Entrepreneur Rx_Emilio Galan: Audio automatically transcribed by Sonix

Entrepreneur Rx_Emilio Galan: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

John Shufeldt:
Hello everybody, and welcome to another edition of Entrepreneur Rx, where we help healthcare professionals own their future.

John Shufeldt:
Hey everybody! Welcome back to Entrepreneur Rx. Today I have the great pleasure of reconnecting with somebody that, gosh, we haven't talked in probably ten years or more since he was an undergrad at ASU. Emilio Galan has ten years of experience in a healthcare field focused on healthcare data analytics, provider, workflow, and system measurement. Emilio is also CEO of Robin Healthcare, which we'll spend a lot of time chatting about and catching up. Emilio, good to see you, man.

Emilio Galan:
Good to see you! And I have two kids, I didn't mention that, so I have aged a lot, It feels like a warp-speed aging for me. Pleasure to join, Happy to chat.

John Shufeldt:
Excellent, All right, so you have such a cool story. So let's just back up to kind of the pre-med days where we met and then take me through the next few years because there's, I know there's a lot to digest in this.

Emilio Galan:
So I'm a wide-eyed, optimistic, Looking forward to the future undergrad student when we met and I really was very excited about becoming a doc. That was my path, I had known it for quite a long while actually. I had concluded I wanted to be a doctor back early high school, Lots of reasons for that. And while at Arizona State, was trying to figure out how to blend that desire to become a doc with some of these other interests which were all healthcare-related. So my undergrad thesis was, if you remember, on performance measurement of healthcare systems. That's why I worked closely with Mayo and Denny and how we met.

John Shufeldt:
Excellent, all right, so you do your undergrad, you finish, and then what happened?

Emilio Galan:
Straight to UCSF, straight to med school, live the dream, really excited to go there. Honestly, had a little bit of like, okay, it's cool to go to the Bay Area and see what's happening in the entrepreneur kind of startup space as well. But get to UCSF, do a combined program between UCSF and UC Berkeley, where I did a master's, where I focused on healthcare, economics, and policy, and so did that at Berkeley while doing the first few years of kind of pre clinicals at UCSF. Go through clinical training, honestly, during clinical trials like, Oh, this is great, this is exactly what I want. I love meeting with patients, I love chatting with patients. Get to my last year and am at the point of figuring out what residency I want to do. And I was between two, I, between EMT and urology. EMT because I saw this procedure where they're like shooting lasers in the ear and affecting the tympanic membranes and replacing one of the small bones in the ear, and urology because they're hilarious. And in that process ended up talking with a bunch of docs about how much they like their practice and what does life look like on the other side of residency, which we all in medical school fear as the hazing of medical training and could not really find a doc that was describing a life that I wanted, or really a doc that was saying, I love what I do. There was more doctors that were telling me at that time, Hey, you've got this background in healthcare economics, you've got this background policy, you have other opportunities, you should look at those. It's not as green over here, the grass is not as green as it might seem. And I had three attendings in my last year quit during my fourth year of medical school.

John Shufeldt:
Quit medicine, quit?

Emilio Galan:
So two of them straight quit. So that meant one of them went and started teaching kind of graduate medical education. So became involved in the school, stopped all of their clinical training or all their clinical work, and then the other just actually quit and said, I need to go spend time with my kids because I am basically doing full days of clinic and then coming home and then doing a whole 'nother half day of catch-up paperwork rather than spending time with my kids, and then one of them basically dramatically reduced their clinic time. And so those were the three attendings that I was looking to, and at the same time, there was this group of students either during medical school or after graduation that were deciding, I'm not going to go to residency, and they formed this group here in the Bay Area called the Dropout Docs. And so I got involved with some of them talking about what they were doing. Long story short, I do my clinical rotations, third year, I do my boards, step one, step two, all that, and then decide I'm going to do something different. And so started Robin in 2017, now, five years ago and have not looked back.

John Shufeldt:
Wow, okay, so how close were you to walking down the aisle?

Emilio Galan:
I can't say it too loudly because my mother, who lives 5 hours from here, may hear it. Five months left for the M.D., and what some folks were trying to convince me of at the time was, fourth-year medical school, after you do all of the hard stuff is like the most expensive vacation you'll ever take, just finish up, get the MD. But the opportunity and the conviction around starting this company was just too great, so decided to drop out and start Robin.

