 Hello everyone, welcome to another Thought Leadership session powered by Voice of Healthcare. My name is Kaustubh Chatterjee. I'm working as a principal with Frostman Sullivan's Global Healthcare and Life Sciences team. And today I have with me an esteemed guest from one of the leading hospitals in India, is Deepak Venugopalan. He has over 23 years of experience in healthcare business management, the last eight years of which has been in senior management and leadership roles. Directly, he has worked with proprietors and board of directors. He has gained a substantial experience across all functions, functional areas of management, including enterprise-wide B&L management, green and brown-fill initiatives and public-private partnerships between leading private hospitals and large and government agencies. He has worked across different healthcare markets of the country. In fact, he has traveled all over India. He has experience working in Bangalore, Chennai, Hyderabad, Maharashtra, Goa, Gujarat, NCHH, Kolkata. So East-West, North-South, he has been everywhere. So he's basically at the center of everything happening in the private side of healthcare today. Right now, he's working as a chief operating officer regionally for Manipal hospitals. And he is managing a large team and an entire flagship hospital with 600 beds that has been put up for quaternary care setup. So Deepak, thank you very much for your time today. I formally welcome you to the conversation. Thanks so much, Kasta, and thanks for the introduction. And thank you to the Voice of Healthcare team also to get me on this program. So looking forward to spend some quality time with you. The pleasure is all ours. So let's start with COVID-19. We have done a lot of webinars already around COVID-19 and what COVID-19 has changed in the hospital operation side. As we are slowly moving past this deadly pandemic, we now need to know how hospitals are fundamentally changing their healthcare operations and restructuring their cost frameworks to ensure that they stay resilient and sustain the momentum of high growth in the next three to five years. So the first question to you is, you're managing a pretty large hospital, one of the fairly well-known hospitals in India, Manipal hospitals in Bangalore. How have you steered the ship during this huge pandemic and disruptions in elective surgeries and obviously fluctuation in inflows of patients? So how have you managed the operations of such a large hospital and what is ahead in front of you as we are moving past this pandemic? So that's an interesting question, Kasta, especially as I say, the human memory typically is quite short-lived and it's not even a year since, I think it was March 21st when the honorable Prime Minister called for this Janta curfew, right? And then there was this period of lockdown which was in 24th of March. So as healthcare professionals, I would say that it's been a roller coaster ride for all of us. And I remember the 22nd of March when the PM asked everybody to come out and clap for the healthcare providers. And there were these emotional videos flowing around how doctor mothers could not come back home for Diwali. There were multiple stories of heroism that I think as healthcare players have gotten to displaying. There were also the downsides where I think the industry was subjected to some media trials for COVID billing, as they said. There were South societies where doctors and nurses were asked to move on because of risk of infection. So I would still say that for us, it has been this model of Kavikushika become exactly going to this last one, one year almost, which is going to be concluding now. But I think some three broad learnings that definitely came out was dealing with uncertainty for sure. Because we did not know what we were dealing with. I think number two was developing a protocol around that to kind of deal with these uncertainties and also be very nimble and on the ground because it was constantly evolving parameters. And for Manipal Hospital, I think the core was around our people, first philosophy, cross the river to summarize it in a way that we felt that our employees are most important to us. We ensure that their health was taken care of. I'm proud to say that we didn't have a single layer of a single person who was asked to leave. It's a large financial distress that happened in the quarter one, quarter two. We did go through our little pressures and funds. But I think the philosophy from the senior leadership team was very clear that let's stay together, take care of each other. And I think that set the ground to deal with this pandemic that you were specifically asking. The second part was of course, the human part of healthcare brought out because we started working very closely with the government missionaries. The stakeholders from the communities got together. So there was a lot of team mystifying healthcare, if I could use the word just to kind of get closer to the reality on the ground with people and their emotions. And the second part was about building clinical predictability. So I think the disease began to evolve and doctors began to understand what's working on them from tablet protocols to egg mowers to pro-ventilation. I think the clinical predictability is something which kind of made us very distinct from a lot of other hospitals, especially treating patients and creating a brand loyalist out of that because people who got treated with us when they were most vulnerable, if you would imagine for the fear of losing their lives and then coming out of a hospital safe. I think has created a very new band of loyalists to our brand because they believe that this was a place where they kind of caught a second life to that extent. So that was the second part which kind of became a cold focus. And then specifically to your question on cost research, I mean, there have been a restructuring that we have built into a system in terms of more efficient consumption handling, doctors restructuring in terms of helping them and us kind of ensure that these costs are better managed. Infrastructure also cost a lot of changes in terms of dealing with