Inside Reproductive Health, Ep 25

Buy-in: Necessary for Successful Implementation of an EMR System? An Interview with Nicole Koczanowicz

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In this episode, Griffin Jones hosts Nicole Koczanowicz, the Vice President of Artisan Medical Solutions. Koczanowicz’s focus on adoption and adaptation of Artisan’s EMR program to every practice has set Artisan apart. Jones and Koczanowicz have an honest conversation about the delicate dance between a practice fully adopting a necessary change, to the EMR team adapting to the individual needs and workflow of each practice. After all, Wall Street and Silicon Valley both want your patients, but there is a plan, if you are willing to take action.

Griffin Jones: Today on the show, I am joined by Nicole Koczanowicz. Nicole is the Vice President of Artisan Medical solutions. She joined the company at the end of 2016 as the director of business development. During her time at Artisan she’s worked extensively with practices all over the United States. Helping them optimize workflows, train users in every department of the practice, and getting them out of paper or prior systems. She’s had the pleasure of working on strong relationships with companies and partnerships with stand-outs in the industry such as Embryo Options, EngagedMD, Progenesis, most recently Igenomix.

She's worked independently with clients to help them release new features and new versions to support fertility practices at large. And this is Nicole's fifth and most exciting year in the fertility industry. Nicole Koczanowicz, welcome to Inside Reproductive Health.

Nicole Koczanowicz: Thank you Griffin, I’m excited to chat with you today.

GJ: Is it really the most exciting year, or do you just say that for a good intro?

NK: I definitely think this is the most exciting year. It’s been a major year of both professional and personal growth in this industry. Very exciting year for us.

GJ: There’s a lot of stuff happening in the field. A lot of people want to talk about consolidation. Just because we see it so frequently, I think a lot of people like it just as a water cooler topic. I still do not see the Godzilla. I have talked about consolidation on this show very frequently. We had David Schlanger on a few weeks ago talking about new opportunities and maybe pitfalls and downsides of consolidation. There very likely certainly are some. But i still think that there is more opportunity for the independent practice, let’s say, for anyone than there has ever been because of technology. What do you think?

NK: I actually really agree with you, and we continue to on a weekly basis hear about new practices opening all over the country. And they’re not necessarily part of networks. Usually it’s one or two doc shops popping up in areas everywhere. And so I do agree with you. I think we are seeing both. We are definitely seeing these big consolidation networks growing and growing and acquiring. But simultaneously I get calls on a weekly basis from practices planning to open their doors in an independent fashion. So I think you’re right. I do agree.

GJ: How do you see people being able to adapt, and I think of an EMR as one particular tool, though there are various. To me it seems sometimes you might be at an advantage opening a practice in 2019 simply because whatever the folks used for payroll in 1996 was definitely a lot more cumbersome and expensive than using Gusto at $5.00 per head. Or EMRs that might be built on other platforms. Or phone systems that might have literally had to have been systems installed in practices before. How are you seeing, as somebody starting in 2019, 2020, being able to leverage the low cost barrier of technology? Whether it’s your EMR specifically, or any technology?

NK: I think that it’s definitely become something that practitioners are thinking of first. And that's one of the interesting things that I’m seeing as we get these phone calls from people planning to open in 2019 or 2020. They’re looking for a space, so that’s really where it begins. They’ve decided to go out on their own, they’re looking for a space. They’re looking at buildings. They’re trying to identify the right market to be in. And then we usually get the call. Even before they have a lease. And I think that technology is becoming such an integral part of the practice, and I am amazed at how people have so quickly identified this and this shift that we’re no longer just another vendor. It's becoming the part where they say from the start, “I need to figure out how we’re setting up the business, and I need to identify how our data is going to be managed and what aspects of the practice are going to flow through this system. How is that going to define our workflow? And how are we going to then decide how to staff appropriately around that?” These doctors both more established and the younger ones starting on their own are all understanding that technology is going to play a massive role in their practice. They are putting it at the forefront of the decision making when opening a practice. And we are in that first phase of the budget, rather than later down the line of, “‘Oh yeah, we also need an EMR.” And so that I think I have seen as a shift from the beginning time of when I was at Artisan to today.

