Commure: The AI Operating System for Healthcare

1. 0:00 – 2:30

   From Rejection Letters to YC Acceptance

   1. TTTanay Tandon0:00

      I actually applied immediately. I got rejected, because I was in high school. [laughs]

   2. AGAnkit Gupta0:03

      Yeah.

   3. TTTanay Tandon0:03

      And then I applied again, and I got rejected again. And then the third time, we came armed with a prototype-

   4. AGAnkit Gupta0:08

      Nice

   5. TTTanay Tandon0:08

      ... that actually worked. The market is a great... I mean, it's just like punch in the face.

   6. AGAnkit Gupta0:12

      Yes. [laughs]

   7. TTTanay Tandon0:12

      Like, it teaches you a lot, like, very quickly. I, I think our biggest learning is get in front of the customer, and then just solve problems for them. And, and start with one specific problem, regardless of how small it looks. We went from having no revenue to having $3 or $4 million in revenue in, like, a year. And it was like, "Well, we're done."

   8. AGAnkit Gupta0:29

      Yeah.

   9. TTTanay Tandon0:29

      Like, we solved all the, all the problems-

   10. AGAnkit Gupta0:30

       Yeah. [laughs]

   11. TTTanay Tandon0:31

       ... that are to solve. And then-

   12. AGAnkit Gupta0:31

       Yeah

   13. TTTanay Tandon0:32

       ... and then you're like, "Well, no, actually, the game starts now."

   14. AGAnkit Gupta0:34

       [upbeat music] I'm thrilled to be joined today by Tanay Tandon, the CEO of Athelas Commure. We're very excited to have him, because he's one of the leading providers of enterprise software to healthcare. Thanks so much for joining us.

   15. TTTanay Tandon0:48

       Thanks for having me.

   16. AGAnkit Gupta0:49

       Why don't we kick things off? Why don't you tell me what Athelas is and what are you guys working on?

   17. TTTanay Tandon0:53

       Yeah. Uh, Athelas Commure builds software products for providers. And so we have tools that automate their day-to-day workflows, like Commure Scribe, which is an ambient documentation tool. Athelas Revenue Cycle, which is a payment stack. It's basically Stripe for healthcare and doctors. It submits their claims, uses LLMs to negotiate denials with insurance companies, appeal those denials, and then really render all of the data viz and business intelligence to run your practice from a financial standpoint. And then also a whole host of clinical tools, Commure Engage, which does back office and front office interactions with the patient, explaining their bills to them, uh, explaining what types of tasks they need to do to get prepared for a procedure like a colonoscopy, sending them appointment reminders. Do on the order of a couple billion dollars worth of payments volume every year. Um, help document, using our ambient AI tool, 20 million appointments every year, and then, uh, probably 150 million touch points, uh, annually on, on, on our patient engagement piece, um, spread in large health systems and private practices.

   18. AGAnkit Gupta1:56

       And so this is sort of a bundle of pieces of software that are each solving kind of independent problems for a practice, and collectively sort of serve as the software operating system for this entire practice.

   19. TTTanay Tandon2:05

       That's right. And so, you know, our solutions are used by the physicians and the nurses in the practice or the hospital, and then also by the back office. So your accountants, your, uh, billing team, what we call revenue cycle in healthcare. Everything from, uh, you know, submitting the claim to actually, you know, ledgering everything up for the, uh, CFO's office.

   20. AGAnkit Gupta2:24

       And you can actually do all of this with technology today. You can have an AI model that'll call up an insurance company and negotiate with them, and that actually works.

2. 2:30 – 5:33

   What Athelas and Commure Actually Do

   1. TTTanay Tandon2:30

      100%. I mean, I think the ability for language models to both interact via voice and text with humans just got there a year ago. And so we're just at the precipice of what it can accomplish. Um, and when you walk into a health system, there are tens of thousands of people whose sole job it is to do these types of tasks. And if you can free up their time, you can bring that productivity back onto what matters the most, which is patient care.

   2. AGAnkit Gupta2:53

      And I imagine a lot of those tasks are already outsourced to some degree. So you're kind of just slotting in to where they've already outsourced it to someone else.

   3. TTTanay Tandon3:00

      Exactly. They, they use vendors like R1, which is an offshoring RCM provider, Access, Omega. Many of them have their own in-house shops where they actually, you know, it's effectively outsourced, but they actually have the individuals on site. And the, the direction of the industry for the last 20 years has been offshoring. It works okay. For what it's worth, I mean, these became big businesses. But I think LLMs, there's an opportunity to reimagine all of that, where it's, it's pure software.

   4. AGAnkit Gupta3:24

      And this ultimately becomes a product offering for all types of hospitals, both small and large.

   5. TTTanay Tandon3:29

      Yep. We work with the HCAs of the world, which is $100 billion hospital empire, you know, 3,000 sites of care, 186 hospitals, all the way down to your private practice owned by a single physician. And, you know, they use varying parts of the solution, but it's provided as one platform, which is revenue cycle, workflow automation, and patient engagement in one.

   6. AGAnkit Gupta3:50

      What does that actually mean? Like, for someone who's not in healthcare, like, what do these roles actually look like in terms of where technology fits into them?

   7. TTTanay Tandon3:56

      Yeah. The, the way I think about it is the physician's day-to-day is really defined as interacting with a patient and treating that patient, uh, and then often generating the relevant documentation so that their back office, which is, think of it like their accounting team, their AR team, invoicing, can actually submit those claims to insurance.

   8. AGAnkit Gupta4:14

      Yeah.