fibril as a disease, right? Fibril clinics, respiratory ICUs, especially like ENT, octel, dental again, very close proximity to treatment plan. So I think what we realized is we have modified behavior as a new normal as we kept using the word has definitely got reinstated in our system now and it's much more robust and strong to deal with this. So I think that's broadly what it is. And specifically to your question again, people did delay their healthcare buying behavior. So the complexity of care and kind of bent up. So somebody who was dealing with an acute abdomen not coming to a hospital got into a few complications because he or she had to stay back at home with the fear of not coming to the hospital. So we went through that exercise, but I think the last quarter and the quarter for the bent up demand is beginning to come out into the hospital and people are visiting it more, you know, bolder to believe that the hospital is better to handle their emergency. So if I could quickly ask you about the role of technology in reimagining healthcare operations for you post COVID-19. We briefly chatted before the discussion about the role of artificial intelligence and other progressive technologies for you to deliver healthcare at scale and also approach every patient individually based on their, you know, individual health history. So could you talk about a little bit more about the technology, appetite, manipul hospitals have right now post COVID-19? Do you believe that COVID-19 was really an accelerator for higher adoption of progressive technologies across all departments within a hospital? I think that's a great question, Gospa, because I think all of us as healthcare managers have never put on a hat of a data scientist, right? I mean, we're all being running hospitals on a very brick and mortar model and believing that we need to be on the ground. But I think the moment we put in this and you have a vast experience in this area because of the digital practice that you have. So, you know, all of us need to start visualizing the power of data and begin to realize that how do you use it on a daily basis? So to give you an example, I mean, in my 23 years as I've been building my career in healthcare, initially I never visualized a quality video consultation happening with a patient and his doctor where they could make meaningful diagnosis and which is exactly what happened on those April, May, June where almost 100% of our opiaries were actually being video-concerted, you know? So the doctor and the patient had a very meaningful transaction. The EMR was getting built in, you know? And that EMR began to get into a longitudinal flow across the period of his stay or his hospitalization with us. So I think that was a major breakthrough in our minds when people began to consult through a video consultation and also pediatric cases, you know? We had dermatology issues, we had, again, cardiology, follow-ups, so the continuum of care was very strongly put around this. Yeah, so I think that has been a major change which we have been noticing and rest of them are evolving. So, you know, the artificial intelligence we used in terms of having a disease management program, a chronic disease management program, again, are, again, evolving. And I think we are partnering with a lot of like-minded players in the field which have their core competence in these areas because we are a healthcare delivery company. We are not technically an information technology company, but one of our cornerstones for the next years of growth is the digital transformation. So the entire team is oriented to it and it's working well for us, yes. Speaking about digital transformation, let me quickly share findings of a consumer survey we did among the top CEOs globally, not only in India. And almost 65 to 75% of them mentioned that yes, digital transformation is their core agenda and they're actively placing strategic bets towards making their infrastructure more digitally savvy and they're also making investment towards external collaborations. They're beefing up their own internal IT teams to ensure that they can successfully collaborate with a lot of third-party players to ensure that the care continuum is completely digitized and their patients receive care in equal standard when the patients are in the hospital and when the patients are moving away from that hospital. And we'll talk about the aspect of care delivered beyond hospitals, but right now one key question I wanted to ask around digital transformation is although 75% mentioned that they're eager to invest towards digital transformation, all of them also believe almost 90% of them believed that it's not an easy task to do and it's a long-term game, three to five years is the timeframe they have in mind before they can completely digitize their entire healthcare ecosystem within the hospital and outside. And some of the challenges they're facing is obviously centered around interoperability. Interoperability is one of the core issues that these large hospitals are facing. And when I talk about interoperability, it doesn't mean always the fact that a hospital is not able to collaborate or exchange information with another hospital outside its network. In many cases, even in India, we found that some large hospitals, these are integrated delivery networks which were not able to exchange information within their own hospital from one department to another department. So if a pharmacy within a large hospital system would like to send some information to the lab or the physician directly through our central EMR portal or HIS portal, many large fairly well-known hospitals in India are not able to do that. So speaking about your experience dealing with progressive technologies in Manipal Hospital, have you faced any such challenges of, first of all, establishing seamless interoperability across all the departments and second, dealing with external health systems to exchange information or share information? I think there's a concept of a unique health identifier number, the UHID, as we have for last 10 to 15 years. I mean, very early part of our careers, there was a concept that one