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The Cloud Doctors are Here

Episode Description

Don't dig your grave with your own knife and fork says an old English proverb. COVID has made all of us very aware of our overall health and wellness needs. By 2025, India will need an additional 1.5M doctors and 2.2M nurses. Life expectancy at that time will be 70 years with about 90M diabetics. Unless we shift to a new way of looking at managing healthcare, we will be in a constant state of catch-up. Thanks to the 2k+ health tech startups (of which 350+ are funded and 4 are unicorns), we believe the DIY age of health is HERE. India will democratise its way to universal healthcare. Prevent rather than Treat is the new mantra. Have fun listening. Do record or write in to tell us what you think of this episode.

Transcript

Hi, I am Samiran.

I am Nilesh

Hi I am Sheetal, and you are listening to 3TB, 3 Techies Banter.

Hi, everyone this is Samiran, Sheetal, Nilesh, we are back with another episode of 3 Techies Banter, this is the Podcast that looks at Tech in a non-tech way, in fact I am wondering if we may have coined or patented the fun Tech.

So this was really our attempt to make tech conversational, make it easy and understandable and relatable to all of you.

In season 2 we have taken the thematic approach, so we did the India stag 1st and now we have moved down to everyday Tech, we did the Home automation in 1st Episode, now we are going to look at Health as an area, of course Health is extremely Large and vast, so kind of its narrow it down to everyday health which you and I interact with and use which is probably Oximeter have become really very close to you device because of COVID, but we will look at little more as we go along.

One of the things I realize when I was going through the Podcast is, Pramod Verma have a big profound influence on me at least in terms of Scale, so I was just looking at numbers and I look at doctors density and we are around 1.5 to a million and Govt told we need to double that. So when we look at doubling the density it means we have to go from 1.5 million doctors to 3 million doctors in a few years, and how do we do that? Is there a way that everyday healthcare looks at it?

So Nilesh, maybe we can jump into this with a little bit of History and then we will go from there.

Playing Background Music.

So, in terms of History, instead of talking particularly about Health tech and when it started and what are the roots of it, I believe wearable tech overall and miniaturization of Tech, is the place where Health Tech finds its route and at some point, of time we will talk about standardization and various protocols and how it helps this technology to come up.

So let me start with the 1950s and this is the time when Sony transited TR55 came up and it was revolutionary and the form factor was really small and they had cracked it and it was the 1950s of technology that you could carry with you.

1960s had a very interesting development that caught my eye, 1961 a math professor Advert taught, he created small computer it was more like Machine which could count and it was something which can be kept in your shoes and reason was the Math’s Professor was trying to beat the Rule Machine and when the Rule started, the person wearing this device could predict where the ball will drop, so interesting timing device.

The 1970s is very interesting and in 1975 String wore a calculator watch on the cover of the Police Hit called “Wrapped Around Your Finger”, wondering if String was doing today so will find a Bluetooth ring wrapped around finger, but at that time he had to make a calculator wrist watch.

I was just wondering if it was wrapped around his finger or his wrist.

It was an interesting calculator watch, so this watch used to be extremely costly at that time, just imagine 1975 the price today would be 3000$ that puts it bang in the luxury watch segment but yes Casio later Industrialized it and was cheap.

Another thing in the 1970s caught me was a head mounted camera for blind which used to be at a certain vibration and help blind to avoid the obstacles and I presumed GoPro today is Avatar of that form factor, so that was interesting.

1980s was Walkman and 200 million plus units were sold, some amount of heart monitor started in late 80s but it was really Athletic use, so if you had to do performance, Athletes use to check their heart rate, BP and all so 80s saw some type of health tech crimping into it. In the 1990s I read there was a bearable Wireless webcam by a Canadian researcher. In 1994 there was a kind of active batch which used infrared signals to provide someone’s location, so that was quite interesting.

