Virtual Doctor House's Team to Empower Patients and Support Doctors: Basem Higazy & Baher Higazy, Consulto

Basem Higazy, Consulto: 0:00

Why can you help one patient at a time if you can actually help hundreds and millions at a time by fixing the core problems that we have in healthcare?

Alex Jani, X-Health.show: 0:11

Hi, I'm Alex and welcome to the X-Health.show, where a doctor visionaries behind the latest innovations in healthcare. For the eXtra health of the future. We're in Geneva, Switzerland, in an old industrial district turned Merck Serono headquarters bought by Swiss billionaires to create Campus Biotech Innovation Park. My guests, both medical doctors, studied Global Health in one part of the campus, set Consulto office in an old school building and have their lab in a magnificent glass construction across the lane. Baher Higazy worked for Doctors Without Borders while Basem Higazy at World Health Organization. Consulto is an early stage Swiss startup that aims to bring all your healthcare providers together to consult each other and have all documents in one place. You'll hear about Dr. House and how can patients benefit from doctors working as a team, virtual team-based care, clinical intelligence but first, the grandmothers story. [INTRO ENDS] You told me that when you started studying medicine, you had this idea of Dr. House's team treating people and their diseases – doctors coming together in one room discussing things and then treating patients. What was the reality

Basem Higazy, Consulto: 1:27

Reality check was very simple: check? healthcare system fails patients once their needs are complex. It happened with my grandma. So she unfortunately died undiagnosed. After two years of going to so many doctors, everyone was trying to say "There is no problem with the liver","There's no problem with the kidney". But actually no one really looked wholly at her.

Alex Jani, X-Health.show: 1:52

What was the problem she had?

Basem Higazy, Consulto: 1:54

She had ascites, which is accumulation of fluid in the abdomen. She would have had liters, like five, six liters, and the only way to deal with it would be to remove it, to aspirate it, and then it will come back. You can imagine she couldn't even breathe well, she couldn't move well. It was really, really hard. And it's a serious disease. It's not something you can say, "Oh, she has nothing". And then they simply said, Okay, there is no problem with this organ, this organ. And the idea would be Okay, instead of telling us what it is not, just tell us what it is. And maybe not one person, not one doctor – even if you're the best in your field, you are unable to... you're too focused in your area.

So it just makes absolute sense: 2:34

put everyone together in one room and get the diagnosis. Something similar to Dr. House. That was back, way back, actually. And then there was no digital and the only way to do this really – physically. So it was just a ridiculous idea back then to think of. Even if it makes sense.

Alex Jani, X-Health.show: 2:54

But that was back in Cairo, when you lived in Cairo. So your grandma had access to good specialists, right? It's not the problem of there weren't specialist to treat her.

Basem Higazy, Consulto: 3:08

The best actually. You can imagine being in med school, one of the best in the country, one of the best in the Middle East, we had access to the best of the best of every speciality. That was not the problem. The problem was

very simple: 3:21

they did not talk to each other, we had to make sense of the story. And at the end, she was not diagnosed.

Alex Jani, X-Health.show: 3:31

So let's go back a bit. Why did you choose medicine in the first place, to study? Like, both of you. You're twin brothers – guys listening, you know, we have twin brothers here working as a team.

Baher Higazy, Consulto: 3:42

I think it was an a natural choice. We... I discovered that, at least I, maybe we, love to help people. This makes me happy. I remember yesterday, I saw a guy fall in the street. And he had injured his his head. And I couldn't leave before helping him and I was helping him not for helping him, I discovered I was helping myself. I felt so good. Just being with him in this moment, giving him something to eat. And what I got from it is more than what I gave to him. And I think with medicine is the same. When you're studying it, you feel you are going to be useful and when you do it, you feel you are.

Basem Higazy, Consulto: 4:27

There are very little professions that you can feel the gratification immediately, many times a day, every patient every interaction, even if it doesn't go well, you trusted you did your best to help someone when they are most vulnerable. And it's such an honor as well because you share a lot of vulnerability with people in very difficult situations. And yeah, that for me makes the profession incredibly beautiful to be part of.

Alex Jani, X-Health.show: 4:57

Fast forward, why didn't you become doctors in the end?

