Ian Bergman:

Today. I couldn't be happier to welcome Amanda Goltz to the show. Amanda is the US lead for the worldwide public sector healthcare, venture capital, and startups at this little company, you may have heard of called Amazon Web Services (AWS). Amanda, that's a mouthful of a title. I love it.

Amanda Goltz:

It is. It is. Hey, Ian, I'm so happy to be here. And it is just a bunch of words, but I can explain what it means in a moment.

Ian Bergman:

Well, it's great for our audience. Amanda also happens to be a driving force behind the AWS Healthcare Accelerator in partnership with Alchemist X, And in a previous role, Amanda led Partnerships to Power Voice AI experiences at Alexa Health and Wellness. Before Amazon, Amanda was vice president of Digital Innovation at BTG, a Global MedTech managing a portfolio of digital initiatives combining clinical interventions, device technology, and digital services to incorporate the patient experience and improve measurable outcomes. 

Amanda has launched a new venture herself, led innovation and patient-centered initiatives at major organizations across the US, and regularly engages with startups as a mentor and advisor. Amanda, it's just awesome to have you here on the show.

Amanda Goltz:

Thanks so much for having me. I've been looking forward to this all week. I'm excited.

Ian Bergman:

Oh, I'm glad. It's a great way to capstone the week we're recording on a Friday; we get to go clear our brains through conversation and head into the weekend, right?

Amanda Goltz:

Absolutely.

Ian Bergman:

Let's just jump right in. You have a really interesting background and personal story. Can you tell us a bit about it? And how did you end up at this really fascinating intersection of health and innovation?

Amanda Goltz:

I'd be happy to, Ian, if you'll do me one favor, and that's cut me off if I start going on and on and on.

Ian Bergman:

Absolutely.

Amanda Goltz:

Awesome. I've had the privilege of being able to do a lot of different things in a lot of different healthcare settings and roles around the ecosystem. And I find it all fascinating. I consider myself super lucky to have been able to observe the inside guts of healthcare from so many different perspectives. So it really can fill a book. So please feel free to cut me off and move us along. 

Let's see. So let me start with where I am now, and then I'll go back to the beginning, and I'll roll forward. So that bunch of words in my title actually reduces down to a mission that I feel really strongly about, and that is driving innovation into healthcare organizations, which is the throughline for my entire career. But I get to do it in a really practical, effective way at AWS because we're able to find really promising emerging startups, generally in health care delivery or health care software or services and drive them into the public sector, health care customers that we serve here at AWS. So those are not-for-profit hospitals, academic medical centers, state and local governments working in healthcare, such as departments of public health and then federal health agencies, CMS, obviously the VHA and the VA and the military health service and many more. So what we're able to do even more than taking the startups and having like a showcase of great solutions out there, is we're able to curate our startups and the cohorts according to what those customers, those healthcare organizations, have told us is their priority problem.

It's not necessarily what they want to innovate on or what they want to do in terms of disruptive AI, Ml, Bitcoin change. It's a problem that is top of mind for them strategically and operationally, and we're going to leverage innovation and the startup world to find great solutions to that problem that at the end of the day, we can say, “Hey, hospital or Department of Public Health, we know that you don't have a team of developers sitting around ready to do fancy data integrations. You're on AWS, the startup’s on AWS. We'll help you do it.” So we'll eliminate some of those technical and operational barriers to actually moving forward to a pilot or, better yet, a phased deployment of that startup. And we select startups that have been clinically validated and are in the market, and are looking to scale. We're Amazon, we have a lot of innovative new products, but we're really good at taking small things and making them grow fast. So that's our attitude towards startups. You've done a bang-up job in your initial pilot or your initial deployment. Let's take you huge; let's take you to 50 hospitals or 20 states or across the VA. And really, what we focus on and AlchemistX is key to that.

Ian Bergman:

Well, that's awesome. And I'm going to extract more of your background and how you got here in just a minute because it's a really interesting story. But I want to note something that you just said. You noted that you could go to these large organizations that serve millions of people across the country. And help them extract strategic priorities and avoid buzzword bingo. And when we're talking about corporate innovation, I think that's always one of these really interesting challenges is how you focus on the actual problem that needs to be solved and how you identify it. So I kind of wanted to call it out and maybe put a marker because we're going to come back to that if that makes sense.

Amanda Goltz:

Yeah, that is really helpful. Thank you. And I didn't mean to slam AI and ML. Many of our startups are really great at that. What I was trying to – I did maybe mean to slam Bitcoin, honestly – but what I meant by that is you don't adopt the technology. You adopt the result that it generates, right? So instead of pursuing what's a cool machine learning startup, you should be saying, “How do I prevent patient falls?” And if the solution is based on ML, great.

Ian Bergman:

That's incredible. Well, so you're in this amazing role. You have one leg sitting here in the ideation and the energy of startups. You have this other leg sitting here in, deep understanding of the health system in this country. How did you get here?

Amanda Goltz:

Yeah, it's a great question. So I think, like many people, the day that I graduated with my shiny master's degree in public administration and healthcare finance and management, I knew exactly how to fix the United States’ healthcare system. And with every day that I've spent in it, I know less and less about how to fix it. So I think that's that that resonates with many people. But what I did know, or what was quickly apparent to me… I started out in the private, public safety net hospitals in New York, New York City Health and Hospitals Corporation, and then moved up to Boston to work for what was then called Partners Health Care, now called Mass General Brigham. So that was also an interesting dichotomy because it was a very underfunded, scrappy safety net hospital. And then it sort of, if you will, academic, academic medical center, an ivory tower that gets the best patients from all over the world. And that in itself was an interesting lesson in what gets done and what gets prioritized. But what became rapidly evident is that there, just like you described, you know, having two legs in two worlds, the chasm between those two worlds that really isn't crossed by a lot of the mechanisms that allow the crossing in finance or other industries.

