How to Improve Patient Experience?

Afsal Salu

This is a transcript of a talk given by Afsal Salu at Medicall, 2022 in Hyderabad. Afsal was a co-panelist in a session on How to Improve Patient Experience. Afsal’s talk centred on the problems in patient experience throughout the patient journey and how technology is assisting in addressing these challenges He also shared his perspective on the future of patient experience.

Afsal Salu: At some point in our lives, definitely, we would have been in situations where we would have to go ourselves or take someone else to hospitals and doctors and we would have experienced the way healthcare was being delivered also.

A Brief Background of BestDoc

So, before we get into our presentation, let me give you a brief background about what we do. I am the Co-Founder and CEO of BestDoc. We work with hospitals in improving patient experience. So, we are a SaaS-based – how many of you understand Saas –  can I get an expansion of SaaS? Software as a Service. So what we are trying to do – most of us, in our early days, we would have seen software coming in CDs, where it’s packaged and then given to us and then we need to install and start using it. 

We have moved to a world now where software is available at a tooltip (inaudible) domain, or it can be installed as soon as possible at the click of a button. So that’s Software as a Service. What we’re doing is improving patient relationship management at healthcare providers’ hospitals. When you come to a healthcare setting, the patient is the centre of everything. We are replacing the customer by the patient, and how he or she experiences the service in that context.  

We work with about 300 hospitals across 20 states in the country. We also have a presence in the UAE, Middle East. Since 2018, when we did our commercial launch, we have handled about 3 million plus patients and 7 million plus appointments. Very recently, we have introduced our IP patient engagement product, which is known as Concierge. I’ll be touching upon that also as we move ahead. 

Patient Experience Challenges – Outpatient Journey

This scene reminds us of how crowded our hospitals are. And the larger the hospitals are, when you go to those tier 1 metros, you would see that the hospitals are bursting at the seams. At every single touchpoint, you’ll see long queues. Hospitals, who are experiencing 1,000+ – the actual clinician facetime is only about 2 minutes as recorded by WHO. So where is the patient and the caretaker spending time? They are mostly idling pre-consultation, waiting at various touch points where they are getting things processed. And when they are in front of the doctor, they get only 2 minutes to talk about what illness they have, what they’re experiencing. And then after that, they move on to the post-consultation substream activities, which would be either investigation, it would be a scan, or a pharmacy purchase. By the time they get out, it would be almost half a day.

COVID-19 Induced Digital Transformation in Healthcare

So what we have seen is in other industries – as the previous speaker, Deeksha, has mentioned – have moved on and are delivering service as a service. We are now seeing healthcare still lagging behind in terms of the old way of doing things. We see a lot of paper throughout the patient journey whereas it would have been easier for us to digitise all this information into easy-to-use, referable data which is available at the tooltip – it would have been either a mobile app or a website. So why is healthcare lagging behind? Because this is one industry I believe – because I am an engineer myself. During childhood, we are given two options – either you take this stream or that stream. And what I believe is healthcare is one industry where we have seen a lot of aversion towards adopting technology. 

Luckily, it is changing, over the last few years. COVID has actually changed and brought a phenomenal shift in how technology is being used to deliver healthcare now. So, during the last two years of the pandemic, you would have seen that you would not have been in a position to go to the hospitals, you would not have been able to go to a place to get your tests done. But, we are getting all these things delivered at home, just in front of our mobile phones or computers. So healthcare is also slowly adopting, and that is where we are helping healthcare providers move faster, so that they are also able to deliver care using digital technologies.

The Outpatient Journey: Opportunities for Improving Patient Experience

The reason why someone is coming to a hospital – it is not a leisurely activity. As patients, you would have experienced that we will try to handle the pain or whatever we are experiencing to the maximum point till we need to actually take a pill or go to a doctor. That is because of the experience they would have seen at the hospitals where they have to wait, and they are not sure. So when a patient is coming to hospital, there are two reasons why they’re coming – either it’s for an outpatient visit or it’s for hospitalisation. An outpatient visit is where most of us would land in a hospital and would have spent a good amount of time, and that is where the volumes are also huge. Whether it is a small hospital, mid-sized or a large hospital, you’ll see at least 10x the number of patients coming for outpatient visits. And that is where hospitals need to invest in technology where they can streamline this patient journey. 

