Learnings from Building a Healthcare Startup in India

Shashikant Kore interviews me about my previous startup.

(From 2008 to 2011, a doctor friend of mine, Amit Paranjape, and I ran BharatHealth, a healthcare startup, which failed. In conversations about startups, I would often mention learnings from this experience. For a long time, Shashikant kept asking me to write an article about it, and when I kept putting it off, we finally decided to do it as an email interview.)

Please provide your academic and professional background before starting up.

I am currently a co-founder and CTO at ReliScore.com, a startup focused on helping companies filter job candidates based on evaluation of actual job-related skills. I advise a couple of fintech companies and a Govt of India initiative for startups.

In the past I’ve worked for large companies, and small; I’ve worked in India and in the US; I’ve seen a successful exit, and I’ve seen a dotcom failure; I’ve done product development, and I’ve done research; I’ve written consumer software, and I’ve written enterprise software; and I’ve been a developer, I’ve been an architect, and I’ve been a manager (but hated it).

I’ve done my BTech in Computer Sciences from IIT-Bombay and a PhD in Databases from the University of Wisconsin, USA. I am an inventor on 18 US patents, 2 European patents, and 1 Japanese patent. I’m interested in a number of areas of computer science, including: highly scalable systems; distributed and fault-tolerant software systems; text search, information retrieval, and analysis of unstructured information.

You took a sabbatical after leaving Veritas/Symantec. What were your plans for this period?

I had gotten bored of my big-company job, and I was lucky financially to not have to worry for a few years. So my plan was to just work on things that I found interesting.

As a result, I spent a couple of years doing a bunch of things: I worked on my Hindi song lyrics website . I helped Meeta (@meetalks) set up her movie reviews site. I started https://punetech.com because I felt that the tech community in Pune needed a forum like that. I consulted for a few friends’ companies.

How did you come up with the idea for BharatHealth? Who were your co-founders at BharatHealth?

The doctor friend came up with the idea. He felt that a web-based system to capture all the health records and interactions between a patient and a doctor could revolutionize how healthcare is conducted, especially in case of chronic problems where the care requires lots of little tweaking over the long term. (Note – chronic diseases are defined broadly as conditions that last 1 year or more and require ongoing medical attention.)

He approached Amit Paranjape and me and both of us liked the idea. That’s how BharatHealth was born.

Who were the target customers of BharatHealth? What problems did BharatHealth solve for those customers?

It’s easier to explain with an example. Let’s focus on diabetes patients as that was one of the first verticals we targeted.

Our initial target customers were doctors providing long-term diabetes care. The idea was that the doctors would offer BharatHealth to each of their patients. In the beginning, the patient’s basic history, the doctor’s current diagnosis, and medication protocol would be uploaded to the system.

After this, on an ongoing basis, the patient would keep uploading blood sugar readings into the system as recommended by the doctor. The doctor would check this on a regular basis and if any problems were noticed, they would recommend adjustments to the medication.

Similarly, if the patient had any non-emergency questions, they could just ask it in the system itself. The doctor would check the system a few times a day and answer any questions. This was much better than the patient having to come to the clinic and wasting a few hours, or calling up the doctor on the phone. More importantly, the doctor would be able to see the full history of the patient right in front of them along with the question so the answer would be quicker and more accurate.

We felt this was a win-win scenario.

What were your initial hypotheses for BharatHealth? 

We felt that this would:

  • Improve patient outcomes because of better availability of patient history, symptoms, medication
  • Decrease the amount of time spent by the patient waiting in waiting rooms
  • Increase the throughput of the doctor because the system would allow answering a question in 30 seconds, whereas the same question on the phone or in person would end up with at least 5 minutes if not more.
  • Patients would be happy to pay the doctor for the use of this system
  • Doctors would be happy to pay us a cut out of #4
  • Once a system like this was up and running, we would be able to monetize it in various other ways

What did the early version of the solution look like? How long did it take to get the first version in the hands of the customers?

This was at a time (2009-10) when touch phones hadn’t yet become common in India. Hence the system was a web-based system. We expected that all doctors and most patients would access it from laptops or desktop computers, while a small fraction of the patients would use smartphones to enter their test results and questions.

We built the system using Python+Django. It took a couple of months to get the first version to the customers.

How did you reach out to the early customers for BharatHealth?