So there's all this great innovation happening, and then there's traditional health care delivery and services, right? And never the twain shall meet. And it was always really interesting to me. There are a lot of reasons for that that are obvious. It's a very regulated industry. Obviously, the stakes for making a mistake are very high. We're talking about death and suffering. We're not talking about "Oh, my unmanned drone crashed.” We're talking about people's lives. There's a very strong culture in the US of at least medical care doctors. It's being artisans. It's like, you know, half art, half science. They lay on hands, and they heal you. And that has trickled its way down to a lack of data. We're obviously very slow to digitize our records. We have been dealing with paper for a long time. There are a ton of reasons. But when you get right down to it, it has to. And I can talk about this later. It really has to do with the payment system. And because I had an inkling of that, I was like, “Why don't I plot a course through the health care system where I spend some time at each side of the table and try to figure out why that chasm is so deep and so broad and find good examples of success in crossing it?”

So from there, I actually – just a quick note at Partners – getting into some of this data stuff. This is how long ago it was. My project there was to do a web-enabled report card. We now call those things websites, but back then, it was very exciting, and I put up the individual hospitals and our individual physician groups' performance against certain publicly reported quality measures. And I felt for sure that this would (this is the arrogance of youth) cause this sea of change in people's behavior about where they got care, that people having massive chest pain would stop and be like, “No, no. Let me look up where the best heart attack care is before I call the ambulance.” But after six months, I looked at the Google metrics, and the primary visitors to the site were myself and my mother, who was very proud of what I had done.

Ian Bergman:

That's really nice of her, though.

Amanda Goltz:

Really nice. Especially because she, you know, lived in Maine and didn't have any reason to be selecting a Boston area hospital. But it was super nice. She was very supportive. And I realized I had to be another way that, okay, that's not what activates patients and families in their decision-making. That's not what describes consumer behavior in healthcare. So what does? Its 2009 massive law has been passed. The era is high-tech to digitize medical records. Everybody remembers electronic health records and their meaningful use. What they don't recall is that there was an equal financial push and grant program for states to wire themselves for data exchange, not health insurance exchanges, but health information exchanges. I moved to California. I figured the biggest state, most tech. Surely they'll get it right, right? We didn't. We wrote a beautiful strategic and operational plan, submitted it to the office of the National Coordinator for Health Information Technology, set up an organization called Cali Connect, and launched it. And we're still using the fax machine 13 years later. There are really good reasons for that. And I learned an incredible amount and built a great network across the state through our statewide committees. But it's really hard. It's hard to create a system in which the incentives and disincentives for freely sharing data align.

Ian Bergman:

Sorry to interrupt, but is, is this about incentives or is there something else going on for the laypersons like myself who don't understand the inside the ins and outs of this and get stunned every time we see a fax machine? Is there sort of one example that you can surface from your experience? You're like, “No, here's a very logical reason why the fax or something similar is still in play.”

Amanda Goltz:

Sure, I can give you three. So let's talk about the fax machine. So there's a law in the United States, the Health Insurance Portability and Accountability Act of 1996, called HIPAA. The easy way to remember it is there's only one P, and it's not for privacy. The P in HIPAA is for portability. HIPAA was a very well-intentioned law. It was written, you know, if it was passed in 96, probably the bulk of it legislation was written in 94 and 95 before the Internet was a thing. So it's talking about the stewardship of paper records and how you exchange data from those records. And it didn't contemplate what we're now able to do with the internet. It badly needs to be updated. So if any Congresspeople are listening to this, I volunteered to help draft, but taking the technology that was prevalent in 96, it said this: Look, there's no reasonable way your expectation that we could regulate people involved in somebody's care having a vocal conversation on the phone about needed information, for example, I'm sending the ambulance to you, that needs to happen. So we're going to make something called the conduit exemption. The conduit exemption exempts telecommunications from protecting the data that would otherwise be protected health information under HIPAA. But when you write it down, then HIPAA applies. The fax machine runs on a phone line. It's a telecommunications protocol. HIPAA doesn't apply. So that's why we still use the fax machine. Or you have to go through these incredible gyrations to protect your email and protect your system, which nobody wants to do because the penalties for violating HIPAA are actually very high. The Office of Civil Rights gets involved. It's a serious thing. So that's why we still use the fax. 

The second example of incentives being wrong is one of the things that we wanted to do when we set up universal data exchanges: We wanted to prevent a phenomenon. This is just one of many examples – this isn't the biggest priority.  When people go to see their PCP. They're like, “My knee hurts,” and the primary care doc says, “OK, I'm sending you for a knee MRI.” The MRI shows that there's something that needs surgical repair. So the primary care doctor sends that patient appropriately to an orthopedist. The orthopedist says, “Send me the MRIs, or don't send some of the MRI records because you can't do it, or it comes on CD, or it's unreadable. Or I'm going to do my own MRIs because I make money when I do a new MRI.” MRIs are expensive. They're good. When I was last looking at this, they were between three and $5,000. With inflation, they're probably more than that. And we want to eliminate duplicate MRIs. Why are we doing that? Just make it easy to go from the primary care doctor to the orthopedist. That way, the patient doesn't have to take time off from work, sit in a big, loud magnet for a long time, etc. But if both docs are making money off the MRI, why why would they have any incentive to spend money out of their pocket to build a connection between their two offices so that they can easily pass through that MRI, right? 

And then the third big example, and this is something I atone for daily, is in our mad rush to digitize records and get to electronic medical records. Which we thought we were going to save the world with it. It was going to be super easy. If you were admitted unconscious to an ER, people would know you are allergic to antibiotics. If you were traveling to another state, they would have instant access to your current health conditions. It was going to do so much good for patients, and we created meaningful use based on the electronic health record companies that existed at the time. They're still largely the same ones, Epic, Cerner, etc. Not singling out any of them in particular, but they were built without a lot of input from physicians, and their user interface is not set up for clinical care. They're really fancy billing machines, and I don't think that's a controversial statement –  that that's their purpose by design. So when you get that, then you've created a system that's not good at exchanging data on the patient's behalf. It's not good for helping clinicians do their jobs. It's super good at helping the hospital get paid, the clinic gets paid, and the doctor gets paid, which is important, but it doesn't do much else. So then to turn around after setting up that infrastructure and paying doctors $40,000 to adopt this record and complain that they can't do the things that the record doesn't help them do is a little bit two-faced. So that's when I say I atoned for that. That's what I mean.

