Improving At-Home Surgical Recovery - Dr. Sanjeev Suratwala and Gary Arora of Recuperet Health

Michael Carrese: Hi everybody, I'm Michael Carrese. We've talked quite a bit on Raise the Line about at-home monitoring technology for chronic disease management and maintaining wellness, but today we're going to explore the use of that technology for a different aspect of the patient experience: post-surgical care. 

To do that, we turn to Dr. Sanjeev Suratwala, an orthopedic spine surgeon and co-founder of Recuperet Health, a health tech startup which is focused on using technology to reduce inefficiencies in post-treatment care of patients and to demystify the recovery journey.

Also with us is Gary Arora, who is helping to develop the technology platform underpinning the vision of Recuperet. He's a software engineer by training with a background in management consulting where he works on health tech, cloud, and AI for Fortune 100 clients. 

We're going to find out about the different types of technology Recuperet's employing and how it works from both the patient and provider perspective among related topics. Thank you both for being with us today. 

Dr. Suratwala: Thank you, Michael. 

Gary Arora: Thank you for having us. 

Michael Carrese: Let's start with you, Dr. Suratwala, and learn about how you first got interested in medicine and then orthopedics and surgery. 

Dr. Suratwala: Medicine is a really fascinating field. It's constantly changing and innovating. What we do today is so fundamentally different from even twenty years ago. Think immunotherapy for cancers. This makes it a really challenging profession and just a really interesting field to be in. Orthopedics was an interesting choice for me. It is a fantastic

surgical field which gives you an opportunity to make an immediate impact on a patient. Patients with fractures or worn-out joints can be essentially fixed with a one-to-three-hour surgery with limited risks. The field of surgery of orthopedics allows patients to have life improving interventions with minimal risk. In my fourteen-year practice, I've had an opportunity to help thousands of patients in a meaningful way. I'm humbled and grateful to have this opportunity. There are lots of great fields in medicine. You just find a specialty that appeals to you the most. For me, it was orthopedic surgery. 

Michael Carrese: Even in those fourteen years, speaking of technology, a lot has changed with being able to customize the implant to the patient and the longevity of these implants. It's just constantly changing. 

Dr. Suratwala: Yeah. I remember from even my training, I don't want to date myself, but we used to have joint replacement patients stay in the hospital for three, four days. They went to rehab for a week or two weeks. That was the recovery. Now, you're lucky if you get to stay two nights in the hospital. Most patients are being sent home the same day or the next day. They're going home. They're not even going to therapy. It's just changed dramatically in the last fifteen years. 

Michael Carrese: We'll get more into that post-op process in a second. First, Gary, what are some highlights of your career journey?

Gary Arora: Thank you, Mike. I started out as a software engineer. I was developing applications for my projects, for my clients, and all while following the design choices made by the software architects and the business analysts that were on that project. I did that for a couple of years and I realized a natural fault line between the engineers that were developing the solutions but were removed from the problem that they were trying to solve, and the architects and the business analysts that were solving the problem but were removed from how the solution was being built out. 

I noticed this growing gap between outdated design and modern engineering practices. I thought maybe that's the gap I should fill myself. That's why I decided to become an architect myself and design solutions that were current and grounded in reality and were actually addressing the problem at hand. That's some of the same design thinking that we have brought for Recuperet to build a solution out. 

Michael Carrese: Gary, just to stay with you for a second, do you see yourself as a bridge between those two worlds? 

Gary Arora: Yeah, absolutely. I think that's a constant problem in our industry. You have these problems that need to be solved, and then you have a different group, often isolated, of engineers that have the skill to solve them. Usually, you're only having a short-sighted vision to just solve the specific symptom at hand, but you're not thinking through a long-term vision on how to develop an application or a solution that can be extensible...something that not only meets the need of today or the next six months, but also can be taken forward for the next two years or three years or five years. There is a certain sense of domain knowledge that you need in the domain that you're solving the problem and the engineering skills that you need to build out that solution. I think that's the role I'm trying to fill for Recuperet Health. 

Michael Carrese: Solving a problem is really where most companies start. Tell us how you identified this problem and how Recuperet came to be and how you guys are trying to address it?

Dr. Suratwala: The idea for Recuperet came from a patient experience, like a lot of companies. I had operated on a patient for a significant problem in her neck, in her cervical spine. Her spinal cord was being compressed. She had a pretty straightforward surgery and was discharged home and doing great. Five days later, the visiting nurse service called me and said the patient wasn’t doing so well and was barely moving. Was something wrong with her and what should they do? It turned out that she had some postoperative bleeding, which is a known

side effect or complication of these surgeries. It was causing pressure on the spinal cord. 

