Dr Sunita Maheshwari, a Yale educated physician, describes how technology and different time zones can offer solutions to medical staffing issues around the world.
Sunita M.: I could bebop to that. Good morning, everybody. It’s great being here. It’s a long way from home, but it’s a pleasure and an honor to be here to share my story. I was asked this morning at breakfast what I was doing at an Agile conference. I said “I don’t know, but I’ve been told that I’ve been accidentally Agile.” I shall take you on basically a little story of how it began. Some of the challenges we faced along the way, what we did about them. We weren’t always right, we weren’t always wrong, and how we got to where we are today.
I trained in the US. I was blessed to be a beneficiary of America’s great universities. I trained at Yale University, but I had a prenup. I married an Indian man. He was also at Yale, but before I agreed to marry him, I said “We need to finish training here, and go back to India.” It wasn’t because I wasn’t having a good time here, it’s just that I felt as a doctor, the greatest good I could personally achieve would be in India and in Asia where there was such a shortage of specialists. This man was in love with me, he said “Okay, honey. Whatever you want, we’ll finish and we’ll go back to India.”
We finished, we both had great job offers at Yale and at Hopkins, but we finished our training and went back. It’s interesting because you kind of go back with this hope in your eyes and the moon and the sun and the future, but we get there and every hospital in India told him, told Arjun, “You’re overqualified.” They said, “You’re from Cornell, you’re from Yale, you’re from [Orland 00:01:52] Institute, you’re too senior for a position here.” We go back and for two years, he doesn’t get a job in India. I got a job at a local hospital. I was very happy, blissfully doing my work, like, “Okay, this is what I set out to do in life,” and there I was.
He was basically hanging around and in India, they tend to ask you, “What do you do?” This is a big question. “What do you do?” It’s very difficult for a man to say, “I don’t do anything.” I said, “Well, just say ‘I’m a full-time dad.'” That doesn’t go down very well in India either, because there are no full-time dads there. Needless to say, it was a tough two years, and we meantime had a son there. On my second day of “maternity,” my boss at the hospital calls me and says, “Hey, can you come back to work for three hours a day?” Arjun tells me, “There’s no concept of maternity leave in India. Let’s go to the US.”
Fortunately for him and I, I think this is one thing, I’m very happy to come back into the US, because I think they do recognize when someone’s good. Yale had kind of kept him on as visiting faculty. They said, “Your crazy wife’s going to change her mind, and you’re going to be back in America, so come back to us.” He was going there one month, coming to India for three months, back and forth, we’re in a global world these days. We come back and we’re house sitting for the chairman of Yale. He was off to Italy, and as we go to take the keys from him, he says, “You know, Arjun, I just can’t get anyone to do the night shift in New Haven.” He says, “It’s just such a challenge to get the attendings to stay up at night.”
Arjun’s like, “Hey, Jim, I’m not doing anything in India anyway. I’ll do the night shift for you. It’s my daytime.” He goes, “Wow, that’s a fantastic idea. You’re already on faculty. Let’s do it.” He calls me from Jim’s home, says, “Jim says I can work for him from India.” I’m like, “Come on. You’ve got to be kidding.” This was 2002, this was just 10 years, but there was no concept of a doctor in India working remotely for a patient in the United States.
Seven years later, after this conversation, we went for Arjun’s 25th reunion to this medical school in Delhi. He was voted as the least likely person to become an entrepreneur. I think if I went back to my med school, I would be the least likely person to be standing here talking about entrepreneurship. I think my learning from that is there were plenty of good ideas, and some of them sound very crazy when you first talk about them, but there’s no such thing as a crazy idea. Any idea that’s taken can do magic.
From there we set up what was at that point something very radical. It was international teleradiology. Essentially, teleradiology is where a CT scan or an MR or an X-ray of a patient done anywhere is transmitted to a doctor somewhere else and the doctor sends back a report and tells them what’s wrong with it. This was tele, and we started very small. Started essentially with Yale University, working from a home office and covering the night shift at Yale.
In six months, it ran into a lot of political hot water, because the New Haven doctors, the emergency room physicians were like, “Why are our scans going to India? Isn’t there anyone here in New Haven who can report them?” Jim is like, “No, no, it’s not going to India, it’s going to Arjun, who’s our faculty, sitting in India.” The difference was very hard to explain, and basically he called and said, “I’m really sorry. This is too new a concept, it’s too early a concept, and we need to shut down the program.”
Six months into finally “having a job” and doing something while he was sitting in India, Yale shuts down the program. They say the one closest to the future has the best view. At this point, we were like, “You know what? Yale may not think it’s a great idea, but it is a great idea. It makes no sense for any doctor to be up at night if he can be up in the daytime in another time zone.” Especially for something like radiology, where you’re not seeing the patient physically, you’re just seeing his scans.
We got a nephew, he was at the University of Mysore, and gave him 1,000 rupees, which was $20 and said, “Build us a website. Put us on this thing called the World Wide Web.” This is 2002, 2003, we’re on the World Wide Web, offering a teleradiology. It was funny, because we went to the registrar’s office and in India to set up something, you need to be an organization. We weren’t a hospital, we weren’t a clinic. We’re a company, so we go there and the guy says, “You need a name for your company.” We scratch our head and go, “Okay, it’s teleradiology and it’s a solution,” so we came up with this really dull name, Teleradiology Solution, which I think if we had to do again, it would be zippier. Anyway, we set this company up and put it on the World Wide Web.
My learning, looking back at that period, was believe in yourself. Once you’ve seen the future, and you have a dream, and everyone else is telling you it’s not going to work, and there were enough people telling us it wouldn’t work. Including Arjun’s parents, they’re Konkani, they’re typically not into “business,” so for your children to be doing a company versus being an Assistant Professor at a university was mentally, I think, a tough thing to accept. Everyone was telling us, “This is really crazy, let him just keep looking in Bangalore for a job.” We said, “No, we’ve seen that this can work. It makes sense.” We pushed along with it.
We started small and we grew. We had a small home office, then got a couple of other radiologists, and we decided we would just focus on quality. I know that’s a hard thing to say, because everybody says “I’m focusing on quality,” but we said, “We’re just going to do our work and do it well and see what happens.” We went for the joint commission seal, which is an American accreditation for healthcare organizations. We were the first Indian organization to actually get the gold seal, in 2005.