John Shufeldt:
That's very cool. Well, as we mentioned before, it takes a large shot of something that one of your specialties would focus a lot on. And I'm not talking about EMT. So first, congratulations, that's very cool. So I want to hear about again, so I know about Robin, obviously, but give me the elevator pitch, or give us the elevator pitch for Robin, because it's pretty compelling.

Emilio Galan:
You know, it's all related, right? What was the reason why these docs were dropping out? Why have my friends, a number of my classmates dropped out since they graduated? Is that, the experience of the doctor has been, has taken a back seat to a whole bunch of other priorities within the healthcare ecosystem, and it's just not why they went into school, it's not why they went to get the MD. It's not why, as a 8-year-old, or a 15-year-old, or a 22-year-old, you're like, You know what? I want to be a doc. That's what I want to do every day. My wife, who I met in medical school, is a doc in intern year in residency right now at Stanford doing internal med and every few days, my daughter asks, Hey, where's Mommy going? And her response, my wife's response, and my response is, Oh, she's going to go take care of sick people. I mean, that's like gold, right? That we get to tell that to our daughter. That's why my wife went into training and wants to be a doc. That's why I originally went in. That's not what docs spend the majority of their time on today. It's a whole bunch of other priorities that have to do with compliance and billing and coding and authorizations and fighting insurance companies. And so the real push for me to start Robin, was that I had that personal experience of doctors that were either quitting or pulling back any time, and then my background in health economics and policy and just the way that the world was changing and becoming more comfortable with smart devices and recording devices in every room of their lives, homes, hotels, etc., presented an opportunity. And that opportunity was, let's take a device like an Alexa device, like a Google Assistant device, let's put it in the exam room with the explicit goal of allowing doctors to focus on patient care, and it's been super rewarding.

John Shufeldt:
That's amazing. Some ask the question, Do you think we, meaning physicians, did this to ourselves? Because I, we know each other, I've done this for a long time, and I agree with you, a lot of medicine is not what any of us probably signed up for. But I wonder, had we, and I don't want to use the word unionize, but had we actually had a more cohesive group that we could have stopped a lot of this.

Emilio Galan:
So I would not say that docs did it to themselves, but I would say that docs did not do enough to prevent that.

John Shufeldt:
That's a better way to say it, I agree. Yeah, we could have taken a much firmer stance. It's funny, I was talking to a relative who works for a health plan and I said, I don't know what you're marketing or something. And then I said, How much do you make? I said, Don't even tell me, let me guess. You probably take 350 a year, and she nods her head. How much do you think the average physician makes? And she's like, Oh my God, you know, 750, and I go, No, it's under 200, and she couldn't believe it. And I know, now, let me ask you another question, what value do you add to the healthcare system? And I'm up for anything. Whatever you say, I'll just say, believe.

Emilio Galan:
Patient, to the patient care, to health.

John Shufeldt:
And she couldn't think of anything, and this is exactly why physicians are frustrated. It's the pediatrician, I got, the Medscape survey. Pediatricians make, I think the average was a hundred and.

Emilio Galan:
150, 140? Yeah.

John Shufeldt:
Not that that's horrible, but what, you know, a quarter million of debt coming out of medical school, all those years, an opportunity loss, that's not all that much.

Emilio Galan:
Yeah.

John Shufeldt:
So all right, let's, I want to hear how you're going to fix it. So what does Robin do?

Emilio Galan:
Well, okay, before we get to Robin, but, docs have a role to prevent the, either further subjugation of their job, and their title, and their everyday practice. And I do think that there is a larger opportunity beyond Robin outside of just docs themselves turning the tide back to who actually provides value in the chain to patient care. But it requires docs to be organized and frankly, to stop being scared of risk. You have to take financial risk if you want to do it as docs. I mean, the idea that you're just going to punch in, punch out and get your fee-for-service yum-yums is not going to be enough. I think the only way to actually change it is for docs to get in the game of financial restraint, which is the whole deal behind ACO reaches and it needing to be doc owned. I think that's, there is a path. What is Robin's role? Robin's role is that in as little effort, time, distraction as possible, you get paid, right? You comply, you protect yourself from liability. The reason why is because, instead of doing a whole bunch of paperwork, there's a freaking recording device in the room. Via that device in the room, I have the ability to support everything you do, everything you say, everything that the patient does and says because of that kind of assistant device that's there with you. So we do a whole bunch of the billing work, a whole bunch of the compliance work, and a whole bunch of the liability work behind the scenes so that you can be done, I mean, done with your day-to-day. All of the things that take hours today for the average doc, 90 seconds per patient.