Quite early we decided that this would be a B2B2C solution. We focused on getting doctors as our customers, and the doctors would ask their patients to join the system. In other words, we would never be selling to the patients directly.

We used our doctor co-founder’s connections to reach out to doctors in Pune, and made the sales the old-fashioned way –  by meeting them, showing a demo, and asking them to join.

What were some of the early marketing channels you used? Did you also have a sales team?

We only did direct sales. We did all the sales ourselves. The idea was that once we had figured out how to do the sales ourselves and streamlined the pitch and process, we could then hire a sales team. However, we never reached that stage.

What was the customer feedback of initial versions? Did any feedback surprise you? How did the initial feedback shape your product roadmap?

I’ll answer this in terms of general “customer reactions”. We ran into these major categories of customers/potential customers:

  1. A small number of doctors quickly understood the pitch and started using the system. They were generally happy how it worked and how it helped them and their patients.
  2. A number of doctors said they liked the idea but they did not think it would work in their situation because of one of these reasons:
    • They felt that a good fraction of their customers were not tech savvy and would not be comfortable using a web-based system
    • They would need to teach their receptionist to use the system, and that would be impossible
    • The system was in the cloud, and they didn’t think the internet was reliable enough
  3. Some of the doctors liked the system, sounded enthusiastic about wanting to use it, but when it came time to start using the system, they never got around to it, because always some higher priority thing came up and operationalizing this system kept being pushed lower on the todo list.

What were some of the hardest challenges in terms of product, marketing, sales and the market itself?

An experienced entrepreneur had told us that our product required behavior change on part of the doctors, and that would be very difficult. We never really appreciated how big of a stumbling block this was. In retrospect, I feel that a number of the problems in points #2 and #3 in the previous answer all stemmed from the fact that behavior change was required and our product did not provide a big enough incentive for driving that behavior change.

Speaking of incentives, based on our initial market validation (with about 5-10 friendly doctors) we felt that the significantly increased patient convenience and potential improvements to medical outcomes would be strong incentives for doctors to use this system. However,  once we moved past our friendly doctors, the impression we got was that in most cases, “Can this system get me new patients” was the more important question on their minds. And since we did not do a B2C play, our answer to that question was No.

Another problem we ran into was that doctors are used to the pharma-medical-representatives style of sales, where there is lots of hard-sell, lots of money flowing around, and royal treatment of doctors, and without that kind of a sales model, we were not very effective at selling into this market.

Another problem with this market (or the way we were selling the product) is that every doctor wanted customizations to the product to incorporate their own workflow into the system. While this is true of the early stages of any B2B product, I felt that this problem was more pronounced in case of doctors, because most of them have high-throughput practices with workflows that have been optimized over the years, and getting them to change those workflows would require too much behavior change. We tried hard to build a very flexible system that could easily incorporate the requested changes via configuration, but in many cases we had to give up on the customer after a number of rounds of changes.

All these reasons that affected our ability to sell to individual doctors were multiplied by N when we tried selling to hospitals. In the former case, we had doctors who didn’t feel they could convince their patients (and receptionists) to use the system. In the latter case, the problem was compounded because we had hospital administrators who had even less confidence in their abilities to convince doctors (who would then have to convince patients).

BharatHealth came up at a time when mobile phones were ubiquitous, but smartphones were just starting out. How big a role phones played in your solution? Would a smartphone have helped in some way?

In this sense, we were too early to the market. A few years later, when touchphones were truly ubiquitous, the resistance to our solution would have been much lower. Without the guarantee of an always-on smartphone with every patient, the (mental) barrier to entry was too high, and as a result the behavior change required was too high.

What were the signals that indicated the product is not working as per your team’s expectations?

While we made quick progress with the initial set of doctors we had talked to, we soon found that expanding past this inner circle was quite difficult. As we approached more doctors, we found that the meetings and demos went quite well (according to our possibly inexperienced judgement), and they sounded positive about the product, but getting them to take the next step was difficult.

In many cases, in spite of positive feedback, we would not be able to get them to set up their account on the system. There was always a plausible reason for it; some emergency that came up, or some other higher priority activity because of which they wouldn’t have time to learn the system. And in the cases where we got them to create an account and learn the system, we found that they wouldn’t actually sign on patients.

As a result, growth just slowed to a crawl.

At what point did your team decide to pause efforts on this product and company?