In 2005, we also had a booth at the Radiology Society of North America. It was quite interesting, because we were a very brown booth in a very white space. We had all the Indians coming to our booth to see what these Indians were doing in something that was traditionally a very American, white space. All the other companies in teleradiology were essentially US-based. Some of them were in the process of going public, and so on. We gradually built up a team in India.
In 2006, we built our own campus. One of the reasons we did this is because our employees kept thinking we were going to run off to America. They would be like, “Are you sure you’re here next year? Are you here the year after?” We kept having to deal with this, and we said, we need to be something. We’re, again, not a hospital, we’re not a clinic, we’re a company. We need our own building. When we started building this campus, we had 20 employees. We had this small little board that used to advise us, and they were like, “Are you guys a little crazy? We know you’re a little crazy, but now we’re thinking you’re a bit bigger crazy,” because we were building 70,000 square feet.
We said, “Yes, we know. We’re building more than we need, but we’ve seen the future.” My learning from that was dream big. Build a space knowing, put the thought out there. That we’re going to fill it up over time. Many times we’re limited by the limitations of our own mind. “I have 20 employees, I’ll get 2,000 square feet.” Dream bigger. Just say, “This is a great idea, we’re taking it global, and we’re putting those dreams right out there.” We built our own identity, which for us I think was much needed, because we were struggling with “Are we docs? Are we entrepreneurs? Who are we?”
Interestingly, we had a buy out offer. We set up this company in 2002, we were outside the registrar’s office in Bangalore. 2003, we had a buy out offer from a large Indian software company. At that point, I was earning $300 a month in India as a doctor, 18,000 rupees. Arjun, of course, was not earning anything. They offered us a million dollars. It was very tempting. We were like, you’re planning, we put in a fixed deposit at 10% … You know, you can live the rest of your life. We went back and forth with them for a week about the sale.
It was tempting. I won’t say that we were able to automatically say “No, I don’t want your money and I’m going to build my dream.” It was tempting, because it was security. Here we were in India but struggling. It would have meant we won’t have to struggle. We debated back and forth. It’s funny because we just got profiled last month in Forbes India, and Mr. Bagchi, one of the things he put in there was “life brings you many distractions, and one of the distractions early in the life of a company is money. Taking money at that stage is a one-way street to obscurity.”
It’s so true. We elected not to sell, for many reasons. One was we felt we didn’t want to be … We were doctors. We didn’t want to necessarily be in a software company. We very much wanted autonomy. I think more importantly, it was that bite. That bite, that chance to take an idea and create something magical. Once you’re given that, and we were given that, we didn’t just want to give it up and retire in our 30’s. Our learning was, take a chance. You have conviction, take a chance, give it everything you’ve got and the future shall unfold itself.
We had tough times. I won’t say that this was a journey without tough times. Excuse me. Bandwidth costs were and are still very high in India. In the US, you get blazing bandwidth for $50, there you spend $2,000 for each of your links. Unreliable electricity. The roads would be dug up and there you have no electricity or no bandwidth. I remember times when the bandwidth was off and we were running to the linesmen’s office and the guy’s in his pajamas telling him, “Fix our bandwidth,” so that we could get going.
We learned through trial and error. We didn’t have senior management. Sorry, this is called the Freudian … When you need to speak you get a sore throat. We didn’t have senior management to fall upon. We weren’t MBA’s, we hadn’t got a degree in how to run this company and how to do HR. It was tough, but again, the learning was stick it out. There were times, and I will be honest, we felt like just running away.
We were offered citizenship by the Singapore Health Minister. We’re like, “Okay, that sounds better than what we’re going through.” We wanted to create something within our country. We wanted to fight it out and create it for India within India. We stuck it out. The learning was, believe in yourself. It’s going to be tough. It’s not going to be easy, but keep going.
We also were at the, you can say, the brunt of the whole anti-outsourcing, 2005, presidential elections. ABC, NCB, you name it, they honed down on our company as an example of high end outsourcing. They’re like, “Oh, you’re talking about call centers, but here are doctors who are actually reporting scans for American hospitals.” Strangely enough, it wasn’t even outsourcing, because it was essentially US-trained, US-certified radiologists, just sitting in another part of the world using the geographic time zone. It wasn’t true outsourcing in that sense, but it was a very tough time.
We hired an Indian PR company. We said, “You’ve got to help us with this. There are all these perceptions out there that aren’t necessarily true, and how do we deal with it?” It turned out, they didn’t know how to deal with it either, so they gave us really bad advice, like “Don’t say anything. Mum’s the word,” which got us into even more trouble, because we weren’t explaining our stance. I think media is great when they love you, media is very difficult when they’re out to find something.
At that point, I remember talking to Arjun. I am, as you can see, naturally the optimist. He’s naturally the pessimist. We’re the yin and yang. I said, “You know what? It doesn’t matter. They don’t quite understand it. We don’t know how to explain it to them. Let’s just keep doing what we’re doing, and let it figure itself out.” My learning years later from that was nobody remembers what you were in the paper for. They just remember that you were in the paper. We today have people say, “Hey, weren’t you in the Washington Post?” They haven’t read the paragraph that you didn’t want them to read.
Also, that just because somebody thinks it’s a bad idea, or somebody perceives it to be something, it doesn’t make it a bad idea. I think having that kind of confidence and that knowledge that just because ABC thinks we’re doing XYZ, as long as we know we’re doing the right stuff, the right way, and it’s fulfilled a need, and it’s doing something it was set out to do, and it’s magical, let’s just keep doing it. Things get better. I think they say, whenever things can’t get any worse, they tend to get better.
Currently we have, this is the present, they are waving to you from Bangalore. We cover more than 100 hospitals in the United States and this is essentially how it works. You have a radiologist, a doctor, looking at a scan of a patient with a transcriptionist. We’ve made it very efficient for the doctor, so they’re not spending any time transcribing or downloading the image. They can just focus on the patient image and getting the report out. We just completed 10 years, so this was all our staff in the 10 taking a picture there.
We at some point realized that just working with the United States had certain upsides and downsides. One was that there’s a lot of competition. There are other groups doing it, but there’s also a lot of need in other parts of the world. We were not only US-centric. We got approached by the Singapore government in 2005, because they had on the island of Singapore, 70 doctors, 70 radiologists. There was a shortage of radiologists. It used to take them three days to get a report. If you broke your finger today, on Monday you won’t know until Thursday whether the finger was broken or not. The health minister sent this team out saying, “Look at India’s doing in teleradiology.”