2000s when very solid innovation started and this was the period when Bluetooth came into picture. When I look at wearable tech and devices today, the underlying protocol is that some interesting stuff is happening at protocol level, but Bluetooth really revolutionized the space. 2000s were also the decade when iPod kind of rule the roots, so 2010s is the time when you see the real serious wearable health tech coming into the picture, so Fit bit came in early 2010. 2013 was instantly Google glass though it is the failed project of the Google, I believe it is making the come back and it has lot of potential especially when you talk about Metaverse and stuff, Oculus was another thing which was in 2016 which was another kind of wearable tech, which may find its usage in Metaverse plus in some shape and form in Health Tech.

2015 was the Birth of the Apple watch and it has gone to a number of vibrations and today it is at a level. Apple watches have a lot of sensors now in your watch.

So, 2010s is serious wearable health tech stuff and 2020s people are doing crazy kind of things so you are talking about smart clothing and something I read is kind of POC right now, some kind of Yoga Pants which tells you to correct your posture, so smart clothing.

There are some companies working with Tattoos, so that is the next level of stuff happening. So that is kind of a short History of wearable flash tech.

Nilesh, your history as when I think of History so I go back to BC, apparently the earliest recording thing is 950B.C where Egyptians were into prosthetics and leather toes. It was related to their empire or soldier something but they were into prosthetics at that time. In fact when I was reading I found that some of the medical devices also have some of the interesting origin, in fact the stethoscope is kind of build out of respect from women, Rene Laennec was a true gentlemen and an engineer so he wanted to diagnosis patient Heart condition, so he actually rolled up the newspaper and placed at the patient chest and that is how early stethoscope was because he did not wanted to offend the dignity of women, similarly the X-ray was also build accidently where W.C Roentgen he pass X-ray through his wife hand, she could see the bones and she in fact remark that I have seen my death, so that is how X-ray came about.

Not to be left behind, Indians also have been at least in the 4 front of the surgery, if you kind of think speakers of Wearable or M-Tech, so Sushruta was one of the early pioneers, in fact if you go back to his writings, he actually say that A surgeon should equip with 20 sharp and 101 blunt instruments to perform a surgery and plastic surgery, Gallbladder surgery stuff like that was very prevalent in the good old days, that is history, in 1940s what is this.

Well, Samiran you know that generation changes or shifts was supposed to be in 10yrs and now it is happening in 5yrs, as far as I am concerned, Nilesh History is more relevant than yours. Who cares what the Egyptians did or did they tell you to walk like an Egyptian. I don’t care for that old history but having set that I think what we are trying to say is there is a symbiotic relationship between Health and Technology today, and the kind of work that is happening between Health and Technology we will see impact on a couple of levels.

1. Improvement in Healthcare itself, to a large extent Machine Learning, AI is going to help improve Health care. It cannot replace people and doctors bedside manner but definitely it can help doctors to make better diagnoses, so to that extent Tech in Health care is going to help us in improving treatment.

2. It is going to play a very large role in Proactive management of health, Predictive management of health, which we are seeing and that is what we are going to cover in today's session which is Wearable tech which we make sure to stay healthy and stay fit, we are measuring all kinds of things.

3. The third place where Tech is going to play a role in health is going to be excess, I think there is lots and lots of company which are working hard to make sure that there is access to health care using technology, especially those unreachable places where Doctors can’t really go there to promote remote Health care solution.

4. Last one, which is how you do Population scale health management, that is going to be a tough one in my understanding, when we want to do Population level health management, then it is going to be a long time play or I think technology is going to land up very large impact on all aspect of Health care and we have seen lot of players come up.

We are going to jump in segment 2, which is really about various types of personal health, devices which we are using, Health vs Cure ness vs prevention and how does it all fall in place together, see you in the next segment.

Welcome back to the second segment of our Episode on Health Tech. In this segment we decided to talk about Health v/s prevention v/s cure, so I will give some of my thoughts on it that I have read.

So, I think like everything else the economics kind of situation, will guide the will whether it is political will or management will, the economics guide the whole segment.

Let me start with the recent example, it was kind of controversial aspect whereby, Nitin Kamath of Zerodha said that for his employee if your BMI is below 25 you will get half a month salary as a bonus, so it was interesting take on whole health wellness, prevention and cures kind of thing. Now think about the economics here I will say that his thought process was correct Healthy Employee means lesser sick days, productivity is higher, multiple positives comes out of it, so Economics here is if I am paying half a month salary as bonus, so you are balancing the whole idea that if a person gets sick it pays itself.