John Shufeldt:
Wow, is it an AI-driven process at the end of the day?

Emilio Galan:
It is every tool under the sun. So this device in the room has four microphones, it's a microarray, has a camera on it. I have one, I should grab it, I can show it to you maybe at the end here, a 160-degree camera. And so both the audio gets automatically processed with a whole bunch of models, and that's natural language processing, natural language understanding, and then the video is also processed with a whole bunch of models. That then goes into the back end where we will quality review it up to three times. So that's a human review, that's checking it for accuracy because as we know, you need to build accurately, you need to make sure that the data is accurate. This is patient care that we're talking about, and then it all gets exported to where it needs to go. So that would be to your billing team, that would be to the insurers, that would be to your EMR practice management system.

John Shufeldt:
So is there a scribe component as well? I ask you a question, you answer it.

Emilio Galan:
It's more, so you talk to other folks in this space and the folks that have humans in the loop will, they have all kinds of names for them. Augmetics, because there's medical decision support, medical documentation specialists, MDSs. We have coders, we have scribes, and then we have a whole set of auditors that will go through and do the review. At the end of the day, what it looks like is, did the doctor address at least one chronic condition? Yes/ No. Did the doctor modify medication? Yes/No? Is the condition of the patient worsening? Why are these the things we look at? Because these are the things that drive billing.

John Shufeldt:
Well and drive liability, obviously, as well.

Emilio Galan:
And drive liability.

John Shufeldt:
Okay, so typical emergency department patient and there's probably more for a primary care office. You know, you walk in, you see the patients, you do an exam, and then I walk out and the scribe who is following me, who is, you know, one of these super smart pre-med kids who I can never compete with at their age, puts down, you know, they put out a complete exam for me, and I'm like, Well, no, no, wait a minute. I did not check their patellar reflexes, so, but now I'm on camera. So is someone saying, Wait a minute, this isn't a complete exam because you didn't actually do X, Y, Z?

Emilio Galan:
Yeah, John, the sciences say this all the time. We didn't build Robin with this device and all of the technology and all of the systems behind it so that we could continue status quo .... No more documenting .... That wasn't done. I don't want to see an orthopedist who has no murmurs rubs gallops. It hasn't touched a stethoscope in 15 years. I just don't want to see that. We didn't build our company to continue status quo. It is a change, it is a significant change and we are upfront about that. So when we work with docs, this is going to be a change in the workplace, it's going to be a change in the output, but this is the future. And three-page nodes and documentation that you're used to, which is bloated with a whole bunch of ... You didn't do, copy and paste, macro, blah blah blah that you think is covering you and getting you paid but actually is not, that's just not going to be what you get from Robin, right? It is better, it is next generation.

John Shufeldt:
Where did the name Robin come from, by the way?

Emilio Galan:
A whole bunch of debate with my co-founder early on. We landed on Robin for a whole bunch of reasons, but the most important one was the sidekick. We want to support docs. There are very few words.

John Shufeldt:
As in Batman and Robin.

Emilio Galan:
As in, potentially, and as important, There are very few words that are As ubiquitous, easy to spell, to understand, but also that are both a name and a thing. And so you have the robin, which is the device, and you also say, Hey, Robin, when you want it to do something specific. And so the fact that it had both of those qualities made it a slam dunk.

John Shufeldt:
And I think when people hear I mean, at least people might share the name Robin, you instantly think of Batman and Robin, the sidekick. Pretty cool name, so hats off to you. Okay, so you're in the exam room, I say, Hey, Robin, I'm doing an exam right now. There actually was nothing.

Emilio Galan:
Less about that, it's more so when the patient gets roomed. Hey, Robin, this is John Smith here to see Dr. Jones. That is the start of the visit, the doctor's experience for us, those 90 seconds, we try and make it as unintrusive and at least distracting as possible. So if there's something you really want us to catch, you could say, Hey, Robin, but we're catching all the stuff for billing and compliance just off of the natural visit itself. The important piece for you, right? Documentation, these visits have value for you next time you see the patient, maybe less so in emergency med, but hey, other folks need to take care of this patient as they go to the floor or they go back to the primary care doc. And so it is important that the clinical care component gets addressed, right? Part of documenting is for actually taking care of patients, not your general exam with patella reflexes, but the clinical decision-making, the synopsis you do, that assessment and plan that you put together. And so there is multiple workflows that docs can use, but one way or another, we do want to hear, What do you think about this patient? And so you can say that to the device as a, Hey, Robin, here's what I think in summary, and that typically takes about 90 seconds. You could actually do it with the patient, and so we call that an interactive dictation where you're talking to the patient, in summary, here's what's going on, here's what I recommend. We'll take that, we'll convert it and make that the clinical care component. And then lastly, if you want to do it outside of the visit, so let's say you see the patient, there's things that you didn't want to quite get into with the patient while you were there. You can either do it to a device after the fact or you can do it on your phone, so walking between rooms.