We went through this two year accreditation process and became accredited by the Ministry of Health of Singapore. We’ve been reporting for them now for the last seven years. We did 79,000 exams in 2011. Up from 35,000 in 2006. It’s been a really good partnership. One of the things we promised them was we will reduce your turnaround from three days to one hour. Essentially, we had to add value. We added value to what the patients in Singapore would be getting. Actually, from this whole Singapore adventure, I learned a lot, because in Singapore, they could have imported a lot of radiologists in, but they chose, and we still do one third of their work. Two thirds is done within Singapore.
They create a little bit of competition. The Singapore guys will say, “How are the India guys doing? How’s their quality, how’s their turnaround?” We’ll be, “How’s [inaudible 00:17:37], how’s Spittle doing?” The Singapore government kind of creates this little bit of competition between the two of us, so neither of us is complacent and the best quality of work at the fastest rates is given to Singapore patients. My learning from the whole Singapore government experience was create solutions that work. In that case, it was for a country, and a little bit of competition is not a bad thing.
Currently, we provide teleradiology to hospitals in over 20 countries. In the Maldives, in the remote parts of India, in parts of Europe, and especially in Africa. I will talk about that, because when we talk about business, we’re always talking about great opportunity. Where is the next big thing? It’s important also to think of where is the next big great need. I personally, in India, we get a lot of African students who we train and when they come through, they really have not … They’ve done medical school, but they haven’t had specialist training. We’re training them and they said, “There’s just such a shortage of specialists in Africa.” Most of the Africans who were there, there’s a lot of strife, they’ve moved. Either to Europe or to the US, to other parts of the world.
A lot of countries in England are filling up their hospitals with the docs from other countries, but then there’s a huge shortage in those countries themselves, and this is a big problem. We really feel like in Africa we can make a difference. If you have a patient in Nigeria, and he doesn’t know if he has a brain tumor or if he has a migraine, he doesn’t know what treatment to get. Taking a diagnosis to parts of Africa could do a lot of social good. We started working in Tanzania and now we work in Djibouti and in Nigeria and other parts Africa.
My learning through that was use the same domain knowledge. We’re using exactly the same technology, the same bandwidth, the same doctors, the same processes, and putting it to social good in a country where there’s a great need. When you have great need, it’s also great business opportunity, but it doesn’t mean that it’s only business opportunity. You can fulfill both of those at the same time.
We’ve had, I guess, I’ve been asked, “You seem to be an innovator in healthcare.” If you asked me five years ago, “Are you innovating?” I’d be like, “I’m not innovating. I’m just figuring out how to do what I’m supposed to do.” We have, over time, you can say, innovated without realizing we were innovating. We were essentially finding solutions for our own problems and solutions for other people’s problems. Some of the innovations is we essentially use one reading center, so say our Bangalore reading center, to cover multiple hospitals. Imagine a hospital in Texas, at night they would need to have one doctor on to report five or seven scans. If they sent it to one reading center, wherever they may be, Sydney or Bangalore or Florida, one radiologist, one doctor could report for 10 different hospitals.
You’re using an efficiency of one place covering multiple things, versus each hospital, and in fact the American model of having a doctor stay up at night is actually a very expensive model. When you have a doctor sit up at night to report those seven scans, he works one week on, and two weeks off to do his night shift of one week. Versus if you send it to Australia or India where it’s daytime, our doctors all work a five day week. They’re working 20 days in a month. You don’t even have to have cost cutting in the traditional sense, you have cost savings by just having that same person work much more.
That’s one innovation in healthcare delivery. The geographic time zone makes a big difference. For instance, in our daytime, our model, no one ever stays up at night. We are not going to pay top dollar to have a sleepy doctor in the middle of the night. We have radiologists here in the US, they would cover 5:00 p.m. Eastern to midnight, then they go to sleep. Then the guys in India would take over, and they would cover about 11:00 p.m. Eastern to 7:00 a.m. Eastern, and then we have a team in Israel that covers the later part of the shift.
You essentially use time zone advantages and also use the model of one hub and then multiple spokes around it to make it a very efficient healthcare model. We use the same technology and domain in Singapore, but not for the night shift model. In Singapore, it was more to reduce their turnaround from four days to one hour. A patient could go to a clinic, know what was wrong with him, get his treatment, and go home. It’s the same technology, same domain, same know-how, same process, but used to fill a different need.
Now, essentially, to take diagnosises to a place like Africa, or remote parts of India where there is none. One of the controversies with a model like this would be, “Are you displacing doctors?” For instance, in the US, when we were at the butt of the anti-outsourcing movement, they’re like, “These radiologists in India, taking away the jobs of radiologists in the United States.” Funnily enough, not only do the groups we work with, none of their jobs were taken away, they actually were able to take on more and more work, because they were able to dial out at 6:00 or 7:00 p.m. to us, so they could take on hospitals around them. It became a win-win, symbiotic for both sides.
That’s what we’re finding, even in India, for instance, we’re now setting up telemedicine. They’re saying, “You’re going to displace the local doctor.” We’re like, “We’re not big brother. We’re taking telemedicine to where there is no doctor.” You’re essentially not displacing anyone, you’re using it to fill a gap. That gap could be in Africa, it could be in India, it could be turnaround times, it could be night shift. How do you use the same solution and then use it for different kind of arenas of life?
This is my little, you’ve called me all the way to Dallas from Bangalore, so I had to put my little [tomtom 00:24:02] slide in. We are the first healthcare organization outside of Singapore to be accredited by the Ministry of Health and the first and largest telerad company in India. I think last year, I really cried when the class results came out in the United States and we were ranked the number one national teleradiology company in the US. I truly felt that America is a fair country. In 2005, we were at the butt of every media. In 2011, they rated us the best teleradiology company.
I told everyone, and I tell them in India, I say, “Look, sometimes we’re not fair. Once we get stuck on a perception, we’re stuck on that perception forever. Whereas the United States shows the world that it continues to be great because it continues to be fair.” The class is an independent survey. We cannot fiddle with the results, we don’t even know how they do their survey. I truly believe that being … When you work towards something, it’s important to set that goal out there. In 2002, we just had a goal of let’s get started. 2005, let’s just put our heads and keep working. By 2009, we were getting ambitious, and in 2010, we got rated the number three provider in the US.