Basem Higazy, Consulto: 5:02

That's a very good question

Baher Higazy, Consulto: 5:03

When we started medicine, and I can say it for both of us, you quickly understand that the problem is not if I continue to give care to my patients, this will not help a lot. I just helped this one patient. But the problem is bigger, the problem is in the healthcare system. How it is organized, how we deliver healthcare.

Basem Higazy, Consulto: 5:24

And I became very obsessed, actually, with how to fix healthcare, how to transform healthcare, really, the bigger picture. Why can you help one patient at a time if you can actually help hundreds and millions at a time by fixing the core problems that we have in healthcare?

Alex Jani, X-Health.show: 5:40

How did you want to proceed with that? Or maybe let's go one step back, what didn't work? Or, in this system, where is the patient? What's the role of the patient?

Basem Higazy, Consulto: 5:54

So I will jump ahead and back as well. So here in Switzerland, my wife as well had a very similar scenario, much lesser in gravity. She had fatigue for different reasons. And over five to six years, she went to so many doctors in Geneva, in Zurich, and all the time they tried to find any excuse for that fatigue, and not actually try to fix it. Again, it is not a blame for the profession at all, everyone is doing their best. Anyway, after going with

Alex Jani, X-Health.show: 6:21

That's doctor shopping, right? her, multiple visits... And one thing you as a doctor don't like is to go to another doctor with another patient no matter who.

Basem Higazy, Consulto: 6:34

That's doctor shopping and you go as if you correct on what they do... which wasn't the intention at all. It's just really to understand, what's the problem? Why aren't we able to at least have a diagnosis. Putting all this information together with a very good GP, general practitioner, she helped us. After one hour of listening to all of that, "Maybe it's gluten intolerance". Test. It is. "Stop eating pasta and bread, your life will changed forever".

Alex Jani, X-Health.show: 7:01

And it did?

Basem Higazy, Consulto: 7:02

It did. So we went from not being able to ski together after above certain altitudes, to actually be able to spend days doing lots of activities. So yes, 100%, it did.

Alex Jani, X-Health.show: 7:19

The GP basically analyzed the whole data that you already gathered.

Basem Higazy, Consulto: 7:24

Exactly, exactly. So it's not rocket science, it's really just the flow of information. You asked, what is the role of the patient. The role of the patient, in a system like Switzerland, or anywhere where we practice Western medicine as it evolved, is to be the center of clinical intelligence. Which is interesting, right? Because you did not train as a patient to collect and all of the sudden make sense of all this information.

Alex Jani, X-Health.show: 7:50

What do you mean – clinical intelligence?

Basem Higazy, Consulto: 7:54

Think, like, intelligence, like the CIA and all these people, what do they do? They gather

intelligence, meaning: 7:59

information, meaning: knowledge about things. And in a different context, try to analyze the situation to reach a solution, right? It is the same thing with our body. We have a knowledge about the body, that's the doctors or and other healthcare professionals. And we have solutions. But we need to first know the problem, right? And imagine if I know about one area, and then you know about the other, and another knows about the other. And then me as a patient going to all these doctors, I'm actually the one who's helping them gather all this intelligence to help me at th end. So yes, I help them by doing that. But the question, Am I in a position to do this? Am I empowered to do that? Am I even appreciated for doing this? Because it's like, as if you speak about your case, as a patient to a doctor and say, I know about myself more than you do. It's a fact.

Alex Jani, X-Health.show: 8:55

And I use Google.

Basem Higazy, Consulto: 8:59

And I use Google, and I live with my condition all the time.

Alex Jani, X-Health.show: 9:04

Sorry, even ChatGPT now.

Basem Higazy, Consulto: 9:06

Yeah, ChatGPT passed the med exam, I think it's brilliant. So that's the role of the patient here. Patient is the navigator of their healthcare, the scheduler of all the appointments, the gatherer of the information, the center of clinical intelligence. This is the reality. So what we can do and what we're trying to do is to make the system better for them. And to empower the patient to take this role, by the different tools we offer in our companion and the platform, and so on.

Alex Jani, X-Health.show: 9:42

What's the role of a doctor in the system then?

Basem Higazy, Consulto: 9:45

To understand the role of the doctor today and how we deliver healthcare, we need to look into three different things. First is the medical knowledge, second is technology, and third is how we deliver care meaning, how we deliver this value to the patient. Over the last century, the amount of knowledge that we got about our bodies is enormous. To give you a number, in the 1950s, it was expected that our knowledge about the human body would double by the end of the century. We did this in '83. So in 1983 it doubled. And today, every 63 days the corpus of knowledge doubles. How we measure this is by how much publications are being produced on medical topics.