   9. TTTanay Tandon4:15

      One of the challenges in healthcare is the person paying for the, for, for the service is not the person receiving that service.

   10. AGAnkit Gupta4:21

       So a person paying is like an insurance company or Medicare or whatever.

   11. TTTanay Tandon4:23

       Exactly.

   12. AGAnkit Gupta4:24

       Person receiving it is the patient.

   13. TTTanay Tandon4:25

       Is the patient-

   14. AGAnkit Gupta4:25

       Right

   15. TTTanay Tandon4:25

       ... themselves. And that individual, the beneficiary, you know, their incentives are to get treated, to get treated fast-

   16. AGAnkit Gupta4:31

       Yeah

   17. TTTanay Tandon4:31

       ... to get the best treatment in the world. And often, the insurance company's incentive is to pay out as little as possible, and hopefully treat as little as possible, which is a counter-incentive to really what the patient is trying to accomplish.

   18. AGAnkit Gupta4:43

       And so when it comes to then building technology, then you guys build technology for all parts of this, from the patient experience itself, as well as the kind of front and back office accounting and the kind of administration-

   19. TTTanay Tandon4:53

       Yep

   20. AGAnkit Gupta4:53

       ... of that patient experience.

   21. TTTanay Tandon4:54

       We, we see it as, you know, there are two key protagonists in our story, which is the patients and the providers, and we build software solutions and hardware solutions for that group of individuals. And there's an effective enemy that's created as a result, which is the insurance company. And all of our tools are pointed at the payers in, in terms of trying to make their lives harder and make the lives of our customers easier.

   22. AGAnkit Gupta5:15

       Okay. Very interesting. Okay. I wanna dive into your technology. But before that, I'd love to hear a little bit about the backstory of Athelas.

   23. TTTanay Tandon5:20

       Yeah.

   24. AGAnkit Gupta5:20

       So why don't we rewind the clock, uh, to the very early days. Like, how did this company come about? Like, what was the very early days like? Um, what was your experience at YC like? And kind of how did you even begin to arrive at this idea that

3. 5:33 – 9:00

   Building a Medical Device at 19

   1. AGAnkit Gupta5:33

      you're working on now?

   2. TTTanay Tandon5:34

      So I, I was very fortunate to have grown up in the Bay Area.

   3. AGAnkit Gupta5:36

      Okay.

   4. TTTanay Tandon5:36

      And when you're in the Bay Area, Y Combinator is just in the ether. Like-People like Kasaar and Justin Kan and Sam Altman were, like, our heroes. And the ... I remember it was, like, 2013 or 2014 that we somehow snuck into YC Startup School because it was happening-

   5. AGAnkit Gupta5:52

      Yeah

   6. TTTanay Tandon5:52

      ... in Cupertino. Uh-

   7. AGAnkit Gupta5:53

      I think I was there too, actually. Also sort of-

   8. TTTanay Tandon5:55

      Yeah

   9. AGAnkit Gupta5:55

      ... snuck into it.

   10. TTTanay Tandon5:56

       It was a great-

   11. AGAnkit Gupta5:56

       Yeah. With-

   12. TTTanay Tandon5:57

       ... Startup School.

   13. AGAnkit Gupta5:57

       Yeah, totally.

   14. TTTanay Tandon5:57

       I think Zuck came.

   15. AGAnkit Gupta5:58

       Yep.

   16. TTTanay Tandon5:58

       Jack Dorsey was there.

   17. AGAnkit Gupta5:59

       Yep. Yep. Same one.

   18. TTTanay Tandon5:59

       Um, Flexport did their interview on stage. And I remember I was, you know, I was, like, a teenager in high school, and I was just in awe of, of, of these people that had built such amazing technology.

   19. AGAnkit Gupta6:08

       Yeah.

   20. TTTanay Tandon6:08

       And YC is this ecosystem that had enabled a lot of it, uh, and was starting to enable more and more of it. So y- you know, fast-forward a couple years, Y Combinator hosted this hackathon called YC Hacks. And, uh, I had read a couple papers about, uh, how you could use computer vision to potentially analyze blood cells and also use really cheap pieces of glass to enhance a smartphone camera to basically turn into a microscope.

   21. AGAnkit Gupta6:32

       So this is, like, in 2016 or '17, something like that?

   22. TTTanay Tandon6:33

       This is 2014.

   23. AGAnkit Gupta6:34

       2014.

   24. TTTanay Tandon6:34

       Yeah.

   25. AGAnkit Gupta6:34

       Okay, cool.

   26. TTTanay Tandon6:35

       This was 2014.

   27. AGAnkit Gupta6:35

       So this is, like, early computer vision. Like, d- deep learning is, like, just starting to happen to some degree.

   28. TTTanay Tandon6:39

       It's ... Yes.

   29. AGAnkit Gupta6:39

       Computer vision's just barely starting to work.

   30. TTTanay Tandon6:40

       Like-
4. 9:00 – 16:39

   Lessons from Clinical Trials and Early Healthcare Startups

   1. TTTanay Tandon9:00

      I, I would say two key sources. One, my co-founder, Deepika, who's also one of my closest friends, uh, we used to compete in science fairs against each other, and her research was always way more, uh, uh, call it med device or bioengineering focused. And she worked through high school on this, uh, microfluidic test strip that could detect salmonella very quickly from, you know, produce. And, you know, I thought it was remarkable that you could build something like that in, in high school 'cause it was, you know, it was hardware, there was bio involved. You have to have a good understanding of, uh, y- you know, how these detection strips were actually fabbed and cut and whatnot. And so it was clear that, okay, we could build things in the real world with, uh, with microfluidics. And then number two, I think the ... Y- you know, when you're at Stanford, you get to meet these amazing professors. For me, uh, Chris Manning was, was someone who gave me my first shot in the Stanford AI lab under Richard Socher, um, who started Metamind, where I was a research intern as well. And I, I think they were just ... It was really motivating because for them it was like there's, there's no boundaries to what machine learning can do. You should go after these complex industries. Um, and they ... You know, Richard was ended up being the first check right after Y Combinator.