John Shufeldt:
Do you see a future where the patient's room and you say, Hey, Robin, this is Mr. Smith, and the door closes and Robin says, Mr. Smith, hey, before Dr. Jones is into the room, let's go over a little bit of your history? Have you changed any medications? That sort of AI process.

Emilio Galan:
Some of that's already happening, and so we have the ability to get information from the patient. The way it works now is via standard interface tablet. I do see a future where it could be via the device, via the speaker and microphone on the device.

John Shufeldt:
Interesting, because, I mean, and then imagine Dr. Jones comes into the room and Robin turns into the resident. Hey, I just talked to Mr. Smith, and here's what he said, and so that would be amazing.

Emilio Galan:
Yep, the prompting of the position of the information they need that both take care of the patient, but also what's the minimum you need to do. If you were going to do three things to get paid better, to comply better, or cover yourself from a liability standpoint, what are those three things? That kind of push of information to the position is super important.

John Shufeldt:
And what is the interoperability currently, the different EHRs?

Emilio Galan:
A mess! A giant stinking mess. We pull every trick out of the hat to integrate and interoperate with the EMR and practice management systems, everything from CSVs to RPA to full integrations to manual pushes and pulls. I think it's going to get better, John, with the latest rules for interoperability. I think, I haven't seen it yet, but I hope.

John Shufeldt:
Interesting, I mean, it can't get any worse. I mean, you've already suffered the worst part.

Emilio Galan:
It cannot get worse than manually going in, diving through the dumpster of the EMR, pulling out information manually, going in, and pushing information. So that is our backup worst-case scenario, which we already do.

John Shufeldt:
Well, how many different facilities or practices is Robin deployed in right now?

Emilio Galan:
So we are in three hospital systems and about a dozen other multispecialty or physician groups. We primarily focus on orthopedics today, but we, overall, every week will process something like two dozen different specialties on the system. Our primary metric is looking at how much the volume of patient, kind of, minutes, hours that come through our system that we need to process. And we're doing, we've done, I don't know, ten million hours of patient visit processing.

John Shufeldt:
Wow, all right, and then, is the billing model just a percent of collected revenue? Is it just a standard user fee?

Emilio Galan:
Flat fee, flat fee per visit. We did that as a part of COVID. We wanted to be variable cost because patient volumes were up and down and all around, and so we just wanted to model after-hour clinics.

John Shufeldt:
Right, it does de-risk it. Do you think that COVID actually accelerated your business or that it slowed it down because no one wanted to do anything different or new?

Emilio Galan:
Okay, so I saw both, right? So there was a COVID clinic that got started at UCSF where they needed docs going in, hazmat situation, fully geared up. And for folks that would have had an MA, or a resident, or a scribe, or someone else there to help, they put the device in instead. And so we were in the COVID clinics, kind of tents that they put together. So in that way, I saw some acceleration. We got to do some cool projects with some payers during that time. On the flip side, volumes are down. Just patient volumes across the board are down. There's a money pinch, and so things that are innovative, fundamentally changing the status quo, or frankly focused on bettering the physician experience take a backseat.

John Shufeldt:
Which is mind-numbing, of course, the one time, you know, since 1918 when physicians needed a little extra help, yet again, we take a back seat to it, that's wild. What was your biggest surprise during these last ten years, or maybe last five years, since Robin started, what was your biggest surprise? Like, what didn't you see coming?

Emilio Galan:
John, I think it's more I am constantly surprised at just how ... up the healthcare system, healthcare billing, the administrative war between providers and payers is. It is a never-ending, like Dante's Inferno, going to the seven rings of hell surprise fest. It cannot be, there is no way that we spend like 500 billion to a trillion dollars on paperwork and insurance-related ....... It can't be that we have seven FTEs for every doctor that are basically doing paperwork. It cannot be that we still primarily push information via fax. It cannot be like the, just getting into the actual work required to automate or extract out billing compliance liability from the physicians' workflow brain space requires us to get super deep. I feel like I'm Alice in Wonderland.