Alex Jani, X-Health.show: 10:36

It's not possible for a human being to absorb all of it.

Basem Higazy, Consulto: 10:41

Impossible.

Alex Jani, X-Health.show: 10:42

Hence the specializations.

Basem Higazy, Consulto: 10:43

Hence the specializations and the sub-specializations. Specialization and sub-specialization is healthy, it's normal but what is not normal is that we continue to deliver care exactly the same way as we did in the past. We need to really rethink how we Right, the patient basically goes with different parts of his deliver healthcare. Because that's what's happening: you can easily say there's an exponential increase in knowledge, there's also exponential growth in technology. Just the beginning of last century, we discovered penicillin, we made anesthesia became mainstream, surgery became mainstream – all of these things, just the beginning of the last century. And the trends are, the technology will continue to increase and be amazing, but again, how can you bring the benefits of these technologies, all this knowledge, to the patient with the same model of care, it's impossible, or her body to different doctors. Exactly. And the interesting part is that in the past there was this one doctor who knew everything. But actually, collectively, all the doctors didn't know much, right? And now we know a lot but you go to multiple doctors and then they are able to deliver the value. So for that reason, what we are developing is simply to offer a chance for humanity to change how we deliver healthcare, very innovative, and really how to bring the best of the knowledge, the best of this technology for every patient, every time they need it when they need it.

Alex Jani, X-Health.show: 12:17

Again, one step back. You studied medicine and then you, Basem, you worked for World Health Organization and Baher you worked for Doctors Without Borders, right? Why you joined the organizations?

Basem Higazy, Consulto: 12:32

So a quick answer... actually maybe Baher can take over this and I continue.

Baher Higazy, Consulto: 12:37

I think the shift from medicine to working in global health, public health, it came from reading a sentence on a pen. This pen was promoting Johns Hopkins School of Public Health. And on it, it said, "Saving millions at a time".

Alex Jani, X-Health.show: 12:57

That's what you wanted to do!

Baher Higazy, Consulto: 13:00

I was in the third year of med school and I was doing this project with Johns Hopkins on environmental health. We were measuring the particles in the air, calculating it and just stating it to understand what harmful particles exist in our environment.

Alex Jani, X-Health.show: 13:19

Cairo is full of them, right? I mean, the traffic is terrible.

Baher Higazy, Consulto: 13:22

Yeah.It shifted 180 degrees because you discovered with that one piece of work that you are doing, you could help millions live in a better environment that could make them healthier and healthier. And then this came at the same time when our grandmother was going through this sickness. And then we discovered really the problem in healthcare is not the practice of medicine. It's mainly how we organize our system. And we discovered that there weren't so many doctors that actually work and study, learn, and do their apprenticeship to deliver this value, organizing health system, transforming health system, understanding health system across its value chain from delivery to reimbursement to assembly, designing, redesigning, monitoring and evaluation, all of that. And the organizations, whether it's the World Health Organization, MSF – Doctors Without Borders, they all deliver this value in a different way. Especially WHO it questions all the determinants of health: social, environmental, finance. Working in the World Health Organization, I would say, it's a school of its own, its own school of thought about what is health,

Alex Jani, X-Health.show: 14:48

Where the idea of the platform that you work now on came from – the Consulto platform?

Baher Higazy, Consulto: 14:54

So the idea of the platform, Consulto, came at a time that we, Basem and I, wanted to go back to medicine, to practice. And I almost started in psychiatry.

Alex Jani, X-Health.show: 15:09

So that was when you were here, already in Geneva?

Baher Higazy, Consulto: 15:14

Yes, we both were here in Geneva, this was 2019 – around COVID. Around COVID the idea came. While starting the pass to rework again and practice, the idea of Consulto came again. Because of Basem's wife, because of the situation that we were going through. At the same time COVID was going on, everything was going digital: banking was going digital, meetings were going digital, and health was going digital. And then somehow our brains connected the dots. Somehow we kept asking people, What do you think about that? And, to the surprise, the idea is so simple: we just want people to talk to each other, and the information of the patient flowing between them – they're making collective decision-making in diagnosis and case management. And we discovered that in Switzerland, this is a very good idea that there is a need for it. We spoke with doctors, some people that we know in hospital management, and with some insurance companies in a very unofficial way. And then we got a lot of supporting feedback, Please do it, if you can. But we think it's very difficult.