   2. AGAnkit Gupta10:08

      Oh, cool.

   3. TTTanay Tandon10:08

      It was a 50K check. And, and I think that support really encouraged us as well.

   4. AGAnkit Gupta10:11

      Yeah, totally. Okay. So, so let's now talk about your time in YC. You know, at this point it's just the two of you. Um, you're working on this regulated medical device. What did you set as kind of your demo day goal? And like, how did you ... What did you accomplish in those few months of YC that ultimately then put you on a trajectory to build something somewhat different now from what you describe now? And we'll kind of talk about that, that transition. But yeah, what, what did that first few months look like?

   5. TTTanay Tandon10:33

      I, I think the first week itself of YC was total shock because we came in with these traditional timelines for how long a med device should take or how long anything in healthcare should take.

   6. AGAnkit Gupta10:42

      Which is, like, years or something.

   7. TTTanay Tandon10:44

      Years.

   8. AGAnkit Gupta10:44

      Yeah.

   9. TTTanay Tandon10:44

      And, and that seemed pretty good to me. I was like, "Cool." Like, we're gonna be on this for a long time. It's, you know, we're gonna go super slow. I remember I had a conversation with, with, with Kasaar, who was our group partner and is also now on our board. Um, and he, you know, he, he, he was basically like ... He made me walk through every assumption on, why is that months? That, that just seems like it's like paperwork. You should be able to do it in a week. Why are you waiting for Stanford IRB to approve this trial where you could go to some local lab and probably get it done in a week?

   10. AGAnkit Gupta11:12

       Right.

   11. TTTanay Tandon11:12

       Um, and I think because of that, Deep- can I sat down and just, like, reimagined how quickly you could build this stuff and, and really went from almost, like, zero-based budgeting but for a clinical trial.

   12. AGAnkit Gupta11:21

       Right. Totally.

   13. TTTanay Tandon11:22

       And the other piece was, you know, if you're a competitive person, in our batch we had companies like ... Y- you know, Scale AI was in our batch. And, and this was a company that pivoted mid-batch and got to, like, millions in revenue by the end of the batch. You know, for us, we never wanted to just be the best healthcare company in the batch. We wanted to be the best company in the batch. And, [laughs] and so it was, it was this, this pressure that we sort of created for ourselves and the group partners created that really caused us to pace, uh, more aggressively than if we were doing it-Outside of, of, of, of YC.

   14. AGAnkit Gupta11:52

       Yeah.

   15. TTTanay Tandon11:52

       And so we set this goal of we will finish a clinical trial and have a ready-to-go FDA submission by the end of YC.

   16. AGAnkit Gupta11:58

       Wow.

   17. TTTanay Tandon11:58

       Um, and it was crazy, but we actually got the clinical trial done. We needed to redo some of the experiments per the FDA's request. And so the, the approval itself took a little longer, but we, we, we got the, the core basis of, of the, uh, clinicals done in those 10 weeks.

   18. AGAnkit Gupta12:11

       I mean, that's pretty absurd pace, right? I mean, I think, like, when you think about a normal regulated medical device, we're talking about many years in that process. And yeah, I mean, I think this ability to kind of break down into its only ... What the critical components of it are, what parts you can actually shortcut versus not is, it's a very challenging head space to get into. And then you guys as, as 19-year-olds, I mean, I can only imagine some number of people who you talk to are like, "Who are these guys to be making a medical device?" Like, how do you go up against that? Like, w- how did you get yourself to not care, basically?

   19. TTTanay Tandon12:39

       We- we had many conversations where ... And we got a quote from Stanford where it was like, "We can run this trial and it'll be $120,000 and it will take three years."

   20. AGAnkit Gupta12:47

       Right [laughs] .

   21. TTTanay Tandon12:47

       And, and I mean, when you see something like that, it's almost so absurd that it wills you into action a little bit, which is like, if this is the default system, I mean, something is broken. And, and, and I think, um, because of that, we thought to ourselves, "It's time to rethink first principles." And it really came down to, one, identifying a partner hospital that was small enough and willing to work with us very quickly.

   22. AGAnkit Gupta13:10

       Mm.

   23. TTTanay Tandon13:10

       Uh, and that ended up being in Juarez, Mexico. So we flew out there mid-batch-

   24. AGAnkit Gupta13:14

       Nice

   25. TTTanay Tandon13:14

       ... uh, ran the trial with them. Number two is really deleting as many parts as possible and running the simplest form of the trial. So instead of hiring traditional clinical trial operators, Deepka and I ran the trial ourselves. She took samples in the front room. I was in the back room running them on the device. Uh, and then we had a nurse that we had hired for the day who was running them on the traditional system called the Sysmex XE-5000. And we would then compare those results and show that they were accurate and, and equivalent to each other. Uh, and the whole process from finding the hospital to making sure the devices were ready to actually running the trial and then getting the results end to end was probably six weeks of the batch. Once we hit those milestones, that's when we raised our seed round.

