Meet the Indian startupper revolutionizing connected medical practice

Kashyap Purani, the founder of Aarogram, talks about de-stigmatizing the term "referrals" in Indian medical practice, creating a connected network for doctors and patients and geeks out about the future of wearable technology and sensors. Listen in!

It was multiple hospital trips for his grandfather that ignited the idea of creating a connected network for medical professionals in the mind of our guest today. Say hello to Kashyap Purani, the founder of Aarogram, who joins me, Nishtha, on The Sketchnote Startup Podcast, to talk about his very new journey into the world of startups.

Fun fact: Kashyap and Aarogram were part of the first cohort of the ‘Sketchnote 100k Challenge’ earlier this year and we’ve had front row seats to see the growth of his health tech startup. Kashyap takes a deep dive into why he left a cushy job in the US to start something new in India. It was a market that was not only untapped but also had a taboo attached to the term “referral” in the medical context. He also walks us through donning multiple hats as the employee No.1 of any startup, product market fits, the future of wearable tech and a lot lot more. Take a listen in.

Nishtha: Hi Kashyap, how are you doing today?

Kashyap: Doing well, it is so  great to be here.

Nishtha: Glad to have you on air on The Sketchnote Startup Podcast. Tell us a little. How has it been in the last few months? How's it been going for you and Aarogram?

Kashyap: We have been busy for the last few months, and a lot of things are going on. We did a bit of a pivot in our product. And we got some market pull and we are working in that direction; getting adoption of the product. We started with a pilot, got a lot of great inputs, and we validated the product. And it’s now being used by hospitals. There are hundreds of doctors and healthcare providers that are already using it. We’re going to push the thousand mark in the number of patients referred. We’re just getting started, it’s really exciting! We just signed up three new hospitals and we’re going to onboard them. And they themselves have a network of hundreds of doctors and healthcare providers. It’s going to be a very busy time for us.

Nishtha: So, now that you have mentioned a pivot, it is always very exciting and very interesting when we ask founders to explain what their product is in their own words. It doesn't always get the message across if somebody else is trying to explain what your product is.

So, if I had to ask you today, “What is Aarogram and what do you guys really do?” in your own words, what do you think your two-line pitch would be?

Kashyap: We started Aarogram with the simple idea to bring more teamwork into healthcare delivery that would eventually provide more patient-centricity. One type of collaboration and teamwork is across healthcare provider referrals. We make referrals easy. We help healthcare providers receive and manage health care referrals and care-coordination with other healthcare providers. This way the patient will benefit as they would receive continuous, seamless health care delivery, especially in a country like India, where health care delivery is fragmented. We have developed a referral CRM and care communication for hospitals. It engages with the referral network and avoids patient referral leakage, which makes the process easier for everyone involved, including patients.

Nishtha: Aarogram, you say is a connected medical practice and you also mentioned that healthcare in India today is so fragmented. Why do you think there are so many doctors but it is such a lonely job? And what do you mean by "connecting" over here?

Kashyap:  Even if you’re a patient, you would know healthcare is not given by just one person, it is teamwork and that is what is missing. When we say connected, there is a lack of collaboration and connectivity among healthcare providers, even in countries like the US. India and the US both have their own challenges but one common challenge is the lack of coordination and connectivity to share patient info, exchange case-notes and give the realtime care to the patient at the right time.

This is important, especially in a country like India, where you have to go to different doctors who specialize in different areas. As a patient, I would benefit if there is connectivity. Right now we have hundreds of information management systems, and healthcare management systems that are a monolith, they don't connect outside of the hospital.

There is a need, especially as we have seen during the pandemic. The government is putting a lot of emphasis on building a UPI kind of network of healthcare information exchange. What we want to do is build real-time communication and sharing of patient information. That's what we mean by "connected" and that's our goal. Our ambition is to build a connected healthcare delivery practice platform.

Nishtha: When you guys were ideating about Aarogram, did you find any specific stories or specific instances that are happening a lot in a very populous country like India that made you believe, yes there is definitely a need for a connected platform for doctors to be interacting with each other. Like a unified platform for data about a patient so that everything is on one page. Did you find these regular occurrences that can easily be avoided?