If you look at the top two reasons why patients are not happy with an outpatient visit – waiting time is the most common insufficiency across hospitals. And that is where we are seeing how we can actually improve TAT or turnaround time using technologies, which are helping patients understand what’s happening throughout their care. 

This is similar to the patient journey which was listed by the previous speaker, but we’re just going deep. So if I double click what happens in an OPD journey, there are at least 5-8 people a patient would speak to before reaching the hospital, once they are inside the hospital, and after they left the hospital. 

Before reaching the hospital, they will be starting with the call centre for an appointment. Now most of the hospitals have started providing digital channels, which would be a website as well as an app. What we have seen is when the patient is talking to the hospital, there is various information, which is getting collected at that point. And that helps the hospital staff plan the patient journey in a seamless fashion.

Throughout the journey, what we see is there are various employees who are speaking to the patient. At each of these touchpoints, we are collecting data or otherwise giving information, which is useful for the patient. And what we believe is, we need to double click each of these engagements, and see how we can use technology to our best so that we can bring down the time. So our goal is how can we get a patient in and out of a hospital for an OPD visit in less than 30 minutes. Is anyone working in a hospital who has been able to achieve that here? Can I see a show of hands? Most of the hospitals today are at a minimum of one hour for a patient, who walks inside the facility and before he or she finishes the activity, it will take at least an hour before they get out. We have been able to achieve a 30 minutes turnaround time in most of the hospitals we work in Kerala that’s where we started. We would love to actually show how we have been able to achieve that at some of the touchpoints. 

Once they have reached the hospital, registration is an activity, which every one of us have to do. With the National Digital Health Mission coming in, all of us will be entitled with an ABHA, which is an Ayushman Bharat Health Account, which is similar to Aadhar, which would help us get inside hospitals without having to give our personal data because it is already there with a government registry. But till that happens and it becomes a reality, we are signing forms, we are waiting in queues, handing it over to the staff who is sitting in front of the computer. She or he is typing in, and after that, they give us a registration ID. 

I believe that’s a process which most of the hospitals follow whether it’s small or large. We believe that registration on average today takes about 7 to 10 minutes. We’ve been able to innovate and bring out a digital innovation, which is a mix of hardware and software – a patient kiosk which is shown here. I would walk you through the video of that product. With that, we have been able to bring down the registration to 20 seconds. And this is achieved because of Aadhar-enabled integration, and we would show you the video. And that is how we are revolutionising how we can bring down the patient turnaround times. Can I move to the video please?

Transforming the Patient Registration Process: Key Learnings

This is Baby Memorial Hospital, Calicut. We are also in talks with some of the large hospitals in Hyderabad. We already have about 30+ hospitals in Hyderabad using our various products. So, this is the kiosk, which we have implemented at hospitals like Baby Memorial. This doubles up as a front-office desk. It has got a camera at the top. It can actually take the picture of a patient. It is similar to the phone face ID recognition. So when you’re coming to the hospital for the first time, we request you to register your face ID. And next time, you just need to stand in front of the kiosk, it automatically recognises you, checks you in, if there is a payment, it sends you a link, and you can pay on the phone. You don’t need to touch the kiosk, you directly walk to the OP.  To that extent, we have automated processes in the hospitals. It has also got an industry-grade touch screen device, and the application which is there is run in 12 languages as of today. 