   26. AGAnkit Gupta13:56

       Okay, so what you started there, though, you started with this medical device. Today you're not a medical device company for the most part at least, or at all I think. What was that arc like? I'm sure there was many steps in which the company changed, but I mean, tell me a little bit about how you segment your brain into like the few eras of this company and how you-

   27. TTTanay Tandon14:12

       Yeah

   28. AGAnkit Gupta14:12

       ... went from one of these to perhaps pivoting to a kind of another version of the company over the last few years.

   29. TTTanay Tandon14:17

       You know, we did YC. Uh, we raised our seed round from Sequoia, Alfred, um, over at Sequoia. And the next 18 to 24 months just became brutal focus on getting an FDA clearance. Um, get the device to a state where it can replicably run in, in, in clinical trials, uh, where you can, you know, all kinds of crazy tests. Like we have to drop the device and kick the device and, you know, things break and you have to be able to continue to pass the, the relevant tests. And that was it. We were laser focused on this one goal. And I think that was very freeing in some ways because it was the only thing we had to get done. We also only had $3 million to do it.

   30. AGAnkit Gupta14:52

       Right.
5. 16:39 – 21:24

   Pivoting from Hardware to Healthcare Software

   1. TTTanay Tandon16:39

      We, we wanted to go from making their lives easier for a percent of their patients who we were serving with our Athelas One device to 100% of their patients, uh, and their whole chronic care panel with, you know, the telehealth tools and the revenue cycle tools. And, and I think, you know, my looking back, the, the reason this time period was so valuable is we would not have had, you know, a value giving relationship with these customers had it not been for the device. They trusted us.

   2. AGAnkit Gupta17:03

      Right.

   3. TTTanay Tandon17:03

      They saw us as more than just a device company. They saw us as those kids that would show up in their office, set up the device, train them how to use it. And because of that, they would tell us about all these other problems they had in their clinics. Like, "Hey, when I get the result from the device, I have to upload it into this portal manually, and then I have to call up a pharmacist and tell them like, 'Hey, the fax is coming through.'" We would just hear these, you know, these complaints like, "Well, it would be amazing if I could, you know, upload this automatically or if I could fill this claim form out automatically to get the next set of medication adjudicated." And that's when we started building software and it honestly felt like playing on easy mode after two years [laughs] of building, building hardware and dealing with the FDA.

   4. AGAnkit Gupta17:41

      You know, at some point presumably the software starts to take off and become a pretty significant part of your business. At, at some point do you ... You know, what is that process like of leaning in on that and perhaps, you know, abandoning the thing that, or, or at least leaning out of the thing that has been your initial driver that got you there in the first place that has this big pharma deal, for example.

   5. TTTanay Tandon18:00

      Yeah.

   6. AGAnkit Gupta18:00

      What does that process look like?

   7. TTTanay Tandon18:01

      It, it was interesting because we had two paths in front of us. Be the best Athelas One medical device company in the world and just, you know-Build a great compounding 40 50% annualized grower in that, in that segment. Alternatively, it was bet on yourself again and expand the TAM and do more for these customers, um, based on the learnings we were getting from the market.

   8. AGAnkit Gupta18:22

      And also, when was this, by the way?

   9. TTTanay Tandon18:23

      This was in 2020. Um-

   10. AGAnkit Gupta18:25

       So you've been at this now for, like, four-ish years. Like-

   11. TTTanay Tandon18:28

       Yes

   12. AGAnkit Gupta18:28

       ... this has been your thing. You're a med device company. You're growing this thing.

   13. TTTanay Tandon18:31

       Yes.

   14. AGAnkit Gupta18:31

       Now, 2020 is coming, a lot of things are happening in the world, uh, as I'm sure is gonna be relevant here.

   15. TTTanay Tandon18:36

       Yeah.

   16. AGAnkit Gupta18:36

       And then also you're starting to see that there's an interesting new opportunity in software.

   17. TTTanay Tandon18:40

       Yep. And I remember it was, I, I forget, was, it might have been Robinhood or it might have been some company. We, we had this interesting, uh, uh, fireside that we went to, and they talked a lot about share of wallet and this concept of you wanna do more and more for your consumer and go from just being, you know, with Robinhood, like their toy stock, couple hundred bucks playing around, to like, "No, this is like a meaningful financial product for your entire portfolio." For us, the na- the analogy was, w- was apt because we want- we, we wanted to go from treating 1% of their patients, these refractory schizophrenia patients that were treatment resistant, to treating all their patients. And I remember Deep, my co-founder, she was in one of these clinics. She spent a lot of time in these clinics, and she was like, "It's insane. We are helping them for 1% of their patients, and they love us so much. Imagine if we could br- build tools for all of their patients, their 4,000 patient panel." And, and I think that's when we took the bet, where like we can build a multi-billion dollar software business, sensor business in this segment by expanding what we do for these customers and, and, and grow a lot faster than the 100,000 total patients that had this one condition.

   18. AGAnkit Gupta19:43

       And then this was before the LLM era was really taking off. You were obviously a machine learning company, and you had a lot of experience with building software. Um, but like what did that initial software look like? Like, what types of problems could you solve then? Presumably now you can solve many more.

   19. TTTanay Tandon19:55

       Yeah. We started with the basics, which is one, uh, COVID hit, and, and as a result, our providers needed ways to monitor their patients in their homes. So we built a basic telehealth portal and a set of remote monitoring devices that connected into it and allowed them to inter- interact with those patients, many of whom also use the Athelas One device in the point of care or in their homes. The very next thing we started playing around with was workflow automation as it related to claim submission and payments. So everything from collecting dollars from these patients to, uh, you know, starting to submit claims to insurance. And first we did it just for our, you know, this subset of remote monitoring and clozapine patients, and then expanded organically to more and more of the practice.

