Founder Stories: Shiv Rao, Co-Founder and CEO of Abridge

Thanks for tuning in today. I'm Dr. Nick, the Incrementalist. Join me as I seek out the small incremental changes being applied in other industries that we can learn from and that can be applied in healthcare. Can these changes bring immediate value, but also add up to the big improvements and revolution we need in healthcare? Come along with me to explore the possibilities. My innovative guests from around the globe have used small incremental improvements to achieve their moonshot.

And today, I'm delighted to be joined by Dr. Shiv Rao. He is the CEO and co-founder of Abridge, and also a cardiologist. Shiv, thanks for joining me today.

Pleasure to be here. Thanks, Nick.

So for the benefit of the listeners, as we always do, I like to sort of dive into a little bit of your background. Yours is not a traditional journey necessarily to medicine. Tell us a little bit about how you got to this point in your career.

Yeah, and if I start to tell you too long of a story, just let me know, and I'll cut this short. But I'm a cardiologist. That said, I've been living at the intersection of healthcare and tech for over a decade. Way back in the day, I went to Carnegie Mellon for my undergrad. And, uh, amazingly enough, I studied everything I'm not doing today. I was a history major. I wanted to be an architect, spending too much of my time skateboarding. And then I was convinced by an architecture professor that I was rebelling against all the Indian doctors in the world and in my family, and that I actually wanted to be a doctor. And he was right. He told me a really inspiring story about an ophthalmologist who had given eyesight to, you know, hundreds of thousands of people in India. And I made a late pivot, did my pre-med requirements while making music and helping, you know, a record label sell records in Japan, believe it or not, and then went to med school and had a good time initially, but quickly realized that I didn't see a lot of room for creativity or obvious places for me to be creative. And have all the respect in the world for basic science research, but that 13-year bench to bedside feedback loop isn't for me. And that's where sort of tech entered the story. I discovered what tech could do when I helped to develop an application of sorts for my residency program at the University of Michigan and experienced some peasant level of product market fit. When people were using it, but also offered to pay for it. And I decided then and there that I wanted to really, really double down on, on what software could do for healthcare over time. So fast forward, you know, many, many years later, um, and, uh, a couple startups later, I ended up being in the right place at the right time after my cardiology fellowship at UPMC and landed a job at their a corporate venture lab of sorts. It's called ePMC Enterprises. And I violated Peter's principle, I'm sure, several times over a few years, going from someone who was helping on product teams to being head of strategy, and then ended up being one of the 3 checkwriters, one of the 3 investors investing on the provider side of their portfolio. But I quit that job in March of 2018 to fully focus on this idea. And I think what I realized about this specific idea about a bridge was that this specific technology has the potential to help so many more people than I could see in my weekly clinic.

So I mean, there's so much to unpack there, not least of all the sort of pivot. Do you think— because one of the conversations I hear repeatedly is, you know, to get into medical school, you really have to be heads-down focused. Do you think that gave you an additional important perspective that you weren't focused on it initially?

Yeah, I like to think so. You know, IDEO talks about T-shaped people, people who are really, really deep in one area but can cross the T with another discipline. And but that, that being able to cross the T, they, they say, I think, that it gives the individual a lot more perspective potentially, and a lot more ways to sort of be creative because they can connect the dots across different disciplines. And I hope that to some extent, I'm able to do that in that I studied pretty disparate fields and also was able to spend a good amount of my time as an undergrad doing creative things.

And it's interesting, the architectural world has obviously lost a leader in that space since you came over to the healthcare space instead. And in that journey, you talk about multiple startups, ultimately coming to this one. Tell us a little bit about Abridge, what it is, and how it came about.

Yeah, absolutely. First of all, I don't want to overstate my contributions to architecture. That journey never really began. Our vision at Abridge is to bring more compassion and confidence to every step of a person's health journey. We help people capture the details of their care so they can follow through on their doctor's recommendations and gain more peace of mind. And to date, more than 50,000 people have downloaded Abridge across the United States, and they're using Abridge for all types of health conversations, from annual examinations to specialist appointments. It helps them understand the details of their health, from the high-level care plan down to the details of their diagnoses, procedures, and their medications.

So in the genesis of this, how did you come up with this idea? I mean, it resonates with, I think, patients, probably resonates with physicians, but where did this come from? What was going on to sort of drive you to this concept?

