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THE RISE OF SYMPTOM CHECKERS & ONLINE MEDICAL INFORMATION
Here come the Informed Patients of Modern Medicine
Modern medicine evolved in the 18th century. Traditional medicine, like our very own Ayurveda originated even before, somewhere between 4500-1600 BC. Sushrutha who is considered as the Father of surgery in India, is lauded for perfecting the science & art of rhinoplasty aka ‘nose job’ and skin graft procedures. Infact his compilation called Sushrutha Samhita is regarded as the cornerstone of surgery in Ayurveda, comprehensively describing 120 types of surgical instruments and 300 surgical procedures.
Be it modern or traditional medicine, up until recently one thing remained unchanged – doctor was the center of the medical universe!
So much so that, the doctor prescribing and the patient obeying rather blindly was the norm. In this system, patients’ lack of medical knowledge and experience combined with fear is assumed to cloud their judgment, when making medical decisions. However, the paternalistic doctor-patient relationship has been eroding over time, albeit at varying pace across different countries.
When did the cracks first appear? In the western part of the world, it was in the 1950s & 60s, when groups of activist women began to refuse radical and super radical mastectomy. In other words, surgeries that involved removal of breast, surrounding tissues and even parts of rib cage for treatment of breast cancer. For decades, these aggressive surgeries were performed with either only their husband’s consent or no consent at all. The first consumers of healthcare, so to speak, who pushed for consent & more autonomy over their medical care were women.
In the 1970s, this was followed by the unraveling of Tuskegee study – a case of medical betrayal and exploitation at highest levels. In short, this 40 year long research (which started in 1932) involving over 300 black men, studied the effects of untreated syphilis (a sexually transmitted disease). These men were recruited under the guise of receiving treatment for “bad blood”, a commonly used phrase for syphilis, tiredness and other conditions.
The researchers did not take consent, knowingly withheld information and actively prevented these men from receiving Penicillin, even when it became available for treating Syphilis in 1947. Instead in exchange the men received free medical exams, meals and burial insurance.
40 Years of Human Experimentation in America: The Tuskegee Study, McGill University
Tuskegee represents a rather extreme case; yet many other similar incidents, not quite of the same magnitude, have resulted in a tectonic shift where patients now wish to seek comprehensive medical information independently. An informed patient is equal to a more informed healthcare decision. Informed decisions directly impact various factors like, length of stay (LOS) at hospital, likelihood of getting readmitted or having to visit emergency room post-procedure, so on and so forth.
Who then can provide accessible quality health information with the right insights to the masses? Is this where doctors and technology lock horns? If technology is partially the answer, can such a tech product be monetized even?
Dr Google, WebMD, Healthline – Gone Are The Glory Days?
Say you wake up feeling feverish and have a weird looking rash on your back. What do you instinctively do? Call up your family physician as you should or quickly type in your symptoms on Google and wait for it to churn out a million search results, most of them pointing to a strange cancer type you have not heard of? I’d bet that we have all begun to do the latter, more often. What aggravates the problem further is that in countries with high patient volume (much like India), there has been a drastic reduction in the face-time that the patients get with their doctors. By some estimates, an average doctor in India can see patients for only 2 minutes.
Sure, so getting offline facetime with doctors is tough, what if we leverage online/telemedicine approaches to increase accessibility to accurate medical information? While telemedicine has its merits, we would strongly argue that there is a definitive place for credible online medical information combined with data driven symptom checkers. Why do we say so?
Borrowing Dr Rohit Sharma’s rather clever way of saying it – telemedicine cannot solve the poor doctor-patient ratio. They only shift the existing ratio from offline to online. What we need instead is a better way to triage only those patients most in need to a doctor’s physical/digital front door.
Online health information sources 1.0
Great, so Google & WebMD it is for now! Or is it? Our beloved Google, the most popular and most used search engine, was never meant to give the right diagnosis for a specific set of symptoms. However, it did not go unnoticed that health related questions popped up frequently as search queries. In 2019, Google Health VP, Davide Feinberg is known to have stated that, ~7% of Google’s daily searches are health-related, which translates to over 1 billion questions daily, i.e.70,000/min. Despite its continuous efforts in enabling better search results for health related query, via knowledge graph (right side of the image below), Google has thus far simply not succeeded.
WebMD on the other hand, was created for that very purpose. At one point in time, online health care information was synonymous with WebMD. Launched in 1998, by Jeff Arnold, WebMD had a stellar start. It merged with Healtheon a year later, Jeff literally became a billionaire overnight, only to exit the company a year later. During those early days, they featured hit articles written by doctors and the upstart had a strong community focus with chat forums and educational subscription services (Medscape).
As more people began to look into WebMD for health queries, they launched the Symptom checker, which would churn out a whole laundry list of all possible diagnoses. End result? Unnecessarily anxious patients phoning their doctors.
A query on back pain spit out this terrifying list of potential possibilities: gas pains, shingles, ovarian cancer, acute kidney failure, and tick bites. No context — just a list of scary diagnoses.
Julia Belluz, The Truth About WebMD, Vox
But how does a company that provides free online health information generate revenue? The answer is as old as the internet itself – by renting out virtual real estate space for virtual billboards. That is, mostly via advertising and sponsored content for pharma, medical device companies and hell, the entire healthcare ecosystem.
By 2016, WebMD was on an upward trajectory! It had an impressive 70 million monthly unique visitors, $705 million full year revenue (11% y-o-y growth) and an EBITDA of $230M, (19% y-o-y growth). No wonder that a year later, it was scooped up by the private equity firm KKR for $2.8 billion.