Alex Jani, X-Health.show: 16:30

May I just ask, Have you always worked

Baher Higazy, Consulto: 16:33

We did, we did! And this is the best together? part of Consulto. Consulto came after a period when Basem and I had not worked together for around five years and half. So all our lives, we are together, nine months before we were out to life. And we studied together, we did everything together, I would say except to the first couple of years in Geneva, I was working in MSF, and then went to consulting. And then Basem worked with the WHO. And then we both had our paths of life somehow, and then Consulto got us again to work together.

Alex Jani, X-Health.show: 17:17

Tell me then now about the virtual clinic you want to create.

Basem Higazy, Consulto: 17:21

What Baher was referring to earlier, our idea at its score is very simple. We just want the doctors to collaborate and to work together. Okay, let's develop a platform that helps doctors to collaborate, it has a nice interface, the depth of the workflow. Everyone loved it, we loved it. But then we discovered, we, if you just bring another tool, like a platform, it will not help the situation. The problem is not in technology, the problem is with culture. And the problem is in the underlying causes of the healthcare, how it's organized, and how it's delivered.

Alex Jani, X-Health.show: 17:56

Now, that's complicated to fix.

Basem Higazy, Consulto: 17:58

It is, it is. But again, an easy way out of doing it, Oh, I make a platform, few doctors will be using it. You will make an impact, honestly, but not big impact. And it's not the impact that we aim to achieve. So we started to think differently, we started to think, Okay, if we want to change the culture, how do we do that? So we started with this in mind, and then we ended to what we are developing today. We said that in order to change the culture, you need to start with how the clinical model works, what is the patient journey? Who are the doctors and other healthcare providers that work with that patient profile? And how can we, from the start, make them work together? So that's the question or workflow, and how can we influence that? To influence that is actually to be in the seats of the clinic. People think of a clinic in many, many ways. For us, we think of it in a very abstract way. It's a space where doctors and other providers work with the patient to achieve some health goal. And in that space you have a certain pathway, as a patient, to go from point A to B to C. And every doctor has a role – I do this, you do that. At the end, care is delivered. Everyone is happy – best case scenario for sure. And that's exactly what we're creating. We're creating a space, a virtual one, so it's a space in the cloud that connects the doctors and the providers in that patient journey with their joint workflow.

Alex Jani, X-Health.show: 19:42

Will they want that? The doctors?

Basem Higazy, Consulto: 19:46

That's actually a very good question. And a question that we constantly are answering. The

answer is: 19:53

Yes. And overwhelming Yes. The harder question to ask is after the Yes – How. That's the hard thing. And the Yes, the intensity of the ask is different between different specialities, different conditions, different ages, demography. So it's really a whole community with different affinities.

Alex Jani, X-Health.show: 20:19

Could you give an example here?

Basem Higazy, Consulto: 20:21

For sure. The first clinic we're working on is low back pain. Anyone who worked on pain management is jumping on what we do. They understand that because if you want to give better value for a patient, you do multimodal therapy, which means you address not only the physical but also psychological aspect of the pain, and neurological, and so on. And the only way to do this is by working together, that's how you give excellent care to your patient. So these people who work in that area understand very well the value of team-based care. And also this is why we started with it. Because it's actually very hard. It's not a low hanging fruit, but at least the value of working together is very, very clear.

Alex Jani, X-Health.show: 21:03

So you're saying that you're starting with back pain virtual clinic?

Basem Higazy, Consulto: 21:07

Yes, yes. And I want to go back to the philosophy that a clinic is a space and we are a virtual one. But we did not want to just create a virtual clinic, meaning the patients are receiving the care virtually. We wanted to work with existing actors, so networks, hospitals, independent doctors – to deliver a better value, not to replace them. And that's also one of the Unique Selling Points. And what we do is that we complement the system, we add to the system and make it better, actually, for everyone: for patients, for doctors, and even for the insurance. So for the doctors, for the patients, they can actually visit the doctors physically or virtually. It's hybrid. So we are a virtual clinic offering hybrid care.