Well, I think there's a founding story between myself and my co-founder and our CTO, Sandeep. Where both of us, I think, have personal experiences that inform our conviction around this idea. There are also, I think, kind of theses around the market that inform our perspective and our conviction on pursuing this. So from a personal standpoint, or maybe I'll start with a thesis. I think a part of our thesis is that upstream of all the diagnostics in healthcare, whether it's a chest X-ray or a CT scan or, some blood chemistries, and upstream of all the therapeutics in healthcare, whether it's a baby aspirin or a pandemic vaccination or some cutting-edge immunotherapy, upstream of everything in healthcare is a conversation. And that is increasingly happening over telemedicine, but certainly it will always also happen in person. And in that conversation, all of us as people, we're telling the story of our symptoms, the stories of our families. And what are clinicians doing? Clinicians are writing histories and physicals. That's the archetypal clinical document, a history. And so our thesis is that if we can empower people to actually capture the details of these stories as they're being told and the details of their care plans as, as they're being told, and if we can structure that information and make sense of it, then we can help people do two things. And this is really the mission of the company to number one, help them better understand understand their health. And number 2, we can help them better follow through. And if we can do those 2 things, then over time, our ambition is to, to, to move the needle also on not just clinical experiences, but also on outcomes.

So tell us a little bit about the personal stories of, you know, how this came about.

Yeah, absolutely. So My co-founder Sandeep would tell you his story about his, his grandmother with breast cancer and accompanying her to the hospital and gaining conviction that he wanted to play a part in improving that healthcare delivery experience for everyone. My personal story is that years ago, my wife and I found out about a rare disease in our family, and to have a healthy child, we needed to go through years of IVF. And it's a happy ending. We have twin 4-year-old boys who are incredibly privileged. But so often my wife would come back from a visit and I'd ask her, like so many family members, what did the doctor say? And so often she'd say, I don't know. And some portion of the time it's because they were telling her, but when you're going through something, it can be in one ear, out the other. So hard to remember what's happening. It can be overwhelming. Also, I think a third of the time, I realized some portion of the time they weren't telling her. Some portion of the time, the way the system is designed, you can feel as a person and like you're being sort of shuttled through a maze. But also there's another third of the time where I realized that she knew exactly what was going on, but it can be, it can feel like death by a thousand paper cuts to have to repeat your story over and over and over again to everyone from, you know, the radiology technologist to the med student, to the consultant, to every single family member. But as a doctor, I saw a patient in March of 2018, the same month I quit my job as a cardiologist or mostly walked away from it. I still see patients from time to time, but certainly walked away from my job as an ambassador for UPMC. I saw a patient in my weekly clinic. She had a 10-year history of breast cancer and she was about to start chemotherapy that could affect her heart. And she, she was coming to see me for cardiac clearance because some chemotherapeutics can, can affect the heart muscle. And she was super nervous and anxious, like crawling out of her skin. And so at the end, I asked her why and if there was something I did or something I said to make her feel so uncomfortable. And she told me that for the last 10 years, her husband had come to every single visit with a, with a doctor or a nurse, except this one. He just couldn't make it. So I asked, I asked her, well, what does he do that's not obvious? And she told me that he sits in the corner, he's quiet, he just takes notes. She's an English professor and incredibly eloquent, but she taught me, she explained to me that when you're going through something and it doesn't matter how serious, it can be very overwhelming and it can be really hard to be present and to build a relationship with your doctor or your nurse. And so him taking notes meant that she could feel liberated to be in the moment, knowing that they could go home and unpack all of those notes and combine them with with their own thoughts, their own research, their own potential second opinions from family, friends, and they could go to the next clinician, next doctor or nurse, and armed with this better understanding, they could feel like the main characters as opposed to someone looking in from the outside. So in a sense, everything that her husband did in the corner of the room, everything that they did at home in terms of unpacking those conversations and better understanding them and then better following through is what we're trying to distribute, democratize for everyone out there.

So for those of you just joining, I'm Dr. Nick, The Incrementalist, and today I'm talking to Dr. Shiv Rao. He is the CEO and co-founder of The Bridge and also a cardiologist. We were just talking about the setup and the story behind The Bridge. And what it sounds like is we all need one of those individuals in the corner of the room. But of course, that's not easy to do. It's not a scalable solution. And here you come and say, well, we can put technology to work at that, but that's not a simple task. How did you go about that process to create something that would allow for this?