We set ourselves that big, hairy, audacious goal that we are going to work towards number one next year. Some of the changes we did, and I attended a session by Verne Harnish on getting your company to the next level, and one of the things we weren’t very good at is we had these monthly meetings. Operations meetings. We would sit down and we would go over all the issues of the month and put in plans for all the solutions for the next month. Of course, with 100 agenda items, you’d get through 10 and you’d implement four. A lot of things would fall through the cracks.
In 2010, we implemented the huddle. I’m not sure if the scrum is similar to that, but we had a daily operations huddle. We would have members of every team, be the doctors, and the transcriptionists, the coordinators, just standing up seven minutes, what are the problems? What are the problems? We started having, we have our own call center, which calls in reports to the hospitals, telling us any time anyone was annoyed. If there was an emergency room doctor who said, “Your reports are taking too long,” we wanted to know.
India is a very submissive culture. You tend to not want to tell your boss bad things. Bad news is hidden. You put it under the carpet. You think he’s going to get annoyed with you. We had to break that culture by saying we want to hear, we want to hear when a client’s annoyed. We want to hear when something didn’t go wrong, so we can fix it. We’re not going to fire you, you’re not going to lose your job. We just want to fix it. I think those changes really helped, because customers and hospitals said they’re responsive. I think that daily responsiveness kind of took us to the top of the charts.
Your president came in 2010. It was a real honor to be invited. We were invited to be showcased to him as one of the innovations coming out of India on his Bombay trip. For me, personally, this has been a very interesting journey. A doctor, two hats. I was very uncomfortable for many years being an entrepreneur. I would tell people, “No, no, I’m a cardiologist for kids. I’m just helping my husband on this company.” It just didn’t fit with who I was. I saw myself as a Mother Theresa doctor, so business and money and profits and revenue didn’t fit with it.
I think they both have a place. As a doc, I work in someone’s hospital, I get a salary, it’s very predictable. I don’t have to worry. As an entrepreneur, there’s a buzz. You can dream, you can do crazy things. Ultimately, money gives you the power to do good. I truly believe that entrepreneurship was about taking an idea, making it work, and then using that money to do something really magical with it.
This is some of the crazy, wacky stuff. This is India’s first and only electric car. Actually, a Stanford graduate who came back and made it in Bangalore. We do eco-friendly doctor visits. Eco-friendly blood draws, eco-friendly physiotherapy in the electric car. Stuff like that, I don’t have to ask permission, I can just order the car and say … They all think it’s a bad idea, by the way. They like the big diesel guzzling van to be able to do all this. A couple of times, you can say, “Nope, this is the way we’re going.”
I think it’s also fun to create a culture. It’s interesting, because when we started off, everyone talks about human resources. Yes, human resources are the key to any company. We brought in a human resource consultant. We had a lot of challenges. We had to work 365 days, we had long shifts, how do you keep people motivated? How do you keep them coming in on Sundays? He looked at all our processes and he goes, “Everything you’re doing is wrong.” I was like, “Everything we’re doing is wrong, then how come no one’s leaving?”
My realization, that was the first and last time we used an HR consultant. Sorry, any HR consultants out there. My learning from that is there are many ways to do it. You’ve got to create what works for you. We have a very inclusive culture. India is a country where there are hierarchies. For instance, the CEO is not going to have lunch with the office boy or the cleaning staff. Unlike America, it’s a very hierarchical country. We tried to break that, because that was not who we were, and that was not the culture we wanted.
If you’ve seen this picture down here, I’m actually dancing with the office boys. This was a very difficult culture for the doctors. They’re like, “The transcriptionists are calling us by our name. They should be saying Dr. So-and-So.” We said, “That’s our culture.” We want this to be inclusive, we want it to be non-hierarchical. In some sense, we wanted it to be an American culture in a very Indian company. We have our own band, the Teleradiators. They have a space where they practice at. Every birthday of an employee, anniversary, an email goes out. When they finish five years, seven years, 10 years now, there’s either a cake cutting or they get a cap or they get something fun.
We have a masseuse, because they’re working a lot with computers, so we hired a full-time masseuse. Advantage of low cost in India. Full-time masseuse giving massages at the work station. We even once dressed up at Hill and [Billary 00:30:57] Clinton. These masks were great and it was funny because everyone actually thought we were Hill and [Billary 00:31:03] Clinton, so we said, we’ve created this aura in the office that they believe anything is possible. We had staff going, “A pleasure to meet you, Mr. Clinton.”
I think just creating … We realized it’s not the big things. It’s not just your pay package and your bonus at the end of the year. Yes, that’s important. Your stock options. It’s the small things. It’s the knowing it’s their birthday and everyone going and wishing them. It’s the small things that do matter in making people feel wanted in the workplace. That’s the culture we’ve … This is a slide we have in our office. We used to say on your birthday you go down. Now it’s so dirty we said we’ll push you down if you don’t perform. Creating different spaces within it.
We’ve had to innovate continuously. I think, as I said, I didn’t know what innovation was, now I can be the innovation guru because I’ve realized innovation is about trying to figure out what you need to get done and then figuring it out. That’s basically what it is. For instance, US is a tough market. There’s a lot of teleradiology companies there providing similar solutions, so we expanded geographies. Africa, there’s nobody providing teleradiology solution. The other thing is we needed to cover 365 days. We’re a healthcare group, we have to work. Our busiest day is Sunday.
Nobody wants to work on Sunday, so there’s whining and moaning and we have the US radiologists work every other weekend as is. They’re like, “I can’t do every Sunday.” We were like, “Okay, okay, okay. We’ll pay you double to work Sunday, we pay triple, we’ll give you two days off instead of one day off.” It wasn’t working. We said, “Where in the world do they work every Sunday? Where would they come to work with a smile on a Sunday?” The answer was Israel. We started recruiting in Israel, where Sunday is not a holiday. We said, “You can have every Saturday off,” because Saturday is a working day in India, “and work every Sunday.”