GJ: That’s a big point of friction normally, isn’t it? Is finding an EMR software, a strategic partner, any kind of a solution to fit into your existing workflow, right? But if you could create your workflow around a certain solution, so that it fits more seamlessly, to me that seems like such an advantage that would be such a headache for someone else that doesn’t have that advantage of a blank slate. It’s like what we see with people that are starting their own practices. Sometimes they’ll come to me and say, “Should I come back to you in a year? Or is there anything you can do for me right now?” Well, of course we’re not going to do the same strategy that we would with an established practice, but if we could just start with a blank slate down to your brand...I love it when people don’t have a name yet. When people don’t even have a name and I can help them with that, then we can really get you so far ahead of positioning. How do you help people do that if -- do you find that you’re doing that? Helping people create a workflow? Or do people typically have that already set when they’re coming to you?

NK: We see it both ways. Some of the practices we’ve dealt with who I call -- are the baby practices -- the ones that are starting off and they put Artisan in the beginning. They do obviously have workflows they’re comfortable with, right? They've never worked with a practitioner that has just started out of school. These are people who have worked at other practices. They understand how they want to practice medicine. However, they are open to: what can this system do? How can I leverage it? How can I leverage it to lower my staffing costs? And so we do see a lot of that. And they want to understand, how does this system work? What can it do? What can I eliminate in my initial start up costs by implementing this system that can do a lot? We also see the other side of people who’ve been on paper or in existing systems that are what they consider to be insufficient or just not meeting their needs anymore. And their looking for another option, and a new way. But I would say strongly that most of our clients come with a somewhat established workflow or at least something they’ve been comfortable with. Whether it’s optimized or not, it’s something they’ve done for ten, twenty, thirty years. And so the flexibility of a system to meet that workflow, yet to guide them along that path and provide areas where we believe you could be saving thirty minutes every single IVF cycle by doing it this way instead, which over the course of a month or year is massive cost savings and staff time savings. Those are the areas where we like to point out “hey you could do it this way and really leverage what this technology is bringing to optimize your practice flow and make you more efficient.” Because that’s really why you’re spending the dollars to have a new EMR. Why buy a tool and not use it for everything it can do? We really coaxed the practices to see it that way as much as we can. While still allowing them to feel like we’re not changing their workflow. Because I will tell you that is the last thing any practice wants, is someone coming in and telling them what to do.

GJ: Where do you draw that line? Because I know that sometimes we’re a pain in the ass for people, in terms of just the initial -- that’s also why I put all that stuff up front, because when a new client gets through the permissions getting us the Facebook and getting us the Google Ads, once we get through that stuff, we get through that smoothly, we know things are going to be good. That’s why I put all of the pain in the neck stuff up front. And I tell them ‘this is going to be a pain in the neck. Tracking all of this down is not the fun, cool, creative part of marketing. We’ve got to do some of this really boring, cumbersome stuff up front.’ And then we make decisions together about processes and strategies -- and there are times we have to be realistic about who the client is and be accommodating of them. But there are other times when it’s just a fundamentally flawed process that we would be setting ourselves up for failure, just by engaging with it. And I need to have that conversation with the client. How do you have that conversation of when ‘okay, our software could do this to be more accommodating to you’ vs ‘this really is a busted part of this workflow’?

NK: So I, like you, try to set expectations of what I have what I call the “90% role” - and we do this even in the sales cycle process. I feel like we do a disadvantage to practices by not telling them up front that this is going to be a challenge. This is going to be hard and there is going to be staff who resist. We’ve been at installs where people up and quit in the middle of an install. And that’s not Artisan, that’s just -- change is the scariest and the hardest thing for everyone. My team and myself, we always take an approach of hand-holding. We probably cater to our clients more than we should at some times. But this is also going to be one of the hardest probably six months to a year, their practice endures, and we have to hold them through it to get them through it. Because we know on the other side of that things get better. And it does. And everybody says it. But getting through that hump is really hard. I would say it's like ballet. It’s a dance. It’s always giving and taking and knowing in those moments when to push and when to give in. And really trying to find what works for each practice. Which arguably I have been accused that that isn’t scalable. But I also think that that’s what’s led us to our success. This is not an out of the box process. I don’t think it should be. I think it is disrespectful to not acknowledge that every practice is going to be different and going to have different needs. That’s why we have continued to do what we do and built the reputation we have, because we are the people who listen, and we care and we cater. And I think in our industry, that is what people want today. The service aspect of what we do and what you do is what keeps people happy to the best of our abilities. Our 90% -- which I mentioned and then I realized I didn’t say anything -- is that we start off by saying best case scenario with any EMR you’re going to have 90% satisfaction. This is never going to be a perfect solution. It is an off-the-rack dress. It is not a custom made shoe. We will do our best to make it fit you like a glove, but it never will. And there will be things that don’t always match, but we are shooting for 90% on a good day. And to set expectations that this is going to be everything, is going to set you up to fail, in my opinion. It is still technology, it is still a solution, and it is designed as a shared resource. A shared resource is not going to perfectly fit every single practice across America.