Kashyap: We met with hundreds of doctors and healthcare providers and experienced it first hand and would visit clinics and doctors in the networks. I also volunteer, when my grandfather was admitted to the hospital, I would stay and observe things. One thing I noticed is that even though most of the hospitals have their own hospital management systems, healthcare providers still end up using WhatsApp. If we talk about small clinics and doctors running their own, they don't use anything.

And WhatsApp, if you think, is also a software solution. But I thought there could be something better than that. There was definitely a need. We see in a lot of cases, especially in a fragmented system, we find out that say a patient thinks that they need appendicitis surgery and goes to a surgeon and then they find out that they actually need to see a gynecologist. The patients are left on their own, they don't get any guidance or navigation. Informal practices that exist do have their pros and cons but there is still a lack of assisting a patient through their journey. Whether it is primary, secondary, or tertiary care, from rural to more urban care where there are more facilities. Yeah, we saw many cases where we thought there needs to be This is where we thought, ok there needs to be something better than this.

Nishtha: I've got a very basic question to ask you. Why is healthcare such a touchy topic in India even now in 2022? Healthcare is still a very touchy topic for people who are trying to innovate in this space as well as caregivers, doctors, and even patients. It just feels as if people are treading on eggshells when it comes to healthcare in India. It is such a confusing problem to have because we are such a hugely populated country, which obviously means that a lot of people require a lot of healthcare at every step of the way.

So why don't we talk about innovation and healthcare and try to work on healthcare? Why is it such an India-centric problem?

Kashyap: Yes, healthcare is an India-centric problem but it is also a topic of discussion and debate in developed countries including the US. It is everywhere from politics to technology to businesses, right? In India it is a touchy topic but was also kind of ignored before the pandemic happened.There was a little underinvestment. People who were not getting insurance, they were not covered. But after the pandemic, there was a lot more focus on prioritizing healthcare. Whether it was infrastructure and insurance coverage and usage of technology. People are now realizing the importance of healthcare. But because it has to deal with patients and the lives of the patients, it is going to be very regulated.

There is already an established system and people are used to that system because of the historic reasons like the doctor-patient ratio is low, there is a lot of disparity, and there is a lot of imbalance in the system. In that scenario, what ends up happening is that things are hard to change. But now, new factors are emerging and you can see the change. It is gaining momentum so we have to build up on that. There is an infraction point, I would say, for healthcare in India. I think we should definitely leverage it at this point in time.

A lot of things are converging, whether it is technology or policies, or even the attitude of the people, including doctors and healthcare providers. In terms of doctors, we are going through a generation change, new doctors are coming up, and they are more willing to use technology. We are building more capacity, especially in urban-centric India we have big hospitals coming up. But there is a disparity. There is a lack of infrastructure in other parts of the country, especially remote areas. There are a lot of bright spots but we have to leverage this moment in time to build a very futuristic system. That's what makes us very excited about the future.

Nishtha: You spoke about how the face of healthcare seems to be slowly changing after the pandemic. Of course the space that you are innovating in has definitely changed around the pandemic, but you are also running a startup and running a business in such trying times. What are some of the challenges that came along with not just innovating but also running your startup successfully, coinciding with the first couple of waves of the pandemic in India. How challenging was the time? How did you manage to run around it?

Kashyap:  That's when I moved back to India, in fact, from the US. I have completed two years, it's a good time to reflect on the journey so far. Also, because it is my birthday today, there's a lot to reflect on.

Nishtha: Happy Birthday, Kashyap!

Kashyap:  Thank you!

Kashyap:  As I said, the pandemic threw a lot of challenges but as a tech entrepreneur, you've got to build with whatever you've got. Whatever resources, people, or money you've got, you can still find opportunities. Sometimes constraints make you innovative, finding innovative and creative solutions. We have had long-term visions, we have always focused on the things that are in front of us. I think, in terms of challenges, there are some good things as well. Patients were rushing to only one type of healthcare delivery system, and there was a lot of stress. But there are other types of doctors who were free, and they had more time. They were willing to engage and talk more about issues. Also some doctors adopted the use of technology to communicate instead of being available in person. That used to be the way earlier. Everyone, even senior doctors, would know how to do Google Meet or Zoom calls. That actually helped us. Again, we were working in healthcare so what we were doing was relevant.