This was actually an urgent surgical condition. She had to be brought back to the hospital for surgery. Surgery went smoothly and she did fine. She had a complete recovery. This was an eye-opener for me. If I had known that the patient was not moving much, I would have intervened much sooner than five days. Thankfully, in her case, there were no issues long-term. 

Every year, thousands of patients are not as lucky. They end up with long-term complications because things are not identified quickly, or they're not addressed in time. We needed a better warning system. It might sound counterintuitive, but with all the technology we deal with in our lives every day, healthcare is actually pretty conservative with the use of technology. It's not a pioneer in use case of modern technologies. We're fairly conservative in our medical records, how we manage our patients with the use of technology in general. That's something that we need to address. 

The insight from this experience was that the whole postoperative period is a huge black box of missing information. We really don't know how patients are doing after their surgery. We get some data points when we get a nurse's phone call or somebody checks in with a patient and has a one-time visit, but we really are not capturing the 24-7 experience that the patient is living through. We founded Recuperet to just tackle this gap in patient monitoring and assistance after surgery. 

This is actually even more relevant now because the burden of recovery is shifted to the patient. I mentioned earlier that in the past, patients would be in the hospital for three, four days after surgery. They'd go to rehab. We'd have extensive monitoring. Now, you're lucky if you get to stay one or two nights after your procedure and really, you're on your own when you go home except for maybe a phone call or an occasional visit from a physical therapist or a nurse. 

This whole burden of recovery has shifted from the hospital to the patient. While this is not necessarily a bad thing, I don't think most patients are prepared for it or feel prepared to take on this responsibility. This is even more challenging in this COVID era where it's difficult to find adequate social support and there is an ongoing shortage of healthcare labor in general. We felt that having technology that assists both the patient and the provider during the recovery would overcome some of these challenges. We created a solution that we felt is intuitive and seamless and directly addresses some of these issues that affect both the patients and their providers. 

Michael Carrese: So, Gary, Dr. Suratwalais making a strong case there for having essentially virtual eyes and ears in patient homes, but how do you pull that off? How do you do that technically? 

Gary Arora: So, talking about technology, that's really my favorite part of this solution because there are two main aspects to our technology choices which we have made and which I think makes the solution unique and highly extensible and significantly low cost -- all of which I think are very important, especially in healthcare. 

So, first, we are using cloud services. Our entire solution is running on the cloud and as a user of this solution, you simply log in with your credentials. It's like watching Netflix on your browser. You don't need to download anything. You don't need to install anything. You don't need to set up server space in your IT department or even require a whole lot of IT support to run it. So, this is a SaaS offering -- which is software as a service -- and you simply log in on any browser and you are on the platform. This also makes updates to the platform a lot easier. Because there's nothing for you to download as a user, it's easier and seamless to push new features and upgrades to the platform. You simply log in and voila, you have the latest and greatest site. So, that's the first one. 

The second aspect is that -- and this is a little technical -- we are extensively using serverless technologies. What that really means is we have chosen a usage-based service model. So, our cost of running the solution on the cloud is directly proportional to the usage of the solution. We aren't paying simply to keep the lights on here. There is no running the server cost here. So, as and when our usage increases, our costs will increase as a proportion, and if our usage is low, our costs are low. 

This allows us to offer low prices to our consumers and allows us to keep our costs low, which again, as I mentioned, is really important for the healthcare sector. This allows us a bit more flexibility to focus on developing features that matter rather than just maintaining the infrastructure of the solution. 

Michael Carrese: So, what are some of those features? Like, if I'm at home recovering, aside from my logging on to my browser, what else is involved?

Dr. Suratwala: What we're trying to capture is the patient experience after surgery and we've seen tremendous improvement in wearable devices that patients can use. You're familiar with Apple Watches or Fitbits. So, what we use is a Fitbit device that gets put on the patient after their surgery in the hospital. The hospital enrolls the patient on our platform and from that point, the patient really doesn't have to do a whole lot. It's monitoring the patient 24-7. It monitors their activity level, their heart rate, their sleep cycle. So, we're capturing real-time data on patients after their surgery and this is what Gary was talking about, synchronized with the cloud and it's available both to the patient and to the provider. We're capturing the hard data that we're missing in the recovery period. 