GJ: And I think even those super large fertility groups that have in-house EMR’s would agree with that. They would stay the same thing. They built it for themselves, and it still doesn’t fit perfectly.

NK: It’s still technology! And technology has its limitations, even when it feels limitless. And we continue to change how we practice. This is not a static industry, and so the technology supporting it needs to continue to evolve along with it. There’s a little bit of a “running to catch up” process that happens because we move faster than anything else in fertility. The technology is always catching up. Sometimes we lead and sometimes we’re letting the practice lead.

GJ: Yeah -- there’s a give and take and though I would say conventional wisdom for running a business in 2019, 2020, 2030 world— I was at a mastermind meeting of other digitally agency honors, and one of the other agency honors said something that really resonated with me, which is “the deep adoption of almost any software is the solution to a lot of our problems”. And he’s so right about that to the extent that even recently I have our project manager and I told her “I just want you to spend an hour a day in Asana” — which is our project management software — “and in Harvest” — our time tracking software— “and I want you to come back and show us all of the different things that we could be doing, should be doing. I just want you to spend an hour each day this week.” Those five hours paid for themselves many times over— woah, we could be doing this, we could be attaching things this way, we could be doing it right from our email, we could add a task and assign it over this many times, we could make them integrate this way? It was so valuable in that small exercise. I think it’s just so true that whatever software we are using, there is an onus on us to learn it to the best of our abilities and be able to adopt it is as best as we can, because it can solve so much of our time. That’s what it’s designed to do.

NK: But, what you’re describing is unfortunately something that very few practices in America can do. Which is: give their staff the time to take to just fiddle and learn. And you know they’re carving out moments in the day for training, which is great and necessary, but that time for a user of the system to really just sit for an hour a day and self-teach and play— not in a classroom traditional setting— is really hard. These are busy practices, and they can't push pause and they can't stop cash flow, and they can't shut down, and we never ask them to. I believe when people talk about adoption problems with EMRs— and I’ve read about this in other industries, not just ours— where there is sort of a drop off. People learn enough to survive, but they don’t always learn enough to optimize. There are so many features they could be using, but honestly, the biggest resource that nobody has enough of, that is the most valuable is, of course, time. And in these practices and for their employees showing up for their eight hours, or whatever their time frame is, noone has that carved hour of the day to say “Hey, here’s your new tool. Can you just spend your time and play?” There’s patients and there’s demands and there’s their everyday job. And so I think that is probably the hardest struggle, that I have yet to identify in our company the solution to help. I hope that we get there, because I think that greater adoption and understanding of what the tools can do, really is what takes it to the next level. But there is the limit of time. If you have the solution, please whisper it in my ear the next time you see me.

GJ: I’ve got a fricken podcast of this systemic topic that comes up recurrently on this show. I just had an interview for this show with Marianne Kreiner from Shady Grove and we were talking about this issue of time and learn-by-doing. The solution is that this type of learning needs to be built into the practice and there needs to be time reserved for other things than the current day to day demands. It seems like a big time investment to give a few people a few hours to play around on the EMR, but when you think about the return on that time investment over the course of— you stay with that EMR three years? Five? Seven years? Twelve years?

NK: It’s a marriage, Griffin, it’s a marriage. Your EMR— and people do get divorced -- however, most people enter their EMR contract hoping that this is forever. They don’t want to have to switch providers, they don’t want to have to move their data. This is not a three to five year, this is a long term relationship through the life of a practice.

GJ: So does that say 50% of practices will switch their EMR?