UHID, that UHID stacks the medical record with the patient and the patient can flow from one hospital to the next and is seamless. But I think that cost of is a change in mindset where every one of us, including say the nursing, the lab technician, the nursing doctors, your paramedical staff, everybody starts contributing in building that digital story, right? And what happens is, this interoperability does fail when the chain starts getting broken out because there is a paper pen that comes to the table and the paper is scanned, that the data can be mined forward. So honestly, we wouldn't want to claim that we have really mastered this art, we are going through the transition and the senior leadership team again is believing that it must become a way of their daily life. For example, if I start interviewing a candidate without getting them to fill up a paper pen and get everything digitized, the person has a form to fill up a CV and we start practicing digitization in various aspects of hospital operation, not just the clinical part. I think we are going to start walking the first journey. So computer on wheels, point of care devices which can kind of capture the vitals of a patient directly from the monitors and start building that electronic record is the start point. And I think in our context, we have a fairly robust IT system which has stabilized for last many years and that has helped at least, as they say, the health level, the staging. So we would definitely be in a stage where our lab diagnostics in the back systems are all now kind of interoperable. The gap still remains around capturing that core clinical histories at the bedside because or the OPD desk because the doctor would prefer to have a dialogue and still have a pen and paper written which is the journey we are trying to now cross. I think it has to be where the users see value in why they're doing it. And I don't think it can really be enforced in a way that they are forced to do with the single key typing which kind of takes away the charm of it. So even today we are doing this chat on an online platform and it's as meaningful as it would have been if you were face to face. I think that evolution is more of a change in our behavior as a daily transaction with digitization, which will then go into your operational transactions at the workplace too. So I think that's the way I would look at it. We are walking towards it. It's not easy, but for sure as we are moving along we're beginning to realize that it has to be around the daily lives. So it has to be as seamless in terms of applying for my leave on my app which has been developed. Now we were Dr. App which is fairly robust. We have a patient app which is robust. So I think when people can transact their banking on an app, why not healthcare, right? So we need to start moving that journey and I think we're making some first steps there for sure. Thank you for that insight. Deepak, let's now touch upon the other aspect we briefly talked about prior to this question which is how care is delivered outside hospitals and how hospitals are playing an increasingly important role to make that happen on behalf of patients. And also I wanted to understand from your standpoint if you're delivering care outside your hospitals and basically bridging the gap that we are witnessing across India when they leave their health systems and go to their homes or go to another hospital. So what role Manipal is playing to ensure that the gap is mitigated and second how Manipal is collaborating with other stakeholders, be it in terms of M health companies, digital therapeutics companies, or even payers that are responsible to reimburse the hospital expenses on behalf of their patients. Yeah, yeah. So Kosta, I think again one reality check that has come to us is that we are a part of a larger ecosystem and there are players across different spectrum of care where there's a primary care, the diagnostic teams that are doing diagnostic labs, the pharmaceutical companies and pharmaceutical retail outlets, you know, the kind of care at home through physiotherapies and people going to their home. We are beginning to realize that the ecosystem is becoming larger and much more better wired and connected because that is the transition which we have to realize earlier. They were silos, the hospital believed that they can manage on their own. And also I'm saying it is much smarter now for us to kind of decongest our hospitals and eventually focus on surgical work, focus on critical care admissions, or make hospital as a destination for doing only those kind of works which typically cannot happen at home, you know. To the extent that there are now models of care at home where even ICU can be created at the house but I'm saying we don't want to go that far but definitely if we focus as a tertiary care, quarterly care player where our focus would be to do a high end surgical work. We take in patients with high comorbidities and acuity of care to do critical care work, then a lot of other activities can be decongested from the hospital's portfolio. So I think that's one way going forward and we have definitely evolved very strongly in that segment. You know, we have a team now which does a lot of work in terms of post-reader consultations ensuring the drugs are delivered at home. We have a team of laboratories to go down and collect samples. We were the first few who actually did even sample collection for COVID-19 from home because the inertia of not coming out of the house was almost six months to nine months as elderly patients, pediatric patients, they didn't want to come home, so come out of their homes, right? So they finally had to reach out to us and we developed a system around that, payment gateways are interfaced so that the work is seamless. So it has been a very, very satisfying journey in that fact. I think right from delivery of drugs at home to samples being collected because we have an advantage of closing the loop from the doctor perspective, doctor doing the consult, he advising what tests to be done, the test reports come back into his portal for him to use the values and then he has a follow-up