Yeah, it's a great question. And it's taken a good amount of time, a good amount of R&D to get to the point where we could deliver a user experience, a useful user experience. In terms of the problem, because I think that maps to the solution and the R&D, we realized very quickly that a few things about humans actually, and this, a lot of this from our own user research, but one is that people forget the details. We, there's research out there out of Dartmouth that suggests that people forget up to 85% of what the doctor said, which is, you know, a mind-blowing statistic. And we also, there's good research out there to suggest that lower health literacy is associated with lower recall and that The current solutions out there are either not personalized enough, they're way too cookie cutter in terms of patient education, or they're way too specific and not necessarily meeting people where they are. When we asked our own users about how much they forget, they told us that they forget up to 40, 45% of their conversations with doctors. That's a crazy number in and of itself, but then The real kind of kicker for me personally as a clinician was when we asked them what they actually remember. They said the very beginning, the pleasantries, you know, like, "Hey Nick, it's been 6 months. How's your family? Like, how's soccer practice with the kids?" That kind of thing. And then the very end where it's like, "All right, Nick, you're doing great. I'll see you in 6 months." But everything in between where, you know, a new diagnostic, a new therapeutic, a drug formulation, you know, how many milligrams of a pill and when to take it and like with what, all of that in one ear and out the other. And that's mind-blowing to me because we use words that don't, don't really make a lot of sense, like compliance in healthcare, you know, in the healthcare system proper. And we also use better words like adherence, but how can we expect any of us as humans to adhere when we don't remember any of this? And part of the reason we don't remember is that people feel very emotional when they're in a visit, especially when they're talking about something real, when they're talking about their health. And it can be very difficult to focus. And we also learned from people that they want to take an active approach to their care. They want to be on the same page with their care team, but also everyone around them. Something that we learned during the pandemic was that this problem, everything I just mentioned, is amplified with telemedicine to some extent, because telemedicine visits, the nature of the medium can make them shorter, more transactional. And that as care gets more fragmented, as I use a consumer app for a certain pill and then go to an urgent care for different problem and then go to an academic health center for something else. There, it's very difficult to connect the dots across all of those conversations, all of that care, and understand the bigger picture of this. So from a technology perspective, we needed to make sure that we could not only capture the conversation— and so there's challenges around being able to capture audio— but also go beyond that and structure the information in the conversation. So there's information extraction, some challenges, and also from a machine learning perspective, there's extractive summarization challenges that we've been working hard on over the last couple years. And it took us a great deal of time to get to the point where we felt like we were there. We had built something that started to approximate, you know, my patient's husband in the corner of the room.

So as you think back to that journey, I mean, it's been an extended period of time applying components of machine learning, natural language processing, obviously audio issues, and technology has improved over that period of time, but I can't imagine that the audio has made a big difference. Maybe it has, I don't know. Looking back, were there any sort of inflection points you go, wow, that was a really helpful insight that made a difference and really changed the trajectory for the better for the company and what you were trying to put together?

Well, I think we can also almost map every single one of the Influxion insights within the company to the mission of the company. We want to help people, one, better understand their health, and number two, better follow through. And all of the technology research that we do, all the machine learning, all of the app and user experiences have to map to those two, like, aspects of our mission. Um, because the four main benefits that we help people with is we help them, as we heard from our users, is that we number one help them stay on top of their health, two we help them see the big picture, three we help them all stay on the same page, which is so important, important during the pandemic, And then 4, this is maybe most profound of all, but we heard from so many people that it gives them peace of mind. So in terms of that technology and how we sort of grade ourselves and how well we're helping people, so far to date for over 50,000 people, we've helped them better understand over 400,000 medical terms in a conversation. So that point when a clinician might say to you, like use the word arrhythmia, or might start a new medication called hydrochlorothiazide, or might talk about a surgical procedure like a transcatheter aortic valvuloplasty. So this is medical jargon, and we're trying to translate that for people. We're trying to help them better understand that. And similarly, there are those moments in the conversation where the doctor or the nurse or the PA, you know, gives, drops a takeaway, like a next step. The care plan, like everything from you gotta stop smoking, I can hear it in your voice, all the way to see me in 6 months, all the way to start this medication or stop this medication. And one of the key technological challenges that we've been working on that is key to our mission around helping people follow through is being able to extract those next steps in a conversation automatically. And then being able to nudge people, being able to remind them of those next steps. And that's not like a low-hanging challenge. And I think one inflection point was recognizing, realizing at some point over the last year that we could really tackle this, that we could get to a certain level of accuracy and deliver an experience that actually helps people after they've left the exam room, because most of the journey doesn't happen in the exam room itself.

Fantastic. So, you know, the application of technology that essentially allows other individuals who didn't go to medical school— and one of the things I recall very early on was being told that it was no different to learning a foreign language, going to medical school, all the terminology. Now, there were some aspects to it, you know, when you talk about those phrases, what triggers in my mind is my Latin because we sort of construct and, you know, you can interpolate terms and phrases that you don't use. And of course, if you don't have any of that background, you've got nothing. So you're applying all of that, improving literacy. And, you know, in the context of COVID-19, of course, we're in even worse circumstances with, you know, limits to people being allowed in. My sense of this is that this is even more relevant at this point in time, both for in-person but potentially for telemedicine. What's going on in that space and where are you sort of providing this? You've got the 50,000, but do you see this expanding beyond that? Yeah, absolutely.