So we are looking at how patients experience care, and we want to make sure that they are able to understand what needs to be done. When someone is coming to the hospital for the first time for registration, they are worried about their health conditions, they are coming to the facility for the first time, they don’t know where to go. So we are looking at customer experience executives who are there to assist them, similar to what we see at the airports and railway stations where someone is telling them what to do. And the moment, they understand it’s so easy. We have seen 80% of the patients just coming back to the kiosk to do the next transaction. It’s also got a barcode and a QR code scanner. The QR code is for Aadhar and the barcode is for the hospital ID cards, which have got barcodes printed in it. It’s got a payment device integrated as well as a printer integrated with that. 

I’ll walk you through the longest use case when someone comes to hospital for the first time and does the registration because that’s the time she would be spending the maximum time at the counter. So, this is what we have done using the Aadhar card. That’s when you can change the language at the top. The patient clicks the new registration button, and this is a form which is there at all the hospitals. A tech-savvy person would fill it on her own in 30 to 60 seconds. 

But for a person who is bringing an Aadhar card, with a scan, in 2 seconds they fill the form. And this is government-validated data, which is going in your database, so that you don’t have to worry about spelling mistakes so that insurance approvals and all can be made easier. Mobile number is the only thing, which is not there in the Aadhar card, which we are asking the patient to enter or someone can enter on her behalf. So in about 20 seconds, we have completed the registration. 

We move to the next stage, which is appointment. This is real-time integrated with the hospital HIS. We have completed integration with 21 HISs with a footprint of 1,000+ hospitals. The patient is given an option to select the slot, if slots are available, otherwise a walk-in is activated, so that you get to walk in. The fees are shown to the patient, and if it is a repeat visit, it will show the subsequent fees. From this time, the clock starts ticking for the hospital. They are able to know that the patient has actually checked into a facility, and she is waiting for the doctor to be called in.

We also have enabled now UPI payment post COVID, where a patient just has to scan the QR code. Or if it’s a card, it is integrated with the payment device, which is provided by your bank. It goes directly into your bank account. The patient need not enter the amount, it cannot be edited. It is also NFC enabled so with a scan, they are able to complete the transaction. So the entire process of registration now takes less than 90 seconds for us. 

We are handling thousands of patients on a daily basis with these kiosks, which are now deployed across large hospitals. And we have also seen small hospitals in tier 2 towns using this, because they know the value of how the machine can bring down the turnaround time for the patient.

Making the Waiting Experience Less Burdensome with Technology

Once the patient has gone inside the hospital is where the waiting time starts. And that’s a painful, agonising experience for most of the patients, including the caretaker where they wouldn’t have to do anything else, other than just wait. I come from a family of doctors. My dad is an oncologist and my mother is a gynaecologist. We also run a 250-bed hospital. So I have been living in hospitals, literally throughout my childhood where I’ve seen people waiting at various points. When the gynaecologist steps out of the room for an emergency delivery during the OPD is when you don’t know when she’s coming back. And that is when the patients and the relatives are getting restless, they are ready to wait for may be 20 minutes, 30 minutes, but when we don’t know they’re coming back. We need to be able to give visibility into what is happening throughout the patient experience. That’s where our queue management system has come into place. It’s integrated with the check-in. So, everyone who’s coming into the hospital, whether it is through the kiosk or the front office, we get to know at what time they got inside. And from that time, we are able to understand that this patient has been waiting for ‘n’ number of minutes, before she’s called inside the doctor’s room. The doctor gets to know the patients in the ascending order of waiting time. So we are able to know that this patient has been waiting may be for an hour. And if the doctor needs to step out, there is a broadcast feature available in our QMS – if the doctor has gone for rounds, because most of the OPDs would be for departments with doct ors doing rounds in the morning. 

If he or she is getting delayed, they can just tell their assistant to broadcast the delay. The doctor can click a button and put a 15/30/45 minutes delay. It gets broadcasted through WhatsApp or SMS to every patient who is waiting – who has got inside as well as who is about to come to the hospital. That way what we’re doing is we’re streamlining the traffic, telling them that you don’t need to come now and waste your time at the hospital. If you are already inside the hospital, please go and have a coffee. So we are helping them adjust to the delays, which are now there in our system by giving them very good visibility. 