Alex Jani, X-Health.show: 22:02

Is the virtual clinic global or what's the area you cover with the clinic?

Basem Higazy, Consulto: 22:09

That's also a great, great question that we're constantly answering. Health is incredibly local. It's not just local health, like, we're here, in Switzerland health is cantonal. So if you have a problem, you want to go to the doctor next door, you don't want to go far

Alex Jani, X-Health.show: 22:28

Or call Chicago.

Basem Higazy, Consulto: 22:32

So health is local, not just in the location. Health is local in regulations. If you are licensed to practice in one area, it doesn't give you the right to actually treat a patient in another area. That was very clear in the States, for example. Even when they wavered... that they said, Okay, if you do telemedicine to be reimbursed equally, a big question happened, I'm a doctor in one state and I'm treating another patient across state borders. It was scandalous to see that actually that was impossible. I mean, at the end they wavered that, I don't know, pathology in the system, but now it's reversed back again. So health is local in terms of location and preferences of the patient, but also regulation. And we respect that, because we believe in order to transform a system, you need to work with a system, not just go against the system. And we discovered also that this is an opportunity for us to build something from the grassroots, and from the ground up. So imagine today, if you say, Oh, we're going to make like this mega system globally, every doctor everywhere is connected can make virtual clinics for any condition, treat everyone... It's an amazing dream. And we will reach that point one day. And I promise we do the podcast again in the same space...

Alex Jani, X-Health.show: 23:52

I wish us that!

Basem Higazy, Consulto: 23:53

...and we will have a map behind us and tell you all the areas we are. But to reach this point, we'll not start from that end. We'll actually start from one city at a time, one condition at a time, five, six healthcare providers at a time for one specific population at a time. And then this will grow into a distributed network. Each clinic will be connected to another in a distributed system. Finally, all of that will be our decentralized healthcare that we are aiming to build.

Alex Jani, X-Health.show: 24:24

I think I understand a bit what's there for the patient because the patient gets care from many healthcare providers, basically. Is it so?

Basem Higazy, Consulto: 24:35

Absolutely. Simply you have a team of capable health professionals who are giving you their best and they know you personally, and they are there for you. So yes, it's very good for the patient.

Alex Jani, X-Health.show: 24:49

And they communicate with each other. So we are back at the Doctor House team's room.

Basem Higazy, Consulto: 24:50

Absolutely, absolutely. So in one of our presentations, we had this effect, like, you have Doctor House scene where they have a chart on a whiteboard and everyone is looking at it together, and trying to solve it. And then we had this effect of switching and bringing our platform doing the same thing. But virtually, yes, doctors communicate and if you want people to communicate – give them a phone, but in order to make it a default, you need to make a culture, not a phone, or a tool. And a culture will be created by incentives, financial, non financial incentives. Actually, I'm not surprised but some people are surprised that non-financial incentives for collaboration are much more effective than the financial ones.

Alex Jani, X-Health.show: 25:44

What do you mean?

Basem Higazy, Consulto: 25:44

We actually pay doctors when they

Alex Jani, X-Health.show: 25:46

And hence your platform? collaborate. If you and I would discuss a case of one of our patients, we both get money exactly as if we were seeing the

Basem Higazy, Consulto: 25:53

Exactly. patient. And we do this because we believe that the money spent on these five minutes discussing could save us 20 minutes with

Alex Jani, X-Health.show: 25:58

[MID-ROLL] This episode is brought to you our patient. And we'd be saving using five minutes just to check on each other and be more human actually. And the clinical information, the clinical intelligence is transferred more effectively. So there is payment and many people like what we do because of that, because, Oh wow, you're giving actually money. But from our research, and from our hypothesis, we see that the non-financial incentives, I'm going to answer the question now, are much more effective. One example is collegial bonds, something very simple. Now imagine yourself as an independent doctor, as, let's say, a generalist five years from starting your clinic, you're on your own. And before that you were in the hospital environment, you had 500 by the X-Health.show and me. So if you like this podcast, be colleagues bumping at each other all the time at the coffee machine, discussing all. Did you see this crazy case that came and Oh, yeah, that's interesting, I heard someone else had something similar, and so on. The amount of interaction that you get around the watercooler or around the coffee machine, you learn from each other. And you discuss things in a light way. And you have these close bonds and learning that you are now, I would say, deprived of with you outside of the hospital system. But why did you leave? You left the hospital system for one reason or another, you wanted to be fully independent, you want to be the boss, you are entrepreneurial. What if you're able to have the same environment without the minuses of it, the control of other heads of departments and all of that. generous hit Follow, leave a review. That'll help me invite more such amazing guests for you. Thank you. [MID-ROLL ENDS] You mentioned that doctors will be paid for the consultations. Now, who's gonna pay for these. Patients or...?

