Can a simulation program, a kind of imagined space, help fix real world problems? The healthcare industry is widely considered one of the least functioning in the American economy. A Sunnyvale-based company, i-Human Patients, aims to promote high quality and cost effective care by providing e-learning products to healthcare professionals. I had a chance to sit down with founder Craig Knoche and CEO Norm Wu to discuss their passion to make a difference in the world.
Gohar. What events lead to the idea of i-Human?
Craig. My wife and I participated in a medical training course for mountain climbing a few years ago and realized that the book learning part of medicine and the actual performance, even in a simulated environment, were very different. Since we both had backgrounds in the software development industry and this intrigued us, and we thought that our background might help address this need. After further research we found out that the medical education community is largely underserved by software technology. We kicked this idea around for a number of years and then in 2009 we put our energies into developing simulation-training program for healthcare. In the early years, our programs were distributed by textbook publishers and medical equipment companies. Several years later we met some medical educators in Chicago who were coincidentally looking for programs that they could use in curricular revision effort which would simulate complete medical patient encounter. Not having found anything that satisfied their needs they took a look at all the capabilities that we had developed over the years and asked us to make a few adjustments. We built a prototype for them and when they looked at it they went, “Wow, this is exactly what we wanted!” Then what often happens in software industry the prototype becomes a production system and we have been revising and enhancing that system ever since. It was very productive to have a relationship with a medical school, where we could discuss intensively all the requirements and then refine the designs, because we don’t have backgrounds as MD educators, so a close relationship with them was very helpful for the refinement of the product.
Gohar. Can you explain how the patient doctor encounter happens through simulation?
Craig. When people visit the doctor and have a conversation about the reason for their visit, they are in fact going through a structured process, which when performed by an experienced physician appears to be very natural and easy. But it is very much a structured and learned process. Medical students need to learn that process. What we do is we decompose that to its essential elements and then we enable the students to step through that in a simulated environment by taking patient history, which, fundamentally, is having a conversation with the patient.
Our system enables an educator to create cases for the students. A case is a patient with a complaint, a history and a definitive diagnosis. Once the students have elicited a chief complaint to the reason of visit, they may ask other questions that qualify that complaint. Then they may ask about past medical history and family history. The particular questions may differ based on the complaint. This is followed by the assessment of vital signs; blood pressure, pulse, temperature, weight, height, etc. Then comes the physical examination. The tests are done at the end of the process to confirm the hypothesis. We simulate all these things.
Gohar. Who designs the patient encounters?
Craig. We don’t design the patient encounters ourselves. We work with clinical educators and schools across the country. They find us and come forward with ideas about cases.
We also recruit people from schools. Let’s say there’s a need for cases such as pediatric problems. We’ll go out and recruit clinical educators in pediatrics and work with them to identify the cases that will be of greatest value to them and then organize the group and work with them to develop the cases.
Gohar. Qualities you look for when you’re hiring?
Craig. I’d say that people have different motivations, some are motivated by making money quickly and there are others who are motivated by being a part of some venture that lot of people will come to know and it’s sexy. Some others are motivated by technical challenges. We are looking for people who are motivated to do something that makes a difference in the world.
A large number of software technology initiatives in Silicon Valley are not things that, at the end of the day, are going to make a big difference and make people’s lives easier. This may be a little bit dismissive but enabling millions of people to share a photograph with one another of what they had for dinner at the end of the day will not make me proud.
We are looking for people who understand our mission and are motivated to make a difference in the world, people who have tried a lot of things and are interested in having a legacy. And the mission is to make the lives of people around the world better.
Gohar. How did you and Norm Wu start working together?
Craig. We had applied for and received a grant from National Science Foundation to help support our development efforts. One of the speakers at the grant award ceremony impressed me so much that I approached him and had a chat and told him that I am looking for a CEO and he gave me Norm’s contact. The first time we connected on the phone we talked for hours and we had a connection right away. He impressed me as someone who understood what we were doing. He had skills and interests that complimented mine.
Gohar. Norm, what inspired you to join i-Human?
Norm. If we can somehow help our most broken industry – health care in the USA – then I’d feel that I’ve really done something. If you think about misdiagnosis rates in US they are really high. The latest study suggests that 1 out 20 patients is misdiagnosed; that’s 12 million people a year, half of which (these misdiagnoses) can be very harmful.
If you’re treating the wrong thing you are wasting money on that, and the thing you should have been treating all along is going untreated and escalates to the point that it becomes more expensive to take care of or the patient actually dies. So, misdiagnosis contributes highly to mortality rates.