There were challenges in our way, we had to adjust our way. But the good thing is that we could iterate the Indian market very quickly and we went through some iterations in product concepts. We stayed true to our theme of bringing teamwork and connected aspects and patient-centricity. But we were pretty flexible in terms of what the first product would look like. So first we started with intercommunication then we went to independent practice and got the pool from the hospital customers, so that's where we focused. This allowed us to iterate very quickly and get to where we are right now.

Nishtha: Now that we are talking about how it worked while innovating, you guys are very bullish on the referral system within the medical community. Can you shed a light on that? Why referrals? Why is it such a pristine thing yet and how do you plan to tap it?

Kashyap: This is a very interesting topic and sometimes very controversial as well. But first I would begin with how referrals fit into our vision.

As I said I wanted to bring more teamwork and referrals are a type of teamwork and care coordination. Even when we started with individual practitioners this was a big theme and now we are having hospitals managing referrals. Referrals are our primary focus.

We spend a lot of time and do a lot of research in that phase so we are kind of experts or semi-experts in this phase.

Coming to your question, see referrals are a widespread practice in India and well established. It has got a bad reputation and it has become a taboo word in many cases because of the cut practice. But if you look at it, the role of referrals goes beyond that. It is about care coordination, it is about handing a patient from one provider to another. It is about the journey of the patient as I had said from primary to secondary to tertiary care. In fact, secondary and tertiary care hospitals are often called referral hospitals. But sometimes when we say referrals, people will think of something else. But the thing is people are frustrated with the existing systems, whether it is hospitals or doctors. There is a lot of room for improvement, although it is not going to happen overnight. It is going to be a process. It has to be a technological solution, a process solution and it also has to be a policy solution. But if I can dig in a bit more about the role of referral in medicine. Say if you go to a clothing store and you are looking for a toy, the people at the clothing store would refer you to a toy store, and that's it. Whereas it is not so in healthcare; referrals are also a type of service which helps you navigate the patient. Sometimes patients may have an emergency or need surgery. They may go to an advanced tertiary care hospital and after their discharge, they go back to their primary care hospital, their primary care physician or they go to physiotherapy. They go to get their treatment, therefore healthcare is teamwork. There are hundreds of branches in medicine, it is a very specialized field, so the referrals are actually about providing complete comprehensive patient care.

The current system, whether it is good or bad, many times it works but a lot of times it doesn't.

If it doesn't exist, then patients are on their own, they don't get any navigation.

That's why it is a very interesting area, where we can innovate. Of course, we know it is not going to change overnight as there are a lot of established systems. What we are excited about is that there is a real problem here is that people are frustrated, doctors and patients included. There's definitely room and we see it as an opportunity to solve this problem.

Nishtha:  When you say that it is going to be a long road ahead, as the space in which you are innovating is already so orthodox and needs to catch up with the time already, where do you see Aarogram in the next five years? What is the kind of change you hope Aarogram will bring in this field, both innovation wise and business wise?

Kashyap: We have always stayed true to our vision, which is to bring teamwork and be patient-centric. In the next few years, we want to be the de facto-layer for real-time communication and replace WhatsApp at least among healthcare providers to exchange patient info. We do everything like WhatsApp except much better. We provide a layer that brings connectivity.

This may help  us to connect with other software systems, whether inside the hospital or across other healthcare providers. This can also help us develop as a platform, where we can enable other tech companies to innovate. We can also enable other platforms to emerge.

That's our vision: how to move towards an ecosystem where there is much more integration among healthcare and technological solutions, also software solutions.

If you see in the US markets, there is a lot of integration going on, a lot of interoperability going on. Whereas in India, a lot of monolith systems that don't talk to each other exist. Our vision is to provide that data liquidity, so as to speak. Our vision is to either make Aarogram emerge as a platform or maybe enable other platforms to work together.