Basem Higazy, Consulto: 28:08

For us it's very clear: we don't want patients to pay anything extra because the are dealing with Consulto. We want Consulto to help them. We don't want to create any barriers. So we're playing by the rules of the system to make the insurance pay for the healthcare. And in our case, Consulto is a virtual clinic. It gives the care for patients. This care is existing under the laws of the service delivery and when the patient gets it, we get paid from the insurance and we'll pay our doctors. The question here is for what and how much, and what are the limitations. And here when I say we work with the rules of the system, it means that we work with the same rules of reimbursement that exist nowadays. Something like the TarMed which regulates how healthcare service in Switzerland is being reimbursed. We did an extensive research by very experienced consultants in reimbursement and we've got codes that allow us to build for collaboration. These codes exist for something like the tumor boards, where collaboration is a norm because it's the only way that it goes through. We aim to transfer this to other areas. However, the limitations of the laws, we are aware of it, and we are not going to be stopped by it. So we are reinventing the system of reimbursement through value-based care, which means that we want to shift the reimbursement from its current state where it is reimbursing for fee, you pay for a fee, to be to be paying for an outcome. That if the doctors work together and they provide a better outcome that the patient is walking three months before they usually do, that they have less infections, they are having a better quality of life, all of this should have a price and it does not necessarily mean that we did something more expensive to reach this, it could mean that we made less. And here we are working with one of the insurance companies to create a value-based reimbursement scheme that allows us to pay for everything that we think could make our patients lives easier, and with better quality. An example for this is we would love that the patients that need life coaches to be in the team of the doctors or the team of providers. Because speaking with one patient, she has a form of cancer, mild cancer that goes up and down in remissions. And with every remission that happens, her life falls apart, who takes care of the kids, who cleans, who will do my job, I need to apply for holidays, I need to apply for insurance, invalidity insurance, all of the stuff.

Alex Jani, X-Health.show: 31:20

This is an extra cost for an insurance company, isn't it?

Basem Higazy, Consulto: 31:23

The answer is yes and no. It's Yes, on the very short term. But on the midterm, long term, it's much cheaper. Here I actually have an example. You have the value-based care approach. It's not new, it's as old as 2006. When Michael Porter came with the idea, more from an economist's point of view, that it makes sense that we pay for what is valuable for the patients, and that really investigate what is the value and how could we put money for this value. And in that case, the patient when they come to a clinic, they want their life to get better. It's not that they want this very specific medical condition that they have to be treated clinically. So if my life is falling apart, and I'm receiving the best care ever, I am so stressed because I don't know how to cook for my kids, I don't know how to file my administrative stuff for invalidity insurance. I didn't know all of that, I'd be so stressed, I will have very bad outcomes in my healing, in my mental health, all of that. Long story short, the quality of life is negatively impacted because of the medical condition, even if you're getting the care that you want. And all of this would mean that you would go visit other healthcare providers and the health system would pay more. And listen, forget about the money because we are not in healthcare for the money. Money is a tool. Is the patient happy? Is the patient getting what they want? The answer is: No. And now, health insurance is onboard that focusing on the value that matters to patients is cheaper in the long term. And in the Netherlands, there is one example that I really admire. They started a program on type 1 diabetes called Diabeter, maybe you already know about it. With Diabeter they do, I would say team-based approach, integrated practice unit on type 1 diabetes. They help kids, teenagers, adults living with type 1 diabetes – to be better managed. And you would see that the most impactful thing in type 1 diabetes management is not the medications and it's not the limitation of food. It's actually lifestyle coaching. When you're a teenager, you used to live in your parents house, now you move out to go to university, you see all your friends are eating pizza, or eating kebabs, I don't know McDonald's, and you see as well that they are doing marathons, triathlons, you want to be this sporty, sport is good, sport is amazing. And you do it, you have a sugar crash and then you go to the emergency. Because you do sports. Is sport bad? Every doctor will tell you: No, sport is amazing. But in that case, the lifestyle does not allow for it. So how could I learn, as a teenager, to eat well and to do sports and to achieve all my dreams that I care about? It's why I want to live, is to be active, is to be participating in the social gatherings, to not prevent myself from doing the things that I love. But how if I don't have the tools to. Should I be so rich to hire a life coach or should I get the medications and not live my life in the way that I want? The