Also, we can significantly increase the supply of qualified nurses and doctors. We think we have shortage of medical personnel in US, with all the baby boomers aging and living longer. But that shortage is nothing compared to what people are facing around the world in the developing countries.
With iHuman we can help increase the quality of healthcare and lower the cost, and we can help address the shortage of healthcare professionals.
Gohar. Who are your customers?
Craig. At the present time our relationship is with an institution rather than an individual. And the reason for that is two-fold: one, we provide a lot of competency based information. A faculty can use our system to counsel and advise the students. Two, there are a few hundred medical schools and for a small organization like ours it is much easier to sell and support to larger institutions than to lots of individuals. But we expect in the future that we’ll make our programs available directly for medical students who would be preparing for their certification exams.
Gohar. Do you work with international clients?
Norm. We are a small company and have been active for more than two years, so we don’t have the bandwidth yet to support lot of customers in other countries. We’re very active in the Caribbean, in India. But there are a lot inquires from all over the world for our program to be integrated in the curriculum of hospitals.
Gohar. How would you characterize entrepreneurship and is it for everyone?
Craig. I like mountain climbing as a vocation. Here’s an analogy: a few months ago there was quite a lot of buzz in the press about two guys free climbing the Dawn Wall of El Capitan. People ask what is it that makes them do something like that. There are a lot of analogies to entrepreneurship. One of them is that you don’t get up one morning and say that you’re going to climb El Cap. It’s an acquired taste. There are a lot of skills one has to acquire, one has to learn how to control one’s fear, you have to develop a sense of confidence, a very sharp sense of confidence, because there’s deadly risk involved. It comes from experience. The ability to undertake that kind of adventure is based on many years worth of climbing experience. But not only that, they’ve stood on the shoulders of others who pioneered the first climb on these walls.
Entrepreneurship for me has been a lot like that and required quite a lot of other life experiences. Those experiences involved building up a sense of confidence about what I could and couldn’t accomplish, an ability to psychologically handle risk. Those I think are foundational. Entrepreneurship is not for everyone.
Norm. For me it’s three things: one, you have to start with a compelling vision. Two, you realize that part of building something is actually taking risk, and realize that when you fail it’s not disastrous. You can fix lot of things as you go. You can surround yourself with smart people who know how to fix those things. You listen to what your customers need, you learn the capabilities of technology, what it’s actually capable to deliver and what it’s not. You check out what your competitors are doing. And as you make those adjustments, you can survive the bumps on the road. The third thing for me is quite satisfying to step back periodically and look at what you have helped create as a part of a team.
Gohar. Let’s talk about decision-making within the company.
Craig. There’s been a lot of research on slow thinking (rational, analytical thought) and fast thinking (impulsive). There are certainly decisions that we make that are instinctive. But part of the trick of being successful is to know when to stand back from that and question it. Switch back and forth between slow thinking and fast thinking. It’s a very complicated thing. Lot of our decisions are made quickly, as there’s not enough time and resources to do research. Then there are other times, when we can sit back and reflect on our thoughts.
Norm and I have different opinions on lot of things. If you look carefully enough there aren’t that many issues in my opinion that are completely binary where you can be at loggerheads. There are almost always ways to find compromise and find resolutions that people can be comfortable with. We’ve almost always been able to find a way for the other one of us to live with the decision.
Norm. In a perfect world decisions can be easy if you have perfect data, but that’s never the case, especially when you’re pioneering new markets. The trick is to figure out how to make educated guesses on what the decisions should be and then be flexible enough to modify your path and make sure that the decisions don’t present an incredible risk to the company. You also want to have very participative culture in the startup so people who have strong perspective can share it. But that doesn’t mean that you have to have consensus in decision-making.
Gohar. Do you think your company will be relevant in the future as computers are slowly taking over various spheres?
Craig. There are smart people who have taken the position that the world is not going to have a shortage of physicians in the future largely because the computers are going to take over the role of diagnosis. I don’t think that’s likely to happen. I think what’s more likely to happen is that the computers will evolve to be better assistants for us but it’s not going to remove the human interaction with patients. There are subtleties in body behavior, facial expression, movement, that computers just don’t understand. People are evasive whether intentionally or not. Patients do not always understand questions and they may need coaching. The subtleties of the human encounter are very important for diagnostic process and I don’t see computers having these skills any time in the near future.