Boosting Patient Understanding and Follow Through - Dr. Shiv Rao, Co-Founder & CEO of Abridge

SHIV GAGLANI:Hi, I'm Shiv Gaglani, and today on Raise the Line, I'm really happy to be joined by Dr. Shiv Rao, who's the co-founder and CEO of Abridge.

Abridge helps people better understand and follow through on their medical conversations. It officially launched and raised $15 million of funding in October and already have over 50,000 users. Dr. Rao is a cardiologist who was inspired to start the company due to a family health experience and from his own experiences caring for patients. I'd also like to thank Jack Einhorn for introducing us in the first place. And Shiv, thanks so much for taking the time to be with us today.

DR SHIV RAO:Thank you Shiv.

SHIV GAGLANI:So can you start by telling us a bit about yourself, what led you to your interest in medicine and then cardiology specifically?

DR SHIV RAO:Yeah, absolutely. So way back in the day, many lifetimes ago, I went to Carnegie Mellon for undergrad and I studied practically everything I'm not doing today. I was a History Major. I minored in Minority Studies. I thought I could spend all my time skateboarding and that there was something there for me. I did a scholarship year where I programmed virtual synthesizers into critical theory classes. And I also heard a lecture from an architecture professor, William McDonough, who introduced this new idea to me at the time called Design Thinking.

He told the story about an ophthalmologist in India who designed this revolving platform that he sits on and he brings patients in at 12:00, 3:00, 6:00, and 9:00, and he does cataracts. He sits on it, does a cataract at 12, he spins, has another cataract at three, he spins another at six and just spinning all day long. And they bring in these patients who can't see from villages and at the time of this lecture, he'd given eyesight to over a million people and he taught the procedure to his daughter.

He didn't even have an MD I think before giving eyesight to over 400,000 people. I just remember my mind being blown and thinking about all the value that he created. Pretty late in the game, kind of pivoting to wanting to be a doctor. I was every Indian parent's nightmare for most of undergrad until I wasn't.

SHIV GAGLANI:That's awesome. And so can you tell us a bit about your medical school experience and then how you chose internal medicine and cardiology?

DR SHIV RAO:Yeah, totally. I ended up going to med school at Pitt, and I didn't see a lot of room for creativity there, despite amazing mentors. It just felt like a ton of rote memorization and at least for me, there wasn't enough direct patient conversations and relationship building for me to be able to get through. 

I went to Michigan for internal medicine residency and the iPhone came out and I taught myself to use Ruby on Rails and made a really bare bones web app -- super embarrassing at this point -- but people used it. So around that time, I was like, okay, this is where I need to live. I need to spend all my time at the intersection of healthcare and tech. I think that's a part of what led me to cardiology too. I was between cardiology and critical care and residency. Loved the ICU. One of my favorite places to be. I think it's actually not unlike a startup, you know what you're trying to achieve. Like when you come in the morning and you're looking at your list of patients and you know your objectives for any given patient, but then they're so sick.

They're all in extremis. You have to build prototypes quickly and throw them out there. Ship them as quickly as you can, get feedback and then pivot or persevere, depending on what kind of feedback you get, what the metrics look like. So I think in that sense, maybe that did prepare me for the mentality you need for an early-stage startup. I think early-stage startups are like ICU patients. But cardiology, otherwise I think is a pretty amazing combination of bedside reports, communication, stories, histories, and also procedures. So again, having the ability to own the whole loop from history taking to diagnosis, to treatment. And I think that was also very compelling for me.

SHIV GAGLANI:I think that's a great description. We've had a number of guests on Raise the Line who are cardiologists, people like Dr. Aseem Desai, who wrote a recent book about atrial fibrillation, Eric Topol, who I'm sure you know, who's also written books on AI as well. And then another person we may have at some point is Dr. Dave Albert, who started AliveCor. So I think there are a lot of cardiologists who've created companies, like yourself. And it seems like, especially that attracts innovative people.

So speaking of innovation, you've described the story of Abridge to me before, but for our audience, can you tell them kind of why this problem and why now?

DR SHIV RAO:Yes. A little bit of context to continue along with that story, which I think will lend some color. When I graduated I ended up at the right place and right time, with a really large hospital system that was, and continues to, invest lots of money into all things' innovation. I violated the Peter Principle many times over just a few years and ended up in a position where I was managing the provider facing portfolio of investments and also R&D.

I learned a ton in that experience over those years. But one thing that I learned was that the barriers to entry in health tech are sometimes as high as the barriers to exit. And so those companies that were stuck in between, and I won't name them, but we all know them, don't have to innovate.

They can still look like these relics of the early nineties and the worst user experience and no real kind of data API, sort of microservices oriented infrastructure that can be incredibly backward yet continue to rake in tons and tons of money year over year over year for a lot of different reasons. 