Nishtha: Awesome! I am going to take a small segue. We've spoken about innovation, let's talk about the business side of things. I am going to ask you a very simple question. You moved back to India a couple of years ago, how different is being a part of a startup in the US versus running a startup in India. What are the biggest differences that you see in your stints?

Kashyap: It is a very interesting question, again. As I was reflecting, I think I had expected a lot of things growing up here but found a lot of surprises on our way.

We had to go through a lot of learning. In terms of surprises, the first pleasant surprise is that India is full of talented people. There is a lot of awareness about technology and software solutions, even in healthcare. There are a lot of successful startups and a new culture is emerging. It is very entrepreneurial. There are really nice surprises, especially in my city Vadodara which is in Gujarat; it is not a Bangalore. We work from across the country but even here there are a lot of local startups emerging. In terms of the difference between the US ecosystem and the Indian market, especially as a startup, when you develop up a product and you go to a customer to sell it, the product needs to have a value proposition. But in India, it is much more result-driven than process-driven.

If your product has a solution for directly addressing the result, directly offering the result, it is much more likely to get demand in India. Whereas, if you go with a solution that helps with some kind of process that leads to a result, it will eventually work out. So if you are offering a solution, there is not only a direct result but it helps the process.

I'll give you an example, if you are saving the time of a physician or making the patient experience better you have to connect this with the end result, which is getting more patients or patient revenue. So the difference I have found in India is that it has to be much more of a holistic solution.

Also, there is no integrated system where you plug in your solutions and make the other things better so you have to go with a complete solution. You have to go with not just helping but also the process but also offering direct results to the customer. Only then do you get the uptake of your solution.

Nishtha: I get it!

Kashyap: Also, another thing is that there are a lot of random factors you have to work with and there are a lot of variabilities. So, markets in a particular industry, you could have a short sales cycle or a long sales cycle but in India it’s all over the map. Sometimes the decision is taken very quickly and sometimes it takes a lot of time, sometimes it is individual driven. Sometimes it’s run by professionals So it’s a lot of mix in terms of customers, you get variability in the market forces. You have to deal with all those things. We had to prepare for this, You have to design your go-to mark accordingly. That's a big difference that I have seen.

Nishtha: That sounds like a lot of challenges.

Kashyap: Yeah, but on the flip side the good thing is that because India doesn't have a legacy system or set system, things are still emerging. There's a lot of room to design the new kind of system you want. Whereas in the US particularly, people complain a lot about a lot of things. Even in healthcare, the companies spend the highest in terms of healthcare but they don't have a first-class healthcare delivery system.

A lot of issues with accessibility, affordability, and a lot of expenditure. People talk about how to improve the system, how to change the system. A lot of smart people are betting on that. But the thing is because there is an inherent system already working, there is an already established incentive structure and legacy system, it is very hard to change. Some mistakes they realize that they should have done a certain way in designing and evolving healthcare. But now we have a chance to not repeat the same mistake and design a better system. So, there is an opportunity to design a better system from the ground up. There are forces behind it. I think, definitely whether we do it or someone else does it, this is a once-in-a-lifetime opportunity to design very futuristic healthcare.

Nishtha: Very exciting that you guys are getting a chance to be pioneers of systems over year-end. You are changing things from the ground up. What I want to ask you is, very interestingly you were one of the few startups that were a part of Sketchnote's first cohort in the 100k challenge, how was your experience being so early on and being a part of the accelerator program?

Kashyap:  It was an excellent experience for us especially because it was a surprise and a very different experience. It was a community-like experience. Mentors were ready to go out of their way as a friend. You also have other startups who are going through the same journey. It is very important when you are building your own startup, when you are surrounded by like-minded people who are also going through some of their challenges because there could be ups and downs while building your own startups. This way, the support network and Sketchnote was very helpful in that regard. I got good friends out of it and made some business connections as well. So definitely I would say that it was a positive experience.