Ian Bergman:

You help put this giant train in motion and sometimes a little hard to slow down. You can't complain when people are on it.

Amanda Goltz:

Precisely.

Ian Bergman:

That's amazing. So you're also hitting on, I think, fragmentation of health care and the complexity of the payer system, the delivery system. Et cetera. We're going to we'll come back to that. Let's take the last leg of your story to how you got to where you're at now. 

Amanda Goltz:

Sure. So this is, you know, this is what I this is why I say I'm lucky. I wanted to figure out what was happening in the system by being in the chair to have the point of view. And that's what happened. So in furthering the uniqueness, shall I say, of the US health care system, one of our statewide committees was run by the CEO of an organization called Pacific Business Group on Health, which represents 60 large US-based employers who collectively are spending 12 billion annually on health benefits for their employees and dependents. And he said he'd been impressed with the work that I did on the operational plan for health information exchange. And he said, “Why don't you come work for me in the big employers?” And I said, “Why? What do they have to do with healthcare?” He was like, “Well, they pay for all of it,” which is true. 60% of Americans under 65 get their health insurance through their employer, and that is paid for through a very complex tax scheme by the employer. Mostly if it's a large company, over 3000 people, it's not the insurance company paying when you go to the doctor, it's actually the company just opening their wallet and paying for it. They use a health plan for everything you use a health plan for: adjudicating claims, maintaining a doctor network, and managing benefits. But at the end of the day, the person who's sending the check to the doctor, it's coming from the bank account of that of the employer. 

So I spent several super fun years there and spun up a consumer engagement and innovation shop. Mostly what I did was generate conflict because I'm really good at that. So I had the employers in the audience. I had great startups on stage saying, “This is how we help your employees manage diabetes. This is how we detect cardiac issues early in your population. This is how we address sleep disorders.” Sleep management is a big issue for employers because exhausted employees don't do their work well. And then I had the health plans on the side Aetna, Cigna, Centene, and Humana. It was a little bit different back. And some of them now got the employer business in the intervening ten years. But Blue Cross and Kaiser, of course, because we're in California and they were only allowed to say one of three things in response to the startups in front of their employers who are their customers, they could say, “That's a great idea. How do we work with you? We'll give you a reimbursement code.” Or they could say, “That'll never work. Here's the data as to why.” Or they could say, “We have a program that accomplishes the same goal, and here's the ROI on that program.” That's all. None of this, like, do you really want to try? 

Ian Bergman:

And this and this is a constraint that you put around them. In order to facilitate wonder. 

Amanda Goltz:

Oh yeah. 

Ian Bergman:

I love that. Constrained communication, effective communication.

Amanda Goltz:

Totally, because I was tired of the whole, “What are you going to trust? Are you trust this new startup with this guy who has no healthcare background? You're going to trust me, the 160-year-old insurance company.” That's not the debate. We're past that. The web revolution has happened. The question is, who's got the best answer, and how do we get it to the most people? 

So Aetna very smartly got tired of me setting them up that way and said, “Why don't you just come work for us as an internal mechanism to bring those great ideas from the outside in?” And I went to Aetna, and I was there for several years working on exactly that as the director of product innovation and really had a ball. That was a chance to really see the ideas happen. We worked with a great company, Omada Health that addresses metabolic syndrome. Now they're into other conditions as well. But back then, it was really about pre-diabetes. We got them into Costco. 

Really cool to be able to see employees sort of averting that course toward diabetes. And Costco is particularly fun to work with. For those of you who don't know, a fantastic company with great benefits that really takes care of employees. And the employees' respond, they get super into these programs, and they would use the giant weight scale like the industrial weight scale to weigh like, I don't know, 50 pallets of tomatoes or whatever. And they would all crowd on it and see collectively as a store how much weight they had lost to compete with other stores – That kind of patient engagement, right? 

So I had a ball doing that. We also worked on maternity programs with Wildflower Health another fantastic company, and I have some other examples, but at the end of the day, the CVS merger happened, and I really wanted the chance to go start my own innovation from scratch. 

So I went to BTG, British MedTech and started their global innovation hub. And what was cool in that role is I still brought startups in, and I did deals, but most of the emphasis was on getting my colleagues the in a fairly traditional pharma company to think digitally. So we had digital boot camps, we learned how to do lean and quick innovation, how to fail forward fast, and all that cool buzzword stuff we actually did. It was a new way of sort of thinking that was so much fun. But BTG got bought by Boston Scientific. Boston Scientific has fantastic, innovative people. They don't need me. So I was casting about for what to do next. A really good friend of mine and a digital healthcare luminary, Missy Krasner, said, Come work with me at Alexa at Amazon. I'm working on some really cool stuff. And I was like, “Oh, Missy, I don't know. I'm a healthcare institutionalist. Like, I believe you have to make a change from the inside. I don't want to be explaining health care one-on-one every day.” And she was like, “No, no, no, just trust me.” So I got through the hiring process and I joined in May 2019.

Very soon after that, we launched HIPAA Secure Voice Skills, the first voice assistant to do so, and I did some really cool stuff there. Before I do that, I just want to mention I was telling the truth when I said I'm a health care institutionalist. I've never done anything else. In my first couple of weeks at Alexa at Amazon, I got a group email announcing a launch. We do this, we tell each other about our launches, and it was Now Grammy’s notifications are available on Alexa, and I was like, “Oh, how cool. You can see if your grandmother has taken her medications if she's like up and listening.” Know it's the Grammy’s, it's the music Grammy’s in the US, it's the Grammys. But why would I ever get an email about the Grammy’s at work? So there was definitely an adjustment period. But it was a wild ride. I did that for the next two and a half years. We did some great stuff. We did refill your meds by voice. We did daily care plans, we did physical therapy, and we did Do I Have COVID. That was a big one. We did mental health help. So there was a lot more we could have done. I do need to note that Amazon has since pulled away from Alexa Health and sort of redeployed healthcare efforts in other directions, which I believe will be very productive. But I'm still very proud of the work that we did. And about a year ago, I transitioned into this role, and that brings us home.