   20. AGAnkit Gupta20:39

       And, and these are problems you basically discovered from being in their offices.

   21. TTTanay Tandon20:42

       Yes.

   22. AGAnkit Gupta20:42

       Like you and your co-founder are in there, and you're noticing and hearing from them about whatever other problems they're facing, and you're kind of seeing, okay, like as exciting as this is, we sort of have to solve these as we go.

   23. TTTanay Tandon20:51

       E- exactly. There is no other way to discover these problems than being in your customer's day-to-day and, and, and just seeing them because there's so much nuance to where they get stuck.

   24. AGAnkit Gupta21:01

       Yeah.

   25. TTTanay Tandon21:01

       And it's not something you can derive, you know, by reading an article or, you know, watching a video online. You, you have to be in the, in the heat of things.

   26. AGAnkit Gupta21:08

       Yeah, totally. I mean, I think we see this with, with companies every day today, especially in this sort of new technological moment, is that it's very hard to conceive of great startup ideas kind of in your home or in a lab. It's much more likely to encounter them somewhere-

   27. TTTanay Tandon21:19

       Yes

   28. AGAnkit Gupta21:19

       ... in the field by being in there. And so for you guys, that sort of was a, was a game changer in putting you in that place.

6. 21:24 – 27:14

   Fixing Physician Burnout with AI

   1. TTTanay Tandon21:24

      100%.

   2. AGAnkit Gupta21:24

      Well, okay. Well, why don't we, you know, kind of move forward now a little bit to, to today and, and I can get there by kind of talking about what the last few years has looked like in healthcare generally. I mean-

   3. TTTanay Tandon21:34

      Yeah

   4. AGAnkit Gupta21:34

      ... there's been an incredible amount of changes happening in healthcare. To your point, there's these massive mega conglomerate style hospital businesses. There's consolidation in payers and PBMs. For you guys, as you see this sort of changing landscape, where do you-- one, where do you fit into that landscape? And then also, how does that changing landscape affect your business and as you think about growing it?

   5. TTTanay Tandon21:54

      I, I think it's, it's re- it's really interesting 'cause if you go back to the '90s, uh, the life of a physician was great. They had a tight panel of patients. They knew them personally. They treated them, and if there was, you know, chronic diseases, they were able to talk to the patient very quickly. Idea of a concierge doctor was, was fairly common. You know, anyone in upper mid- middle class had a concierge doctor of some kind. And as the bloat that came from insurance and regulation and, and, and just what we turned healthcare into and this sort of like admin state-

   6. AGAnkit Gupta22:25

      Yeah

   7. TTTanay Tandon22:26

      ... is what really broke down the productivity of a physician, where they turn into these, these, you know, cogs in this greater wheel, and there's, you know, patient productivity numbers they have to hit. There's countless tasks they have to do. Regardless of how efficient they are, they always take documentation home, and they're filling out paperwork. And I see it as this great misuse of, of talent in that we have some of the most intelligent, well-trained, uh, uh, well-intentioned people in the country spending their time doing tasks that really software should be doing for them, uh, LLMs or not. And what we've seen happen is a lot of physicians give up on this dream of the private practice or the physician-owned practice in change for joining a large health system that does take on a lot of the overhead that you now need to pay in order to just operate a health system.

   8. AGAnkit Gupta23:14

      This is like negotiating with insurance companies and with PBMs and having, uh, pharma relationships and all that kind of stuff.

   9. TTTanay Tandon23:20

      Yep. Paying for an EMR-

   10. AGAnkit Gupta23:21

       Yeah

   11. TTTanay Tandon23:21

       ... dealing with malpractice. And so all of this made it harder to practice care-

   12. AGAnkit Gupta23:27

       Yeah

   13. TTTanay Tandon23:27

       ... and, and, and turned it more into this, this, again, like this admin business. And, and I think now with LLMs, there's this generational opportunity to free the physician and, and really bring them back to what they love doing the most, which is rendering care. And I think our work is in service of that. Uh, take the work tax and just nuke it. Take every part of their revenue cycle, their back office, their documentation, um, and, and use software to automate, uh, large chunks of that.

   14. AGAnkit Gupta23:53

       And I mean, you guys sell to, you know, both this mid-market and larger market or, or any kind of enterprise market. It feels like what you're saying here is that this mid-market is what you see as potentially best suited to take advantage of, of LLMs and especially sort of this broader technological adoption because it frees them from needing to consolidate into these bigger enterprises. And perhaps the advantage of the bigger enterprises won't be as much the case in the future. Is that kind of how you see it, or do you think not so much?

   15. TTTanay Tandon24:21

       I, I, I think it goes both ways. One, I think we will see-- it's sort of the analogy we use is like Amazon and Shopify, where-Over the last 20 years or 10 years or whatever time period, Amazon has grown remarkably, um, as it's, you know, taken a lot of share from traditional retail and also expanded what we order online. But then Shopify has exploded as well as more people are able to start their own businesses. And I think you will have this aspect of the physician who practices in a health system, but then also has their own practice-

   16. AGAnkit Gupta24:50

       Right

   17. TTTanay Tandon24:50

       ... um, and chooses their hours. And because of the fact that software is automating more and more of their day, they can see more patients and do it in, in a way that is sustainable and gives them energy as opposed to drains them out by the end of the day.