Nishtha: So glad you had a lot of good experiences! I want to take a little before Aarogram, ok? You were working for Zansors. Very interestingly, you dealt a little with product development and then a little with marketing. These are two very diverse fields that require a very diverse sort of talent. How did you manage to do a little bit of both together? and what did you learn from your entire experience?

Kashyap:  I did many more things, not just those two things! I was the first employee outside of the founders at the company. It was a really fun and interesting experience to build a startup from the ground up again, I learnt a lot about how to build. The technology that we were working on was very cutting-edge, kind of a futuristic technology. It was very exciting.

In the early phase, you can see how to do things and how to wear different hats and what we can do better. We got a lot of exposure as we worked with a lot of talented people. That helped me a lot back then and even right now when we started Aarogram. I could do it better because of that experience, after startups like Zansors and later on their company Senseonics.

I was always drawn to futuristic technology, especially when at that time digital health was new, and digital therapeutics was a new emerging category. And then there was wearable sensors. There was the world's first breathing sensor to detect sleep apnea. Senseonics I worked with, they were the only company in the world with an FDA-approved, implantable sensor, a continuous glucose monitor (CGM).

It would go under your skin and it detects blood-glucose level in real-time and sends via bluetooth to your mobile app, showing the blood-glucose level. It is very helpful for people with diabetes and they can take insulin doses based on that reading.

This is also a futuristic technology, so it is really an exciting and interesting experience. I’m very much prone towards innovating something new, whether it is a technology or product or a new category or a new system. With healthcare, I would say that I have worked as both an insider and an outsider. There was a mix of consumer apps and also the AI technology I worked with other than this and also medical devices.

I got to observe what's at the frontier and also avoid mistakes: What not to do and what are the challenges when you have a new cool technology. There you have to face market realities and you have to educate the customers. A lot of learning from there as well like how to be practical, and how to lead a change. Innovation is ultimately not about making something creative but how to lead to a change in people's behavior. Changing how things are done, and changing the system, that requires an understanding of how to drive innovation and not just coming up with a cool product but making it happen and changing the system. This is how I got lessons in understanding and how to be practical and pragmatic about implementations, if one really wants to do innovation. It was interesting.

Nishtha: What is the most exciting thing in the space of wearables, sensors, and implantable sensors that you think will change medical fitness in the next few years? What's the one thing that you are very excited about, since you know a bit about it being an insider and all.

Kashyap: The space, if you are looking for the most exciting, Elon Musk has started a company with neuron sensors where it can read your mind! The ideas are out there… we have imagined technology. We had Fitbit many, many years ago. But then there’s always a hype cycle. There was improvement later on.

But now I think CGM is a very interesting space. Right now it is limited to only people with diabetes. But if it is opened up for consumer usage, then you can track a lot of things. Because in healthcare a lot of things are still unknown, with regard to nutrition, and what keeps you healthy. If we had something that would track our body from the inside, we would know a lot about our own bodies as everyone's body works differently.

I think this glucose monitoring, especially in a very easy implantable sensor way is exciting. Right now they are invasive and not non-invasive, and there are limitations even with the existing product but people are trying to do interesting things. Ultimately it will only give you one kind of picture, one side of data that you have to combine with the connected system where the data is only useful if you can use it right.

Nishtha: Only if you’re reading it correctly. Yes!

Kashyap:  AI and machine learning would be useful only if you have data. Right now in India, we don't have a lot of data for a lot of things. So with our tool, we are hoping we can digitize a lot of things if we get more data whether it is a patient journey. Maybe you can predict the next pandemic or you can predict infectious diseases. Based on the data you can predict how patients are going to need based on their healthcare journey. What are the interventions they would need, discharge from surgery for example. So, it will all come together if we had some kind of a platform that enables data liquidity and flow among all the tools and products for you.

Nishtha: That sounds amazing. Wearables and sensors are a whole different podcast episode in itself so I am not going to delve any further on that because I really want you to come back and we can only talk about sensors and wearables and medical technology as a separate episod. But before I let you go, I've got a few rapid-fire questions for you. Since it is rapid-fire, it's got to be quick, so let's start. Are you ready, Kashyap?

Kashyap: Yeah, I hope so!