During a long stretch of low/no growth, Amit and I were involved in some unrelated initiative (part of our PuneTech work), and we hit upon the idea for a different product in a space that we understood much better (hiring for software industry) and we felt it would be easier to sell because we understood the potential customers and their motivations much better (having worked in that industry for 20+ years each). As a result we decided to stop BharatHealth and ReliScore (our current startup) was born.

Last decade saw significant improvements in technologies like smartphones, wearables and machine learning. You mentioned smartphones would have lowered barriers for adoption. What healthcare problems, that you are familiar with, can now be solved in a better way with new technologies?

Since I moved to a non-healthcare startup, I haven’t really kept close tabs on what all is going on in the healthcare tech space.

The potential for use of smartphones, wearables, and machine learning in healthcare is huge. You pick any aspect of healthcare and it has the potential to be revolutionized by these technologies.

However, the challenge primarily lies in the “behavioral change” that I mentioned earlier. This falls into two categories: preventive healthcare vs acute healthcare.

Preventive healthcare could be applied to everyone, and it could have a huge impact on the world. However, getting people to start using an app and/or providing it with the data it needs is not easy. Most people are quite lazy about taking steps now to prevent future problems, especially if it involves a payment. And if it doesn’t involve payment, then there is always the concern about how the company will use the data and whether privacy will be preserved. As they say it is easier to sell aspirin not vitamins. Because of this the companies most likely to make good progress in this area would be those like Apple, who have: 1. a good brand image, 2. an app or device that is already in people’s pockets, and 3. the data entry is minimal-effort, ideally zero-effort.

For acute healthcare (i.e. solving a problem you have right now, i.e. aspirin instead of vitamins), doctors and other providers have to be in the loop (given the current state of technology and regulations), so this involves handling behavior change and incentives for those players. As is clear from our failure, this is not something I understand well, and I haven’t yet seen a compelling model from someone else.

Since you faced challenges with B2B2C model, which seems to be the primary route to market, what are your thoughts on using the B2C approach?

I think the right kind of B2C approach could succeed, but the focus has to be more on psychology, incentives, distribution, rather than the technology. And would need deep pockets also. We considered pivoting to a B2C model, but we decided that we neither had the expertise nor the budget to pull it off.

You mentioned, you thought about B2C pivot, but didn’t work on it for a variety of reasons. Do you remember what some of those B2C ideas were?

We thought of a lot of ideas, only some of which I remember. For example:

  1. Allow end-users to capture their medical history and reports, and enable easy sharing of this data across patient, doctor, pathologists/labs, family (e.g. NRI children), and for second opinions. 
  2. Same as #1, and get medical insurance companies to offer discounts to patients who show good control over time.
  3. Allow end-users to capture their medical history, and allow them to ask questions to our team of doctors
  4. Same as #3 but have software triggers and/or doctors looking at the data to warn patients of potential problems that they’re ignoring
  5. Same as #3 but allow the patients to suggest which doctors they would like on the system and use that to create pressure on doctors to join.

How long did you work on BharatHealth, from starting work on it, till deciding to stop working on it? I could add it to give some idea of  commitment for new entrepreneurs.

Approximately 3 years.

If a new entrepreneur wants to explore this space again, what advice would you give?

I would say this:

  • Focus on psychology, incentives, distribution, rather than technology. Technology is the least of your challenges. Ask yourself if you can do the first 3 to 6 months of your startup using just WhatsApp and an Excel spreadsheet and you personally handle all the customers. You’ll be surprised at how often this is possible.
  • To be able to do #1, steep yourself in the culture of this domain. Talk to doctors who are not your friends, hospital administrators who are not your friends, and so on.

How I studied for the IIT-JEE

(I had written this as an answer to a question someone asked me to answer on Quora. I am a bit surprised by the amount of popularity and the kinds of reactions it garnered.)

I managed to get a rank of 14 in JEE (1988) in a very unconventional way.

I will first give a conventional answer about how I studied (or rather did not study), and in the latter part of the answer, I will speculate on why I think I did well.