John Shufeldt:
It's funny, when you said Dante's levels of hell. I'm having a discussion with a pair right now for an emergency medicine company who wants us to really dramatically cut back on our rates. And so I said, help me understand this. Our staffing costs have gone up, our med mail has gone up and our benefits have gone up. As you know, you're the insurer and you raised yours 9% last year, 2% the year before, your CEO received a $10 million dollar bonus last year, and your EBITA, your profit to shareholders was $9 billion dollars. How is it you can stand here, how to sit there with a straight face and ask me to cut our rates? Because we're not the problem here. And, first off, they had a deer-in-the-headlights look. Secondly, I know you can't answer the question, but I want to hear you try because I can't answer it either. I can't in good conscience sit here and just say, Oh, okay, you know, hit me.

Emilio Galan:
Here's my rate cut, yeah, right. It's so sad, it's like the mental image I have is these mega systems getting built out between the payor and the provider, by Provider, I mostly mean hospital systems, fighting this epic battle between each other. And you've got patient and you've got doctor here just completely deprioritized forgotten, ..., I mean, just forgotten in this consolidation mega war that we spend $4 trillion dollars on per year.

John Shufeldt:
Yeah, no, and I love medicine. I would do it again in a second, I still love practicing medicine, but I'm glad I'm at the end of my clinical practice life. We're not at the end yet, but I'll be there relatively soon, so I totally get it. So first off, thanks for working on this problem because hopefully and I have all sorts of ideas I want to chat with you about at some point, but, and I'd love to hear your thoughts on it, but it's absolutely a complete need, it has to be done or we're going to be in this quagmire forever. And, you know, you said something earlier. I worry that that, you know, this ship has left the port. In other words, there will be little we can do to regain any sense of control, we as physicians, regain any sense of control in healthcare.

Emilio Galan:
You know, I don't believe that.

John Shufeldt:
Good.

Emilio Galan:
I think that it starts with, and this is why we began Robin in the first place, better data, and better data, putting that in the hands of the folks that matter most, the doc, and allowing them, therefore, like, negotiations should not be this, who has more market power. It should be who has better data and better performance.

John Shufeldt:
Better outcomes, yeah, absolutely.

Emilio Galan:
Who has better outcomes? And that shift to better data that can drive better outcomes, can drive better negotiations, can drive better payment, can drive a more equitable future model of healthcare that I think is paying the folks driving value, which is going to be the folks on the front lines. And so we have evidence, we've got a doc that I was talking to recently that is engaged in a value-based, fully capitated risk contract. This is a very small group and they're taking home $4 million dollars a year. And it's like, yeah, if they're providing the value, if those patients actually have.

John Shufeldt:
Better outcomes.

Emilio Galan:
Better outcomes, lower MLR, lower hospitalization, then that's exactly right, that's how it should be. And so I don't think it's over, I think we're more like in the middle of the story than at the end.

John Shufeldt:
Good, good, well, I think there's a lot of us that still have some fight left, but there's an awful lot of people are like, you know, screw this, not what I signed up for. And I think the great resignation, you know, did not go unnoticed in medicine. I mean, COVID certainly pushed a lot of people to the brink of their mental health and their work-life balance, so we'll see if it comes back.

Emilio Galan:
Let's get it in time for my wife.

John Shufeldt:
Yes, three years.

Emilio Galan:
We got three years, John, ...to it.

John Shufeldt:
Classic, well, Emilio, where can people learn more about you and more about Robin? Because I have a feeling they're going to sign up.

Emilio Galan:
Yep, okay, so, RobinHealthcare.com, and I am happy to connect with anyone. Probably easiest thing is LinkedIn, Emilio Galan, ar you can email me, it's Emilio@RobinHealthcare.com.

John Shufeldt:
Perfect, and we'll put all of this in our show notes guys, and get, you know, thank you so much. Great reconnecting again! You haven't aged a bit, so it must be all internal. Thanks, everybody, for listening, and we'll see you again soon.

John Shufeldt:
Thanks for listening to another great edition of Entrepreneur Rx. To find out how to start a business and help secure your future, go to JohnShufeldtMD.com. Thanks for listening.

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