consultation with the recommendation of medication. So I think as a healthcare player which is into delivery of healthcare, we have integrated the other streams quite well. Sure. Deepak, let's talk about various other initiatives, other hospitals are taking to ensure that they stay in touch with their patients. We are aware of a few large hospital systems in Northern India that are now delivering medicines on their patients we have and there are multiple implications to that strategy. One strategy is definitely as COVID-19 has put a break in international patient inflow, these hospitals are trying to capture the most of the local patients and the only way of doing it is to offer incremental value-added services to local patients. Second, as you bridge that gap and continue to stay in touch with your patients, you capture data which is essential for you to train progressive technologies that these hospitals are building right now in-house or they're procuring from Western markets or even local markets. So from Manipal Hospital standpoint, I'm just trying to understand in terms of rehabilitation services, some of the progressive IT companies are terming this service as cardio rehab or on-core rehab services and the services are delivered completely online through digital enablers and developed in consent with senior positions of a large hospital along with senior technicians from all over the world. So from Manipal Hospital standpoint, just trying to understand, would you be willing to experiment with such rehabilitation technologies that can be offered to a patient population both within India and outside? Yeah, absolutely. I think you somewhere mentioned that there has to be a clinical ownership and buy-in. I mean, if there are a set of physicians and doctors who believe that a lot of their care pathways and protocols can be managed remotely, it works well for us. I mean, to give an example, we have been doing this where we partnered with the government of Karnataka to do the E rounds, you know. So our super specialists who were managing COVID in terms of a pharmacist, a critical care team, the infectious disease specialist, all of them formed a panel for the government and we used to do these E rounds to monitor beds in the rest of Karnataka region in smaller towns and cities where the access to super specialists was limited. So it worked well. I mean, they were predefined time into the round. The parameters were predefined as to what you need to look for and the advice was definitely given and documented. So I think that's been a great example. We have also adopted a lot of smaller nursing homes, critical care beds. So a lot of these ICUs are three to four in structure. They have two to three beds with them. They have a good team there, but they are teams trying to be around the top supporting the care. So again, we have taken the EIC as a model where through technology partners, it's worked well for us. So as a receptiveness for the idea, we have already been doing it. Definitely the cornerstone for its success would depend on how the clinicians adopted because they are the ones who have to deliver. So to give you another spectrum, a few specialty like the spine surgeries or the orthopedics, you know, you really can't make a meaningful diagnosis unless you don't kind of examine and see the range of movements in a little touch and feel pattern, right? So if you do this smartly, look at those specialties which can be done easily to a remote monitoring, especially the rehab example you gave in, I think it's definitely doable, of course. And I think we have had a track record of successfully implementing some of them as well. Yes. Okay. We also briefly touched on international patient populations and their impact in the Indian healthcare business. I was interacting with a senior bureaucrat recently and he was concerned about the fact that although medical tourism was promoted hugely by the government of India a few years ago when we had specific provisions in the healthcare budget to promote a higher traction in the medical tourism industry, but the reality, especially due to COVID-19 is a little different. We are basically slipping off that list of being the number one destination of quality and affordable care in a global healthcare scene. We're just trying to understand Manipal historically has catered to a lot of international patients and that continue to happen, but because you're managing this from the front end and you're dealing with a lot of international patients probably you have been interacting with them as well. What has been your experience in understanding their evolving needs, especially in the context of COVID-19 to come to India for quality and affordable care? Yes. I think that's a great question, Kaskar, and I'm even trying to figure out answers to that, but one core area which has definitely come out is that we need to watch which India against some of the competition in terms of the other healthcare destination. So there are markets like Turkey, South Africa now, for example, with its strain of virus there. So there would be a general hesitant behavior in terms of the international patients to go to some of these regions which traditionally they went and as a country we need to start positioning that look, we are now manufacturing vaccines, we are vaccinating our team and the communities with a much safer place to come and this could not be done by one hospital but it has to be an industry movement. Like you said, we have also been in touch with a lot of government missionaries including the foreign ministries, et cetera, so that they also help us communicate the right message out there to know that the India's safe destination to travel now. And of course with that remises, you also are trying to look at options where we can send teams out there to do surgeries abroad as a program which we have been successfully doing where a team of doctors and nurses go from here in time because beyond the point you really can't delay your pain in the knees or a liver surgery or cardiac procedure because you have to get it operated on time. So maybe in air bubble, special provisions for