Ian Bergman:

That's amazing. Well, and you know, in that in that Alexa role in some ways, you also are coming full circle to the launch of your web-enabled dashboard, and you're playing with new interaction modalities, new ways to sort of use technology to increase communication between patient and care. And I think it's fascinating because we zig and zag on all of this stuff. But reducing barriers to knowledge, to action is a lot of what innovation is about, right? Getting that prescription refilled without actually having to dig up the paper, go find your way to the pharmacy, etc. That's really cool. That's a lot of fun. 

Okay. Well, so there's one question that I've just kind of been burning to ask… Peering inside the organizations, medical organizations: Who makes a decision to adopt innovation? Digital technologies, the doctors running the show, the operating staff, how does that work? Because you have a lot of players in care, in billing, in prevention.

Amanda Goltz:

Such a great question, and I'm afraid I'm going to give a slightly unsatisfying answer, which not only does it depend, it varies highly from institution to institution, not just type of institution. Are you dealing with small community physician practice or a major urban academic center? But geography plays a role. The patient population plays a role. Risk appetite. The organization, just like any industry, the more brand capital you have, the bigger the target on your back, right? So I've actually had a lot of success with large-scale, boundary-pushing–  safe, but boundary-pushing – startup work and ways of doing things with smaller hospitals who, you know, are constantly in the news all the time for whatever they're doing right or whatever they're doing wrong. So sometimes my advice to startups is that while everybody wants that big name and big logo as a reference client, sometimes you can get more done. Certainly, collect more data at a smaller organization. I want to give a particular shout-out here to ChristianaCare in Delaware. It was a profound partner for us at Alexa Health. You know, their biggest claim to fame is that they were the ones who gave President Biden his COVID boosters. But, you know, as is common throughout the country, it's the less famous community practice and community centers that are doing some of the best work with the highest patient outcomes. And so I really want to give a shout-out to them there. But back to your original question: Who makes the decision? Sadly, and this is true of delivery systems, hospitals, health systems, and clinics and payers – insurance companies. It's not so much who makes a decision, it's who can say no. 

I think you put a bunch of people in a room who care about patients, and they're dying for new solutions. They're not comfortable with gaps in care. They're not thrilled about falling short of quality measures. They want any solution. The question is, who can say no? I will say that you're your most important, and I'll flip this and go back to who a good champion is. But your most important “no” are the physicians. 

First of all, physicians bring in all the money to a hospital. A Hospital is an empty building unless physicians are doing things to people. So they hold the power of the pen and the power of the money. And if they say “This seems unsafe, or I don't like it,” or “It's too cumbersome to use,” you're dead in the water. So you cannot have enough initial validation from docs: “Yes, I would use this. I know exactly when to use it. It's easy for me to use, and I believe it works.”

The second big no, of course, is risk management and PR. This tends to be a very vicious cycle for startups, and I'm open to you or listeners for any great ideas to get past this. But there's a vicious cycle I'm talking about is that you have to have data that it's safe and works in order for anybody to adopt you. But you can't get data that it's safe and works without anybody adopting you, and you get stuck there, right? You don't have a good.

Ian Bergman:

Classic innovation, classic innovation. A Catch 22 with the added fun of life and death. 

Amanda Goltz:

– Of loss of life and limb, right? So and we don't have good mechanisms. We have a thousand incubators and accelerators. I'm one of them, but we don't have good mechanisms for clinical validation. We don't have like a store you go to and submit your idea for rigorous review. Now, frighteningly, I will say that that's the same for all medical innovation, whether it's startup or tech or not. How do new practices (like a new way to do a knee replacement or a new technique in neurosurgery to fix a chiari?) Or how does that get done? Well, some doctor somewhere does it. They publish a paper, they take it to a committee meeting or a specialty meeting, and others read it and adopt it. That's it. The most rigorous way we have to assess these things are really the FDA clinical trial process, and that has its own problems. 

So this could be a constant refrain for me. I don't like it, although everything should be safe and everything should be transparent and honest, and privacy should be a number one concern. I don't like it when we apply a higher barrier to things just because they're a tech that we wouldn't apply to a similar advance in medicine or drugs. I don't like that. It makes no sense. It's just Luddite thinking. It's just I'm frightened of this because it involves software and keyboards. So I'm going to keep hammering on that one. But I will say that you have to have data that your solution is not harmful, that there are safeguards in protecting the data, that there are safeguards against hurting patients, that you have some kind of clinical validation and that you have some ROI because otherwise PR, risk management, lawyers, everybody at the hospital is going to come after you. "This is too dangerous to do," is a big one that we get. And it's also why most changes are incremental. 

Your third naysayer is operations or finance. Hospitals run at a 2-4% margin. They're like bare bones right now. And in the current environment, they're struggling just to keep doctors and nurses from walking out the door. Burnout is real. The exodus from the profession is huge. So if your thing is going to add friction to a nurse or doctor's day, if it's going to require an expenditure like, “Ugh, I have to go to Epic and make sure they send data to this new startup partner, and they're going to charge me $10 million over five years just to do it,” or “I’ve got to add this to my information technologies internal teams list of to-dos, and they're already booked five years out. I got to hire a new IT person. How much is that going to cost me?” Then it's going to be really hard to do even if there is an ROI because the hospitals and the clinics simply, as hard as it might be to believe, given all the money sloshing around the system, just don't have the margin to. To invest in the short term for long-term gain, they're just trying to get through this quarter. So that's your other big no.

Ian Bergman:

And it's, and I think it's one that would be familiar to a lot of the startups that are selling into other sectors and industries. There's always that – I'm going to call it an excuse. It's not an excuse. It's a reality. But to an extent, there's this fundamental force that says that it's really hard to invest for the long term when you're worried about the short term, and you're dealing with all of the constraints that are always there. I think it might surprise some of our listeners to hear things like hospitals are running on 2 to 4% margins.

