Raise capital from professional investors, as opposed to angels, sooner than later. Venture capitalists who understand a startup’s market can be exacting in their evaluation of investments. That process encourages startups to sharpen their understanding of the market and the problem they are solving. If a startup can persuade a smart investor, they’ve amassed market savvy that will be an asset for subsequent growth. On the contrary, angel investors tend to have a lower bar, and are betting on the founders, not on the business plan. Their investment is frequently not complemented with market intelligence, nor customer introductions. Their judgement of your company’s potential for success is clouded by their relationship with you, and they don’t clearly see the weaknesses in your plan, nor the obstacles you must overcome.
As a part of our series about cutting edge technological breakthroughs, I had the pleasure of interviewing Kulmeet Singh.
Kulmeet Singh is the founder and CEO of Twistle, Inc., which uses secure, patient-centric communication to drive adherence with care plans, improve patient outcomes and lower costs. Kulmeet previously founded MedRemote, a company which leveraged speech recognition and machine learning to change the economics of clinical documentation and medical transcription. Later MedRemote was acquired by Nuance Communications, where Kulmeet led strategic planning. His success is rooted in his commitment to a #patientsfirst philosophy, which prioritizes decision-making based upon the best interests of the patient. Mr. Singh holds degrees in economics from the University of Chicago and in computer science from Columbia University in the City of New York.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
I come from a family that is centered on faith and social activism. In fact, my parents were among the original instructors with the Peace Corps back in the sixties. While many in my family are physicians, I opted to follow a parallel path, one that would also allow me to help improve the health of populations.
My first venture was a social enterprise, which in a way was similar to the Peace Corps. The organization provided opportunities for Americans and Canadians to work in rural India. This venture taught me that operating a start-up, especially in the non-profit space, is much harder than most people think.
I was returning from the sub-continent when I read about growth in outsourcing of medical transcribing of physician dictation from the United States to India. It occurred to me that there had to be a better way than manual typing, especially with advances in speech recognition technology. Shortly after, in 1999, I started MedRemote along with a close friend Harjinder Sandhu. MedRemote developed speech recognition and natural language processing solutions for clinical documentation. Despite the challenges of the Dotcom Bomb and then 9/11, MedRemote prospered. We eventually sold it to Nuance, delivering a significant return for our investors. I stayed on with Nuance to lead strategy at their healthcare division until 2010, for what turned into a brief hiatus from business.
In 2011, even before we knew what we wanted to build, Harjinder and I incorporated a new venture, Twistle. Broadly speaking we resonated with the insight that most healthcare happens outside the four walls of the clinic or hospital. Yet when patients leave those settings, their only connection to their care teams was a phone call. More often than not, telephone interactions resulted in a frustrating game of phone tag for the patient and provider, and not meaningful support for the patient’s care journey.
Other colleagues — Jacob Reider, Dave Ross, and Henry Chueh — joined us on this journey, which started in the Cambridge Innovation Center. We worked like a think tank, exploring a range of ideas that ultimately led each of us to unique paths. Jacob joined the US Department of Health and Human Services; Henry continued to lead Bioinformatics at Massachusetts General Hospital; and after experimenting with a few patient engagement ideas, Harjinder left to start Saykara, a company that uses AI to automate physician charting. As a co-founder and investor, I joined the board of Saykara.
Dave and I continued to focus on Twistle, and in 2014 decided to automate care plans and build a platform that would serve as a GPS for patients, guiding them through any care journey. We made our first sale to a large health system in 2015 and went live in March 2016. And the rest, as they say, is history!
Can you share the most interesting story that happened to you since you began your career?
In the early days of MedRemote we beat several large competitors and landed a huge sale. The agreement was going to be signed on September 11, 2001. Needless to say, the attack on our country derailed the plan as we were all focused on friends and family in New York, DC and Pennsylvania. We were certain that for a number of reasons — political, economic, and social uncertainty to name a few — the deal would not go through. We were surprised and delighted when our customer called and reassured us that they intended to move forward. More important than the deal was her sincere concern for us, and our safety given the treatment some people were receiving because of their heritage. This unexpected kindness was touching and memorable, especially given its stark contrast with the murderous events of the day.
Can you tell us about the cutting edge technological breakthroughs that you are working on? How do you think that will help people?
The Future Is Now aptly describes the state of healthcare as we enter 2021. The advent of COVID-19 and the global pandemic accelerated innovations in healthcare, care delivery, and patient engagement. Changes that at first were thought to be stopgaps are now certain to become the norm.