answer is: 34:59

No, you should be able to do everything you want. And with Diabeter, they managed to do it. And it was proven that it was much cheaper or much more cost-effective that way.

Alex Jani, X-Health.show: 35:11

That's amazing that you have an insurance company onboard, because I have also the feeling that prevention somehow is creeping into the system. Because now we don't have it. When something's gone wrong, we treat it. And what you're speaking about, is more about the prevention and an extra support that we don't have now.

Basem Higazy, Consulto: 35:35

Exactly, you said it. We don't have it now because we don't want to have it. It's one of the biggest difficulties in the healthcare system transformation, the incentives that are not aligned between the providers and patients, and insurance. But the ones that are very falling apart is the incentives between providers and insurance companies, with providers – they are very happy actually, when patients are sick. More sick patients means more visits means more operations, means more tests, means I'm getting more money.

Alex Jani, X-Health.show: 36:12

It sounds terrible, but also about right.

Baher Higazy, Consulto: 36:16

They are right, scientifically, it's written in academic literature. It's unfortunate, it's right. And if you want to grow your business, as a hospital, you want to create one more space, to grow from 60 beds to 80 beds, you need to have more sick patients to fill in these beds. And if you want to increase the employment of nurses, doctors, and create jobs, these doctors, nurses, and all the personnel that works, they need to treat someone who's sick. You need to as well create a budget, choose some stuff that create more flow of money for you. Would I do an intervention that is so cheap, like physical therapy, over three-four months, or just do one operation, that would be a couple of thousands of francs in one shot? And then for the insurance – they are paying for all of that. And they would say, Actually, we would love to pay less or pay more. But it doesn't matter for us as an insurance so much. Do you know for whom it matters?

Alex Jani, X-Health.show: 37:23

For the patients, obviously.

Baher Higazy, Consulto: 37:24

For the patients. And even when you are not a patient, just as an insuree, you are the one that pays your premium every year. And when the healthcare costs increase, the insurance is not the one that is paying the bill. Because next year, they are going to say we have paid so much this year.

Alex Jani, X-Health.show: 37:43

Oh, this is actually what happened this year, right?

Baher Higazy, Consulto: 37:45

6.5% or 6.7% increase in one year. Do the math. In 12 years, we will be double. Say, now the average of the states is 500 per month, per person. So in 10 years, it could be easily, 1000 per month. Is it sustainable? The answer

is: Not. The answer is: 38:05

Not sustainable at all. And now going global, decreasing the cost of care means one thing: decreasing the quality of care. And we don't want to go this path. What we want to go to is cost-effective, is making the cost the same or slightly more or slightly less, but the quality – higher.

Alex Jani, X-Health.show: 38:26

Yeah, but then we enter this area both of you mentioned, the cultural change, which is the toughest thing to do. How do you want to aproach that?

Basem Higazy, Consulto: 38:37

I love incentives, they work particularly at the micro level. When we want to change culture, we're speaking about a system. And this system exists at three

levels: 38:47

micro, meso, and macro. The micro level – this is basically the people that make it, so the doctors and other providers, and anyone who interacts as an actor in that system. If you're able to change something at that very small level, basically create value for doctors and incentives to them to work together. Then on the bigger picture, you will have a system that is connected and collaborative, and the cultural change will happen. The problem with why cultural change doesn't happen in healthcare is because it starts from up, starts as a strategy for a country, strategy for a hospital. But actually, it did not start from the roots. And that's why they always fail and they will always fail. I'm sure you've worked in a few corporates. And if you have any strategies that come from the management, the uptake of it by the employees is very little. But if you have an initiative that comes from the employees about something they care about, they will make it happen and it will be a success. Healthcare is slightly different because every doctor is an entrepreneur on their own. They actually decide what to do, they also even when they are employed, they have been working in certain ways, and they have certain control about what they do. If they want to change the system, they will. Collectively. How to align the incentives? This is what we do. And that's why we believe we will succeed. Because we are not working on a strategy for the whole system, we're working on a strategy to understand something very important, to understand what moves people to actually connect with each other. And it's a human thing in us to connect, but you need to make the medium for the connection to happen.