WebMD has made a lot of people happy by minting money – but in the long run, have WebMD and its likes (read: healthline), succeeded in their true vision? Have they been able to provide accurate, insightful and useful search results? We don’t think so, because most of these websites in their current form are littered with too much dated information, severely lacking in patient context.
If anything, they have added on to the anxiety. Don’t believe us? There is even a word for it – cyberchondria, a type of repeated online health information search behavior, associated with high levels of health anxiety. As Scott Alexander writes in one of his fantastic pieces – WebMD is too big, too legitimate, and too canonical to be good.
Curious as to what a good version of WebMD might look like? Check out this out-of-the-world, well researched piece by Tom, who is taking a second crack at building Glacier MD.
In Tom’s words, a good version of WebMD would include: structured, quantitative health information, which is frequently updated and has summaries of supporting evidence.
A New Market Is Born
But somehow despite all of their deficiencies and there are many – people continue to flock to these websites in large numbers. In 2019, for the first time, the number of monthly visitors on Healthline surpassed that of WebMD by more than 5 million, reaching a record breaking 81 million. To put that into perspective, the number of people looking up information on Healthline were equivalent to Germany’s population. Ironically, even as more people participate in this, the satisfaction with online health information is appallingly low at 38% and it hasn’t changed much in a decade.
A limitless market fueled by a deep consumer need – that, in business school parlance my friend, is a blue ocean opportunity! If WebMD’s revenues from 2016 are anything to go by and considering that the market today has a lot more players, we are looking at a market that runs into billions in size. How much exactly? TBD – to be determined, since the ecosystem is literally taking form as we speak.
Online health information sources 2.0
Recognizing these gaps, there is a new crop of upstarts that are building data driven medical chatbot products with increasing focus on access to credible medical information and personalized preliminary diagnosis, based on data driven symptom checkers.
Ada health: Founded in 2011, Berlin headquartered Ada health has been working close to a decade on perfecting their symptom checker application. During their early days of inception, they were focused on building a decision support tool for doctors. However their decision to pivot into a patient facing AI driven symptom assessment app seems to have worked wonders for Ada. Today, they claim that every 3 seconds, someone turns to Ada for personal health guidance!
In a market that is getting formed, Ada is a front runner in being able to raise close to $190M till date from various grants, high net worth individuals, PE and impact investment firms. Why are investors bullish on Ada? It’s because Ada’s dataset covers 30,000 ICD-10 codes. Fancy word for codes used by doctors to represent various diagnoses. In the words of co-founder, Daniel Nathrath, “it is by far the largest coverage of any of the systems in this space.”
Buoy health: Buoy health started with Andrew’s annoyance (CEO, Buoy health)! During his final year of rotation at Harvard medical school, Andrew grew exasperated with growing numbers of patients misinterpreting their symptoms based on inaccurate online information. The company considers itself as a matchmaker of sorts, diagnosing people via the symptom checker and then guiding them through their employers/payers to the best care options available.
Today, Buoy health is climbing the ranks of the online symptom checker world and has over 2.5 million monthly users and $63M in total funding under its belt.
Zini.AI: Compared to other global front runners, Zini.AI, an Indian upstart is still a fetus. But don’t let that fool you. In a country that is still thrashing under the first wave of online medical misinformation, Zini.AI is truly a visionary. With a multilingual AI-powered, voice based virtual physician, one can “Talk to Zini” (in an almost Alexa like fashion) about their symptoms and get a preliminary diagnosis for over 300 diseases, with a detailed report and recommended next steps. Earlier in the year, Zini received a grant from HDFC to open 3 Zini clinics, which are being called “5-minute clinics”. The idea is to close the loop after online preliminary diagnosis – this way any patient after getting the online preliminary report can walk into the clinic, where a nurse will take all the vitals and arrange for a telemedicine consultation with a doctor.
How do these medical chatbots bring in the dollars? They monetize primarily through B2B sales, where the end customers include the likes of large healthcare systems, insurance companies (payers) or pharma companies. The less dominant method is via the marketplace model.
The largest piece of the revenue pie comes from payer organizations in insured markets around the world. Why do health insurance companies buy these apps in the first place, for their clients? The logic is simple – data driven symptom checkers prevent unnecessary physician visits. In the USA alone, a 5% reduction in physician visits, would lead to annual cost savings of $8B! Let that sink in for a second.
As of today, especially in these insured markets, entrepreneurs building products face significant barrier to entry because of:
A. Lengthy time for development of the algorithm – for example, it took Ada 7 years to build and launch their algorithm. Imagine having to map out an exhaustive database that can effectively match a series of symptoms to 1000s of diseases, given certain patient demographics and other individual context.
B. Closing window of opportunity for new entrants for tie up/sales to insurance companies – current players are already building multiple bridges with the who’s who in pharma and insurance world
Looking around the world and at the fringes of a new beginning it is obvious that – like it or not, accessing medical information online, as well as trying to pre-diagnose, is here to stay.
What does this mean for up and coming entrepreneurs at home? It is a white space ripe for building great products! Some questions need to be answered along the way and like everything Indian, it has to have its own flavor.
Yet the bothersome rupee question remains… Where is the money at? Who will be the payers in a mostly uninsured healthcare market such as ours? Do we have to begin our zero to one story, from the same zero milestone of ad based revenue model? Or can we leap onto the backs of other behemoth platforms to generate sales?
Designed by Priya Manjunath