And once they are done with the consultation, what we see is – large hospitals, there are various blocks, there are flows where the departments – you would have to come down to the reception to do payments. Then you will go for a substream activity, which will be an investigation or a scan or a lab test. Even at pharmacies, you’ll see people pushing their hands to actually get their prescription so that they are able to get out. If you look at the conversion, which happens in the substream activities, it is not more than 50%, because patients are fed up with waiting. They would like to actually have a standard way of communicating to them, what time it would take for each of these processes. 

So we have implemented queue management systems in labs, radiology scans as well in pharmacies, where were able to tell the patient, you are now seventh in the queue and you will take approximately so many minutes. We wouldn’t even wait there. So that’s where we are able to help patients streamline their activities. And that because of which we are able to increase the conversion. And after that, we are also able to push the reports to their mobile phone and the doctor also gets to know this patient has got their reports.

Streamlining Patient Feedback

The last activity which happens – because the reason why someone is coming to our facility is to stay healthy or get better. How do we know about that? If we ask feedback immediately after the OPD visit, you’ll only get to know how they have experienced the service? The quality of outcome, which is the most important thing in a healthcare setting, cannot be measured immediately after the OPD. You need to wait for a minimum of say 8 hours or 24 hours. That’s when you need to go back, when the patient has taken the medication, followed the guidelines,  and then they are in a position to give you real feedback. 

The only question you need to ask is are you feeling better after doing this? And if you are able to get an answer, which is a positive one, you have solved their problems. And if they say that they didn’t like the experience when they were in the hospital – like what Deeksha had mentioned, we have put in corrective and preventive actions and you are able to drill down into various categories where it went wrong, whether it was at the pharmacy, whether it was at the reception, whether it was staff behaviour and then take corrective actions as well as preventive as per the NABH guidelines. 

So, we have about 200+ hospitals, using our feedback, and all of this is digital. It is available on a QR code, it is available as a push notification on WhatsApp, it can be on a tab, where the patient is actually given that product and they’re able to give the feedback. And we are able to complete the loop where we get the patient back for a follow-up visit with reminders, which I mentioned earlier as well. Because we believe that that’s one way to make sure that we’re able to make sure we are touching them throughout the engagement and keeping them clearly notified on what’s happening with the progress of their care.

Patient Experience Success Stories

Moving forward, these are a couple of success stories, which I would love to share. Baby Memorial Hospital is a 600-bed specialty care hospital in Calicut in Kerala. We have been working with this hospital for the last two years. And what we have been able to do is we have put in our PRM product throughout the patient experience on the OPD side. 

And what we have been able to demonstrate is, with 6 kiosks as well as our application being used by hospital’s call centre and front office, queue management being put in front of all the doctors’ OPD as well as patient feedback – closed-loop feedback, which has been put in place– we have been able to dramatically improve the patient experience scores for this hospital in the last few years. And also bringing down the front office costs, because what we have been able to do is – earlier if you had 20 people in the front office, you are able to release a lot of them for other activities because of our kiosk doing the heavy weightlifting. 

And during COVID, this was a very good product, which the hospitals loved because we were on a SaaS model. We were charging per OPD. There is no upfront payment the hospital had to do. So, we actually grew along with the hospital or whenever the numbers go down, we also actually see the downside in our business. We are taking a risk, we are betting on adoption, if 1000 people are using our kiosk, we get paid for that. That has been the way we have been implementing all of our applications. 

This is another case study, which we have done with Narayana Health. Most of you would be aware of this as they are the largest cardiology network in the country with over 26 hospitals. What we have done with them recently is we started with 3 of their units where we wanted to improve their patient feedback. The problem statement was only about 2 to 3 percentage of patients were giving feedback. And hence it was not a good sample set for them to decide what to do with improving patient experience. This was even true for one of their units, which had 2000 OPD per day. We got in, we identified there are various ways, it has to be Omni channel, so we identified people who would be ready to give feedback on IVR, in their local language, people who would give feedback on WhatsApp, people who can give feedback on an app. 