   18. AGAnkit Gupta25:03

       Yeah. So let- let's talk about that a little bit in terms of software automating more and more of their day. There's been a lot of software adoption in healthcare over the last 10 years, most of it through electronic health records and, you know, kind of payment portals with insurance-

   19. TTTanay Tandon25:14

       Yeah

   20. AGAnkit Gupta25:14

       ... and whatnot. Um, but a lot of it has been promised to doctors as saving them time or-

   21. TTTanay Tandon25:20

       Sure

   22. AGAnkit Gupta25:20

       ... helping patients in various ways over the last decade. But the critique has often been that, well, it's not really been about that, it's been about getting paid for care, it's been about billing mostly-

   23. TTTanay Tandon25:29

       Yep

   24. AGAnkit Gupta25:29

       ... and not actually about care. How do you see what that technological adoption story looks like over the last decade and then over this next decade?

   25. TTTanay Tandon25:35

       Yeah.

   26. AGAnkit Gupta25:35

       Like, what are things you think are gonna be fundamentally different about this m- technological moment?

   27. TTTanay Tandon25:38

       I- it's, it's definitely true because a lot of the digitization and creation of EMRs came from a place of compliance and a place of, of, of billing and institutionalizing a lot of regulatory requirements as opposed to true, you know, un- un- unleashing the doctor. You know, Do- Dr. Klasco, who's one of our, uh, uh, you know, he used to run Thomas Jefferson University, the, the health system, um, you know, he calls this the epidemic, which is like there's just-

   28. AGAnkit Gupta26:04

       Right

   29. TTTanay Tandon26:04

       ... this proliferation of, of work tax in every org in the country-

   30. AGAnkit Gupta26:08

       Right
7. 27:14 – 32:43

   The Rise of Ambient Documentation

   1. AGAnkit Gupta27:14

      Can you tell us a bit about that?

   2. TTTanay Tandon27:15

      I would say it's one of the explosions in software categories recently. You've probably had... In terms of like really fast LLM adoption, I think you've had coding tools like the Windsurfs and the Cursors of the world, and then you ha- you've had ambient documentation tools, um, in the, in the healthcare world. And ambient documentation listens to the conversation that a patient and a physician have, it summarizes that, and then it generates all of the documentation based on being trained on previous approvals, previous pieces-

   3. AGAnkit Gupta27:39

      Right

   4. TTTanay Tandon27:39

      ... of documentation, and basically hands it off to the revenue cycle teams ready to go. Yeah.

   5. AGAnkit Gupta27:43

      It's like a perfect problem for LLMs.

   6. TTTanay Tandon27:45

      It's-

   7. AGAnkit Gupta27:45

      Those things, LLMs would be really good at.

   8. TTTanay Tandon27:45

      It's a perfect problem for LLMs.

   9. AGAnkit Gupta27:47

      Yeah.

   10. TTTanay Tandon27:47

       You have transcription, you have summarization, you have, you know, references and citations back to clinical source material all in this one, you know, or one set of models. Uh, and that tool, we went from 2023 doing maybe 100,000 appointments through that tool, to this year we'll probably do 20 to 25 million appointments through that tool. There's a self-serve motion that has gone from last year zero appointments to this year 5 million appointments. Um-

   11. AGAnkit Gupta28:13

       Self-serve motion as in you don't go through the hospital IT team at all?

   12. TTTanay Tandon28:15

       It's a physician finds it online, uh, we advertise directly to them, they sign up often paying with their own credit card.

   13. AGAnkit Gupta28:21

       Wow.

   14. TTTanay Tandon28:21

       Um, from-

   15. AGAnkit Gupta28:22

       That seems new.

   16. TTTanay Tandon28:23

       It seems crazy. I mean, I was shocked.

   17. AGAnkit Gupta28:24

       Yeah.

   18. TTTanay Tandon28:25

       When, when we saw this working, uh, it was... You- this is not behavior you've seen in healthcare before.

   19. AGAnkit Gupta28:30

       Yeah.

   20. TTTanay Tandon28:30

       And from that, we, you know, we then go upsell almost like Slack or Dropbox or one of these traditional software tools-

   21. AGAnkit Gupta28:37

       Yeah

   22. TTTanay Tandon28:37

       ... the whole enterprise, where we pitch the integrations into their EMR, the whole workflow tool. Um, and that's been a massive, you know, source of, of, of expansion for us.

   23. AGAnkit Gupta28:47

       If I'm a founder, you know, I, I might be thinking, "Well, isn't it gonna be really annoying in terms of HIPAA and in terms of all these rules and whatnot-"

   24. TTTanay Tandon28:53

       Yeah.

   25. AGAnkit Gupta28:53

       "... in terms of actually getting a doctor to sign up?" Like, it's not even intuitive to me that a doctor is allowed to self sign up for, for this type of thing. How do you guys think about that? Is that... Has something changed that makes it easier or was it never actually as hard as people thought?

   26. TTTanay Tandon29:05

       It, it's a good question. I think there's definitely a lot of compliance departments in hospitals that are, are very much against self-adopted software. But the productivity gains are so, so great that it's happening one way or another.

   27. AGAnkit Gupta29:16

       Yeah.

   28. TTTanay Tandon29:16

       Um, and the options that a compliance department at a hospital has is either, you know, sign up and make this part of the institution, or-

   29. AGAnkit Gupta29:25

       Right

   30. TTTanay Tandon29:25

       ... you know, tell your physicians to continue being burnt out, and usually they're picking the one that then ends up with happier physicians. You know, there are totally ways for there to be HIPAA compliant self-serve tools.
8. 32:43 – 36:45

   Stripe for Healthcare: Rebuilding the Financial Layer

   1. TTTanay Tandon32:43

      now.

