Today's article in @TheKenWeb contemplates "what ails" Indian #ECG Companies and concludes "Plenty as it turns out, starting with #healthcare providers themselves."…

I have heard these sort of comments a lot in various flavours from different #HealthIT
What usually happens is a group of highly skilled, honest, hardworking Engineers or Management Graduates #Startups develop a product or service, test it and find it successfull but when they want to market is doctors don't buy
They start blaming doctors, directly or indirectly saying that this is a magic solution which will revolutionalise health and save 20 crores people per year, but this dull headed docs are not able to see the potential and / or afraid of technology
The Ken story is also telling the say

So This thread is about what is the actual gap between the Healthcare industry aka #doctors and #nurses and #HealthIT

If you are planning to make a product or service for hospitals or doctors, or going to write about it
you need to know
few basics about the domain

First and foremost

There are four levels of health care
0. Basic Care : Sub Centres
1. Primary Care eg PHCs
2. Secondary Care eg Taluk Hospitals
3. Tertiary Care eg Medical Colleges
4. Quarternary Care eg TNGMSSH
Then there are types of organisations
1. Run by Central Government eg AIIMS, Armed Forces
2. Run by State Government eg Madras Medical College, All GH, All PHC
3. Run by Quasi Government Bodies / Factories for their employees
4. Run by Trusts / Real NGOs to serve people eg Aravind Eye Hospital,
5. Run by Businessman to earn money, but on paper is run by Trusts eg most private medical colleges
6. Professionally Run Corporate Hospitals eg Apollo
7. 40 to 50 bedded hospitals run usually by few doctors in partnership
8.10 bedded nursing homes run by a single doctor
9. Single Doctor Outpatient Clinic

If you place the Level of Care on X Axis and Type of Organisation on Y Axis
and make a 9x5 matrix
You will end up with two dozen variants
(Technically it is 45, but certain combinations don't exist)

As a HealthIT Startup
You need to
1. Know these levels and Management types
2. Know the Challanges in Each of these types
3. Know the Finances in Each of these types
4. Know Patients in which of these types of hospitals will require the device or service
5. Know Doctors in which of these types of hospitals will find it useful
6. Know Management of which of these types of hospitals will actually be able to invest the money for this
The problem which most healthcare IT Startups land is

They get the product design from
1. Central Institutes
4. Run by Trusts / Real NGOs to serve people eg Aravind Eye Hospital,
6. Professionally Run Corporate Hospitals eg Apollo
and design the product
There are two main reasons for this
1. Most of the IT Startup Engineers have visited only these type of hospitals from their childhood
2. Doctors in these hospitals are ready to innovate

The product is designed well
They do a pilot
The doctors in 1,4,6 hospitals are happy
Patients in these 1,4,6 hospitals are happy

They even sell 10 to 20 numbers in these hospitals

When they want to expand
They hit a road block

Why ?

1. The product designed for 1,4,6 may not adequately cater to the needs of others
2. The cost of the product / service may be within the bracket of 1,4,6 but is too high for the other segments

End Result
The Sales Dip after the initial Mount and the Valley of Despair or Valley of Death is reached

It is at this phase where the phrase in Ken Article "Yet they have cornered a minuscule 1% of a $60 million market that has been pegged as the fastest growing in the world." comes to play

Funders get exasperated
Promoters get struck and depressed
Q. What is the Solution
A. Find a Good Consultant who is well versed with (1) Both IT and Health (2) Both Government and Private healthcare (3) Both Medicine and Economics
at an early stage and learn from him
The Bulk of HealthCare delivery in our country is by
2. State Government eg Madras Medical College, All GH, All PHC
7. 40 to 50 bedded hospitals run usually by few doctors in partnership
8.10 bedded nursing homes run by a single doctor
9. Single Doctor Outpatient Clinic
These hospitals have different aim, different management priorities, different doctor attitude, different patient profile as compared to 1,4,6

Be it 2 or 7/8/9
They have common factor

1. They are always running short of money
2. They cannot turn away a patient
3. They are over crowded and understaffed
4. The people who come to them cannot afford much
5. Insurance is not common here
6. The patient wants quick treatment and trusts the doctor more (as compared to 1/6)
7. Everyday is a Disaster Management
(7. Everyday is a Disaster Management means
The load other hospitals encounter during natural disasters / accidents is encountered daily here)

When you go with a new product to these hospitals
It will be accepted only if

1. It reduces the Cost of Health Care delivery
(so that Patient can spend less + Doctor earn more in private or hospital can treat more with same budget in government)