NK: No one goes into it hoping to switch in three to five. Everybody’s planning the long term which is why I think it is our duty as EMR companies to continue to evolve with the time. That is probably the only reason people look to leave. The two reasons would be: A. Just less than satisfactory service, and 2. Would be that the system becomes insufficient over time. It doesn’t evolve with technology, it doesn’t provide new features for, let's say, embryo donation, 3rd parties. All of the things that maybe we didn’t do as much 10-15 years ago, we are doing a lot of today. Those systems need to keep up. It’s a challenge. It requires more and more money to go into development. And more and more time spent with these practices really understanding what their true needs are. All of that is expensive and exhausting, but it’s a requirement to keep competitive in the space.

GJ: Insufficient over time. That is the exact same reason why practices or any group needs to be spending time to invest in software development of any kind. Insufficient over time is the product of not reserving time, energy and focus. Or development, improvement, innovation, technological literacy, upkeep. That is the byproduct of that. It’s costly up front to have a couple hours here for training. It is also the price of being relevant and adaptable over short and long periods.

NK: And having staff that knows how to use the tool, right? Because there is no long term free EMR. There are systems that will give you an upfront break, or a few months free. But this is an investment for any practice or any company. To optimize that, making sure there is the appropriate time for the staff to absorb what’s being thrown at them is, to your point, going to make this investment worthwhile over the long run. But again, change is hard and I fully appreciate that and that is something, as a team at Artisan, we talk about constantly. It is that pervasive problem of buy-in acceptance and then change. I encourage practices to not make this a unilateral decision. Although it does slow down our sales cycle, to be honest, the more buy-in you get at the beginning, the better it goes. If you have one person come in and say, “Yep, I love Artisan, let’s put it in!” I know that’s going to be a rocky road. Because the lab didn’t look at it, the billers didn’t look at it, the clinical team hasn’t seen it. The physicians have not asked their questions. Honestly, as long of a road that it takes to get that buy-in, it smooths the path for what is to come next.

GJ: You would rather have happy clients, than happy prospects.

NK: And it’s not going to set the rest of my team up for success, right? Because my training team is then going to go in there and say, “Nobody wanted change, I am hearing that this wasn’t what they wanted.” And then what? You have 2 sets of non-decision makers who don’t know how to sort this out, when the decision makers in my team and decision makers in the practice are not on the ground floor. And that's why I think we also need to consider that the decision makers do not always need to be the people who write the check and receive the check. It needs to be the people in the practice who are going to touch this every single day. And I do see that happening in more and more practices, where they are including more people in the conversation, which I think is fantastic. But every single person in these practices is going to have to touch this system. They're going to stare it at every day. It’s got to be something that makes them comfortable and important and makes them feel like their job is both pleasing and productive and that they are contributing to the whole. If they find that these processes do not meet their needs, I think it’s only going to create complications down the road. Getting over those humps early on really improves our process and makes all things possible later on.

GJ: We do the same exact thing to the point where people come and they’ll say “Can’t he just do a social media campaign for us?”— the amount of time that it takes me to educate you why that’s a bad idea, is enough for me to charge for. In other words, people can come to us and say they want to do social media. Well, are all of the physicians comfortable with that? Is there someone in the practice that can be the thumbs inside the practice? Are they going to feel like it’s another task that’s assigned to them? Can they do video? Can they edit things? Can they just take pictures? Will the nursing and billing staff even get in a photo? Will they fight you tooth and nail? Before we ever tell someone “Yeah, we are going to do this much” or “This many posts for you,” or “We are going to do this much in Facebook or Instagram advertising,” we need to know how much can you even be a part of that? And that’s just one tiny segment of marketing, which is one segment of business development, which is one segment of running a business. We always start with as many people as we can up front. So we tell people in the beginning, it’s a physician-owned practice, we’re not just going to talk to the practice admin. We are going to talk to the doctors, the practice admin, if there is a clinic liaison, we might want them there too. If it’s a larger practice, we might want these particular officers or executives, or the physicians on this committee. We want as many people as we can in the beginning to flush out the goal of where we are going, and then we can move down to one point of contact after that. But in the past, when we didn’t have that discipline, we would get people who say “can’t you just do this?” and we would say “Alright, I guess we could do that,” and inevitably, four months in, in comes some marketing liaison that I never met before or a physician who’s a partner, but previously didn’t give a crap about marketing, and all of the sudden have a real big opinion. It would just blow things up. Now, we just do this from the beginning and a lot of times it does deter prospects that are like “I don’t want to get my team together and think about this, I just want you to give us a price for what a web site costs.” So sometimes we lose prospects. But we have healthy, good relationships for long periods of time. I would rather have that because we already went through the crappy stuff in the beginning.