Amanda Goltz:

I mean, not all of them – that's the bulk in the middle for sure.

But I think I think you're absolutely right. Those are familiar challenges from disruptive innovation and other industries. I think what's weird and surprising to the listeners, maybe to your point, is that these are nonprofit hospitals. Like they're not trying to mpress the board and quarterly results and thinking toward next quarter's guidance. This is their lived reality. So that's what makes it a little different.

Ian Bergman:

So let's talk about what happens in the success case. Right. So you talked about medical devices. Someone comes up with a new medical device, a new, slightly different curve to something that holds open a vein, and it slowly gets adopted and kind of lands and expands out. How does that happen in digital innovation? A hospital takes a bet. A clinic takes a bet. How do others learn about it? How does it expand through a highly fragmented system and get adopted as a universal best practice? And how long does that take?

Amanda Goltz:

Well, I think I'm still waiting for an example of a universal, but I will pop the champagne when we have a startup that becomes common practice, that switches over from "look, we did this cool new thing" to "why wouldn't you do that? Everybody does that." That's why they're so successful, right? So I think it goes back, and this is why I really appreciate your line of questioning here. I think it goes back to the nos I just listed. So the things that can really address a current pain point, alleviate some of those existential crises that the delivery system is experiencing. The hospitals and clinics are almost so desperate that they're, you know, they're sort of impelled to take a try. It's what converts innovation from nice to have to must-have. So that's why we're focusing this accelerator program on workforce burnout, retention, and training. Because while I expect many, if not all, of the startups applying to that accelerator are going to have really creative, disruptive, highly advanced technical solutions to that problem, the problem is not a technical problem, right? It's what our hospitals and federal health agencies told us they were facing. And I said, "Okay, I'm not going to find you technical solutions just to find you technical solutions. I'm going to find you real solutions to that problem." If you're a hospital facing an existential crisis where your procedural lists, your orthopedists, your cardiac guys, and your neurosurgeons are bringing you in the money that you need to stay alive, that you need to run your ICU to keep your emergency room doors open, which is often how the pattern of finance inside a hospital works.

And those guys are pissed at you, and they're leaving, and you're not billing as much as you used to. You're facing a real problem. So you'll adopt almost anything that will keep those guys happy and doing multiple hundred thousand procedures on a daily basis. So a lot of the work I do is trying to translate from one side to the other. Yes, usability is great. Yes, ROI is great. Yes, high degrees of feature-sets and flexibility is great. But what really matters at the end of the day? Are you helping the hospital fill out its census? Keep the people who make money, keep the wheels on the bus turning really quickly. It's a lot more basic stuff than it is like, "Oh, I'm going to have, you know, augmented reality for surgery." That's awesome. That's great. There are five hospitals in the US that can experiment with that right now. But what everybody needs is a way to have patients seen at the appropriate level of care quicker, make better use of the existing resources, keep doctors and nurses happy, and make sure the patients are being monitored at home so they don't crash. That's what everyone needs.

Ian Bergman:

Well, that is a great transition. Let's actually talk about this accelerator program you're running for a little while. The official name, The Global Cohort for Workforce Development, leads right in from the problem that you're addressing. Applications are open, and they're coming in from around the world. What is this program, and what are you hoping to accomplish with this?

Amanda Goltz:

Yeah, so if you think back at my experience, I'm sitting inside a big employer coalition, I'm sitting inside a big health insurance company. I'm at all these places, and I'm trying to pull innovation in kicking and screaming. Right? And I'm having limited success, frankly. There's some stuff that I'm super proud of, and I think some people have helped along the way. But I do not have the secret. I do not have the formulas. I'm still looking. 

So I think it comes back to the payment system, which, I'm sure, we're getting to that. What I hope to do with this accelerator is to take another step forward on that journey. So if there are practical barriers like what I mentioned before, “I don't have money in the budget to buy another IT director to manage this project.” Can we help? We're AWS like that's what we do. We have pro serv which helps you with consulting. We have an architecture that helps you design things safely. We have services and products to help you do that. So I don't have the IT knowledge to work with this startup or surface my data to their APIs is something we should be able to solve. So I'm really excited about that.

We have an excellent relationship, not through me but through the fabulous work of our account leads and the general public sector. Health and Healthcare and life sciences team at AWS, where hospitals know and trust us. Departments of health really want us to be bringing the best ideas to them. The federal health agencies trust us with their data. So it's very it's a huge advantage to build from that and say, no, we really believe in this startup, and we've taken a look at their tech. Second, the data is safe, and we really think you should use them. That's a much more powerful way to advocate rather than just being like, “You guys should really use these people. They're cool,” right? 

What I hope to do with the program, though, is make those promises true. So we get hundreds of applicants, which is amazing. Your team is doing just an amazing job along with Plexal, all in our Europe, Middle East, and Africa regions, to sort through all of those applications and select a certain number of companies, a group of them in the Americas, and a group of them in Europe, Middle East and Africa, which we refer to as EMEA. And those companies will be selected.

Applications are free to anybody, open to anybody in the world, and those companies will be sorted into those two regional cohorts based on where they want to grow their business, not necessarily where they're based. So if you've done an amazing deployment with the French health care ministry and you want to bring it to the US, that's exactly the intent of our Americas cohort. 

The programming is going to take place in May. Opt for those selected startups. It's going to be a number of experts who come talk about how to scale, how to grow, how to validate your product, all the issues we've been talking about on this podcast, but very specific to the business models of the respective companies. 

They also get assigned a business mentor and a technical mentor who essentially become parts of their team that join the startup more or less for the four-week program and help make true those promises I was talking about before, about safe architecture in the cloud, regulatory and data certification compliance, which are things AWS offers, the ability to leverage certain features, so they don't have to build them themselves around machine learning or do it yourself by algorithms like Sage Maker. And so when those companies graduate, we're really able to say, “These guys are great, we believe in them, we trust them with our data, so should you. And we also have faith in what their product does. And we have the data points to prove the ROI.”