And you're spot on. And now more than ever, this is really important. Like a quick story. Amazingly enough, this is a story about the first patient I ever saw as a resident at the University of Michigan in my first week. I'm about to walk into her room and I'm feeling pretty arrogant about being at Michigan and that I probably know 10x more than the patient and I can really deliver a care plan and help them. And little did I know that in Ann Arbor, so much of the patient population has a PhD already. And so I walk into the room without doing too much pre-reading, and within a minute this patient is starting to quiz me on whether or not she has multiple endocrine neoplasia type 2A or 2B. And, you know, for those who don't know, this is like, this is like a question you get on your MCATs, you know. This is like a question you memorized and you forgot, you've forgotten, it's never applicable again.

Yeah, except at this point in time.

Exactly. And I remember feeling like, at first being like, what is this? 'What is this? Like, I did not expect this conversation and this level of discourse.' And really quickly, thankfully, realizing that we should chat about this and I should be transparent. And I told her like, 'Okay, great question. Let's look this up together. I vaguely remember, but it would be better if we both looked it up together.' And we did. And we had a conversation about it. And I still had something differentiated to offer. I remember feeling good. That I could translate things in a way that, that could be useful. But I walked away thinking, like, if this is what healthcare delivery looks like, this is not something I was prepared for. And what I subsequently realized over the next 3 years of residency is that it's not what healthcare delivery usually looks like. But if it was what healthcare delivery actually looked like, what would relationships between clinicians and consumers, you know, doctors and patients, look like? We think it would look really powerful. Like if all of us felt like we were truly building relationships that we were both benefiting, that both parts of the story, not only like the patient's symptoms, but also the clinician's care plan. These are the bookends of an archetypal clinical document. The history of present illness comes from the patient and the assessment and plan from the clinician. They're both equally important. It takes two to create that healthcare narrative. And so what if like in using a bridge, we can actually thread the needle through both sets of important end users, anchor on the consumer, and help people better understand and follow through. So yeah, I'm sorry if I didn't answer your question, but I think when we pitched our company for seed financing, we used a metaphor where we called this SoundCloud meets Rap Genius for healthcare. SoundCloud in that when you record a conversation, you're creating content in a sense, but Rap Genius because We can help translate not a rap song's lyrics, but we can translate the actual medical conversation and help people better understand it. So a lot of our mission, at the end of the day, maps to that ambition.

Fantastic. So in the remaining time that we've got, can you share any insights of where you see this going?

Yeah, absolutely. I think one really quick point about the current pandemic is that we've heard from so many of our users that they're unable to bring their member into their exam room, whether it's in an urgent care or a hospital, and they've been able to use a bridge to stay on the same page. So that's like one important reason why now more than ever there's so much value in being able to record these conversations and keep everyone on the same page. And we've heard the same thing from clinicians, that it's helping their patients do the same thing. But I think like from, from a really high-level perspective It's an interesting time in the country, obviously. And while the political future of something like the ACA may be unclear, one aspect of the ACA that is absolutely here to stay with strong bipartisan support is that the patient is entitled to an electronic copy of their records, including the clinical notes, as we've seen over just the last few weeks with the information blocking rule and hospital systems exposing clinical documents to their patients. So this is very aligned with that same idea, with the same mission. This is an arc of history that everyone gets behind, which is that everyone can benefit when they better understand these medical conversations. So we're riding that. And I think what we're really excited to tell you and everyone else more about over the coming weeks is how we can align everybody in the system, not just the end users, like the patients and the doctors, but also the hospitals, around this idea.

Fantastic. Unfortunately, as usual, we've run out of time, so it just remains for me to thank you for joining me on the show. Shiv, thanks for coming on the show.

Thank you so much, Nick. It's been a privilege.

Thanks for joining me today. Do you have any better ideas, or have you found a small incremental change that's brought about a big improvement in your world? Let's continue the conversation on our hashtag, #TheIncrementalist, or share with me @DrNickWong on Twitter. You can find more information about the show on our program page at healthcarenowradio.com, and tune in next time to hear my discussions with leaders and innovators from around the globe who've revolutionized their space by using small incremental improvements to achieve their moonshot. I'm Dr. Nick, the Incrementalist, and I'm starting a revolution through evolution.