NK: It’s entirely necessary and I think there is something very attractive about moving from prospect to client, but because these are long-term relationships, it’s just never as successful. It makes the road very bumpy. We have done it both ways, and I can tell you that the more buy-in we have, the better it goes. It’s interesting to watch how these things unfold and continue to evolve.

GJ: Where do you find the most resistance when getting buy-in?

NK: I would say on average, it’s been really unique. We’ve had some experiences where— so I have a practice in mind, that was a two-physician practice, owned by one of the physicians. They had been on paper for thirty years. The physician made the unilateral decision and did not want to do things our traditional way, in any way, shape or form. He didn’t want to have everybody’s buy-in. We did a few demos with more of the staff and people were like “yah, it looks good, okay.” Usually our training methodology is about one to two months, depending on the size of the practice, where we do off-site GTMs and things like that. He basically told me he didn’t want to do that. He wanted to learn it himself, and then he wanted us to do the in-person install, like we always do, and that is when the staff would be exposed. It would be total immersion. I can tell you in this practice it was very, very, very successful, but only because of the leadership style in that practice. We would never have done that anywhere else, because in his practice, “You do it this way or you don’t work here anymore.” I have never seen that in any practice, but I can tell you that, under four months, they were 95% off paper. They were one of the most successful using practices of our system. They have adopted more and more features, more quickly, but that’s a really rare case. We rarely see things happen that way. A lot of people in the practice push back. I believe that’s why we get people to buy-in, is usually how we treat them. We listen. My team has a lot of diverse experience: some have been nurses, some have been practice managers. We recently added and embryologist. People who have walked in the same shoes. I think the relatability of that helps because I am not in that same role. I can’t say “When I was a nurse, and I used Artisan” — I can’t relate in the same way. It’s really important for the practice to understand it does get better. We are one of those campaigns where it does get better. Bare with us and learn it and you’re going to get there. It’s really special when we see those “Aha!” moments in the practice when the nurses come to us and say “Oh my gosh, it’s so easy to make an IVF calendar,” and “I love messaging with the patients. It makes things so simple and patients are really happy,” and everything shifts. Resistance-wise, it depends on the practice. We have seen it in every department, honestly. Sometimes it’s the physician, who just doesn’t feel the need to change.

GJ: How do you deal with “The Debbies?” “The Debbies” is my name for established office personnel, who in my mind smoke too many cigarettes— it’s my sort of persona for grumpy, established office personnel who are just not pleased with their job or different tasks any time of change or improvement is another thing they really disdain. That disdain ripples throughout the rest of the practice. And even if you’re as empathetic as you can be and you’re really trying to make they’re job better, I imagine that at some point you just run into “The Debbies” -- how do you deal with them?

NK: We do. We try to throw different personalities on our team with them and see who sticks. I have one person who is a real Xanax for most people and so it’s good. We pull out that card when we need to. The biggest thing is if we can get someone to identify why they don’t want to change and verbalize it, we can then make them feel heard and then say “Okay, we get that.” Again, the empathy strategy really is our strongest strategy. We do understand that person continues to be difficult, but we can usually wear them down. There have been a few— we use the term Eeyore’s in our company— the Eeyores sometimes just want to be Eeyores. Sometimes we have to say, that’s who that person is, we know what it’s going to be like interacting with them, we know what they bring to the table. A good 70-80% of the time we can win them over. That’s why we joke that our tagline at Artisan is, “A little EMR and a lot of therapy,” and that’s mostly what we do. Sometimes we do a little EMR, but we mostly just talk to people.

GJ: I swear half of my job— especially the account management side— that really is a big part of any consulting operation, any sales process, any customer service. Helping people walk through their own heads sometimes, walk out of their own heads sometimes, and really trying to understand where they’re coming from so that you can help them arrive at the solution.