And then we do very we have a big demo day, we do a big splash, we usually, I do it at an external event like health, but it's really in the one-on-one conversations we're able to set up with our health care organization customers. That's where the magic happens because then we're able to leverage the relationship, the value of the tech, and the particular problem we know that customer is facing to solve the issue. 

So that's what I hope to accomplish, I am duty-bound to say. Another thing that I really like about our accelerator program is we don't take equity, and there is no cost to be in the program. A lot of people ask me, “Amanda, why do you have a job then?” And I say, “Well, you know, you can sort of you can guess that if a startup grows quickly on AWS and a customer buys a startup service on AWS, then both of their billing goes up.” So it's good at the end. But I'm really glad.

Ian Bergman:

The business model is not rocket science, but you talk about aligned incentives here, and I actually think that's incredibly powerful, and sorry, I actually cut you off. .

Amanda Goltz:

Just say like it's really nice not to have to burden the startups with another equity partner, so it's good.

Ian Bergman:

That's absolutely true. Well, and, you know, you talked about sort of developing belief. And when we talk about like real innovation, we often talk about how it requires something of a leap of faith or taking a risk. You have to build conviction around this. And it really sounds like this accelerator program helps build shared conviction between the startup founder and the hospitals, the clinicians, and the folks that you're working with around the country. And so if you get a couple of those, you know, as an outcome of the program, you can make some real impact.

Amanda Goltz:

And I think... You know, it's the efforts of my team. And, of course, all of this comes back to the startup themselves. I didn't come up with these ideas. They did, right? They're the entrepreneurs who had a vision and made it real. So they're the ones who deserve the credit. But we have had some major successes. We've had some companies get real traction and exit like One Record. We've seen tremendous growth in scaling to multiple customers and hospitals. And best of all, we've seen some real patients' lives improve. And that's what we're about. 

What I don't have yet and what I set for myself as a challenge looking forward is even though the accelerators have themes and work for a serious issue, we just did health, equity, access, and justice – also a real imperative issue. It's still one on one. It's still 1:1 matchmaking. No matter how universal the problem I'm trying to solve or how great the set of startups is, both are as good as I can make them. There's no real aggregation or a tidal wave of concern. It's still fragmented hospital by hospital, employer by employer, and payer by payer. And I have the sense that we're running out of time. But, and I don't want to grandstand, but I don't know that we can really drive innovation in waves instead of doing these like 1 to 1 phase deployments until we have significant financial incentives for different types of behavior of healthcare actors than what we see now. And at the end of the day, that relies on a payment system that's largely organized around the Centers for Medicaid and Medicare Services. But I share that because I want to recognize that that's where we are on the journey, that we're still solving individual problems with largely point solutions. Now, even as Paul Slovic said, “Even partial solutions save whole lives.“I am not ashamed of that. But what I would love to see is, is whole-scale transformation. I'd love to see that.

Ian Bergman:

Well, it's wonderful to hear. And these are big problems for transformation. So who's working on that? Is there someone is there somebody that our listeners or some organization of listeners should be looking up and following to say, “Hey, who is maybe driving some of this change that needs to happen to enable the whole-scale adoption of new ideas and new technologies?”

Amanda Goltz:

I'll give my own personal revolutionary call. I'll mention one organization I think is doing fantastic and unsung work. There are many others. And then I'll sort of talk about what individuals can do, certainly entrepreneurs and investors. 

So, my revolutionary call is, you know, there's it is human nature. I do it, too. I've been dealing with like a bum knee for a year, and I refuse to go to the doctor, which is the most ironic thing ever. It's human nature to not want to be sick, to not think about your mortality, to see a terrible headline about insulin costing $600 a month, or that the black women's mortality rate is sextuple what it is for white women, and be like “That's really bad, but I don't want to think about it because it's terrifying and sad and awful.” Try to overcome in yourself that natural resistance to thinking about death and suffering. 

First of all, all of us get old and sick so, we should be realistic about it. And secondly, we really need to to to work together to harness that energy that, you know, indignation and healthcare should be a right, and we should have quality measures that are basic undertakings. Nobody should die of a medical error. We need to sort of coalesce around that and make it a real population movement, just like climate is, if you will. So so that's my revolutionary call. I think anybody can get involved at, you know, a state or local level or get involved in an advocacy group that's helping to draft legislation or advise congresspeople on what to do next. So , that I would love.

My recommendation for an organization that is doing amazing work at scale in innovation is its healthcare transformation for Medicaid. So nowhere is it truer, surely, that that necessity is the mother of invention than in Medicaid. So for those who don't know, Medicaid is the state-run program to address three groups: people who are impoverished, expecting moms, and the disabled. And it's basically the safety net. It's ensuring that if you're in one of those three groups, you don't die of a treatable disease. Different states deliver on that promise at different levels. But it's it could not be a more underfunded program that is aiming more at a more complex group of people with complex problems. So the things that they've come up with in those programs are really worth knowing. 

For things like Smart, a lot of people get lost in follow-up, and they do really smart ways of finding people and helping them stay in contact with their doctors and get the care they need. Amazing work connecting people to community resources that already exist. They just don't know about them. A Company in our last cohort, Samaritan, is focusing laser focus on health care for unhoused people, for homeless people. I can't even tell you how hard that is. And they're just diving in with both feet. So there's a lot of fantastic work against long, long odds being done in that. And HDFC has chapters in each state and then also a specific aim to get really cool experiments in one state flow out across the other 49. So really love the work they're doing. Yeah absolutely.

Ian Bergman:

Which is so important.

Amanda Goltz:

And you know, people who work in Medicaid tend to be a tight bunch. So it's a dense social network, which is also really helpful. What was the third thing I was supposed to talk about? I can't.

Ian Bergman:

We'll just keep going. But it's I just got so encouraged about hearing that not only that people working in the space, not only are they talking to each other, but they're deliberately looking at scaling lessons across state lines, etc. I think that's so important. 

