The best way to think about Forward, the new clinic in San Francisco, is like a smartphone app. First, there’s the front end: a slick, seamless, Uber-like experience, a bit like a luxury health spa on the starship Enterprise.
At the clinic in San Francisco’s financial district, patients glide from the lobby to an infrared body scanner that reads their vital signs. In a warmly lit examination room, the doctor flicks on a black wall-size screen visualizing the data. Medical recommendations flash across the screen. Speech-recognition algorithms help transcribe the conversation in real time and add to a patient’s health records. Patients can swing by the on-site pharmacy for drugs, health sensors, or a Forward-branded water bottle. After walking out the door, an app relays biometric data to the clinic, where medical staff monitoring patients can respond to text messages within 30 seconds and around the clock.
But the real value is everything you don’t see. Behind Forward’s high gloss is software and data running what the company promises will be the new operating system for health care. Its thesis is that much of the $3 trillion or so Americans spend on health care each year is waste: rife with poor processes and expensive labor, says Forward’s founder Adrian Aoun. As a serial entrepreneur who once led special projects at Google for Alphabet CEO Larry Page, Aoun sees health care as one of the biggest, most expensive, unoptimized engineering problems in the world.
Almost every step could be improved, he argues. Some of the most expensive human labor on the planet—medical doctors—do routine and inefficient work (insurance paperwork, transcribing family histories, etc.), while giving patients an underwhelming and often frustratingly inefficient experience. “The rest of the world is failing doctors, especially engineers. We’ve built them the crappiest software you can imagine,” says Aoun. “Doctors just need better tools, that put all the information they need in one place and then build an algorithm on top of it.”
Forward plans to earn its money longterm by operating a global network of primary care clinics and building the backend to run them, although the plan is still emerging. To do that, Forward is taking a Silicon Valley approach. Forward’s team, drawn from Google, Uber, and Facebook, spent a year watching doctors treat patients at its makeshift clinic in a San Francisco warehouse. Their observations led them to rethink the doctor’s visit from the ground up.
First, it tackled aesthetics. The clinic’s resemblance to the Apple store a few blocks away is no coincidence. Forward wanted to avoid clinics’ association with sickness and discomfort, so Forward’s “user experience” is crafted to appeal. Rather than gowns that gap open, the clinic lays out DKNY pants and shirts for women and Lululemon ones for men. Surfaces are smooth and inviting. There’s a hidden alcove for urine samples in the bathroom, and no need for an embarrassing walk down the hall.
The lobby area at Forward.
Bathrooms (and urine sample vestibule) at Forward.
Next was efficiency. Physicians already spend half their time filling out paperwork, compared to just 27% seeing patients, a 2016 study in the Annals of Internal Medicine found. Forward is automating as much of this as possible. Technology replaces the standard 15-minute examination. Blood tests are conducted on site. Remote workers help run office operations. Doctors use patients’ vital signs to establish a “baseline,” and then monitor it for opportunities to enhance health and prevent problems before they spiral out of control.
Body scanner at Forward.
If it sounds too good to be true, Forward still has much to prove. Aoun is not the first to take a stab fixing health care, points out Abhas Gupta, a doctor, former venture capitalist at Mohr Davidow, and founder of the health startup Calyx. He’s skeptical of Forward’s premise, pointing out that entrepreneurs entering the space underestimate the difficulties of the market, despite all that cash sloshing around. “Building a better primary care office has never been that valuable,” Gupta says.
Forward faces the same gauntlet that conspired against other entrepreneurs. Concierge medicine, while profitable, has yet to deliver venture-size returns for investors. Regulatory barriers are high. Sensors, real-time monitoring and machine learning, while powerful, have yet to deliver clear benefits for the bottom line or patient outcomes, says Gupta. Finally, the efficiency gains from technology for medical practices are incremental, 20% to 50%. “They make for great marketing but are not necessarily tied to outcomes,” Gupta says. “Are people actually healthier as a result of it?”
But Forward is banking that its technology and build-it-from-scratch approach can deliver more than incremental change, and bring basic primary care costs down significantly. Aoun uses the body scanner and streamlined office operations as examples: A machine that takes a few cents of electricity to run replaces the traditional 20-minute examination for blood pressure, heart rate and other vital signs. The information is automatically entered into patient’s records. Machine learning, and a virtual outreach team, lets the doctors see hundreds of patients remotely and manage complications before they arise. Medicine, Aoun says, can start benefiting from the efficiency and scale of software.
For the company to scale up, it must first generate enough cash to justify a second infusion. Having raised $30 million in venture capital from investors such as Khosla Ventures, First Round Capital, Peter Thiel’s Founders Fund, Alphabet’s Eric Schmidt, and Salesforce’s Marc Benioff, among others (few of which specialize in health care), Forward will need to hit a valuation of around $100 million for a large second round.
Forward is forecasting serving as many as 10,000 patients per clinic paying about $1,800 annually (and lower prices over time), which includes visits, monitoring and the first prescription for certain drugs and sensors. In an optimistic scenario, that means about $20 million in revenue per clinic for now—potentially a tough target in markets where One Medical, a primary care provider (albeit with far less technology), offers a $149 annual membership. (Forward does not accept insurance yet, and offers free membership to 15% of its patients who are from underserved communities).
Forward will need to unlock unprecedented time and cost savings if it is to succeed. Shaving off 20 minutes from patient visits, or achieving a better doctor-to-patient ratios, is significant but not transformative. Aoun says the company’s technology will get it there. ”If I was going to spend decade of my life on something, then maybe that thing should be more important than photo sharing,” he said. “We are going to try to build the operating system for health care.”