NK: We’re in an advantage point in my mind, because the number one complaint, aside from outdated technology— which people complain about, but a lot of people live with— is that they just feel they’ve been treated like crap by their other EMR companies. Whether they pick up the phone and are on hold for 45 minutes and can’t talk to someone, or they send an email that never gets answered, or they never talk to the same person, or they’re speaking to people who are not in the United States. It’s opened up this lovely little space for us to just be entirely different. That’s what we did. It’s the platinum role that I ask everyone to practice in our company, which is: we don’t treat people the way we want to be treated, we treat people the way they want to be treated. That’s what we really try to do. Nobody’s perfect. There are days that I am certain that we fail people and it sits heavy with me and people on our team. We all take things too personally, but we always show up to do our best. To our best for our clients and to try to make their lives easier. As long as we’re coming in that spirit, we will continue to be successful.

GJ: What was the phrase we used? Less functional over time. No, insufficient over time.

NK: That’s the word that was used recently by someone who I am speaking with who has described their EMR as the insufficient medical system. That’s his terminology. That happened with time. As their practice grew to as large as it is today and their needs have evolved, the system became insufficient. I don’t think when they started with it, it was. That is the parable sitting out there for every tech company: “Watch out, because it’s coming up behind you. Never get too comfortable.”

GJ: Every company. Period. Every government organization. Every volunteer group. Every family. Every entity has a threat of being insufficient over time. This was my talk at last year’s conference. I grew up in the city of Buffalo, which had been a booming city and then was not. I am a Catholic, and there’s lots of Catholic churches that used to be jam-packed, but now there are eight people in them and I am the only one who’s hair isn’t totally gray. Most of that stuff does not happen with one boom. It just happens over time. And then it happens some more. So what do you do as a company to make sure that that’s not you in thirty years? Or seven years?

NK: It could be tomorrow. I don’t get comfortable. When I joined Artisan, we were in a position where I would introduce myself and people had no idea, and people had no idea who we were. They had never heard of us before. Today I get phone calls from people who say “everybody’s saying your name”, which is just the most wonderful thing someone can say to you. That has been done through force of will by all of the people on my team. I am fortunate enough that I get to be the face, but there are a lot of other people pushing this boulder up the hill together. And we do it every day. Part of that I think has made us so sensitive to the fact that you can slide fast. You can lose it like that. And we don't get cocky or comfortable or complacent. I keep looking in that rear view mirror to see who’s coming up behind us. We were the nobodies and now people know our name. That doesn’t mean that’s forever. We could lose it just as quickly as we got it. We have to keep listening to our clients. We have to keep building. As much as it would be lovely to say “Okay, we’ve built and built and built, and now we’re going to take a moment and breathe”— we can’t! We had a development meeting a few nights ago and I think there was a hope we could maybe round out some development 2019 and call it a day and our developers could breathe and we could just do data mapping for new clients—- no. There’s so many people who want to integrate. There are so many new projects and new ideas and patient experiences. We have to keep rolling. We are going to roll harder and faster. We need to keep hiring more developers and keep moving down a path so we don’t lose the momentum we’ve built. It is up for the taking. Someone else could do it the way we did it. If we get comfortable, we will end up like everybody else. We just don’t sit down. We just keep standing. We keep pushing that boulder. We keep listening to our clients. We keep listening to what makes people unhappy in their other systems. Stay alive and be grateful and thankful to the people like you, who give us a platform to speak. And people like Dr. Beltsos, who wants us to speak at Midwest, and just keep showing up! That’s our plan.

GJ: That is such a philosophy to live by. And that was a very lovely compliment to that person or those people who paid you. I was just recently paid a very similar one of— you know, five years ago nobody knew who I was, I have been here the same amount of time you have— and now a lot of people know who I am and who my company is. But it doesn’t matter. You are only as good as your last act. Somebody could come out with a better podcast tomorrow. Somebody could come out with a bigger agency or anything tomorrow. I will not settle for “That’s pretty good, we’ve got this many clients, and really effective work, and people are really happy” — that’s not good enough. That’s just the beginning. There is no time to rest right now. Practice owners that I have conversations with and see that they are in the most trouble, are those that think. “I am just not paranoid enough for you, man.” Whenever I hear somebody be a little too cavalier with what they talk about their competitors— that is a criticism that I have very often of practice owners, that they’ve just got these blinders on of who they are vs. what the other practice is. “They do things like that. They have a lousy success rate.” They are probably pretty similar in a lot of different capacities. They might be really different in others. But certainly not enough to rest one’s laurels on. Those are the people that are comfortable. If you’re a fertility practice owner in a small market, where there’s no competition— now I am specifically talking to you. A lot of these big markets have been saturated. A lot of these larger groups are going to think “you know what, there’s not a ton of cycles in Omaha, NE. I don’t know if we’ll practice in Omaha” - just using it as an example. Let’s go do 200 more in Omaha and let’s go do 300 more in Kansas City. That’s where the next round of heat is going to come from. Especially market’s 1-5— they’ve always been very competitive— New York, Chicago, LA— since they’ve always been super competitive, we’ve seen the heat turn up in Houston and Dallas and Orlando in the last decade. I think the next round, where people are going to start to feel competition and pressure, is in the small markets. What do you see?