Well, so we've covered a lot of ground here, and you've had some really interesting moments in your career. And I want to just kind of dig in and ask a couple of little questions about some lessons that you've learned. But first, before we get there, we've got a bunch of nerds who listen to this podcast. We've got people who just geek out on cool technologies. What is one (just geek out) that is awesome and impactful that you have that you've seen in your career that you want to talk about?

Amanda Goltz:

Gosh, so many. 

Ian Bergman:

It's a tough question, right? It's like asking you to pick your favorite pet examples.

Amanda Goltz:

And I'm also happy to come back to you with a list of ones I think are really cool, maybe appended to this podcast or something because yeah.

It's so funny because I feel like I spend not just this podcast but most of my time trashing doctors and hospitals. And I don't mean to do that. There is no bigger fan girl of modern medicine than me. I mean, there are literal miracles that happen every day.

All I'm begging for is a little bit more data and more consistency in outcomes across the board. But I've seen some medical breakthroughs that are aided by technology that I think are fantastic. I mean, it goes without saying any radiologist will tell you what we're able to do with imaging now is unbelievable. I mean, I can scan you a couple of times if a digital twin of you practices surgery on that digital twin to ensure that when I actually cut you open, everything goes well. Like, I cannot tell you how amazing that is.

Ian Bergman:

I mean, that's just unbelievable.

Amanda Goltz:

Like talk about no risk, all upside, like just power of computing. Like, it's just so good. 

We're doing amazing things with sensors. I think it started off as all technologies do. It started off a little, a little rough. There were a lot of false signals. There was a lot of measuring the wrong things. But I'm starting to see the measurement of things that really matter. I just saw a wearable watch that detects something called D-dimer in your blood, which is a major predictor of stroke or stroke risk. Stroke is one of those things where if we can prevent it. Huge gain. And even if we can't prevent it, but we get it within the golden hour after you have it, we can save so much of your cognitive function and your mobility. So it's really, even if we can't predict it way ahead of time, it's still critical that somebody knows about it at the time. I actually worked for a great neurologist who was head of a fairly quixotic, but I think a reasonable effort to get just the public to call strokes brain attacks because heart attack, everybody knows the symptoms of a heart attack like that. The American Heart Association has said, "It's a heart attack if you have chest pain radiating down your left arm," or whatever. And he wanted the same attention on brain attack and stroke is kind of like, what does that mean? I don't know.

Does that even happen in your brain? An embolism, aneurysm -- What's the difference? And he was like, let's just simplify for people. And because there are five symptoms of a stroke anyway, so being non-invasive just by wearing a watch to be able to see, I mean, that's a very early stage. We need to do a lot of trials on it, but I'm super excited about that. 

And then the third one that that I'm really psyched about is (and there's a lot of variations), but so much of what happens in delivering care because it's urgent and it's fast, and there's a ton of information and decision making is critical, and there's a lot you don't know. If your patient's unconscious, they can't tell you what they're allergic to or like that they have a fake hip or whatever, you know, like just information you need to know you don't have. And all of these great communication protocols that there's smart messaging where I can even detect from the ambulance coming in. We took an EKG in the ambulance, and the person is having this specific type of heart attack, assemble this team with this cart in this OR like the speed and the quality of the decision making that flows from that rather than, you know, me yelling over a loudspeaker is incredible.

Ian Bergman:

Yeah, well, actually, and I love that example, right? Because it's, you know, it's maybe not as flashy as the human digital twin. Right. Or the augmented reality surgery or the avatar-based patient communication, whatever it might be. But it's important, maybe more important – It saves lives and that's really cool.

Amanda Goltz:

Right? It's reducing everything down to the skill of the surgeon, the management of the nurse, the counting, the instruments that the team does, the titration of the anesthesiologist, like everybody who has these incredibly rare and advanced skills, gets to do only that.

Ian Bergman:

That's awesome. Well, so I'm going to take us just a slightly different direction as we wind down a little. I want to get a few more of the lessons and insights from Amanda. So you've talked about the challenges facing the health workforce today: burnout, people walking out retentions really hard. You know, I think we're all aware of some of the external causes, and you've enlightened us on some of the maybe more systemic causes behind this. How about you? You've you you're busy. How do you avoid burnout? How do you stay refreshed every day?

Amanda Goltz:

You know, my flip answer is I run on rage. I don't. Like.

I've been doing this for 25 years and, like, nothing. Still killing a 747 worth of people every week through medical errors, I sort of get angry about it, like, no, it's unfair, and it should be different. And if I have nothing else, I have the energy to keep attacking it every day. Maybe I'm not particularly good at it. Maybe anger is not persuasive, but like I got something that impels me to get out of bed every day. Other people don't have that. And so let me jump back in the fight. 

I do think it's useful to understand both in a micro sense, this is a system that humans built, and humans could take it down. We waste a lot of time on a kind of bull hockey conversation, which is that insurance companies are evil, and if we just got rid of them, everything would be better. Or doctors are saints, and we should never measure what they do; we should just trust their decisions or employers having control of your health plan is evil, or health insurance coverage is evil. Like maybe those things are true, or maybe they're not. But how does that conversation advance us?

Ian Bergman:

There's very little nuance and very tribal perspectives in that sort of conversation. 

Amanda Goltz:

It's the system that's wrong. And we built the system, and we can build a better one. I really believe in that. But it will take all of us sharing what we know and working with each other, and being willing to suffer through some short-term pain for long-term gain as it is, and our brains are wired to do that. When I work with diabetes startups and metabolic syndrome and obesity startups, I think about that, what I call, “the I cake tastes good today. Diabetes hurts tomorrow,” problem. 

The way your brain works is it loves short-term rewards, and it doesn't construct future punishment in the same reality. We need to be conscious of that, and we need to. We need to. We need to think past that. We need to look very deliberate. Just like I was saying before, we need to wrestle with sickness and death as part of life and look out for each other. We need to get past that sort of short-termism as well. I believe we can. I've seen unbelievable change even in just my short term, short, short term working on this. I mean, when I started, the idea of telehealth was laughable. The idea that I would see not be able to touch a patient or put my stethoscope on them or have their record. And I would write a prescription. Give me a break. That's commonplace now because of COVID, and it's also because telehealth tools have gotten better. 