But when you're downstream of that kind of a legacy and system, no matter how good your idea is, your math, or your statistics, you're beholden to them. And your business model is not going to be better than them. Distribution is going to be incredibly difficult to get. In the best case scenario, maybe you're looking to exit to them. If that's something that can like inspire you to wake up in the morning and go for it then, great. But if you're looking to do something a bit bigger than you have no choice but to invoke first principles and think about what the original signals in healthcare are.

For me, for personal and professional reasons, even as a cardiologist, healthcare delivery, the point of care is the most exciting place and it's like the trickiest place. But I think that's why it's also the most exciting place. Because I think people could argue that so much of the $3 trillion in healthcare is actually downstream of those conversations, because that is what the original signal is, upstream of all the diagnostics, whether it's a Covid test or a chest x-ray or CT, upstream of all therapeutics, whether it's a baby aspirin or a Covid vaccination or some cutting-edge immunotherapy. Upstream of everything usually is a conversation between a clinician and a patient.

And it's happening increasingly virtually. It's also happening in person. Creating technology that can find a way to structure the information from those unstructured conversations, for us, means that we can do two things. And this is really the mission of the company. We can, number one, hope people better understand their care, their health. Number two, we can help them better follow through.

So in terms of the problem we're trying to solve, when you think about it, and when you look at the research, people forget most of what the doctor said. And there's research out of Dartmouth that suggests that people forget up to 85% of what the doctors said, 85%! And when we did our own research with thousands of our own users. We found that they remember just the very beginning of a conversation -- where you might just exchange pleasantries, talk about the NFL season or the weather or your kids -- and then the very end where the doctor might say, “All right, Mr. Smith, you're doing great. See you in six months.” But everything in between, where a medication dose was adjusted or referrals placed or a diagnostic was ordered - all that -- sometimes, in one ear out the other. And that's, mind-blowing to me as a doctor because inside the hospital-industrial complex, we use words like compliance maybe better than that we'll use words like adherence. 

We know that adherence, even for one diagnosis, like diabetes is like a 20 something billon-dollar problem. We use these words, but are they fair to use when like people are forgetting 85% of what they're actually told? How can we expect any of us as humans to follow through? To give you a sense of the problem from a bit more of a visceral perspective, both myself and my co-founders and our CEO, came at this with, for personal reasons and also for professional reasons.

From a personal standpoint, what I realized years ago when my wife and I went through an IVF journey for years to have a healthy child -- and it's a happy ending, we have twin four year old boys – is she would come back from visits and I'd ask her what happened and so often she'd say she had no idea. Some portion of the time they were telling her, but when you're going through something, it's so hard to capture the details. But some portion of the time I realized they weren't telling her actually, and sometimes the incentives aren't aligned within the system to actually talk to your patients about what's actually happening. But then I think there's another portion of the time when she knew exactly what was going on, but it's like that 5,000 paper cuts to have to repeat your story over and over and over again, to everyone from like the med student to the resident, to the consultant, and every single family member when you get home.

But as a doctor in March of 2018, I saw this patient in my own clinic. It remains an incredibly inspiring story for me personally, because I think everyone in our company has their own story of what's so special about this problem that we're trying to solve. But this patient of mine had a 10 year history of breast cancer and she was about to start chemotherapy that could affect her heart.  She's super nervous and anxious with me, like crawling out of her skin. So at the end, I asked her why, and if there was something I did or said to make her feel so uncomfortable. And she told me that for the last 10 years, her husband had come to every single visit with the doctor and he just couldn't make it. So I asked her what does he do, that's not obvious. And she told me that he sits in the corner, he's quiet and just takes notes.

And she's an English professor, incredibly eloquent. And she explains to me that it doesn't matter if it's a really bad skin rash, or if it's something like what she has, cancer, it's so hard when you're in that visit to be present. There's so much power asymmetry, so much information asymmetry and you're so worried that you're going to forget something incredibly crucial to your health, that you're sort of just incredibly anxious.

So him taking notes meant that she could feel liberated to be in the moment knowing that they could go home and unpack those notes, digest them, and then go to the next clinician and feel like the main characters of their story instead of someone looking in from the outside. So essentially what our app does at a really high level, we are trying to distribute, democratize, and automate everything that he did in the corner of the room and they did at home together. 

SHIV GAGLANI:That's fascinating. I can definitely relate, having both been a patient and also taken oral histories or tried counseling patients as a medical student. You're building a treasure trove of data. Can you tell us a bit about any statistics you can share at 50,000 users -- how much recorded conversation you have and then what are some of the coolest applications. Not just coolest, but most game changing applications you think Abridge will have… getting that 85% forgetting, down to 30% or lower, and then improving adherence as you were mentioning is definitely one. But what are some of the other things we should be thinking about?