It’s interesting, because now all the Israeli guys want all the Jewish holidays off, so they all have to be off on Hanukah. We’re not thinking, “Okay, where in the world other than Israel do they work Sundays?” The answer’s in the Middle East, so we’re looking to hire some Muslims in the Middle East where Sunday’s not a holiday and they can take Eid off and not the Jewish and the Christian holidays. I think innovation has to be very specific to one zone organization sometimes, to one zone needs, but finding solutions that work within that. My learning in this process has been that you have to constantly innovate to stay afloat.
We’re now 10 years old and we have employees, knock on wood, who’ve been with us from day one. They say it’s changed. This is like a criticism. When they come up to you and say, “The company has changed. It’s not the same.” I’m like, “That’s good.” They’re like, “It’s not good. I liked the old company.” The fact is you have to change, so I tell them, I say, “Guys, if we don’t change we are dead.” I said, “There will be no company. If we are going to do things exactly the same way as we did it 10 years ago, then let’s all just retire.” I think it’s difficult to manage change. It’s difficult for people to accept change, but change is essential. Innovation is essentially about constantly changing to stay afloat and to stay ahead.
I’m just going to check … I have time. I think as I said, we’re accidental entrepreneurs and accidental Agile guys. Once you start doing things, it does give you the courage to do other things. When we started thinking, “Why do we have to only do tele and radiology and do hospitals?” We started working in the imaging space and clinical trials, so we actually are the partner for Biocon, which is India’s largest pharma company. We work with Siemens USA in the clinical trial imaging space. That’s just an offshoot of what we do.
One of the things we have done, we were using .. There was no real teleradiology software out there. We hired these two software engineers. Bangalore, as you know, has a lot of good software guys, and we put them there, and we said, “Okay, now you do this code, now you do that code. This is what we want.” They created for us a workflow, a teleradiology workflow which we used then, because we were covering all these hospitals all over the place. We wanted everything on one platform. The doctor on one platform could report, the hospitals could be any number of hospitals on there.
As we created this thing, our clients started saying, “Hey, I noticed you have this unusual workflow. I’d like it too, because we cover three or four or five different hospitals.” We were like, “No, no, no, we’re a services company. We’re not a product company, we’re not a software company. We’re only doctors doing our work. We cannot give this to you because we don’t know how to service you with it.” Then we started thinking, “If it’s a product and they like it, why not productize it? Why not make it into a product?” We didn’t know how to, because we were doctors, we were not software engineers. I told you, we didn’t have an MBA, so how do you take this thing that you’ve created and then sell it as a software product?
We looked around and we found Mr. Ricky Bedi, been in Silicon Valley in America for 20 years, moved back to India for his heart. We said, “Would you like to come and run this thing? This is the idea, this is the half-baked product, can you make this into a product?” He came onboard. My learning was if you have a great idea, get help in implementing. I think for four years we sat with this idea. We just kept using it and refining it, and we didn’t do anything with the idea, because we weren’t capable of doing it ourselves, so it just sat on the shelf until we got someone in who could take that idea and implement it.
He came onboard with his passion and energy and this is Lord Ganesha. He is the god in India of new things. We have a large statue of Ganesha, of Lord Ganesha, outside our office. We pray to him and then we say, “Let us start the new thing.” I think to start the new thing, you need the right people, and you need to get the right help. That’s what we learned. After we got Ricky in, we gave him the autonomy to run it the way he wanted. We did give input from our entrepreneurial experiences, and we created a product called RADSpa, which is essentially a spa for the radiologist. It’s been interesting running, actually, a software company. We now have 30 engineers on the second floor of the building.
The first floor has the teleradiology. The second floor has the engineers creating the teleradiology software. I think, from seeing this now, most engineers don’t work with the end users right on top of them. In this case, right below them, on the floor below. We had a very tough time the first year, because you had all these doctors, and doctors are used to saying, “This is what’s wrong with you.” That’s our job. “You’re sick. Here is your treatment.” We were doing the same to the software engineers. “This is what’s wrong with your software. This is how you need to fix it,” and this was not going down very well.
We clearly had different styles here of functioning. They were like, “These teleradiology people, bossing us, just because they have funded us doesn’t mean they can boss all over us.” The net result was they would not listen to anything we said. Here we’ve got this half-done product. We’ve got this great CEO, and we’ve got these 30 engineers who think we’re a pain. I said, “Okay, solution.” What do you do in this situation? Finally I told them, I said, “Okay, since we’re so painful, and we’re clearly unable to work with each other, we think this product’s a good idea. We will be your angel investors. We will fund you, you make this product, and you take it to the world, but we are going to use our American company in North Carolina.”
This worked like a charm. I think many times, when you have an internal group … The software company was like a part of us. They didn’t think they should be held to the same standards with us as with an external client. When we told them, “We are your external client. We should have the same kind of relationship. Treat us as you would an external client. Bid for our work.” We were their largest client, so to speak, because we were giving them all our work. We said, “Bid for our work. Otherwise, we’ll get anyone else to bid for it.” The whole attitude changed, they were more receptive to us. Now they have a team that works on our staff. We were able to separate ownership, in a sense, the same group, but treat each other separately, and treat each other like external agents.
The learning from that was that there is a space for arm’s length in every organization. It’s interesting, when we set up this teleradiology software, we are actually helping companies do teleradiology. We were asked, “Aren’t you creating your own competition? You’re essentially allowing anyone in the world to do teleradiology.” We said, “Yes, in a sense we are, but there’s a finite amount of teleradiology we can do.” Practically speaking, we can’t have 10,000 doctors working for us. The HR would be a nightmare. There’s only a certain amount of servicing we can do. By allowing others to do teleradiology, they grow and we grow along with them. My learning was, there’s a word called “coopertition,” which is cooperation in competition. You all actually end up growing when we cooperate and compete with each other. That’s our little saga into software.
Now, we’re doctors, so our natural instinct is to do the servicing bit. One of the things, I think, that’s interesting about a global world is that we learn from each other. I learned from my time in the United States that clinics are really important. In India, all the healthcare is now focused on hospitals. On larger and larger hospital groups. We actually set up a clinic where doctors just talk to the patients, and only if you need an operation you go to the hospital. We set this up on that 70,000 square feet, so on the ground floor. It’s funny, it’s a popular little clinic in Whitefield and it’s got a lot of good doctors who have returned from around the world.
