasticsearch system and imported the medication data so that he could quickly build a report for any patients with a history of both drugs. The results indicated that, according to our data, there weren’t any patients in Manhattan with the dangerous combination in our system. Eliot informed Stephen and our Chief Medical Officer.

So at Iora, the story wasn’t over. Eliot and Gerardo did not stop with just the Manhattan practice; they decided to do similar work for all our practices. And good thing. They identified 13 patients in total across Iora Health and informed the appropriate teams.

Those teams were then able to very quickly look through 12 patients one at a time (instead of thousands) and determine that only 1 patient was potentially at risk for the interaction. Our care team contacted the patient and confirmed that he was not taking the combination.

An Iora physician reads about a newly published drug interaction, submits a support ticket and our tech team was inspired and empowered enough to spring into action to check on our patients nationwide. Only hours after first becoming aware that this interaction existed, we had a care team on the phone with a patient thousands of miles away to prevent the possibility of sudden death.

One Culture

Iora’s culture is something that is hard to define but I believe it is rooted in a desire to serve others first and foremost. No need to ask permission or beg forgiveness, Eliot and Gerardo felt empowered to just solve the problem. They were not asked to do this but felt that this was the right thing to do so they both dropped everything and got on with it.

At Iora Health, our product development is centered around cross functional teams consisting of clinical, engineering, design and analytical team members. The cross functional team is empowered to build a solution to a given problem and, at the same time, it is one of many components that help maintain one culture across the company. During the team collaboration, we get to hear about what is good, bad or missing in our systems and, as importantly, we get to see our colleagues using them. Those who use the tools we build (patients, health coaches, physicians, etc.) are part of our day to day interaction. Other tech teams don’t often get to have this tight collaboration and because of this, we don’t look at our users like customers but coworkers and patients — people we have an intimate relationships with. This connection is what encourages the behaviour Eliot and Gerardo demonstrated.

I consider myself to lucky to work as an engineer at Iora Health. Not only is the mission of the company noble, I get to create solutions to difficult problems — with people like Eliot and Gerardo — which is rewarding when seeing its impact to ourselves, our colleagues and most importantly, to our patients.

Transforming Health Care One Book Group at a Time

Our ultimate goal at Iora Health is to transform health care. As a Health Coach, I am lucky to work towards this aim daily by building relationships and partnering with patients to address acute concerns, to help manage their chronic conditions, and to support people in reaching their individual health goals.

This is incredibly important, powerful, and gratifying work. Transforming health care is quite a big task so our team needs to be creative every day, always on the lookout for ways to enable this change in – and out – of the exam room.

This creative approach to our work recently led us in a new direction at our primary care clinic in Hanover, NH. We decided to experiment and offer a weekly workshop entitled “Women’s Book Club: Finding Your Own Healthy Body Weight”.

As a company we frequently ask ourselves: How can we connect people who are ready to work on their health? How can we purposefully design interventions that result in creating a healthier overall community?

The formation of a book club seemed to be an innovative and engaging format to address both of these questions. Within several hours of announcing the group in our newsletter, twelve women signed up.

This 10-week session grew out of a weight loss group that had been working together for nearly three years. Recently, the women involved had participated in an online Coursera Nutrition course, had gone walking to increase activity, and even done some simple healthy cooking together. Now, as facilitators, we were looking for a next step, one that would serve to inspire, that was fun, and that would intrigue and engage more participants. Ideally we wanted one that was provocative and different enough to catch people’s attention.

Thus the idea of reading “Half-Assed A Weight Loss Memoir” by Jeanette Fulda was born. This book chronicles Fulda’s journey towards lifestyle change during which she sheds nearly 200 pounds and blogs about it. It is a funny and engaging story that has Jeanette hiding loaves of bread from herself in the trunk of her car, learning to cook, and discovering a love of physical activity she never knew she possessed.

Our intent with the group was to promote discussion and to incite personal action. But how can simply reading a book about lifestyle change actually inspire action in others? This is where Motivational Interviewing entered the picture. We intentionally designed the workshop to mirror a motivational interviewing session (a process that engages motivation within a client to change behavior) and focused on the Stages of Change with participants. During our weekly meetings, participants identified where they fell on the spectrum of change and considered ways to increase their motivation.

At the outset of the workshop, patients were invited to meet with their care team (doctor and Health Coach) to develop a lifestyle approach and food plan that aligned with their health goals. They checked in midway and at the end of the course with their Health Coach to discuss changes – both mental and physical. Book group members were asked to read two chapters each week as “homework” and to reflect on a series of guided questions.