NK: That’s interesting because I am not certain. I am not certain because I live in the greater Southern California area — if you can’t tell by my accent— there’s always new practices opening. I don’t think we’ve seen the same level of consolidation in the exact same way that we’re seeing it in other places that you’re describing. When is it going to hit LA? When are we next? Maybe everyone’s afraid of the earthquake, so they’ll just hold off. And then after the earthquake, they’ll put a big practice together. It’s interesting, but these pracicing keep popping up. I do agree that as 1-5 continue to consolidate, I think it’s the middle of the country that we are going to see more and more happening. The needs are changing and part of the really interesting thing happening is seeing practices do new stuff. Practice different ways. Practices that aren’t just doing it the way we see things in general. You know some of the examples of this. People are looking to offer to the 99% vs the 1%. People are looking to bring costs way, way down. To give alternative options to what’s always been. To offer something in a completely different vein. We have a client who is strictly catering to same sex male reproduction. Offering these other types of options within the industry, that’s always catered to other types of reproduction, is very smart and relevant right now. We are only going to see more of that. Those are going to be the new markets that are going to open. Things that not everybody is specializing in. Which is why I don’t think these network consolidations is going to wipe out these options for boutique or private practices. There will always be people who want a different kind of service too.

GJ: The opportunity for boutique practices is better than it’s ever been. We’re talking with one group -- I think that they have 5 or 6 people that run their whole practice. They do a good amount of cycles for one person. Just the ways to reach— the larger private equity backed groups need huge volume, but if you’re a single practitioner in a large market and if you have 400 patients a year and you’re doing good conversion rates, then you’re doing 200-250 retrievals a year. That’s sustainable. Your access of reaching patients and potential patients is unbelievably more open than it was. I also see far more disruption going and another reason why I am not as concerned about consolidation as everybody else— I am focused on it, I talk about it and study it— but, I still have much more of an eye on the other boxing glove that’s coming out of Silicon Valley that we haven’t even seen yet. There’s a lot of start-ups that are starting to grab little pieces of market share here and there. They’re pivoting a ton. A lot of them are wasting through VC money. But one of them is going to figure something out. There is a whole other disruption— we might be the motel that’s worried about the Marriott or the Hilton Inn coming in and building a bigger, more cost-effective hotel, while I am worried about AirBnB. What do you see happening in Silicon Valley or a couple potential areas for disruption that we are probably still in the infancy of or maybe have not even tasted yet?

NK: The two areas that I see that are going to change would be patients who are receiving fertility benefits through work. I think that’s going to change and it’s going to change the way we approach this. It might make our decision making about reproductive health more proactive, rather than reactive. More people in their 20s— not just egg freezing, but from a more holistic approach. If it had been a benefit when I was in my 20s in my insurance plan, would I have started considering looking and forecasting for my own reproductive health? Yes. And if that would have been standard of care, which I think one day it will be, I think that is a way we are going to see this medicine shift. From more of this reactive, elective medicine to something that is comprehensive care. That’s one area. The other that’s going to change is -- I don’t exactly know what Kindbody does, but I know that they’re trying to angle in a very different way. I am looking forward to learning more about them and what they’re bringing to the table, but I think they might be the Airbnb. Or at least they have the flavors of what AirBnB might be in this industry. Of really approaching it differently. I am excited to see what else is coming to the table. Other than just this brick and mortar approach to what we’ve done. Genetics is going to play a huge role, as it always does in our industry. And empowering people with their own information about who they are and what they are and what that means for their fertility and their health overall. We need to continue to educate other aspects outside of our industry about fertility health. I don’t think every OBGYN is telling their patients enough about what they need to know in the beginning. When you’re in your 20’s and your 30’s, there could be more guidance to lead us to where we need to be to be prepared for our optimal fertility health. I don’t think that is 100% there yet. Maybe there are opportunities to bring more of that into the mix.