None of these changes would be possible without bleeding-edge technology that can also be widely accessible to patients of all types. And, while there are many companies offering solutions, our unique approach drives near 90% adoption. This ability to activate patients in their care is foundational to our nation’s ability to meaningfully change patient behavior and improve health outcomes.
We developed an automatic navigation (GPS) system for health. It offers “turn-by-turn” guidance to patients — whether for preventive care, before and after an appointment, pre-procedure preparative steps and follow up care, or throughout a chronic care management journey. The key is our library of clinical communication pathways and best practices that keep patients on track as they navigate care journeys. Optimal clinical content, language and message frequency produces high adoption, satisfaction, and functional patient outcomes. We also integrate sophisticated automation with multi-channel communication, engaging patients through their preferred method: secure text messaging, interactive voice response, patient portals, or the health system’s digital applications.
How do you think this might change the world?
Imagine parts of the world (including places in rural America) where the nearest medical care is literally hundreds of miles away and the dire impact that has on the health of populations. Seeing a doctor for routine visits most likely doesn’t happen, often leading to serious illness that may have been prevented.
Twistle solves that problem. We provide the tools needed for medical practitioners to guide patients through their health journey and improve care, regardless of their location or condition.
This is how Twistle is changing the world.
- We fill the gap between clinician visits and provide an extension of clinical care into the daily lives of people.
- We meet people where they live their digital lives — their mobile phones.
- We educate, engage, and empower people to take an active and informed role in their own healthcare.
- We improve health outcomes.
Keeping “Black Mirror” in mind can you see any potential drawbacks about this technology that people should think more deeply about?
At Twistle, we believe our technology is a force multiplier that enables healthcare providers to accomplish more, to see more patients, and to improve health outcomes with existing resources. We use AI and machine learning to augment healthcare providers so they can do more. But we don’t aspire to make AI that can replace clinicians.
This is a big distinction.
We believe that human interaction is a central component of good healthcare. In fact, there are numerous studies that provide evidence of the therapeutic benefit of clinicians who are empathetic in terms of major, positive impacts on outcomes. An article published in The Medical Futurist in October 2020 stated, “While some AI might eventually be endowed with ‘artificial empathy’ skills, they will not replace a real-life doctor-patient relationship. On the contrary, as these tools manage repetitive and monotonous tasks, they will free up time for doctors, nurses and other care providers meaning they can devote more time to nuanced empathy and compassion that treating patients requires, which is only achievable through the human touch.”
Our focus is to manage routine tasks so that clinicians can focus their time on patient care (work at the top of their license) and focus on elements of care that machines can’t provide or can’t provide well.
Was there a “tipping point” that led you to this breakthrough? Can you tell us that story?
There were many influences, but I’d say the tipping point came after an interaction with a couple of extraordinary physicians in late 2014. I learned that providers who produce positive outcomes and are well-liked by patients also tend to engross themselves in the details of their cases, especially the complex ones. By the end of a workday they are drained but still have to document their work, often in poorly designed electronic health record systems, and also communicate, mostly through voice mail, with patients about care plans, or to educate or answer questions. To achieve a good outcome, competent care providers invest so much of themselves that last year 42% of physicians in the US reported feeling burned out. Data also showed that patients are not always active in their own care, nor do many understand or follow their care plans.
It occurred to me that we could automate physicians’ routine tasks and free them to focus on patient care. Automation could solve the documentation challenge, and also help address the mismatch between the shortage of providers and a growing patient population. We can use technology to get patients engaged and active in their own care through education, encouragement and monitoring. We rolled out Twistle’s care plan automation and patient engagement platform in late 2014. That year Harjinder and I also founded Saykara to automate documentation.
What do you need to lead this technology to widespread adoption?
We need to continuously improve the effectiveness of our automation using behavioral science, Natural Language Processing, and machine learning. This will lead to more intuitive messages for disease-specific populations, and hyper-personalized communications for individuals. As a result, patient understanding, activation, and care will continue to improve as well.
In addition we will continue to integrate with EHRs, wearables, sensors, and other devices to facilitate remote monitoring and assessments. The more we are integrated with the healthcare ecosystem, the more we can personalize and improve patient behavior. Ultimately we will become a fundamental part of that ecosystem.
What have you been doing to publicize this idea? Have you been using any innovative marketing strategies?
Our most powerful marketing strategy is delivering real value for our customers. Healthcare leaders look first to each other to find successful IT solutions and our clients have proven to be enthusiastic champions. They consistently recognize us as a partner that they can work with to make sure the solution we implement meets their patients’ needs and can be applied across the organization for almost any use case. We also monitor clinical, financial and operational ROI, and maintain real transparency around metrics so that organizations can understand the value of our platform and identify potential opportunities for improvement. The trust we have built with our existing clients gives merit and weight to our marketing claims and continues to open doors to new opportunities.