We just completed week ten. Was everyone successful? I don’t know. You’d have to ask them as this depends on individual goals. We shared a lot of laughs, everyone finished the book, and the ladies wrote letters to themselves explaining how their lives would be improved if they made the changes they desired. The cards are in the mail so everyone should be receiving an inspirational note in their mailboxes soon with a reminder to stay motivated.

Did people make behavior changes? Yes! One participant lost 10 pounds. Another started working with her spouse on meals that include more greens and moderation. Some started planning and cooking on Sunday afternoons for the week ahead. The group gelled and formed a strong support network for each other. And they all want to continue.

Did we transform health care? If working with a patient one-on-one in a visit to affect health change is powerful form of intervention, then sitting down with 12 women for an hour every Monday at lunchtime is an extremely powerful way to create change on both an individual and cultural level. We truly can multiply our impact in these group visits. Our team realizes we will only be successful when we work together to affect the culture in which our patients live. Transforming health care is ultimately only possible when we build a community with shared goals and support.

It is energizing to work for a company that encourages creativity and new approaches to help people feel their best. Never doubt that small group of committed individuals can effect change in the world, one book group, one community, one Iora practice at a time. And you might even be surprised by how many people sign up.

Commonality: finding the common threads

Commonality is the state of sharing features or attributes. It’s an amazing thing when that is found when providing a patient care, care they deserve. In October 2013, I remember sitting around the table in room seven at the Culinary Extra Clinic, Iora Health’s first Las Vegas practice that sits in the Stratosphere’s shadow. Every stakeholder was represented at the table: a very sick patient with multiple acronyms using most letters in the alphabet, a sponsor, a primary care physician and a clinical health coach. Each was there realizing this was the most important thing they could be doing at that time.

Let’s go backwards to go forwards. This patient is under 40 years old and is trying to get their second kidney transplant. They quickly became very ill and it was determined the right course of action was to send them to the emergency department. However, an even better course of action involved a direct admission. Direct admissions need cooperation and communication with the admitting physician, all hospitalists and sometimes sponsors.

The roundtable discussion on that fall day allowed the patient to raise concerns with yet another hospitalization. It allowed the health coach, who had the closest relationship to the patient, to provide an additional voice for the patient and advocate for their needs. It allowed the physician to make a sound clinical decision. And, lastly, it allowed the sponsor to witness all of this and provide input.

Everyone at the table had a voice. While it is not uncommon for physicians and sponsors, especially if they are benefit administrators or the insurance company, to have a voice, let’s be honest, at times they may have too much of a voice, too much to say, chastising patients for poor choices and/or costing the system too much money. But what if we all started to sit around the table and voice our questions, comments and concerns. What if the common theme or commonality amongst us is cooperation and communication? How would that change things? How would that change health care and restore humanity to that end?

These are all things to think about, to contemplate. While we do that, please, let us find the common threads amongst us: the desire to be heard, to be cared for and to be respected.

I have been working at Iora Health for over two years now. From day one, I have shared a value with the company and my colleagues to make sure each of my patients feel cared for, seen and heard. I know how to take care of my patients when they step into our office, but when they have to fend for themselves in the Big Bad City on their own….what is a health coach to do?

Luckily for us, we have a whole team of folks in Cambridge that have created our very own software to help us keep track of our patients medical and wellness needs. They constantly revamp our system as needs arise. In my first year, I would document notes in the chart, type in blood pressure readings, make tasks (our reminder system) for myself to follow up on important matters. I knew this data would serve a greater purpose in the long run, but a major pitfall my first year was that the only way to ensure care needs were being followed up was to continually ping myself with reminders. Or hope they would come in on their own and review the chart when they arrived in the office.

As they say, the squeaky wheel gets oiled, and I find truth in that here — the patients I remember best come in often, keep in touch, stay on our radar. However, many patients do not keep in touch and they ought to be on our minds. I used to fear that these patients would fall through the cracks if I did not happen to set a reminder. Year two has upped the ante and empowered all of us. For a year I have been plugging in data and now the software team has given us the gift to use this information to our advantage: we can target specific care needs.