GJ: I think that there’s an entirely different interface for patient acquisition possible. We are too slow, even in an agency like mine that helps people with website and social media. We have helped to a really large degree, but there is an entirely available position for a platform to come in and sort of be the distribution point in the same way that Airbnb did for different housing units. I don’t know if that is fertility IQ, so Jake, if you’re listening, my assistant has emailed you to be on the podcast before. I am asking you in front of everybody— I want to hear your take. There is an opportunity or platform to attract and acquire patients and then essentially sell them back to the provider. There are apps that have done this in small scales that are tasting this, but I don’t think anybody’s knocked that over, it’s just an inevitability. The user experience that clinics offer right now is just getting further and further from the user experience that patients use in every aspect of their lives. I just had my groceries delivered while we started our podcast interview from Instacart because I pressed a button. As we start to serve a patient population that has never picked up a phone to call someone for almost any reason, we just get further and further from how we’re able to acquire them. Someone else will probably view that better— and I venture that will be a technologist that, if they don’t do it first, will eventually have a lot of VC money behind them.

NK: With some of the larger players that we work with, we are seeing that approach being taken. One of the really exciting things that we get to see is the evolution of the patient journey and patient experience. There has been an awful lot of thought put into patient acquisition and patient interaction, and even from a UI perspective, what is this patient going to feel prior to being seen? And during the course of care? How can reach them in a way that is familiar to them? Which is their phone. One of the bigger players we work with has spent a lot of time and money throwing their efforts at this. Anyone who is going to be patient there will see how differently they do things. This is becoming more and more of a common thread, though. There are other practices we’ve seen that are putting an awful lot of focus on that. That is one of the tools we are bringing to the table. We are not doing it in the method you’re describing, as a universal platform for all practices to interact and as a patient. On a practice by practice level, we are providing some of those features. Of course patient experience, cell phone app, integrating with our other partners out there, like engaged MD to help in that patient’s movement into the decision making process and through that decision making process in an informed fashion. You should definitely talk to the guys over there and hear about all of the cool things that they are bringing to the table to support practices as well.

GJ: This is a freakin cool conversation. I could have this for 3 hours. Always being hungry, as a solution to not being insufficient over time. And that being a means to which one survives, thrives, adapts to, benefits from, this massive technological change, which we are only in the beginning of. If this is the printing press, we’ve just had Gutenberg release the first one. We are so in the infancy when you think about how much things are going to change in 20 or 30 years. How do you want to conclude?

NK: I want to talk about the bigger piece, as far as technology goes with EMR’s. What we call the “tower of babble.” Which is, we have all of these systems out here both in fertility and in the world of medical EMR’s in general, and how do we make things better for patients when there are providers everywhere. Even within our small Artisan network five months ago, before a lot of the wonderful things that have come to pass happened, we had patients who had gone to multiple practices using Artisan in our small user base already. That’s just in our universe. What about the other fertility EMR’s, what about their OBGYNs, what about the urologists. What about everything that comes next? How do we overcome all of these technologies that don’t talk to one another. How do we find that common language that we can all begin to speak to better support these practices and patients as a whole? For me, and for our company, this is something we talked about - we definitely don’t have a solution today, but we need to think in our industry how to work collaboratively, which It is such an emotional hurdle for most people in this space, for the betterment of our industry as a whole and for the patient experience. THat is why we all show up to work everyday. For the patients. That’s got to be the goal we all continue to work for, which is how do we make this better for the patients.

GJ: Half of that was the episode we were going to have, another half is an entirely new episode. I love the episode we did have because that conversation was so authentic and can help so many people when they adopt. Nicole Koczanowicz, thank you for coming on Inside Reproductive Health.

NK: Thank you, Griffin. This was really fun, and I appreciate you being so generous with us. Thank you.

*Edit to add: Koczanowicz was mispronounced on this podcast episode.