Nishtha: Question number one, since we are already talking about wearables and sensors and stuff like that off the top of your head, if money innovation was not a factor, what is the one futuristic device that you would wish to build.

Kashyap: Instead of building one device, I would build a kind of a dashboard for your body. If you have dashboard maintenance for your car then why not for your body, where you can keep track of your health.

Nishtha: Totally makes sense. Question number two. Tell us about your latest win in your business life. What is that one thing that you thought, yes this was great? The last thing that happened to you.

Kashyap: We recently signed up a cancer care hospital chain. So it is a new area of specialization and we are very excited about this win. Cancer patients have a very different journey than other typical medical treatment and things we could do in that space.

Nishtha: Congratulations! And question number three. What's the worst business advice that you've been given?

Kashyap: I would have to say, mostly advice is very specific to you. Good advice is good only if it applies to your situation. But I would have to say generalization. People sometimes give generalized advice that I don't like, how it is done and how it is not done. For example, if somebody says you know, “You have to price it this way or it is not going to work”, “You have to distribute it this way or it is not going to work.” Maybe those things are true until somebody comes along and does it.

Nishtha: Awesome! Question number four. When was the last time you used Sketchnote and what do you use it for?

Kashyap: I used it maybe yesterday to write a video script for an explainer animation video that we are going to prepare for marketing purposes.

Nishtha:  High-five! I think we’ve got a lot more in common than we think we do. I used it last time to write this podcast too, so it's been cool. I think I've got two more questions for you. Question number five. What's the one character trait that you believe in yourself that gives you a lot of confidence?

Kashyap: For me, I think it is persistence and keeping at it even if there are ups and downs you still go ahead and push through. I think persistence and patience come in handy in a journey when you want to give it all up some days. Some days you feel like you are going to conquer the whole world, right? And the other people can see through it and that brings credibility. And people would like to support you in that sense, be it friends or co-founders or family. I think you need the help of people and if you are doing something wholeheartedly with genuine efforts, then people would like to support you, you know!

Nishtha: Last question, I know we have spent a long time on this podcast. So the last question before I let you go: What is the one piece of advice you would give to young entrepreneurs who are just starting out listening to this podcast?

Kashyap:  There are a lot of good pieces of advice out there, but my personal one I would say is: Sometimes I see in India there is a fad of doing startups and all that. It could be a good thing, now people do know what an entrepreneur is, you know. In our languages in Gujarati, Hindi you don't have the same word for entrepreneur. So they have a whole new understanding and a new career path. But then I guess, again, advice as I said could be very specific to some person. Otherwise it is a piece of bad advice. If somebody is too afraid to start a startup, I would say just go ahead and do it and do whatever you can do one step at a time. Looking back you will realize that you have made a lot of progress. So don't be afraid. For people who are doing a startup just for the sake of it, you must have some kind of irrational motivation to do that. You really want to do it and when you really want to do it, you will have some idea of your capabilities, the market opportunities, what the future would look like. You will do it anyway no matter what the ups and downs but the reason should be the right reason for you.

Nishtha: Sounds like very sage advice from somebody who knows what they are talking about. Thank you so much, Kashyap, for joining us today on your birthday and making this a very exciting listen. I'm sure anybody who is planning to startup and wants to be in a space like yours, this is going to be a very insightful listen for them. So thank you so much for joining us today.

Kashyap: Yes, if people would get some very useful insights from this and maybe you can ask me next year, maybe on my next birthday, how I am doing.

Nishtha: We can turn this into a ritual, that's a great idea!

Kashyap:   It was my pleasure to be here, it was great talking to you, Thanks, Nishtha.

Nishtha:  Awesome, Kashyap. Thank you so much!

Thanks for listening to The Sketchnote Startup Podcast and cheering Kashyap on. Stay tuned for more interviews, bite-sized productivity hacks, and much, much more. If you don’t already, subscribe to our podcast, available now on all leading platforms. And don’t forget to share this episode if you liked it, you could tag us on Twitter, we are @SketchnoteCo. Until next time, I am Nishtha and this has been The Sketchnote Startup Podcast.

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