2. It reduces the Time of Health Care Delivery (so that patient can go back home quicker or doctor can take rest)

3. It is technically advanced
And the order is important

It is Cost > Time > Technically advanced which matters more in 2/7/8/9 while in
1/4/6 it may be Technically advanced > Time > Cost which is the order of decision making
This is a point which I find Most of the Startup Founders are not able to understand even after me explaining it

Very few professionals had understood and accepted it

They consider that the doctor at the other end is a dull man who does not understand technology
Probably the fact that most promoters are from Upper Middle Class where they are used to purchase something based on Technically advanced > Time > Cost in their personal lives is the issue
(sorry if this comment comes under stereotyping, but i am not sure whether the point
would be conveyed without blunt and direct statements like this)

When you pitch your product or service to 2/7/8/9, it will be looked up if it is

1. Cheap, But does the work in same time with same technology
2. Cheap, does the work in less time with same technology
3. Cheap, does the work in same time with advanced technology

If your solution is Cheaper than the existing version, the management will look into it

How many of the IT Startup Promoters ever discuss the cost as the first point

Very few
Even when I (doctor as a potential buyer) ask the cost
They won't give an answer

The answer will be very vague like
We are working on the concept
It is negotiable
We will work on it

When Some one Says this answer,
The doctor or Administrator of 2/7/8/9 will immediately
decide that this guy knows nothing about healthcare and hence the product he has designed also would be useless and the rest of the meeting would be waste

Don't ever approach a doctor in 2/7/8/9 if you are not sure of the cost
If your sales pitch does not include the definitive first time cost and recurring cost and cost of consumables,
You will be treated like an LKG Kid saying Baba Black Sheep or Tirukural
The appreciations and head nods are for your well made PPT and Flawless English only
You will sell your product
If your product is cheap

Assume your product is costly
Then you have to convince that the cost is justified since it saves time

This saved time should be considerable enough to reduce the cost
Else your proposal won't proceed
I will give a simple example
After Surgery, we need to stich the skin. We use thread - silk or prolene - which costs Rs 300)

The alternative is staplers which cost Rs 1100

That is almost four times
Most private hospitals in 7/8/9 have moved on to Staplers
Why ?
If you suture with thread, it may take 15 minutes
Stapler may take 2 minutes

Most of the Operation Theatres cost Rs 6000 per hour

Cost of Suture = 300 + 1500 OT Cost = 1800
Cost of Stapler = 1100 + 20 OT Cost = 1300
in 7/8
The Stapler is being used only because it saves Rs 500
And not because it is technically advanced
Assume that this stapler costs Rs 5000
It will be used in 1, 3, 4 for sake of its technical advancedment
It will be used in 6 because anyhow the patient is going to pay
Please note that the
Patient coming to 6 is ready to Pay Rs 4700 more to have a technically advanced treatment
Patient coming to 7/8 is not ready

A stapler will be preferred to thread in 6 even if it is 5000
But A stapler will be preferred to thread in 7/8 only if the cost is less than 1600 (The additional money spend has to be recovered somewhere else)

2 - State Government Hospitals - too operate on this principal, but at very macro level and the stapler / suture example
may not be accurate there because OT time is not directly charged in the bill

You can sell your product to the doctor
if it is
1. Cheaper than exisiting product
2. Costlier than existing product but saves time and ONLY IF THIS SAVED TIME LEADS TO SAVING COST
If your Product or service is Not Cheap, Does not save enough time, then it has to be sufficiently technically advanced to have an real impact

Read the words carefully
"Sufficiently" technically advanced
"Real" Impact

For Example
If a Hospital has 16 slice CT
The "Sufficiently" advanced Product that produces "Real" impact is a MRI or at least 62 Slice CT

32 Slice CT, in this case is not a Sufficiently" advanced Product that produces "Real" impact
While your product or service you had spend sleepless nights to plan, build, test and perfect may be a technically advanced product which will produce impact, according to you

The person at the other side of table may not consider it so
And Remember
he does not value your product not because he does not understand what your product can do
It is because
You do not understand how that hospital operates and what are their priorities

Other than the
Cost / Time / Technology, there are few factors too
Doctors by nature of profession buy things every day
They see sales pitches every day
They buy drugs, they buy gloves, they buy catheters, they buy Cath labs
They are well accustomed to all sales pitches
"this is a new technology which you need to use" sort of approach will never work in doctors in 2/7/8/9 while it will work like a charm in 2/3/4/6

What happens is that the IT StartUp Team has already sold the product to 1/3/4/6 using the above sales pitch
Since they have done well in the initial phases
They are very very confident about their pitch idea

They try the same tactic in 2/7/8/9
The doctor or administrator here has his priority different

This is why
Startups get struck after pilot and never reach the masses
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