The things I did NOT do:

  • No classes: I did not join any JEE coaching classes – for the simple reason that I lived in Nashik, and at that time, there were no JEE classes in Nashik. In fact, few people had even heard of JEE or IITs. (I did join coaching classes for 11th/12th board studies, and my performance in board exams is directly attributable to those classes. (Thank you Gadgil and Vanzari Sir.))
  • No skipping college: I attended all the lectures and all the labs and my classes in my 11th/12th.
  • No other exams: I did not appear for any entrance exams other than my 12th std board exams, and JEE.
  • No losing sleep: I used to sleep for 8 hours every day.
  • No sacrificing 12th std: I was not really expecting to clear JEE, so JEE studies were a second preference, and I studied hard for 12th std (HSC, Maharashtra) exams. I did well (2nd in Pune board merit list).
  • No Resnick and Halliday / Feynman / Irodov: I did have my own copies of the two volumes of Resnick and Halliday, but to this day, I have not read more than one page. I hadn’t even heard of Irodov or Feynman.
  • No marathon/heroic study sessions: I never studied for more than 3 hours per day (except in the last month). In the last month, I did study about 8 to 12 hours per day.
  • No JEE preparation/classes in school: I hadn’t even heard of IIT or JEE until my 10th std, so there was no question of doing any IIT-related preparation in 5th/6th/7th as kids seem to be doing these days. I started in 11th.
  • No practice exams: I did not appear for any mock tests.
  • No study buddies: As I mentioned above, I did not know anybody else in my city who was appearing for the JEE seriously. So, I did not study with someone else.

What I actually did:

  • Agrawal Correspondence Course: In those days, Agrawal classes of Bombay (which no longer exists, I believe) had a correspondence course. I signed up for that. I used to get one packet of study material, and practice questions every month. I would go through the study material, and then solve all the practice questions (by myself). Agrawal would also have practice tests, and mock exams, and other such things. I never did any of those. If you sent them your answers to their practice questions, they would send back corrected copies. I never did any of that either.
  • Board exams vs JEE: For most of my 11th std., I attended all my classes, labs, and the (non-JEE) coaching classes, and did some studies, but not a lot. I started seriously studying for JEE around the end of 11th std. From then on, for most of 12th std, I did only JEE studies, and did not bother with college studies (except attending all lectures and labs and coaching classes). About 2-3 months before the 12th board exams, I stopped JEE studies entirely, switched to studying only for the board exams. After the board exams, I had about 1 month of studying for the JEE.
  • Regular Studying – 3 hours per day: Starting from (roughly) the second half of 11th std, I studied 3 hours everyday. Regularly. This included JEE studies as well as college studies. I would start studying at 10pm, after a good dinner, and watching about an hour of TV with my family. I would study until 1am. Sometimes I would go on till 2am if the problem set I was working on had particularly difficult problems. In any case, I would sleep until 9-9:30am in the morning, and then go off to attend college (10:30 onwards), and labs (afternoons). I did not do any studying other than during those 3 hours (except in the last month before my board exams and the month before JEE, when I did not have to attend college, so I would study the whole day, roughly 5-6 hours during the day, and 3-4 hours at night.)
  • Doing everything else: I attended college during the day. In the evenings (starting around 6/7pm) I would go for a long walk. I had various friends and relatives who stayed 3-5km from home, an I would walk to their house, spend an hour with them, and walk back home. In case of friends, I would either goof off with them, or if close to college/board exams, I would help them with problems in their studies. In case of relatives, I would play with my cousins (who were babies at that time). After coming back home, I would watch TV (we had just 2 channels at that time) until 10pm.

Was it a fluke?

Since I never appeared for any mock tests, I had no idea how I would do in JEE. Only 1 guy from Nashik had made it into IIT 2 years before I did, with a rank of around 200, and he had been a state topper in the board exams. I did not believe that I was as smart as he was, so I would have been very happy if I had gotten a rank between 1000 and 1500. But, I believed that there was a very good chance that I would not get in at all.

So, I was flabbergasted when I got a rank of 14. Agrawal classes had invited the top-100 rank-holders for a 3 day celebratory trip to Bombay, and when I met and talked to the others, I quickly realized that I had not done any of the things that the others had done to crack the JEE. This feeling got even more pronounced in my first few days in IIT-Bombay. A lot of my classmates were students from Ruparel college, who used to talk about Feynman’s lectures in physics, and the difficult problems from Irodov, and some particularly arcane paradoxes involving angular momentum, and other such things. In general, they had far, far more exposure than I did, and I managed to get myself a massive inferiority complex, and would often wonder whether my JEE rank had been a mistake or fluke of some sort.

