On the Health Record - Interview with Michael Hsu, COO of Curogram

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In one of our recent interviews, we talked with Curogram COO, Michael Hsu, on why a Skype engineer started a digital messaging platform for practices, and how, despite devastating consequences, COVID-19 has accelerated the adoption of healthcare technology. You can listen to the full episode on Spotify or YouTube.

Can you tell me about how Curogram got started?

Yeah, it’s an interesting story. When Skype was purchased by Microsoft, they were trying to move engineers up to Seattle. Shayan [Curogram CEO and founder] was an engineer there but had always wanted to start his own business. He was very interested in healthcare, as he’s got doctors in the family, and he’d been playing with the current Curogram concept and had actually built a prototype for a doctor locally in the Bay area. It all started because he was in a meeting at Skype one day, and he got a call from an unknown number. He didn’t recognize it so he let it go to voicemail. It turns out it was his doctor calling him and trying to remind him about his appointment. He never checked the voicemail and ended up missing an important appointment.

He asked his doctor why he couldn’t text him, and he said that they didn’t have a way to do it. So Shayan asked, “Can I build you something? And if I build it for you would you use it?” And they said they would. So he built it and didn’t think much of it. Three months later, he checked his database and saw they were still using it, so he started giving it out to a few other doctors. Then he connected with another doctor down in Newport Beach and showed it to him, and the doctor said, “Hey, this is something critical that we really need in our industry. You should quit your job at Skype and do this full time.” And when Microsoft was pushing to move engineers up to Seattle, he was faced with the decision between rainy Seattle or sunny Newport. So that kind of made it an easy decision. That’s really how Curogram got started.

When he moved down, he just started living in the primary care/urgent care office. For six months, he was at the front desk talking to staff and patients like he was an employee. Then at night he’d go in the conference room and code. I think that is one of the reasons why the softwares is so highly used and engaging today - it’s really been built from inside medical practices.

COVID-19 has been terrible and frightening, but it has shifted things in a lot of ways. What are the ways that COVID has accelerated telehealth and healthcare in general?

Not to lighten the negative aspects of COVID, but I think it has really done some things on the positive side for the healthcare industry in general. Telemedicine and remote care interactions with patients really was the future, and the biggest challenge was the bureaucracy of the system and reimbursements. This technology has been around for a while, but the system has not really supported it or made it very accessible, or even incentivized doctors to use it. In a lot of ways, patients didn’t get the benefit of the technology, because the system wasn’t set up to push it, and overnight the entire world has changed.

Within the US, the biggest change was that CMS started reimbursing telemedicine visits in the same way that they reimbursed in-person visits, and then you saw payers following. For physicians now, it’s no different if they see a patient in-person or via telemedicine. Of course today they’re forced into a telemedicine visit because they don’t have a choice, but going forward in the future, assuming that those policies stay in place- which I think a lot of them will- the physician now has the ability to not be restricted by the financial constraints. They can say, “Hey, this is going to be a better experience for both the patient and me.”

If the standard of care is the same, then they’ve saved a patient a trip to the office. I used to hate going to my primary care office, because I knew they lied to me and told me that my appointment is at 8:45, and I know on their calendar, it’s probably 9:30 or 10. I was always in the waiting room for at least an hour every time, no exception.

I want to hear more about virtual waiting rooms, but before that, can you tell me what communication between patients and providers traditionally looked like before solutions like Curogram?

When Shayan first started working with the doctor in Newport, they went around to over 200 offices in the local area. They were just knocking on doors in their scrubs and talking to the local community doctors and understanding what their pain points were and what their problems were. The consistent point of feedback was that everyone hated the phone. The phone was blowing up their office. They had too many phone calls and not enough staff to answer them. Patients hated the phone too, because they hate dialing in and listening to a phone tree and spending time trying to navigate it. Then you finally navigate it and you get put on hold.

What they learned from this whole thing was that the primary form of communication between offices and patients is not the patient portal. It’s the phone, because most patient tools are still under-utilized substantially. At the end of the day, probably 90% or more of the communication between an office and the patient is over the phone, and that’s really the problem that we set out to solve. How do we improve that communication channel, and how do we replace the phone with text? Because that’s exactly what’s happened in our personal lives.

Let’s go back to virtual rooms and virtual clinics. Can you tell me what that’s all about?

Yeah. That goes back to the idea that when you think about how a patient goes through an in-person visit, they’re coming through a physical lobby, and then they go to a waiting room. Then they go to a physical room, and then from there, they go to the exam room. From the exam room, they go to the checkout counter. These are all different physical locations in a practice. When you think about telemedicine, if you’re just looking at a video chat application, none of those touch points exist.

So when we say virtual clinic, we give you those virtual touch points like you would have in an actual physical clinic, so in our system, you can set different statuses. When a patient clicks on that link, they automatically get put into the video chat, but on your side in the office, it will tell you what stage that patient’s in. So when that patient first logs in, it’ll say, “Hey, that patient’s in the lobby.”

So as a front desk person, I don’t need to see the patients that are in the exam room. I need to see the patients that are in the lobby. Now imagine a clinic that has 10 doctors and each doctor is seeing dozens of patients. And that person is looking at a telemedicine schedule that has hundreds of patients. How do you deal with that? Well, as a front desk person, you can filter your tools and just show patients that are in the lobby for Dr. Lee, let’s say. That takes one hundred lists of one hundred appointments down to five.

Then I can go in and virtually check them in, text them a request to pay their copay or fill out a form. I can switch the status, and I can move them from the lobby to the exam room. Then I can switch the status and change it to show they’re ready for a consult. As a doctor, I don’t really care about the patients in the lobby or anywhere else until they’re ready to see me.

Who is impacted the most by these telehealth visits? I personally think about the people who live in rural areas or elderly folks that are unable to drive. But who do you think this has the biggest impact on?

The beauty of what’s happened here is that because telehealth was a niche due to bureaucracy and reimbursement structures, only certain populations could benefit from it, like rural areas and things like that. Assuming that these financial alignments stay in place, the big shift is that now the general population is going to equally see the benefit of it. That’s really the paradigm shift that we’re seeing- this used to be a niche product for a very slim number of people and not just on the patient side, but even on the doctor’s side. Only certain doctors were really practicing telemedicine because the typical doctor wasn’t qualified in-network as a telemedicine provider. So you had these telemedicine companies that are aggregates of doctors around the country, and if I understand those models correctly, a lot of those doctors were doing that on the side part-time. But if you think about it, as a patient with Blue Cross Blue Shield, and I want to see a doctor via telehealth, they might say that they’re only contracted with these certain doctors on Teladoc or whatever it is, so your personal doctor may not be in-network with them.

That’s not very enticing for me as a patient, especially if you’ve got a relationship with the doctor in your community. What’s happened now is that it doesn’t matter where I am or what my situation is.Now, it just becomes a difference of whether it’s better for a doctor to see a patient in person or via virtual visit. It’s just about what is the right method of care. So I think it’s impacting the general patient population and all the general doctors, and so that’s why this is so powerful. We just saw maybe 10 or 20-plus years of acceleration and evolution in this market happen in literally days.

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