   2. AGAnkit Gupta32:43

      And how do you think about yourself in terms of, uh, the types of software you guys have? You know, you call yourself sort of a compound software-

   3. TTTanay Tandon32:49

      Yeah

   4. AGAnkit Gupta32:49

      ... company, sort of a Rippling for healthcare as we've talked about-

   5. TTTanay Tandon32:51

      Yeah

   6. AGAnkit Gupta32:51

      ... in the past. What's the basis for that strategy and how do you guys think about growth and why grow this way versus doubling down on one of these and trying to make that be a massive business in itself?

   7. TTTanay Tandon33:00

      I, I think the complexities of healthcare and the way that people get paid in healthcare and really where the operating cash flow lies really make it ... Like, you can only really build $100 billion business in healthcare as a platform company.

   8. AGAnkit Gupta33:12

      Mm.

   9. TTTanay Tandon33:12

      With that being said, you have to start as a point solution.

   10. AGAnkit Gupta33:14

       Yeah.

   11. TTTanay Tandon33:14

       We started as a med device and then eventually turned into this, again, a point solution for a very specific subset of claims, and then over time turned into this platform. Uh, but now that we're this platform, we also have amazing distribution unlocks.

   12. AGAnkit Gupta33:27

       Right.

   13. TTTanay Tandon33:27

       I mean, we get to work with General Catalyst and their health insurance framework. They have 40 health systems that are all signed up. HCA is on our board. It's $100 billion hospital empire. And so I think in the same way that in the 2010s Palantir solved distribution and defense and a lot of call it, like, Fortune 100, uh, use cases and then just aggregated smart people to go work on crazy problems, we're doing that in healthcare. The hardest problem in healthcare, having now spent eight, nine years in it, is distribution. And you can reinvent the distribution wheel over eight, nine years for yourself or you can go build, you know, effectively point solutions as part of this platform-

   14. AGAnkit Gupta34:04

       Right

   15. TTTanay Tandon34:04

       ... um, and not worry about the revenue engine because the backend revenue cycle has that covered.

   16. AGAnkit Gupta34:09

       Right. As long as you ultimately have revenue cycle management at some part in your platform-

   17. TTTanay Tandon34:13

       Exactly

   18. AGAnkit Gupta34:13

       ... it kind of works.

   19. TTTanay Tandon34:14

       Exactly.

   20. AGAnkit Gupta34:14

       Yeah. I mean, do you think that changes now in this era of kind of doctor-led advocacy of acquiring software? You know, if, if for example it is much easier for hospitals to acquire software than ever before, especially smaller-

   21. TTTanay Tandon34:26

       Yeah

   22. AGAnkit Gupta34:26

       ... clinics, does that change the calculus there at all or do you think, uh, ultimately the same dynamics lie?

   23. TTTanay Tandon34:31

       What you will see is a lot of these, like, small couple million ARR businesses-

   24. AGAnkit Gupta34:35

       Yeah

   25. TTTanay Tandon34:35

       ... um, that might be distributed in this somewhat novel way now that physicians realize the productivity gains far outweigh, you know, the getting a wrap on your knuckles from compliance.

   26. AGAnkit Gupta34:45

       Right. [laughs]

   27. TTTanay Tandon34:46

       It, it's an approach. The issue is is that s- the number of companies, and there's like 40 different ambient scribing companies, they all hit like 100, 200K in revenue and then plateau out, and then the next kind of great wall that they hit is, you know, there's probably a dozen of them that got to a couple million in revenue and then they all plateaued out as well. It's not a venture business in my opinion. Like, a single point solution, unless you rapidly expand distribution or you rapidly expand your, your platform, it's not a venture scale business.

   28. AGAnkit Gupta35:11

       I can imagine then how you think about counter-positioning to what might be many new upstart companies thinking about this. Like, do you think of it as kind of as long as we own revenue cycle management, you know, these folks can basically help us innovate on companies on, on new areas and basically you guys would go acquire them?

   29. TTTanay Tandon35:26

       Yeah. Our, our strategy has been, you know, bundle as much as possible-

   30. AGAnkit Gupta35:31

       Yeah
9. 36:45 – 45:41

   Competing with Epic and Scaling Nationwide

   1. TTTanay Tandon36:45

      Everything I just said is exactly what Epic would say about us.

   2. AGAnkit Gupta36:47

      Yeah, exactly. Yeah. [laughs] Exactly.

   3. TTTanay Tandon36:48

      And, and so the, the, the way that I think about it is one, one of our core company values is speed.

   4. AGAnkit Gupta36:53

      Yeah.

   5. TTTanay Tandon36:53

      And there are a group of health systems in this country who can't wait for Epic to build these solutions for them over a multi-year product roadmap.

   6. AGAnkit Gupta37:02

      Yeah.

   7. TTTanay Tandon37:02

      Uh, I think the, the best stat that I have here is they're... you know, the two best run health systems in the country and from a, for- you know, from a profitability standpoint are HCA, which is like $12 billion in free cash flow.

   8. AGAnkit Gupta37:13

      Yeah.

   9. TTTanay Tandon37:13

      And then Tenet, which is also billions in free cash flow. Neither of these companies are, are, are on Epic.

   10. AGAnkit Gupta37:17

       Oh.

   11. TTTanay Tandon37:17

       In fact, they avoid Epic like the plague.

   12. AGAnkit Gupta37:20

       Oh.