DR SHIV RAO:We launched the first version of our app in July of 2019 and over the course of last year, we're now over 50,000 users. And for those people, we've helped them better understand over 400,000 medical terms and we've also helped them better understand over 52,000 conversation takeaways. So those are like the next steps in conversation, where maybe a doctor told you to start a medication or stop a medication, or get a procedure or see a certain specialist. In terms of that treasure trove of data, there's no question that there's a lot of data involved here. That said, when we started the company, we made a strategic decision that was very expensive, but we think incredibly important for any type of company in this space, dealing with this type of sensitive data. We decided to start this company with this thesis that that privacy is paramount and that we needed to invest in privacy by design principles from day zero.

So that's a lot of work that I think the average consumer tech startup in any other space, probably isn't going to invest a lot of cycles into. So for us, that meant we had to think about not only our operations, but our business processes. We had to build best in class privacy policy. Like from day zero, we only collect and share data with user consent. People really own their own data. Delete means delete, share means share, people can export their data anytime they want. We never sell data. We make that explicit in our privacy policy and all our R&D has been on de-identified data and external data sets. But we have this really unfair advantage in terms of being able to aggregate those data sets, which means that we've to date been able to publish over, I think 10 papers now in medical conversation and AI, that gives us these sort of tools to create and deliver the user experiences that we're really after.

So privacy by design is really fundamental to us. And one of the reasons why we chose our lead investor Union Square Ventures is that, I think a part of their thesis really is that trust is the new network. And that there is this cross gap with a lot of large technology companies and startups have an opportunity to actually think about trust from day zero, think about transparency, reliability, and credibility from day zero. And those companies that can build that can really build differentiated brands. Beyond privacy and trust, I think in terms of user experiences, our mission really helps us make decisions across every layer of the stack of the company. The mission is to help people understand and follow through. I think like the most exciting features that we'll be experimenting on and testing in 2021 really are on different versions of follow-through.

Today, as someone hears this and downloads Abridge from the app store -- it's free -- you can start using immediately and they could test it, right? There are people using it for audio health diaries, for example, where they're just sort of using it as a symptom tracker. And there's COVID long haulers are using it that way, for example. But you could press the record button and you could drop some medical language, drop some jargon, medications, diagnoses symptoms, or procedures, and then press stop and see how well it did, because what we've trained is a system that selectively pulls out the medical moments from a conversation. And then beyond that, it gives you the ability to sort of tap to play selectively that part of the conversation. Then it layers on education on top of all that jargon.

We're trying to position ourselves as an extension of like the best doctors intention to help their patients be healthy and follow a plan. So we're super excited now. The killer features that we're just starting to deploy are really around helping you follow through, where you can record a conversation immediately on the dot on your doctor. I tell you that you really need to get an echocardiogram or take your products every day.

And you might turn the app off and completely forget about Abridge because you know, we're not trying to engage every day if we don't need to, that's not our game. Perhaps our tech cohorted you and, recognized that there's something important in this conversation about a new medication or procedure that you're supposed to get. And you might get a notification that says "share".

“We want to remind you about a key medication that Shiv talked to you about,” and you open up the app and we're helping you play selectively the part of the conversation where I said, “You’ve got to take your products.” We're not putting words in anyone's mouth. You tap, you play it. Then we want to help you better follow through. Maybe that means we're sending you reminders every day to nudge you to take your products. Maybe that means hooking you up with other services that can help you fill that medication. But that's the most exciting direction that we're headed in.

SHIV GAGLANI:Definitely an automated follow-up and what Alexa is doing, and Google Mini are doing for home use, but you guys obviously are well positioned to do it in the clinical setting. One other application that I'm excited about, as I got to know you and Abridge, is the potential to give clinicians actionable feedback whether it's a nurse practitioner or doctor or CNA interacting with a patient. Could there be a feedback loop to that provider on “How do you become more caring?” What types of things could you say in those conversations that would lead to higher patient satisfaction scores? Obviously patient satisfaction will help reduce malpractice, it'll improve outcomes, that kind of stuff. So has that been a conversation that you guys have looked at too?

DR SHIV RAO:Absolutely. It's interesting, I think if we were positioned on trying to help people, let's say save time with their documentation, then I think undoubtedly, we really have to build a solution that helps improve efficiencies and maybe helped improve billing. Then potentially it's a solution that contributes to the inflationary economics that we see in healthcare.

But our positioning is more about what you said. It's about helping improve the quality of the conversation because if you can improve the quality of the conversation, then you should be improving the quality of the relationship. You should be improving the quality of the care that's actually delivered which should mean ultimately, outcomes and costs. And so that idea that you just described is incredibly exciting to us and something that we've been investing a lot of R&D cycles into, especially with our colleagues at Dartmouth, Yale and Carnegie Mellon.

Are you familiar with gong.io?

SHIV GAGLANI:Yeah, the sales training?