None of us is able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?
Indeed my success has been the consequence of standing on the shoulders of those wiser and more experienced than I. While it is difficult to single out one of these role models, I would select my father, who turned 90 last month. He trained as a civil engineer, and then spent an intense decade and a half in public works building roads and bridges. This gave him extraordinary project engineering experience. He took particular pride in delivering major infrastructure projects under budget and within constrained timelines. He then chose to attend Harvard Business School and launch a successful career in social and commercial entrepreneurship.
Throughout my life my father has been a hard taskmaster. Even now as I have my hands full shepherding a burgeoning venture, my father continues to remind me of my social and civic responsibility. He has always inspired me to give 100% or more and to have a relentless focus on excellence. I am immensely grateful that he taught me the power of hard work, focus, and perseverance, to which I attribute my success in improving the lives of patients and caregivers alike.
Today at Twistle, that learning manifests in an internal focus on our “patients first” value. Our team is working to create a culture that pushes the envelope on behalf of patients. This culture is exemplified in various ways: an additional review of patient messages for empathy and literacy levels during implementation, an extra follow up after a patient support call, or refining the user experience during product development.
How have you used your success to bring goodness to the world?
In addition to my work at Twistle, I created a family foundation dedicated to providing education for underprivileged children so they can access top medical and engineering schools. It is named after a heroic Sikh figure, Bhai Jaita, who was born to a disadvantaged socio-economic background but had the good fortune of growing up in an enlightened community that exposed him to progressive ideas, holistic education, and practical training. This gave him the self-esteem to lead a heroic life.
I also hope to return to social entrepreneurship someday. In 1984, my father exited his business to focus on social ventures at the age of 53. He turned 90 in January yet he continues to work six to eight hours each day (even during the COVID-19 pandemic). I believe this work helps him lead a fulfilling life. I hope to have a similar path.
What are your “5 Things I Wish Someone Told Me Before I Started” and why. (Please share a story or example for each.)
1.) Build the company’s culture deliberately. Prior to my entrepreneurial career, I had heard Peter Drucker’s quote, “Culture eats strategy for breakfast,” but I never seriously considered the ideas behind the words. Early in my Twistle experience, an investor and mentor shared a powerful story of intentional cultural change and its sustained impact on growth and profitability. She shared how an important financial services organization had redefined its values, and the specific behaviors they expected from each staff member. These values and behaviors were strongly aligned with the company’s strategy, the people it hired to drive growth and manage risk, and its distinctive approach to remuneration, taking a long term perspective. Most impressively she evidenced that this organization’s annual net profits went up by nearly 300 times over a 30-year period.
I was inspired by her story and the impact of an intentional culture change on employee satisfaction, productivity and effectiveness in growing the company. We worked with key advisors and colleagues to define the company’s values — Patients First, Be Transparent, and Win As A Team — and the behaviors associated with these values. They now shape our culture and continue to have a meaningful effect on strategy, morale, and growth.
2.) When launching a startup, identify, focus on, and master a single market segment, even if it is only a niche. We originally built and pitched the Twistle platform to address all specialities in healthcare because we felt that large health systems would not want to buy separate solutions for each. Despite well-received sales presentations, we did not get market traction. We’d leave a sales meeting with multiple ideas on how Twistle could be deployed, but it seemed our buyers couldn’t figure out where to start. Then we narrowed our focus to one surgical service line, clearly defining the value proposition for a specific set of patients, and we achieved success. Even before our first deployment, we were introduced to other surgeons and made two additional sales. This momentum gave us a network of surgeons, anesthesiologists, and surgical administrators who all knew each other. We were able to generate data to develop compelling case studies and credible journal articles. Even though we served a small addressable market, preeminence in that niche created synergies and network effects that helped a young company build confidence and credibility. This success allowed us to expand into adjacent market segments, and new specialities, and we were able to raise additional capital.
3.) Raise capital from professional investors, as opposed to angels, sooner than later. Venture capitalists who understand a startup’s market can be exacting in their evaluation of investments. That process encourages startups to sharpen their understanding of the market and the problem they are solving. If a startup can persuade a smart investor, they’ve amassed market savvy that will be an asset for subsequent growth. On the contrary, angel investors tend to have a lower bar, and are betting on the founders, not on the business plan. Their investment is frequently not complemented with market intelligence, nor customer introductions. Their judgement of your company’s potential for success is clouded by their relationship with you, and they don’t clearly see the weaknesses in your plan, nor the obstacles you must overcome.