I had an unhappy couple of months until the first mid-semester exams, when I out-scored most of them and it slowly began to dawn on me that in spite of my lack of exposure to Messrs. Resnick, Halliday, Irodov, and Feynman, my JEE rank was not a fluke.

So, what was my secret?

I don’t know. But over the course of my 4 years in IIT, I realized one thing: my basics in Physics and Maths were extremely clear. (The same couldn’t be said for Chemistry, but that is another story.)

I now believe that my success was probably due to some of the books (related to Maths, Physics, and general Problem-solving) that I read (just for fun) between the ages of 5 and 15. (A list of the books is included at the end of this answer)

When I was 6, my aunt (who lived in the US) gifted two books of brain teasers (Master Mind Brain Teasers, and Master Mind Pencil Puzzles – both by Joseph and Lenore Scott) to my sister (who was 4 years older). Many of the problems were too complicated for me, but I would simply read the question, and then read the answer. I do think it helped me develop very good problem solving skills (in spite of the fact that I did not actually solve most of the problems myself). Over the next 3-4 years, I would periodically return to those books and re-read them. (Thank you, Krishna Rajadhyaksha)

When I was 9, my school gave me: Figuring the Joy of Numbers (by Shakuntala Devi). This got me started on a life-long love of numbers and maths. (Thank you, Mrs. Roy.)

When I was 11, I got books on Physics and Maths by Ya. Perelman: Algebra Can Be Fun, Figures for Fun, Physics for Fun and Entertainment, Parts 1 and 2. (I can’t find a link to these exact books on Amazon, but I believe this and this are newer editions of the same books). These books I continued to read on-and-off for the next 3-4 years.

Important point to note: these books are not text books, and were not supposed to be “study” books, and were not prescribed by any teacher or class. All of them are ‘fun’ books that I read just out of interest. In fact, my parents would (mildly) complain that I never studied. But it is because of these books that I have very strong fundamentals in Physics and Mathematics (based on intuition, and not just rules and formulas), and good problem solving skills.

I do believe that these books helped build the foundation on which I was able to crack the JEE with much less effort than it takes most other people.

Random tidbits:

  • The only reason I had even heard of IIT and JEE was that I had a classmate in school who had moved to Nashik from Bombay, and he had a brother who was an IITian. He told me that I should appear for the JEE. (Thank you Suyog Moogi). He himself did not appear for the JEE (in spite of the fact that he would get roughly the same marks as I did in school).
  • As you can see from the “So, what was my secret” section above, I did not have a strong foundation in Chemistry. This ensured that I hated studying for Chemistry for JEE, and I continued to hate it after I joined IIT. At the end of my 1st year, on the day of my Chemistry test, I literally burned my Chemistry textbooks because I knew that I would not have to study Chemistry again in my life. A note to those who are going to use this as an excuse to stop studying Chemistry: The fact that I hated Chemistry meant that I had to spend more time studying it, not less. In fact, that is the reason I hated it.
  • These days I routinely give copies of the 4 Perelman books as gifts to any school kids of my friends/family if they show an interest in Science/Maths. Sadly, many of them never read the books 🙁 but I hope there are at least one or two who are inspired by them the way I was.
  • After all the 12th std exams were over, I promised myself that I would never again give this much importance to academics (or indeed my career) again. I decided that I would take an active interest in things other than studies/work. I have largely kept that promise, and as a result, my career graph has not been as impressive as some people expect (based on my JEE rank – e.g. went to a top-10 Univ in the US, not top-5; did not become a fellow/CXO in a large company; and now struggling with a startup that I *want* to do instead of a lucrative job that I *should* be doing; etc), but I have no regrets. I have done other things that I am proud of.
  • It is important to remember that not cracking the JEE does not mean that you’re not smart enough, or that you’re not going to be successful in your career. Students will appear for JEE, or have appeared and failed, and especially parents of such students – do not give up hope just because of bad JEE scores. I have seen enough people who barely managed to get into tier 2 or even tier 3 colleges, and even there, barely managed to pass their exams, but are now running extremely successful companies in which they hire IITians and later fire (some of) them for being too lazy. I have also seen people who are clearly not as smart as some of the other people around them, but when you look at their career over a period of 10+ years, you see them outperforming the others simply through hard work. Do not make the mistake of underestimating someone (especially yourself) due to lack of academic success.

(Check out some of the comments on this answer, and other related discussion on Quora.)