   13. TTTanay Tandon37:20

       And the reason is, is that Epic often sucks out all of the operating cash flow of the academics and businesses-

   14. AGAnkit Gupta37:25

       Right

   15. TTTanay Tandon37:26

       ... that they work with. We have these like multi-hundred million dollar implementations. And-

   16. AGAnkit Gupta37:29

       Yeah

   17. TTTanay Tandon37:29

       ... the, the, the way that I see it is if you wanna be a fast moving growing business, you probably can't be on Epic because the CIO's office becomes this captured asset, and they're just waiting for Epic to release stuff. Or at least Epic can't be central to your strategy. Maybe you use them for your EMR, but you're, you're building the system of engagement and other tools on top of it and around it. Um, and, and we aim to be that platform for that system of engagement on top of EMR.

   18. AGAnkit Gupta37:53

       And it seems like you're innovating on a very different go to market compared to them too. To your point, they're probably going to the CIO's office.

   19. TTTanay Tandon37:58

       That's right.

   20. AGAnkit Gupta37:59

       You guys, it sounds like, are experimenting with ways to go straight to doctors and then kind of make your way to the CIO's office from doctor demand as opposed to from some large enterprise deal that's forced on everyone.

   21. TTTanay Tandon38:08

       Yep. And ultimately, you have to earn the trust of the CIO. There's no doubt about that.

   22. AGAnkit Gupta38:11

       Yeah.

   23. TTTanay Tandon38:12

       But you can build a lot of momentum-

   24. AGAnkit Gupta38:13

       Yeah

   25. TTTanay Tandon38:13

       ... and add a lot of value, uh, through this physician-led adoption. You know, even at our largest health system partners, we have forward deployed engineering teams that will sit and, you know, just work with the medical directors and the leading physicians in that facility to try to make their day a little easier, and that's it. That's all their job is. Um-

   26. AGAnkit Gupta38:32

       I mean, much like you and your co-founder in the early days. [laughs]

   27. TTTanay Tandon38:34

       Ex- exactly.

   28. AGAnkit Gupta38:34

       Yeah.

   29. TTTanay Tandon38:34

       We, we try to replicate what worked, uh, in the, in the early days-

   30. AGAnkit Gupta38:38

       Yeah
10. 45:41 – 49:33

    The Next Decade of Medicine

    1. AGAnkit Gupta45:41

       or something in between?

    2. TTTanay Tandon45:42

       I, I think in 10 years you're gonna have a lot... You're gonna have sensors kind of built into the home. You're gonna have sensors that are, you know, wearables on patients. The Apple Watch and AirPods are becoming medical s- medical devices very quickly.

    3. AGAnkit Gupta45:53

       Yeah.

    4. TTTanay Tandon45:53

       And that's a, that's a good thing because that passive care where, you know, we can detect things like AFib and-

    5. AGAnkit Gupta45:59

       Yeah

    6. TTTanay Tandon45:59

       ... you know, detect spikes in certain biomarkers is really good because that's how you treat them very, very early. The concept of health insurance and the concept of how care is rendered is gonna look a lot more like how our cars are, are handled-

    7. AGAnkit Gupta46:10

       Oh, interesting. Yeah

    8. TTTanay Tandon46:10

       ... in a sense like auto insurance where-

    9. AGAnkit Gupta46:12

       Yeah, it's like catastrophic insurance in a way.

    10. TTTanay Tandon46:13

        Catastrophic.

    11. AGAnkit Gupta46:13

        Yeah.

    12. TTTanay Tandon46:13

        And, and so when something bad, you break your arm, you have cancer, or you have a, you know, very complex disease, there will be an insurance mechanism and really your insurance will be focused on that kind of care. And then I think the rest of the care, it's actually cheaper for it to be out of pocket and for it to be, you know, outside of the loop and complexity of the insurance system, where you can just get a direct prescription or you can, you know, see a provider on telehealth or even in person for basic therapy. Um, and b- because the system will have shrunk and we have deleted parts, it will become a more efficient system.

    13. AGAnkit Gupta46:42

        And do you also see it reverting kind of back to that version? You said in the '80s and '90s it was great to be a doctor.

    14. TTTanay Tandon46:47

        I think so.

    15. AGAnkit Gupta46:47

        Do, do you see in many ways the sort of consolidation we see happening in this field will at least slow down and perhaps even revert back to seeing more people open private practices?

    16. TTTanay Tandon46:54

        I, I really think so. I, I, I would love a world where the market cap of a UnitedHealth is, you know, a fifth-

    17. AGAnkit Gupta47:01

        Yeah

    18. TTTanay Tandon47:01

        ... but every doctor is a millionaire.

    19. AGAnkit Gupta47:03

        Right.

    20. TTTanay Tandon47:03

        Like, that is a good world for America because patients are getting treated better. The people that are actually rendering care-

    21. AGAnkit Gupta47:09

        Right

    22. TTTanay Tandon47:09

        ... are where value is accruing. It is insane to me that if you think about it, the most valuable healthcare company in the country, what they effectively do is, like, send you a plastic card in the mail once a year.

    23. AGAnkit Gupta47:18

        Right. [laughs]

    24. TTTanay Tandon47:18

        Yes, there's, you know-

    25. AGAnkit Gupta47:19

        Right. Sure. Yeah, totally

    26. TTTanay Tandon47:19

        ... there's straw man, there's more that they do.

    27. AGAnkit Gupta47:21

        Yeah.

    28. TTTanay Tandon47:21

        But really at its core, that is your interaction with them. [laughs]

    29. AGAnkit Gupta47:23

        Yeah, totally.

    30. TTTanay Tandon47:24

        And, and, and-

Episode duration: 49:33