Similarly, if you see the whole Corona crisis where by Political will was there for vaccination, obviously the burden on the healthcare system will just crumble. In most of the country it just meant billions of dollars prevention rather than cure aspect, so economics in my mind to put it very simply drives the will. When Fit bit came in they did a big article on this whole piece saying that, if everything was stable the economics is in favor of cure because pharma industry is a big contributor to any political campaign, political lobby ensure that got more cure and dollar focus than prevention, that is where Fit bit was saying what if people were healthy, you don’t need all that. So, the will is actually driven by economics.

It is quite interesting because many years ago there were various initiatives taken up where everybody was asked to count the number of steps they are doing. The agenda was really to ensure that all of us were in the prevention zone rather than in the cure zone, so getting people to walk 10,000 steps and there was competition in organization. There was so much going on and everybody was looking at watches and saying I have done 8000 and I need to finish 10,000 for the day. You were right, especially in the country like India where healthcare is not part of your social service thing and you are paying for healthcare and therefore, 62.4% is out of pocket expenditure only on Health care and in a country where you do get some amount of basic fundamental healthcare but kind of healthcare you get if you are not paying for it is not the best healthcare in world, so given the fact that India is less expensive on Healthcare than rest of the world, despite that given the way our earning is and people below poverty line and how our earnings so, I think Healthcare industry cost is rapidly going up and they are growing much fast than inflation, so if you look at cost of healthcare v/s Earning potential, I mean you will have no choice but go into prevention zone rather than into cure zone, I would say at household level economics, there is enough story of people to beg, borrow, steal to make sure that somebody family stays in the hospital. We have helped people, done things where somebody is suffering and there is no money.

I remember my mother use to be in hospital in Ahmedabad she was undergoing Kidney Transplant and I meet the family who come with all the jewelry they own and put on doctors table and say this is all we have can you save our child’s life and it is heartbreaking, so when Samiran talks about Healthcare and Population scale, you have wonderful idea of Fit bit for everyone, you should step in because Healthcare and Population scale is going to be difficult from a cure point of view, prevention point of view.

Definitely, there is a very interesting studies, if you look at India Life expectancy is just increasing so by 2025 general life expectancy would be 70yrs, number of senior citizen will be 16% of the population because slowly that population dividend will be changing for us, Middle class will rise, Diabetics will increase, so I think we obviously need to do prevention and next step in prevention will be do it yourself, that is where this idea how you enable more people to take care of their own health and reason for that again is that as I mention, we are 1.5millions doctors for 1.3 billion population, we need to take that up to 3 million up to 2025 or at least that is the target, we need to increase nurses, hospitals.

Frankly telling the pressure on Healthcare system is more as we saw that in COVID and in western country, Healthcare system is not able to cope in if everybody lies up in the hospital, so the only way you can prevent that is to enable prevention and at individual level, my idea was if you are able to give 500rs wearable band to everyone in the country and neighbor doctors could monitor basic parameters till you are ok, Heart rate, blood pressure is ok, SPO is ok, I think that itself will go in long way in enabling prevention at local level, and I am sure just give him the amount of technology available it will allow and give you very interesting population trends because now population have breathing problem, BP, way back the days people use Google search to predict epidemics, if everybody is searching for Dengue or fever in the city of Mumbai you know there is Dengue in Mumbai, I think there is great Merit in doing this, in fact GOVT is thinking of pushing digital in a big way and primary healthcare, what shape or form it takes remains to be seen, but I think do it yourself with the intend to prevent, is going to be a big thing.

So Samiran, I feel while make it do yourself, contactless or remote monitoring I think that is something we can look much faster, because contactless is exactly the same my Fit bit will be there and my doctor don’t need to do my whole community checks but like the Apple example, there was recent news article which says there was rhythm in women heart and apple kind told her to go doctor, so Machine Learning, AI is going to help us in that sense track it better and it may also create some panic if it is incorrect depending on what technology is used by the wearable tech but that is one thing.