We've added other things into this. We've built a messaging platform, so it's much easier for the patient to communicate with their provider and vice versa. I deal with this every day. We have phone trees that the patient has to go through to reach the provider or even the nurse or physician trying to reach the patient always ends up with like a voicemail or something. There's no simple secure solution to communicate and we've added that where you can do messaging, we can do video calling, we can do just a voice call through the platform, and you can directly reach your care team right off the bat. This is really helpful for both the patient and the provider. I think more for the patient because it provides them this support 24-7. It may not be answered right away, but it's something available and accessible to them. We've built in reminders for patients to take their medications and it prompts them to enter their pain scores. 

You know, this is an orthopedic-focused platform at the moment, but it could be broadened to other fields as well. Post-procedure pain is an important component of recovery. So, we want to track patients' pain scores and if they're too high, it alerts the provider to check on that patient. We've added community support options. So, not only can the patient and the provider track this data, but a patient can actually designate a friend or a family member to follow them along in their recovery and it alerts them as well if there's a problem with the patient and it allows the family member to track what's happening with their loved one recovering from surgery. 

So, for example, my father is having knee replacement surgery. He's in Florida and I'm in New York. I can sit here and check and make sure he's doing his steps. I make sure his heart rate's okay, he's sleeping okay, he's taking his pain medications. If there's a problem, I can also send a message to the provider on his behalf and say, “Hey, you know, there's a problem. Can we check on my dad?” So, these are things that kind of all tie into a platform. 

To tie into the modern technology piece is all well and good, but it does require manual intervention. So, we're building an algorithm, AI, that can actually track all this data and then make it easier for the provider to access and manage patients who may be at high risk. If somebody's not doing well, we're building algorithms that can flag those patients. It makes it easier for the care team to target patients that may actually be at risk, so it improves the workflow of the provider as well. The nurse doesn't have to check on like twenty different patients or 100 patients a day. They can prioritize patients who actually need care. The goal is really to avoid a bad outcome or a complication and it's really a win-win for both the patient and the provider. 

When you just look at it from a big picture standpoint, there's an added benefit to the insurance companies and hospital systems who we think will love this sort of solution. Our platform allows a provider to identify complications early and reduce the risk of more serious complications that could happen if we just let things drag on. We also prevent unnecessary re-hospitalization, something that could just be tackled over the phone. We don't want patients to show up in the emergency room with a problem that could be handled just over a phone call. These things do happen every year and the costs are enormous, millions of dollars, and this is a huge cost saving for both the insurance company and the hospital system. 

Michael Carrese: Oh, yeah. Avoiding readmissions is the brass ring for hospitals. So, Gary, Dr. Suratwala mentioned the AI dimension to this. Can you explain how that works and what the benefit of it is?

Gary Arora: So, healthcare is right now still the most complex and expensive sector in the US, so there's a lot of opportunity here in terms of reducing costs and finding efficiencies, and AI happens to be that powerful destructive force that is fueling some of the most innovative ideas today, right? The analogy I like to use is that of a hero and a sidekick. You have a Batman and a Robin, you have Sherlock Holmes and Watson, and the idea here is that you have a really smart hero who's solving puzzles, but still this hero needs a sidekick to bounce off ideas and essentially assist them to speed up their investigation, right? Alone, these sidekicks may not be sufficient, but together with the main player, they serve as a deadly combination. This sidekick is the role that I see AI playing really well, you know, where the main player is still the physician or the caregiver and you have an AI that can help bounce off ideas and just help clear the noise a bit, right? 

So, the way we are using it is that we are able to use AI to learn the experience of hundreds of thousands of other patients with similar conditions and demographics in making highly informed decisions. For example, in detecting anomalies. This is about identifying a natural pattern based on patients' activities. We are using Fitbit in our program, which allows us to track your activity, your steps, your sleep quality, your heart rate, pain score, and then it creates a pattern based on the profile of that patient, their age group, and their gender. Then whenever there are anomalies being detected, it's able to proactively raise alerts and allow the caregivers to know there's something here worth looking at before something gets really bad. 

That's something very similar that ChatGPT -- which is in a lot of buzz these past couple weeks -- is doing as well for a lot of admin-related tasks like clinical documentation or data set of medical records, detailed clinical notes, transcribing the visits and generating structured notes after that. There's a lot of opportunity to reduce time and increase efficiency, and this is where AI comes in really handy. 

Michael Carrese: Yeah, it does seem to be revolutionizing a lot. You know, we have had some guests talk about there being such a tsunami of data that's now available and it's difficult for providers to know exactly how to wrangle all of that. But it's great to have the data, that's for sure. 

So, I want to get back, Dr. Suratwala, to something you were talking about at the beginning... how the burden has shifted to the patient. There are shorter hospital stays. There's not as much support and follow-up. I know you care a lot about patient education, so can you talk about that piece of this whole process? 