4.) In addition to shrewd investors, building a set of astute advisors and seasoned board members can contribute to success. It is important to be selective, however, and to work with a few proactive advisors rather than many renowned advisors. For instance, I brought on several physician advisors who were well-known in the industry, expecting their reputation to translate into value. However, these physicians had limited bandwidth. Many were engaged with multiple startups. Almost all were reactive, and not proactive. I had to actively reach out to them to get their attention and time. But the management team of a startup has limited time too, and pushing multiple advisors to extract value became untenable. Eventually we settled on one or two really engaged and productive advisors that generated considerable value. Similarly, on the board, diversity of experience matters, but I’d give significant weight to operating experience. Building companies is difficult, and someone who has walked that thorny path is a fountain of wisdom.
5. Finally, learn how to strike the right balance between accepting failure and persevering through obstacles. Grit is an important quality for success in any field, especially with startups. However, sometimes a difficult path may mean accepting that you have chosen the wrong road. You shouldn’t give up too soon, but also not be bullheaded. In Twistle’s early years we started working on a solution to reduce the noise of the physician inbox, which is flooded with messages everyday, and most of them don’t need attention. We probably wasted a year before realizing that we were pursuing the wrong problem. Dispassionate reflection on the first few unsuccessful customer conversations would have helped us save time.
On the contrary, we knew that our care plan automation platform was a good idea because we generated a lot of conversation every time we spoke about it. Health systems were trying to solve a serious problem and we were pitching an intriguing idea, but as I mentioned before, they got a bit overwhelmed with how to execute. That’s how we knew that our product was good, but we had to keep searching for a way to pitch, package and market our idea.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
The rise of the Internet, mobile devices, social media, and digital tools has eroded what some writers have termed “deep literacy.” In a recent article, Adam Garfinkle writes: “Deep literacy is what happens when a reader engages with an extended piece of writing in such a way as to anticipate an author’s direction and meaning, and engages what one already knows in a dialectical process with the text. The result, with any luck, is a fusion of writer and reader, with the potential to bear original insight.” Today, the noise of the digital world has contributed to shortened attention spans. Consequently, we spend less time engaging with material that is longer than a page or two, and even less time writing long-form prose. Though I have never been a prolific reader, and I don’t consider myself a clever writer, I’ve noticed that in the last decade or so, my reading and writing habits have declined.
For my own sake and that of my children, family, and society, I would like to spur a “deep literacy” movement. At Twistle, for example, we recently added a new value — Strive to be Better. Deep reading and long-form composition will be among the behaviors we will encourage and measure. I am confident that this will help us gain more original insights and benefit patients and the company in a number of ways. If we could extend this value to wider society, we might build a better country and world. But minimally, we will accelerate our ability to empower patients in their own care, which will improve outcomes and quality of life for millions of people.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
I am inspired by so many poems and couplets that selecting one is difficult. Perhaps because I am visiting northern India as we speak, I am drawn to two lines revealed to Punjab’s most enlightened master, Baba Nanak. Though much is lost in translation, his sentiment might be captured by:
I am the lowest of the low castes; low, absolutely low; Nanak stands with the lowest in solidarity and companionship, not with the wealthy and powerful. For where the dispossessed and disenfranchised find comfort, there falls the favor of Your Grace.”
I’ve always been drawn to initiatives that help vulnerable populations, especially in the context of education and health. When people are managing a healthcare encounter or illness, they are often scared, lack relevant knowledge, resources and/or mental capacity, and in some cases, the motivation, to recover or live their healthiest life. Twistle’s mission is to ensure that every patient is activated, supported and reassured throughout their lifetime care journey.
Someday, like my father, I also hope to return to active social entrepreneurship in education, which can be an avenue for upward social and economic mobility. I expect that this quote will continue to be my north star for that phase of my life too.
Some very well known VCs read this column. If you had 60 seconds to make a pitch to a VC, what would you say? He or she might just see this if we tag them 🙂
Twistle is expanding into new markets, and delivering a more complete digital front door patient experience, which starts with a patient feeling symptoms, searching for help, scheduling, preparing for a visit or procedure, engaging with clinicians, and remaining active in their follow-up, and ends with being monitored safely at home. In this quest we are investing heavily in product development, but we will also be partnering and acquiring great technology. We are looking for the right financial partners to deliver a comprehensive digital front door and virtual care solution that truly puts patients first.
How can our readers follow you on social media?
Thank you so much for joining us. This was very inspirational.