Second is we could do remote patient monitoring that in itself will ease lot of burden on the infrastructure because then everybody not need to be sleeping on hospital bed, if you could do all the vitals sitting at home, and then vitals are going to the hospital so they are doing patient monitoring but remote, that might become lot more interesting and lot more easier, so we will not burden our infrastructure, you will have patient especially with our demographic dividend now going from the young to the old, we will need to create things like remote monitoring and remote management, I think that is the space where. We will need to create things like remote monitoring and remote management and I think that is another space where we should see a lot of change coming in.

I would just add one small point, both of you what you mentioned it's perfect, we need to go there and what is heartening in a probably a morbid way is that this whole corona crisis, what it did was, it has almost given majority of our population a health id so when we are talking about India stack and when we were talking to Pramod Verma, if we all see our vaccine certificate, you have a health id now and that is a boon now. So you have an identity linked with health and this identity with the right kind of protocols can actually enable India and most other countries to go into that remote bed.

So the only concern that will come up with something like this and i think this is something that has been spoken about, so I was reading a PWC report on healthcare and they were doing this emerging countries v/s established countries and privacy and data becomes a big- big issue. So it is very interesting in that report where they talk about the fact that healthcare in that sense with emerging market, they are very pro mobile health and pro health from remote etc. because it is better than not having any healthcare, right and therefore you feel that they are not as concerned about the data as the western world is, if I may use that word. Therefore the acceptance of M-health and the acceptance of health and tech are far- far higher in emerging worlds than it is in established countries because there is this whole fear of my data, my privacy, doctor-patient confidentiality, now and a tech company is sitting on my health records blah blah blah. I think privacy will become a challenge over a period of time with some parts. I don't know if it is as concerning with India per say because what I am hearing and seeing very often is, listen if data is the cost of getting services, I am willing to pay for it with my data because services which couldn't get otherwise which I am now going to get it because somebody is going to get my data, hey, it doesn't really matter, we will take it.

So, in fact the paradigms of decision making were different and I remember during covid we had daily workers venturing out and one wondered why don't they care but their logic was very simple, if I get covid it will take me 14 days to get it and maybe I will die but if I don't go out tomorrow then I will die anyway because I am not getting daily wages. While it is a weird example, it is the same thing with health care. The cost of getting healthcare which you are not getting at all, if it just means parting with a little bit of your data, I think that's the cost lesser developing countries are willing to pay because again, it’s that whole leap kangarooing or whatever we talked about. It is so far away that it will take us a huge amount of time to get this. So I think it is a great way. The other thing I kind of firmly believe is that there was in Wall Street as Gordon Gekko said. Greed is good, there needs to be a greed factor and fortunately for us the market for healthcare, health tech is huge, the medical devices market is huge at 10-11 billion dollars. What is really -really heartening is also, there is a huge amount of funding coming into health innovation. I think about 1.2 billion dollars of funding have come in and there are about 2,000+ startups working in health, assorted health tech space whether it is OPT auto mission to payments, wearable’s and all of that and I think that is what is going to drive a lot of the innovation needed to fix this prevention you with and we will kind of talk a little bit about some of these interesting startups when we come back in the next section.

Welcome back to the last segment of our episode on health tech. We talked about some of the interesting remote related startups that are happening in India or outside India. So let me start with something I came across a long time back and that time it was mind boggling for me. I am talking about 2007 and if you remember at the start I mentioned the history part, blue tooth and technology really gave impetus to such kind of health tech. So in the 2007-08-09 period, I heard about an Israeli company and I think they were trying to do a small pilot in I think Andhra or some other place. This was about how you could do your ECG sitting in a remote part and all you needed was any phone which was not even a smartphone, you needed a 3.5mm jack in a phone and this small device will do your electrodes, it will do your ECG, you just have to connect it to your phone and it will translate the data to your GP or whosoever was the nearest doctor. So I found it just amazing in 2007. I thought Israelis are doing really cutting edge stuff which is helping move the needle in the health tech space. Recently what I found out was, I don't know the time period but in India there are at least 2 startups that I am aware of which have taken this to the next level. I think the device has gotten even more miniaturized, it is all about heart health and ECG and other vitals related to the heart are kind of transmitted over the mobile phone network. I found that this can be a way of achieving remote management, remote health management.