Dr. Suratwala: Yeah, Michael, this is a charged topic and something we deal with every day in our patient interactions. As physicians, we like to believe that we're in the field to help patients. However, how you convey information to your patients can vary so much from provider to provider and from patient to patient and can sometimes lead to incomplete understanding or potential misunderstandings. 

As surgeons, we have an even bigger challenge with informed consents and educating patients about risks, complications, benefits, alternatives to surgery. This is something I go in daily with all my patients who are having surgery. You know, most hospitals have an education program for patients having surgery and their expected postoperative recovery, and they also give patients the chance to have all the questions answered and concerns addressed before surgery. Having family or friends involved in this education can help greatly. 

However, it can be a moral demoralizer or a huge knock on your ego when a patient comes in and they say, “Well, so what was done to me?” Despite all the effort you put in -- and there's multiple opportunities, multiple points of intervention that happened between seeing somebody in the office and have the patient having surgery -- people are still grappling with this information overload. They don't quite understand what's going on. Some people go to YouTube and watch videos of their surgery and say, “Hey, I watched my surgery and I know what you did.” But there's still people that come in saying like, “So, what exactly was done? 

It's somewhat of a failing on our part, but it's hard to parse the blame and say, “Okay, who's really more at fault here?” I mean, there's no faults here. It's just making sure that the message gets appropriately conveyed. I think this lack of understanding has also been published in multiple medical studies. So, it's not just unique to us as a profession or me or our hospital or practice, it's just universal. 

Having a technology tool like Recuperet can be a resource for our patients and can reassure them that help is available and that they're being cared for 24/7 after the surgery. You know, we just don't want patients to feel like they're being signed up for something that they don't quite grasp, and then they're on their own afterwards. Having some security blanket for them afterwards can be a huge relief for them and their families. 

Michael Carrese: We just have a couple minutes left. Gary, I'm curious to know how it's all working and what are you seeing in the data? And where do you think this is heading? 

Gary Arora: So far in terms of hardware, we are currently offering Fitbit as our first wearable device. It's a low-cost device that can track your steps, your heart rate, your sleep, including the four phases of sleep and it requires charging every two weeks. So, it's really robust from that perspective, and it's really low maintenance. But we aren't married to Fitbit. We plan to offer other wearable devices because we want to become a platform where multiple devices and features can be integrated. 

So far with the capabilities that we have offered, and with the feedback that we have received, it has been overwhelmingly positive, especially on the messaging aspects, because it's freeing up the phone lines. Also, people like being able to see their own progress, because we offer a dashboard that can be viewed by the caregivers and also by the patients to monitor their own progress. And when progress is being made, there is a gamification aspect as well, because we have badges and rewards that are offered if you complete the certain milestones that have been laid out for you. 

So, the feedback has been good and now we are thinking about what additional capabilities or devices to offer because we are really liking how this community is embracing something that was not as easily available, or a lot more kind of disjointed to their alternative methods that they have before. 

Michael Carrese: The same question to you, Dr. Suratwala. How do you think things are going and where do you think they're going in the next year or two? 

Dr. Suratwala: We're very positive and bullish on this. We're very optimistic about it, just because it's a solution whose time has come.  In the past, people have looked at this. When you talk to people, it's so intuitive and makes sense that it's a surprise that there's nothing like this out there. So, what we've done is taken the best of modern technology, made it user friendly, and made it accessible to our patients and our providers. 

Where we see it going forward is working with hospital companies, ambulatory surgery centers, and insurance companies to make it a standard of care for our patients and providers. I think the other thing that I'll touch on here is that there's ways to partner with other companies and organizations. I think we're looking at the mental health part of it -- which we could have another conversation about -- which is so huge in the patient's recovery but it's not being looked at. We're exploring that opportunity as well. So, we're taking a holistic approach to the patient's recovery -- we're including the providers, the patient, but also the community and their family in this -- and using technology in a way that's meaningful for everybody. 

Michael Carrese: Well, you know, there is so much talk -- has been for years, really -- about moving care into the home, even “hospital in the home” and the visiting nurses are dealing with much more acute patients and all of that. You can just see how this is exactly the kind of thing that's needed from both ends, from both the patient caregiver end and the provider end. So, we wish you luck with all of that, and we really appreciate you taking the time to explain it all to us today. 

Dr. Suratwala: Thank you, Michael.

Gary Arora: Thank you so much. A pleasure. 

Michael Carrese: I'm Michael Carrese. I want to thank our audience, as always, for checking out today's show. And remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.