We’ve been asked, “So you did the teleradiology, you did the technology, what was your business plan for this clinic?” I said, “No business plan. No business plan. Put a doctor there, say, ‘Dr. Belliappa, do a good job.'” That’s it. That was the business plan. This clinic is profitable. It’s about 15% profitable. My learning was do what you love doing. The money will follow. Everything doesn’t need a business plan, but everything needs passion. If you do it with passion, and you do it with love, and set it up there and put it out there for the world, the money follows you and you don’t know what to do with it after a while. That’s RxDx.
From this whole, you can say, amalgamation of now technology and doctors, not just radiologists, but the clinic having physicians and pediatricians and internists, and entrepreneurship, came more new things. Teleeducation and telemedicine. My learning through this process over the last decade has, one needs to keep one’s mind focused, yet fluid. I know that sounds contradictory, because how can you be focused and yet fluid? Focused, we were always focused. We’re going to work in the healthcare space. We’re going to work in healthcare technology space. We’re not getting into setting up movie halls or restaurants or flower shops. We’re going to work in this [inaudible 00:43:42], but it was fluid. We moved from a pure teleradiology to then teleradiology software to a clinic, and then into telemedicine.
To be able to say we have a focus, but that focus may change a bit, and that focus can be fluid, allowed us to grow into other things. One of the things I’m very passionate about, and so is Arjun really, is teaching. We really feel like in India there are a billion people, but they’re not all employable. They’ve not all been trained. How can we contribute back there is by teaching. Here in the United States, I think we were blessed, and you all are blessed to really have universities where the professors love to teach. Where you teach for the pure pleasure of teaching. I was spending a lot of time, actually, at the hospital I worked at training two postgraduates a year, of whom one would go to America and one would disappear somewhere into practice. This was a lot of investment of time on training, reaching two people.
I got a little tired of it, and I’d been doing it for 10 years, and I’d meet students from other hospitals, and they’d say, “Nobody likes to teach, because everyone’s so busy doing clinical practice.” I feel things happen by chance. My kid was playing tennis with this general manager at Cisco’s kid, and this guy was developing an e-teaching platform that they were deploying in New York for the New York school system. I said, “Hey, have you used it for doctors?” He’s like, “No, but we’d love to. We’d love to use it for medical education.” Piloted it for them, and now of course it’s off the pilot stage so we use Cisco’s WebEx and then do teaching of postgraduates in radiology, in pediatric cardiology, all across India. Now students from Africa logging in.
Using technology to take that same teaching, and instead of two people, benefit hundreds of people at the same time. This truly, I am a grateful to the US for, because I feel America’s greatest gift to the world is its education system. They teach without expecting back. I trained at Yale, I went to India. [inaudible 00:45:57] trained with me, he went to Israel. Kelly trained with me, she went to the Philippines. They train without expecting back, and then we all go off into different parts of the world to be able to do good with it. Teaching is truly, I think, one of the things that can change many parts of the world. Using technology for it has been something that we have figured out how to do in the last two years.
All this, as I told you, we had the entrepreneurship, the technology, the healthcare, the doctors, this all tied in very well with telemedicine. It’s funny, because we’re not intuitively thought of as being into actual telemedicine consultation because we’ve been for so long identified as a teleradiology company only. Cisco approached us and asked us, they had adopted some villages in India, and they couldn’t find doctors who would just do it pro bono. A lot of the doctors who work with us, you’re like magnets, right? Magnets, opposites attract, but anyway, in this case, you tend to attract people who are like you. We have a lot of doctors who have come back from the US, from UK, who want to give back in India.
We said, “Yes, we’ll work with you with this.” We cover about 22, now, primary health centers in India. Cisco’s technology is not just video conferencing. A lot of the telemedicine in the past was just a video conference. There’s actually digital blood pressure and a digital stethoscope and a digital thermometer so you actually get patient data. It’s interesting because Cisco’s a very large company, and we are a relatively small company. Yet we are their managed service provider in India. It’s the same question I actually asked the Singapore guys, because they’re a $1 billion group, and we were this tiny group in a home office. I said, “Why are you working with us? We’re so small.” They said, “It’s because we need the pushers.”
My learning with this, in several times over the last several years, we’re much smaller, but we’re working with much larger organizations. The world needs pushers. Arjun’s title, in fact, mine is Chief Dreamer and his Chief Pusher. He’s like, “They’re going to think I’m pushing drugs.” I’m like, “No one’s going to think you’re pushing drugs.” We need the pushers, the people who are going to take these ideas and make sure they get implemented, and make sure they get implemented every single day. That’s what the pushers do. I’ve realized over the last decade, that’s what we are. We’re the pushers.
We’re able to work with Singapore government, and we’re able to work with Cisco and now we’re going to work with governments within India because you have the viewers, the guys who sit back and say “Things aren’t so good, when it gets good I’ll do it,” or, “If it’s right for me, I’ll do it,” or, “If they make it good for me, I’ll do it.” Or you’ve got the guys who’ll just say, I’m going to do it.” The world needs pushers, so for all the pushers out there, this is what we need to do. To take any idea, any idea, whatever it may be. In our case, it was technology and healthcare, to take that idea and actually transform it into a reality, transform it into something that worked on a daily basis.
For instance, in telemedicine, when we started off, everyone was like, “How is the Indian villager going to adopt to this high end technology?” The fact is that poor Indian villager does not have access to a doctor. He was very happy to have a doctor at the other end, even if it was via high end technology. They come in, and they kind of wave at the camera, and they smile. It’s really interesting to see. This telemedicine program, I just got an email last night from Cisco saying the docs aren’t seeing them fast enough, because it’s become so popular there’s waiting lines at the primary health centers for the doctors. Our average consultation time has dropped from nine minutes to eight minutes. I was like, “Well, we can’t really go faster than eight minutes. We’ll just have to have more doctors on it.”
I think from teleradiology to telemedicine, teleeducation, whatever sphere we’ve been in, the crux of the issue is how well can you push, how long can you push for, and how strongly can you keep pushing even when the odds are against you? With all this growth, I figured there are women in the audience, of course men too, so challenges at home. Pete asked me last night, he says, “Do you have kids? How did you manage kids with all this?” Yes, I have a 15-year-old and a 12-year-old. I don’t know if this is Agile technique, but I figured out ways to involve them in my life.