Ya ya, so a friend of mine is co-incidentally he was partnered with Vienna, now he started his own, I think it is called SMIT. fit. So I don't know how much they have done but they started with this whole focus on reducing or at least managing diabetes and I think we are going to have 90 million more diabetes patients by 2025 by whatever, those are mascon numbers. Very interestingly he kind of approached it from both sides, one is the individual level which is downloading the app and if you have diabetes then they have coaches and all and being from McKinsey he always thinks like that. He also kind of created a corporate version for it, what Zerodha did, there is a version of it for employees so that employers can manage it for their employees, their diabetes, their wellness and also very interestingly they can now negotiate better insurance rates for corporate insurance because now you are able to give a snapshot of the health parameters of your entire employee population so he has seen some very interesting reductions, HBA C some 75% reduction in 2 weeks for a general population, some 30-35% revise their medication, some people even about 20% odd saw weight loss by just monitoring it. There are N numbers of startups like this; I thought I will mention that. Like in the last section we talked about innovation, there are people doing work and as their data gets available, I think people then start doing very interesting things with the information and you find some unusual consequences of the work that you do.

Ya, so you know Samiran it is interesting because you had a friend but I had a client once who, i was doing consulting and things like that and it was very interesting because what they were doing was, they were creating what they call a step down ICUs. So typically when you are in an ICU there is vital monitoring happening all the time but all the beds in a hospital don't have vital monitoring which happens automatically. You will typically have a lot of nurses coming in and taking your blood pressure and your sugar and this and that and they have created this product which is like a sheet which stays under the bed and it is continuously monitoring your vitals. Almost any bed in a hospital could become like a step down ICU bed with this continuous vital monitoring and some of the data they were quoting to us was really fascinating because like you said Samiran, there are not enough doctors, just as there are not enough doctors, there are not enough nurses. Nurses are stretched especially when there is crisis and things like, they are completely stretched and these guys talk about the fact that if you use their product, you would save 80% of nursing time and that could result in a whole bunch of other things that the nurses could do to make patient care so much better rather than having to do this over and over and over again for patients. They also talk about huge amounts of savings for hospitals because you are now not deploying things and there is no crisis etc. because the crisis beeps in a room which you are tracking and monitoring which I thought that and while they were doing it for hospitals, my sense was that if they did it for a B2C piece, right? Imagine when you have parents who are aged, you are not living with parents, there are so many people not living with parents, forget them, I am just thinking about my own situation where both my kids are not in the country. When I grow old, I want something like that so that at least my kids will know that my heart is going to fail or I am going to get a heart attack. So it really helps people who are away from parents to kind of, especially if the parent is ill to kind of keep track of parents. It is for people like me, I am hoping I will never live to be an octogenarian but if I do land up there then I think a B2C version of the same might be fascinating to have. So honestly I think there is so much innovation. I remember when we were writing for Mascom, they do the innovation awards and things like that. Many- many years ago we had written a case study on Cloud doctors and Nilesh that is exactly what you were saying which is remote because there was no way you could get doctors to villages and things like that so we had written a case on the cloud doctors because they were all giving service and they were all giving diagnosis and treatment over the cloud.

That could have been a serial, cloud doctors.

If she is listening, maybe if you tag her on this, if she is listening she will pick it up but having said that I am going to end not on an Ekta Kapoor note but on another note. So with all of these wonderful innovations that are happening in the space of everyday health and I think yes, while all this is happening at the larger scale hospitals etc., I think day to day healthcare and health tech is going to reach each one of us, at least take more responsibility for our own health and this brings us to the end of another episode of 3 techies banter and we do hope you will write into us and tell us whether you like our banter or not and what is it that you would like to hear from us more and more. Thanks a lot everyone for listening in and see you in the next episode.