So, with all this, we are able to now increase the feedback by 5x. So, when you are getting about 15 to 20 percentage of feedback, it’s a good, rich amount of information, which is useful for each of your departments to find out where you’re going wrong. And because of which, earlier when they were able to actually get a good number of feedback, they started working on fixing most of their problems. So now, the units across NH – you can see a snapshot of before BestDoc and after BestDoc, their Google review ratings themselves have jumped by a good percentage points. And this is possible because patients are able to give feedback, and they’re able to see them getting fixed. So they are more happy, they’re not going online and then putting it in a public view. This is helping hospitals also catch problems before they go up.

Inpatient Journey – Key Problems Faced by Patients

Coming to the IPD journey, this is the single biggest problem which we would hear from all of our patients. Discharge takes an enormous amount of time. Average TAT is about 6 to 8 hours from the time the doctor notifies that you can go home today. Why does that happen? I’d like to hear from the audience? Why? What do you think would be the reasons behind this long discharge TAT? Paperwork. Any other reasons? 

Yes, paperwork across multiple departments. There are so many parallel processes, which need to be done, from the time the doctor says that this patient is ready for discharge. You need to notify the billing department, you need to notify the nursing department, you need to notify the insurance department, you need to notify the housekeeping department. There are so many things, which need to be done. And no one is knowing where that particular process is at any point of the stage. Most of the time it is the nurse who’s at the center of all the action. The relatives would be delighted when the doctor says that at 8’o’clock you can go home. They will start preparing so that in the next two hours, they can go home. 

But what unfortunately happens is, at 11’o’clock, 12’o’clock also, discharge summary is not ready. Because the doctor is finishing the OPD, and then only they will come and type the discharge summary. And after that is done, by around lunch time, is when you will realise that insurance approval is not done, because something is missing. And after the approval has come is when you will realise that the patient doesn’t have the money and now he or she is travelling to actually find the balance payment, which needs to be managed.

And then the medicines need to be returned, you need to be given the new discharge medication,  post-discharge medication. And then arrange for the transport, and by the time he or she leaves, it will be around three to six o’clock. We are not able to utilise the turnaround, the rooms. The patients who are getting admitted during the day are left on the corridors or waiting to be admitted. And we’re not able to get the rooms ready for the next patient. And then the housekeeping needs to clean the rooms to get them ready for the next patient. So it’s a long process, which is broken at various points. We are looking at how we can improve that with real-time notification as well as visibility into each of these parallel processes. 

The quality of nursing services is also significant in complaints, where we actually see that if you’re able to put in a way in which you can track everything which is happening in the room. And that’s what we achieved with a new product, which we have released this year called Concierge. Deeksha also touched upon that. So what we have identified is, from the time someone gets committed to a room when a room or bed is allocated to them, there are so many activities which would happen. 

In an average length of stay, ALOS of about 3 to 4 days, there are 15 requests which come out of a bed, which are not clinical. And all these requests are today landing in front of the nurse. The nurse is the one who gets pulled into doing any of this, whether it is hot water or bedsheet to be changed or I need help to go to the restroom. So, what we have seen is, as a result, the clinical team is getting stretched. The non-clinical team may not be able to be utilised properly.

How Technology is Helping Improve the IP Experience?

So, we are seeing that Concierge as an application is able to help the non-clinical teams get alerted on various requests which are coming out of the room. So, we are just doing it in a very simple fashion, where by just scanning a QR code or calling a number, as what has been done in Kauvery Hospital, we are able to see all the various requests which need to come out of a room. Whether I need to order breakfast, whether I need to know where my insurance approval is, how much is my billing up to date – all this can be told to the patient immediately. If a doctor is coming for round, we are able to tell the relative or the bystander that please be around, so the doctor is able to converse with you. 