I used to do a clinic in Bijapur, which was an overnight bus ride away. They would come on the bus ride. I put up these playgrounds in government schools, so the come for every installation. They get to see that life is much more than just the privileged life that they’re leading. I’m very reliable. If I’m going to be late, I will let them know. If I’m out of town, I’ll tell them exactly the day I’m coming back. If my flight’s late, I will call them up. We do big hugs, lots of hugs, and special things on Sunday and Wednesday afternoons I take off with them. My learning was decide to spend time with the ones you love and you will find a way. I think it’s like that about work and about business and about professionalism, and it’s like that at home as well.
I have also learned, I know a lot of you, everyone here is really technology. Technology was owning me for a couple of years. That Blackberry and that ping, ping, ping, ping, ping. Emails all the time. Now I just said, “I am the queen, I am the queen. Technology is my slave. Not the other way around.” Now I use technology, I get home, phone is off for an hour, have my family time, and then conference calls. I’ve actually been able to save on a lot of travel. I do a lot of my medical lectures now using the Cisco platform. Going green also, cutting my carbon footprint.
Even in the office, we use a lot of just emails, no paperwork. I tell them all now, “You’re not going to get a response in 10 minutes. If it’s urgent, call me up. If not, I check my email twice a day and you will get your response.” E-classes, another way that I don’t have to travel an hour and a half to the students. I can sit like in my pajamas, below here, and do the class. I think over the years, learning how to manage it all, what is it called? Life work balance. I think that’s also kind of a process, something that we learn along the way and figure out, as long as we’re able to continuously innovate with it.
I think I shall end with this. I was telling Pete yesterday evening, I said, “I’m not religious. My father is Hindu, my mother is Christian.” I grew up doing Diwali and Christmas. My kids, I’ve given them Muslim names because sometimes we are so in India, there’s Hindu and Muslim and there’s all this stuff, and I said, “You know, we’re all just universal. We’re all human beings, whether we are brown or white or Christian or Hindu.” I’m not at all religious, and so I guess I’m not an atheist either, but I’ve often wondered, why were we chosen to be given this company? We did not go back to India saying, “We’re going to set up India’s next big healthcare technology company. We are going to be the entrepreneurs of the new India.”
None of that. We just went back to go back, to work as docs and here we are running three companies and having multiple trust funds. Getting invited to meet President Obama. Why us? I truly believe that God gave us this company for a reason. That reason is that we are able to use it to do something good with it. How do you get a diagnosis in India? This is how you get a diagnosis in India. You get on a train, or a bullock cart, or a rickshaw, and you go to your nearest hospital. You take yourself, you meet a doctor who you trust. The doctor looks at you and looks at your scans, and then tells you what’s wrong with you and puts you on a treatment path.
The fact is that in medical care, the first thing that you need in order to go on a treatment path is a good diagnosis. If your doctor messed up and you don’t have a good diagnosis, you don’t have a good treatment plan. You don’t need to travel for a good diagnosis. Here in Dallas, you could go to your local doc and he’s going to figure out what’s wrong with you, whereas if you’re in a remote part of India, you are going to be traveling maybe 1,000 miles, or 2,000 or 100 miles in order to get a diagnosis. The answer to that, really, is to be able to use, again, technology to take the diagnosis out there rather than transportation to take the patient to the hospital.
In 2007, we set up the Telerad Foundation with really an aim to be able to use technology to get diagnosises out to remote parts of India. Now we have extended it into Africa. We’ve done over 20,000 patients pro bono through the Telerad Foundation now. This is one example. This is the Ramakrishna Mission Hospital. It’s in Arunachal Pradesh in the northeast for one million, a population of one million. There’s one CT scanner and no radiologist. The swami called us saying, “I have this scanner, and I have a million people. We can’t use the scanner, because there’s no one to tell us what’s wrong with the patient after we do the scan.” We started reporting for them, and they don’t charge the patient. It’s a charitable hospital, so we don’t charge them.
We started from that hospital, and then expanded to two other areas, so we cover, for instance, TB screening. It was actually quite interesting. We had someone from the Gates Foundation visit. We told him all this, but I think when you hear this, you don’t quite believe it. We said, “We do TB screening and we charge about 10 rupees, which is $0.20.” He happened to go to Bihar, which is one of the states in India. He went to this site, this TB screening, and he asked them, “How do you get your X-rays reported?” They said, “We’re using this group in Bangalore.” He emailed back saying, “You know, I saw it action.”
For me, honestly, this has been what gives me the greatest pleasure, is to be able to use the fruits of entrepreneurship and to be able to do good with it. For that, I feel very blessed, and I feel probably there is a God up there. This is tele-echo. It’s the same concept, can be used for cardiologists. For instance, in Tanzania, there’s no cardiologist for the whole country. They actually send patients all over the world for treatment, but you could use tele-echo where the echo is done, the cardiologist somewhere reviews it, tells them what to do, and then only if they need surgery they get transported. If they need medicine, they stay right there in their home country.
There are challenges even in this. We have used a Robin Hood model. We will charge hospitals that charge patients, so we’ll charge US hospitals, Singapore hospitals, the private hospitals in India. We don’t charge the hospitals which do free service for patients. How do you scale this? How do you scale the giving? You’re reading scans pro bono or for $0.10 or $0.20. You got to pay your radiologists, and radiologists are short supply even in India. How do you scale such a model? One of the things we did is to actually tap into the global diaspora of the Indian docs. 25% of doctors in the United States are of Indian origin.
I met so many, all my classmates from medical school, I don’t have a single friend back in India who I went to med school with. They’re all in America. Whenever I meet them, they say, “We’d love to do something back home.” I’m like, “Sure, we can now hook you up. You stay right where you are, because we can’t pay you, and we will hook you up through our platform and you can.” In fact, Cisco’s new technology, the doctor can be anywhere laptop based. We’re putting together a panel of docs, like cardiologists and dermatologists, wherever they may be, give an hour a day, an hour an week. Operationalizing that is our role, but it’s their heart and their soul. That’s how we’re hoping to scale this up.
I think for me, really, the learning from all this has been that the pleasure of giving is unmatched. I think the United States is very good about giving. I think in countries, in India where I come from, many times everyone’s struggling with their daily life. They’re not thinking, necessarily, about giving. Giving is not something intuitive. It’s not something we necessarily all are lucky to grow up thinking about. In fact, there are a lot of studies showing that if you give, you can actually come off anti-depressants. Lower incidence, they’re teaching people to give.