medical travelers just to come in and out because I think honestly, it's all a question of knowing that RTPCRs are done, patients are being identified as negative for COVID and then you just operate them and get them back on the feet. So I think it does need a little bit of an industry push, I think we all need to step up on that direction but we are seeing some trickle coming in now and I think that's a great sign. Yeah, I'm really excited to know that and to continue on that note, let's again come back to the initial conversation around the role of information technology in delivering superior care to patients who are undergoing treatment right now and patients will probably come to the hospital system in near term. From Prostin Sullivan's standpoint, we always try to stratify the application of technology in healthcare in three ways. First one, as you've already mentioned, is the clinical domain where AI is directly used to diagnose what would be the underlying conditions and where is the affected area? I'm talking about the role of AI in tele radiology now and definitely there are other areas where AI is used extensively in ICU's and other critical healthcare systems. However, the application of AI in the clinical domain in India has not been great because of various issues, but one of the key issues that I faced dealing with a lot of hospital systems in India is the concern senior physicians have regarding the authenticity and the accuracy of this technologies in diagnosing this patient's condition. But there are other areas, as I said, the first one is clinical and there are areas such as financial and operational domains where technology can be equally used to ensure that the revenues are optimized and you also kind of reduce the inefficiency you see in gaps in the revenue cycles that you manage in the hospital system. And finally, you have the operations where AI can be directly used in supply chain analytics and other aggressive technologies can be equally used to ensure that patients are educated on their conditions and they stay on course with their care plan and medications after the surgery is done. Now, I'm just trying to get your point of view around this notion of technology being used across different departments in India. Do you believe, do you agree that yes, in India technology vendors should look out for more opportunities beyond the clinical domain to get immediate traction across large hospital system? Or do you think no, we should continue to build technologies for the clinical side of things and not only make it for the Indian audience but also we make it here and then we outsource it to the Western market the way we did it in the ICT technology domain? Right, I would, in my opinion, think that we must focus in terms of a technology working around the clinical domain first and it must come across more as an augmented care rather than a replacement of care. So, I'm saying like you said, if a Delirio.org report has a machine learning capability to read thousands of CD scans and they realize whether a scan needs an intervention, those kind of cues is when it's augmenting the clinical judgment and also trying to make life easier for a doctor. So, now with my 23 years in the industry I realized that what can we do to make the life easy for that core of the hospital to the doctor is what starts technology adoption much better. So, histopath reports getting read to a machine learning option, at least flag off the normals if that's a start of things that if there are normal reports you don't really need to spend time on reading them and flag off the abnormalities which need human intervention or the clinical brain as we call it is when I think technology adoption will do better and second would be the whole story around the patient's life cycle in terms of reminding them of the medicines to take, reminding them of the doctor visits, getting a trend on their blood parameters. We have done this very strongly in our on our money-part patient app and we keep encouraging our teams to keep downloading this but at the end of the day you have the doctor component and the patient component which is married through the technology in the right way. The third component would be what you brought out in terms of running the hospitals better or cost efficiency which are derivatives in my view because if you do the first two correctly the third would obviously flow out. I think if you go forward in that mindset and take small steps maybe ensure that people find the joy of doing this right because like I said a lot of times it is enforced the nurses forced to make those entries the doctor's forced to make those entries and it just kills the joy. So if you tell the doctor look I can give you this patient's diabetic HP1AC for last six months on a graph to you would that help you? You'll say yes it does. Can you help me record this when you are talking to the patient? And can you use this app which does that? I think those are conversations which are better for us and honestly with the kind of pedigree of doctors we have in the system they are looking forward to it as long as you know it doesn't kill the joy of a consultation is true sense because that's where the heart of the hospital lies. Right and speaking about physician burden I think we need another half an hour to talk about the burden of clinical documentation on physicians. I did a lot of reports around that fact and what's going on in the Western market in terms of clinical documentation, improvement technology and how those technologies are automating the process of clinical documentation at scale. Yeah so we'll do another call on that aspect alone but then we're going over time and I would like to thank you Deepak for your time today. It was a great learning experience to be and for everyone who is watching the video today and I hope in a smaller hospitals TA2, TA3 hospitals also get a lot of inspiration from you as they start to manage their hospital operations during this pandemic and after it. So with that note, thank you so much everyone for joining and hopefully we'll connect again soon. Thank you. Thanks so much Krestav. Thanks.