So that is so we are able to achieve such various touch points put together in one single product, and it is not an app. Because we believe, as BestDoc, when we started our company, we thought that people would download the app and start using it. Because I came into this industry with my previous understanding of E-commerce. I was in E-commerce for seven years, where I was working with BigBasket for the last two years. And prior to that, I was with Hindustan Lever, which was a retail company. So there what I’ve seen is daily use cases, people would download the app. If you look at our phones, we would have social media apps, we would have communication apps, we would have banking apps, and we would have at the best some transactional apps, which we want on a weekly basis. But how many of you have downloaded a hospital app in your phone? If I can see a show of hands. Can you raise? 

Yeah, definitely, Deeksha is from an organisation, she has to carry the flag (ph) on her mobile phone. So, definitely yes. But, that’s the case where we are. We cannot expect patients to download an app. And that is why we have put a web app, which looks exactly like an app. That’s the power of technology today. How many of you have downloaded Google on your phone? We don’t need, because it is supposed to give us some information. So transactional systems where we need to store data is where we need to actually have them stored in our phone. Whereas when this is an event tracking, service management kind of tool, we don’t need to download that product.  Whatever we need, you can use it, and when you’re out of the hospital, you don’t need to even store this. 

What we have done is we have put in these QR codes next to the bed where patients are able to just scan, and caretakers are able to scan, and they are able to put in the request. And the requests get thrown up in the air. For example, if it’s patient transport, there are three people who are allocated to that floor, whoever has been idle the most, gets the request. Or we also know that who has been logged in, who is in the shift, they are the only ones who are getting a request, they pick up the request, deliver it like an Uber and Ola. And once it is done, we are able to know how much time it has taken. 

The patient gets to rate on every single service she’s asking for. And they can reopen the ticket, if they are not happy with the service. So because of this, we’re able to make sure that we are able to keep a tab on everything that is happening with respect to that particular patient. And if something goes wrong, the patient care team can just land in the room and then fix that as well. 

Post-discharge feedback is another product where we are able to go back to the patients after seven days, 30 days, depending on different specialities, and ask questions, which are helping us understand the quality of outcome. There are patients where we are asking questions with respect to whether they’re able to regain their motor ability. So these are things, which we need to understand and then go back and collect and then give it back to the clinical team, so that we are able to improve the patient experience.

Replacing the Nursing Call button for Administrative Tasks with a QR Code

So this is how it has been happening. And most of you will be familiar with this nurses call button, which is there at the hospitals. We are replacing that with the QR code. Now if you ask a two-year old kid also, what does a QR code mean, they will say it is for payments. That is the way UPI has revolutionized consumer behavior in the country, that we jumped directly from cash to mobile-based payments.  

I believe the time has come for healthcare also to do this quantum jump. And we should be able to use these kinds of very ubiquitous technologies to deliver care at the tooltip of their phone. Or if they are not tech-savvy, someone else should be doing it on their behalf. And we’re able to release a lot of bandwidth, which is now being utilized by the nursing team and streamline our operations. 

Outlook on the Future of Patient Experience

I’d like to close my session with how the future is looking. Most of you would have heard about the National Digital Health Mission and Ayushman Bharat Health Mission. These are looking forward to digitise the way healthcare is getting delivered. First, there would be registries which would come where they will be able to know everything about a hospital, a doctor as well as various services which are being delivered. In future, there’ll be seamless data transfer, which would be also planned between all the entities.

We see a lot of changes coming up in the insurance claims space. For all of this, data needs to be standardised as well as stored in various applications which we need to use. So even if you’re running a small hospital, midsize or large enterprise, digital is the way to go. And you can start taking baby steps where you look at those touchpoints where you need to invest. It need not be rocket science, it can be very easy things, which the patient can understand. So that you are able to handhold them using a better patient experience. I would like to end my session here. Are we taking questions now? So we would be taking questions at the end of the session. Thank you.