We use the data to show us the general story about our patients so we can learn how to focus our efforts. We call this type of storytelling population health management. I can now plug in certain metrics that I want to see within my patient panel: Who has a BMI out of range, smokes, has had a blood pressure reading higher than 140/90 and is over the age of 40? POOF — a lovely spreadsheet with the patients that fit my criteria pops up. I can filter folks by a plethora of different criteria combinations. I can look at their charts and see if I notice any trends. This new ability to search my patients for specific data points serves as a safety net to my current personal tasking system. This empowers me because I can focus my energies on people who need the attention and we as a team can use our time more effectively to come up with how to focus our outreach efforts.

This summer we took on a major initiative to review, organize data & processes and think about how to best help every patient with an elevated blood pressure in our practice. In the context of a relatively young population without many chronic diseases, we focus on hypertension and other early warning signs for later life problems. High blood pressure generally is not symptomatic until our bodies have taken a beating for many years so it is not often front-of-mind until there is a cardiac episode. We realized we could keep better track of helping patients lower their blood pressure using all the tools at our disposal—coaching around lifestyle changes, counseling and medications.

We began by reviewing their charts but also meeting in teams to consider the big picture of our patients and think about them as human beings with passions and challenges, not just data points. As a team, we came up with some questions we wanted to have answered through information already documented in their charts and minds:

  • What factors are contributing to their high blood pressure (biological, lifestyle, other)?
  • Do they have other cardiac risk factors?
  • How motivated are they to change?
  • What barriers do they have?
  • What is their attitude toward medications?
  • What missing data/markers do we need to get (blood work, blood pressure, etc.)?

Then we came up with criteria for a plan:

  • When will their next blood pressure check be?
  • Where (at the office, home, a pharmacy)?
  • What is the lifestyle/behavior change plan?
  • What is the plan for medications?

This also fits our model better because we believe food and exercise heal just as much as a medication, if not more so for many patients. I have been better able to provide coaching to empower patients now that we have created more structure around the information we gather together and learning more about patient attitudes.

The results were exciting. We reengaged with patients we saw first when we opened two years ago; we made sure patients were up to date on all of their indicated screenings, and we began to have better and deeper conversations about their risk of heart disease and they could do to manage it.

The short-term outcomes were great — our hypertension control rate jumped almost 15%, just from being more organized and using these population management tools. The longer-term outcomes from lifestyle change will take longer to see, but we know we are on the right track!

Knowledge is power. In health care there are many moving parts and copious amounts of information—it takes a whole team to manifest these efforts. At Iora, not only is the doctor thinking of patients, but a whole team is thinking about their health even when they might not be doing the same.

Building a Company on Culture

At Iora Health, we wake up every day with one purpose—to restore humanity to health care. Through our ever-evolving model of delivering health care, we are able to build meaningful relationships with our patients that allow us to support them on their journey toward health. Every day, in practices across the country, our teams of providers, Health Coaches, nurses, behavioral health specialists and administrative support come together to solve the unique, complex medical and social concerns of our populations in ways we never thought possible. Whether we are caring for casino workers in Las Vegas, Carpenters in Boston or seniors in Seattle, anyone who walks into an Iora practice will experience the same something remarkable—true relationship-based primary care. How is this possible? Culture.

Many of us have come from ‘typical’ health care. We left a culture that we knew could not become what it needed to to care for modern patients. We had to select the best that modern health care culture has to offer—a deep sense of responsibility toward patients, incredible technical competence and knowledge, a tremendous work ethic but leave the rest behind. We created a culture around a core set of values not often found in health care: to feel Empathy, to bring Creativity, to act with Passion, to demonstrate Courage, and to serve with Humility. And then we found people that already embody these values, regardless of their background, and brought them together to form amazing teams.

We define culture as a common set of values that allows every member of the team—clinical, operational, technical, to know how to approach any problem regardless of its novelty. Rather than operating our business from a set of top down policies and procedures, drilled into our teams to create uniformity, we have focused on creating a culture first. Our core values inform every aspect of our work. Embedded in every act, whether it’s how we greet you at our practices, how we build our software, how we treat diabetes, or how we raise funds for the business, is the Iora culture. From this culture spring our strategies, policies and process that make it easier to do what we do best—help our patients solve their problems.

Building a culture-based series of radical primary care practices is not easy — and not for the faint of heart. We are used to falling back on the rules of big health care which are comfortable, but false. However, we know where the old way will get us—to the old place. No perfectly crafted set of rules, no brilliantly designed provider incentives, no amount of quality committee oversight will get us to where we need to be.