One of the things I personally do now is I talk in schools in India about giving, about the importance. It doesn’t have to be … For us, what we have done is use our own domain and then used that to give. We gave within our own ecosystem and we gave with the tools that we already had, which is one way, or it could be in any other way. I think ultimately, the joy of entrepreneurship, the joy of working, the joy of pushing through tough times and figuring out how to work through them, is to create something hopefully magical and something where we can give back to the world. I’ll end with that, thank you very much.
This is my title, Chief Dreamer. I used to be head of HR and what was I? New business development. Then I said, no, no, no, all I’m doing now for the company is dreaming. In fact, someone comes to the office, I give them my card and they look at it and go, “I want that job.” It’s been a pleasure being here, thank you very much.
Moderator: If you have a question for Dr. Maheshwari, you can come to the microphones. We have a few of them set up here, right near the front. We’ll give you a couple of seconds so that you can approach the microphone. We have about 15 minutes for questions if you’d like to ask.
Sunita M.: It was too clear.
Moderator: We’ve got one coming, hang on. It’s a long walk up here.
Audience 1: Hi, I just had a technical question, I guess. When you were approaching sub-Saharan Africa, you have all the technology. Do these countries and villages, how do you solve their technology problem? Do they have it there, or how do you deal with that? I think it’s a great idea, but it seems like you got to handle it on both ends.
Sunita M.: That’s an interesting question, because sometimes they don’t have it. For instance, in Africa, one of the challenges in some of the smaller towns is bandwidth. Even our team in India goes, “They just give them all the policies and protocols that we give American hospitals.” I’m like, “No, no, one second. They don’t even have bandwidth. We’re going to have to start from that.” We had to go back to the drawing board with a lot of these places. Our IT teams will work remotely with them. Now, actually, we’re setting up a whole telemedicine linkage for the Tibet government and in Tanzania. We’re actually sending an IT team out there to do that.
Bandwidth is one challenge. Now, they’re getting it. They have a lot of cables being laid. They don’t have the technology, so we actually provide them solutions, whether our own or something else that they would need to be able to do it. They need help in multiple levels. Even in India, we’re working with the Tibet government, the non-China controlled Tibet to set up telemedicine. The villagers keep cutting the cables and taking the internet cables away. We’ve have to work with the government in that area to actually encase it, steel encasing, so you kind of have to get to very basic levels of making this work.
When the Tibet health minister came to visit, he said, “We want to set this up, but please understand, you have to come, you have to plug in the computer. You have to turn on the computer. That’s how you have to build this up.” You have to go down very much to the basic level in a lot of these places to show them, “Okay, you turn computer, then you click on this button.” We’ve had to do a lot of training of our own guys. Don’t assume everybody knows what you already took 10 years to know. I think, again, there are opportunities then for not just technology deployment, training, how do you use the technology, and then of course the service itself in terms of the doctor and so on.
Moderator: I don’t see any other questions at this time, so let’s once again thank-
Sunita M.: There is now.
Moderator: I’m sorry. It’s such a long walk up here, I apologize.
Audience 2: Ms. Chief Dreamer, what is your 2012 dream?
Sunita M.: 2012 dream. See, the thing with dreams is they just have to come. Someone used to ask me, “How do you get the idea?” I’m like, “No, trust me, I do not just sit there thinking, idea come, idea come, idea come.” You kind of have to allow it to flow in, and one of the things I do is to keep a paper and pen somewhere nearby. The minute that thought, that dream, that idea comes, I write it down. If I haven’t written it down, it’s gone. I will sometimes wake up at 3:00 in the morning. You know how to get something as you’re in your sleep? I actually have a list of dreams.
I put it down, I don’t implement all of them necessarily the same time. For instance, telemedicine, I thought of four years ago. I wrote an article in Business India about why telemedicine has failed in India. What are the things we could do to make it succeed? At that point, there wasn’t even the Cisco technology available. I think my dreams, aims for 2012 are telemedicine. To take it into as many villages in India as we can and in Africa, because we’ve been trying for the last 50, 70 years to get doctors to rural parts, and it hasn’t worked. The new health minister in India said, “It’s mandatory that every doctor, when he finishes med school is going to go out to the villages.” The ministers say “mandatory,” they’re all running the other direction. There’s a one-way ticket away from the village.
They were not able to get doctors out there. Ultimately, we’re going to have to accept that and do it. Again, I truly believe in cooperation, that I can’t do this alone. I can certainly do it along with Cisco. To get telemedicine, aim is by the end of 2013 we should be in about 100, 120 sites across India. For that, it takes a lot of pushing, a lot of turning on that computer plug. The dream is one, but I realized I cannot just dream. I can’t dream and then say, “Okay, it’s someone else’s job to make sure this happens.” You kind of have to combine the dreaming with the pushing. I have realized it’s important to keep dreaming, to not stop and to actually put the thought out there.
My son plays tennis and he was 140 in the country. He would keep getting knocked on Monday. Monday’s when the tournament starts. He says, “I don’t think I’ll ever get past Monday.” I said, “No, no, no. You’re going to be number one in India. You put that thought out there, you keep saying it every day. I’m going to be number one in India.” Every night when he went to sleep, I would whisper, “You’re going to be number one. Your time is coming. Your time is coming.”
This year, he’s India’s number one tennis player, and he says, “You know, do you think all that stuff you were saying got stuck in my head? How did it happen?” I said, “Well, you have to learn to put the thought out there.” I’m a realist. I know sometimes you put the thought out and it doesn’t happen, but I truly believe that it’s important to put it out, even if not for the rest of the world, because we are worried about are they going to laugh at us if we didn’t make it, but have our own private little notebook or our little Blackberry or our mirror in the bathroom where it goes out there.
Moderator: I don’t want to overlook anybody. I don’t see anyone else jogging up to the microphones from the back at this point. Thank you, doctor, so much for your time-
Sunita M.: My pleasure.
Moderator: … For coming here and sharing that with us.
Sunita M.: Thank you.
Moderator: Thank you all very much. Let’s once again thank Dr. Maheshwari.
Sunita M.: Thank you.