DR SHIV RAO:Yeah, exactly. But there's some really interesting companies that do that for salespeople. What if we could do exactly what you described? What if we could very gently call out moments where maybe a clinician could have listened a bit more, or maybe where the medical terminology was a bit too expert. So certainly a really exciting area to explore.

We're just rushing up against that now, because now people can record their conversations and they can share a version of the summary. They can copy a version of the summary over to their clinician. Now we're starting to thread that needle between consumer and clinician. So it'll be really interesting to explore these in the years.

SHIV GAGLANI:That's really interesting. And maybe what about powering virtual avatars to do those conversations themselves? Right. Like we've been looking at Osmosis a lot at Amazon Web Services, where you can take our videos and automatically transcribe them into other languages, but also then have Luis in Brazil, narrating.

I think there's a lot of applications where maybe the conversations themselves could be had. Because as far as I know, you guys are among the only ones that are developing really robust data sets of conversations. You know, there's chat bots, there's EHR structured unstructured data, but the actual conversation is something that doesn't get captured as often for privacy concerns. But the fact that you guys are privacy first is really important.

I know we're coming up on time, but I guess switching gears to COVID, I'd love to hear what your thoughts are on how COVID has affected Abridge, and then also what the long-term changes you think will happen to the healthcare system as a result of COVID.

DR SHIV RAO:I think one of the most profound things that we all saw during COVID was that it seemed like healthcare really reduced itself. For example, people put aside billing issues or specifics about HIPAA, even in some instances, all in the name of making sure that everyone who needed care could get it. That meant, for example, some systems using the telephone to connect with their patients to deliver care. Just a humble, old school telephone to connect to their patients, which I think was incredibly valuable and really, really interesting. And I think it's like a tailwind that will be hard to stall now. I think another thing we noticed too, was people actually -- optimizing again for the ultimate end user in healthcare, the patient -- but clinicians, the other set of end users starting to kind of become a consumer themselves. Starting to shop a bit, like trying to find the best telemedicine solution that could suit their needs, starting to optimize for something that's pretty alien to any solution they're probably using within their hospital system.

They're starting to optimize for user experience or their patients’ user experience. So I think that's pretty profound as well. And I think these tailwinds that are in place from COVID in terms of all of us being much more aware of our health, then ever before…people wearing masks is a daily sort of signifier that we should be thinking about our health. Really great tailwinds in relation to open notes…people getting access to their own notes from the doctor's chart, all of this coming together.

I think it sets us up over the next couple of years for unprecedented innovation. Those barriers to entry have calmed down and it's all of a sudden more possible than ever to do all the things that we've been dreaming on for health for the last decade.

SHIV GAGLANI:Absolutely. It's definitely an exciting time. And I think this has been a catalyst for change. I had Vivian Lee from Verily, who also was a former CEO of University of Utah Health, on the podcast and her book, The Long Fix, if you haven't read it is quite a good book, really highlighted this shift from being a caregiver to being a co-producer of healthcare.

She highlighted open notes very specifically. I can imagine if she publishes a second book, Abridge would be part of that too, because that's essentially what you're doing. You're shifting the balance of power away from just the health clinic or that one time you have an appointment with your physician to something that you can continue to refer to and take more control over your own health. Health isn't something that happens to you. It's something that you help produce.

My last question is, you wear many hats -- you're a CEO of a company, you're a cardiologist, what advice would you give to our audience at Osmosis, which is millions of current and future healthcare professionals, given the challenges of the COVID moment and beyond. What advice would you want to give them?

DR SHIV RAO:I think more than anything, it's that their skillset and what they're getting really, really deep in is more important now than ever, and the ability for them to cross that skillset, to cross that depth in healthcare with something else will afford them the ability to really think outside the box and be creative. I think now more than ever, there's room for that creativity.

I was speaking to my uncle recently and he was like, "I wish I could have done what you're doing. I just never had this opportunity." I think it's a different time now where that depth of healthcare is as important as ever, but now also there's more room for people to think outside the box and apply that depth in really new, interesting ways combined with other disciplines that can be impactful.

SHIV GAGLANI:Absolutely just like you did at Michigan, when you taught yourself Ruby on Rails and started building iPhone apps. Today, it's even easier than ever before with the no-code movement as an example. To those in our audience who want to be a future Dr. Shiv Rao should take heart and see if they can start learning some of these other skillsets so they can become T-shaped and go deep in medicine, but have other skills.

With that Shiv, thanks so much for taking the time to be with us today. And we're definitely in the show notes, going to point our audience to download Abridge and check it out and use it with their patients to see if it's something that could add value to them. I'm sure it will.

DR SHIV RAO:Awesome. Thank you so much Shiv, it's been a privilege.

SHIV GAGLANI:Awesome, and with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show and remember to do your part to flatten the curve and raise line since we're all in this together, take care.