Imagine you are the primary care provider on call for your practice. It is 1am and your well-known patient with advanced lung cancer on chemotherapy is calling with fevers. What do you do? Typically, you would gruffly mumble “go to the ER,” if you even received the call. Not at Iora. First, you calm the patient and his wife. You then tell them to sit tight and you will call them back. You call the oncologist (thankfully it is 10pm local time) that you have selected for that patient because of the amazing service that oncologist provides, consistent with our values, to see if this can be managed with antibiotics and an office visit in the morning. When you decide together that it cannot, you call the ER nearest the patient, speak with an attending to prepare them for the patient’s arrival, send what records you can through the antiquated fax system plaguing modern medicine. You call the patient back, (who is shocked to actually get a call back) and let them know the ER is waiting. You also let them know that their Health Coach will call and check up on them in the morning. And at 8:15am they receive a call from their Health Coach who is able to find out exactly what is happening and work with you to plan the next move. Why do you do all of this? Because you love your patients, your work and don’t really need sleep? On the best of days. Because you are paid for every middle of the night well-facilitated ER visit? Hardly. You do it because that is what you do, why you signed up, and because your team would tolerate nothing less from you but excellence. That is the power of culture.

Culture means that even when the way forward is unclear, you can count on each other to build the map to get where you need to go. It means that whether you build software, market Iora Health, or decide where to open new practices, that you work off of the same standards, the same criteria, and seek to optimize the same things. When we think of it, we couldn’t imagine how to build a company on anything but culture.

Patients Driving Innovation in Primary Care

In the spring of 2005, a group of innovators came together at Massachusetts General Hospital (MGH). We agreed that the primary care system was failing and wanted to design a care model that would better support both providers and patients. We heard the Institute of Medicine’s charge to make our care model “patient-centered” but weren’t sure about how best to hear and understand the patients viewpoint.

Around this time I met Dr. Paul Uhlig, a cardiac surgeon who had done his surgical training at MGH. He learned of our work and wanted to hear more. I knew that Paul was interested in redesigning care processes but what I didn’t know was that one lunch with him would forever change my understanding of the patient’s role in the delivery of healthcare.

Paul explained that he had been working at a hospital in New Hampshire a few years prior to our meeting when he and other members of his team began an experiment in the post – surgical ICU. He asked the SICU team that was rounding on post-operative patients to join him at the bedside and to engage the patients and their family members in the decision-making discussion that sets the care plan for each day. Typically, doctors would discuss a patient’s case without including the patient or family. Paul believed that deeper involvement of patients and families could build more trust and assist the hospital in tackling some concerns around quality and safety. While some of his fellow surgeons and staff members were very resistant to this idea, pulled them along with him and what he observed was remarkable.

Patients and their families readily asked probing questions and brought insight to rounds that positively influenced the plans. Patients now had a say in decisions which impacted the pace of their recovery such as when to remove lines and tubes, mobilize them out of bed and begin physical therapy. The simple act of inclusion seemed to bring an energy and accelerated pace to their recovery. Paul also observed a positive shift in the medical team’s spirit and morale. Beyond that, he tracked data that indicated steady improvements in quality and safety including patients leaving the ICU quicker than before and with reduced rates of line infections or readmissions for surgery-related complications. As Paul spoke, I knew that what he was sharing would be transformative for me. I was beginning to understand where our primary care system needed to go and what “patient-centeredness” really means.

Perhaps as remarkable as the sustained success of this experiment over a few years, was the twist on this story that he then shared. Despite the rewards that his patients and immediate team experienced and the measurable improvement in the care, Paul’s department and his entire organization remained quite uncomfortable with this approach. Eventually Paul was dismissed from his position and fired from the hospital staff.

Many of us who have tried to redesign health care have experienced similar barriers to innovation due to our physician-centric view of the world. My own journey at MGH was heavily influenced by Paul’s story and other similarly remarkable examples of patient involvement and patient-driven care around the world. Our own group of innovators eventually designed and opened a primary care practice based largely on the idea that patients are the most important member of their care team and when empowered by a supportive culture that embraces them, they will indeed increase their engagement and this can lead to much better outcomes — better than we have ever achieved in the traditional care model.

We have a path forward away from our broken and failing care system. This pathway will be defined most successfully by organizations that understand that when we welcome patients to manage their own health, much of what we have assumed about delivery of care must be questioned and redesigned entirely, especially our culture. Iora Health has created the culture that provides this opportunity for patients and I believe this is largely why Iora will lead the way in defining the future of primary care. It is also one of the most important reasons that I feel so fortunate to have joined Iora on this journey.