Doctors are younger. You know, they're more they're my age now. They're not older, and they're demanding better lives. They're saying, look you know, the Mercedes isn't everything I want. I want a way to treat my patients. I want a way to participate in research. I want a way to have an administrative voice in my hospital. I don't want to just be a tool for the system. And I think that's great. 

Diversity, equity, and inclusion are only helping us reach a better world. And I think we have a real sense that that population health is a national risk, that, you know, if our is to look at it from a traditional conservative point of view, you know, if our armed forces aren't fit, who are we? And to look at it from a more liberal view: What's the point of an economy if people aren't healthy enough to participate in it? And then there's a progressive view, which is, you know, people should be healthy because healthcare is a right. So we all agree at the end of the day, we're just deferring on the details. So I would say what I take a lot of heart from is: we built this, we can take it down. None of this is the defined rate of kings. Like, seriously, we can change it.

Ian Bergman:

Well, so we can change it: This probably brings us to a really interesting question that you may not have the answer to, but I'm really curious to hear what you're going to say. What does the future look like for you personally?

Amanda Goltz:

Oh, man.

Ian Bergman:

Where are you going to be focusing over the next few years? 

Amanda Goltz:

I wish I knew the answer. You know, I'm still waiting for somebody and my friends who, like, are fine and upstanding people with long resumes of accomplishment and without the skeletons that I have in my closet, you know, they were supposed to become president or, you know, somebody who could appoint me the head of Health and Human Services. They were supposed to do that, and they failed me in that way. I'm still waiting for my call. 

Ian Bergman:

I'm sure they're working on it. 

Amanda Goltz:

But, you know, failing that, I think what I'd like to do, and I'm very agnostic on the way I do it, I don't know whether that's, you know, (A shout out to my employer, I would be more than happy to continue at Amazon, advancing great healthcare startups and helping them scale and working with our channel partners to do so). But I want to go to the place that helps me do that. What I'd like to do is leave a playbook, is leave a set of three or four unimpeachable examples that are not dependent on a particular personality champion or a set of circumstances but really stand on their own. Of openings, portals into opportunities where the incentives of all the players are aligned and where the benefit was significant, unique, and inarguable. Like it's there... I proved the functional status of this number of patients and prevented unnecessary emergency room visits and the long length of stays through this and no other confounding factors. And this is how it got done. 

I would love to leave behind an acute care setting, an outpatient care setting, and a population health-based example as a way, a path for great startups to travel and sort of like cut down that cycle time. If I can accomplish that, I'd be thrilled to death, literally.

Ian Bergman:

I am convinced that that playbook and that accomplishment are coming. Is there anything else that I should have asked you that we should be covering here?

Amanda Goltz:

Today? I love to grandstand. I love to talk about what I've done and Me, I, Me I. But you know, this is all possible. If the work of amazing partners like AlchemistX who literally make this possible, you know, operationally, strategically, constantly lifting up what we're trying to do to a greater plane of impact. Because you guys focus on more than healthcare, and, you know, it frees me up to think about the idiosyncrasies of my industry while you're constantly bringing me insights from others. And I think that's that's really critical. And I encourage everybody to think about their partners and challenge them to have the same quality of work that you guys do. 

The second thing is, you know, this is a constant message. It's a little I think it's embedded in your question about burnout, but it's I think it's good advice that I want to pass on. When you're trying to make change – you’re a change maker, Here's what's important: It doesn't matter where you work; it doesn't matter what your job is. It matters who you work for. You want to work for people who appreciate you. You're trying to upset that apple cart, right? Because believe me, it's misery when you're trying to make change, and your manager wants you to preserve the status quo.

But it's more than that. You want somebody who sees their job as getting you into that next role where you'll have even more scope, influence, and power, and you should be emboldened. This is particular advice for women, but it benefits everybody. You should be emboldened when you're considering a job to be able to ask the manager in a very polite, you know, non-charged way. Can you name three or four people who've worked for you and what they're doing now? Anybody should be able to answer that. I can, like anybody should be. Most people who work for me are way better than me now. It's great. Anybody should be able to do that. If they can't do that or they find that question strange, that's your first red flag. So, you know, if the long-term strategy against burnout is avoiding jobs where you're going to be underutilized, I think that's a good way to get around it.

Ian Bergman:

That's incredible advice. I thank you for your kind words on partnership as well. And I'll you know, I think there's a lesson in there, though, that we're working on really hard problems. You are working on really hard problems. AWS is working on incredibly hard problems. Most of our industry is. These are joint efforts, right? And finding an environment where you can thrive personally and professionally and develop relationships with people that are going to help solve problems. I think I mean, I  buy into a thesis that I think you're saying that's incredibly important. And I really appreciate you sharing that advice with those of our listeners who are interested

Amanda Goltz:

I am on LinkedIn dot com backslash Amanda Goltz Backslashand I welcome , you to connect on LinkedIn. I'd love to hear about what you're doing. I'd love to, to, you know, connect up and help however I can. The Public Sector blog is the best way to find out about all the cool work we're doing with AlchemistX, Plexall, and other partners. There you can find the link to apply if you're a startup who's interested in the accelerator or in our other programs and just learning about how we help startups in general. And I'm trying to think of another great place to find out what I'm doing. I think that's about it. You know, I love a stage, so I'm pretty much always on LinkedIn talking about what I'm doing. So that's really the place. Do not follow my Twitter. I am remarkably unprofessional and unhinged. So LinkedIn is where it's at.

Ian Bergman:

And you just gained about 1000 new Twitter followers. Awesome. Thank you so much for joining. This has been a lot of fun. I learned a lot. I really appreciate you joining us on The Innovators Inside podcast. And yeah, this work that you're doing is incredibly impactful. I wish you the very best of luck in achieving your goals here.

Amanda Goltz:

Ian, Thank you so much. Thank you to the team that put together this podcast. And you know, as a final note, I just say if you're smart and great like Ian is, like many of you listeners are, don't leave, healthcare needs you. Don't leave, don't give up. Keep doing it.