Alex Jani, X-Health.show: 40:36

And this is why you start with doctors or healthcare providers who are already motivated, as you mentioned, right? They need each other to provide the treatment for the patient.

Basem Higazy, Consulto: 40:49

Exactly, exactly. So here, what connected these doctors around low back pain is that they need each other. That's easy, you got the incentive. Believe it or not, they will even work together, even if it costs.. Let's say they will discuss with each other and they don't get paid. They will do it over phone, emails and other channels that are annoying, they still do it. Why? Because they see the value and they do it. Try to make a policy for the whole hospital, give them an incredible technological tool, pay them, but do not explain the value to them or do not make it an initiative from within them, it will fail.

Alex Jani, X-Health.show: 41:32

These are the basic change management rules, you need to have people who want to change, to see the reason why they may change in the first place. Let's talk about the tech, how the platform will work.

Basem Higazy, Consulto: 41:48

For us, technology is a tool to reach this change in the healthcare system that we want to achieve. We have a quite ambitious roadmap in our technology that we will achieve incrementally. The first part is the platform for collaboration between doctors. Imagine a tool that you can have a video chat or video chat with your colleague, imagine a tool where you have voice notes, all the files for the patients are there, visualized in a way that incites collaboration. For example, instead of having a report with all the symptoms that the patient is having – written, we will have a visual interface where the symptoms are visualized with metadata that matters. So a symptom started:

this point, finished: 42:40

that point. We try to not show all the information, gather all the information, but show only the information that matters. And this takes a lot of time to do. But once we do it, we believe in the value of it. That's just one example. This is the first part of our technology. Really a very simple technological tool that we listen to our colleagues, doctors – everyone – to what actually matters for you, to what are the simplest things you need to have in order to discuss

a patient. Three things: 43:14

the communication between them, the patient data, and reimbursement. And there's an admin around it. And basically, we do these three things. And this is our MVP, this is the first version of the platform that will be coming soon. Another important piece of our technology is the patient companion. So that's basically a tool for the patient to be empowered as the partner in their healthcare journey. Speaking again, of clinical intelligence, imagine you go to all these visits, and simply these visits are there. When I go with the timeline, I went there, why, important: because I had this symptom and I was given certain things to do: investigations, treatment. Everything is written in a timeline. Just having this information, this context will help the patients a lot, will help the doctors and other providers.

Alex Jani, X-Health.show: 44:13

Like you have all the documents in one place, which is so amazing. Because here in Switzerland, you go around to different doctors and they keep your documents.

Basem Higazy, Consulto: 44:23

Yes.

Alex Jani, X-Health.show: 44:25

Many times you don't even get your test results.

Basem Higazy, Consulto: 44:28

Yes.

Alex Jani, X-Health.show: 44:29

You get the bill for them but not the results.

Basem Higazy, Consulto: 44:34

Yeah, because you need to pay. So we get your data. This is very important. And we don't get your data – we help you get your data. And not only that, we actually sort this data chronogically and contextually so that it helps you and it helps others. Imagine if you have, let's say a Google Drive with everything in it, all your information. That's not enough. You need them to be organized in certain ways. Imagine if they are organized in a way that is your journey, okay? That will be one part of the application. Another thing is proactive patient journey. So let's say you entered in our low back pain as a patient, we know what you'll be doing in the next month, you will be meeting with around five or six practitioners.

Alex Jani, X-Health.show: 45:24

How they match the practitioners with a patient?

Basem Higazy, Consulto: 45:27

Initially, we had the idea of creating a clinic for each patient. So basically, if you need this doc, we match them. But this is just not scalable and it takes from concierge medicine, which is made for the rich people who can afford anything. So we actually had a different approach. We actually structure our clinics a priori, meaning, we have a clinic for low back pain, these are five or six, seven practitioners, with the specialties we need. When they are working together in our clinic, they are there. And then the patient who has low back pain will come and join the clinic. If the patient has more needs, let's say they are obese, okay, and we don't have a nutritionist in the low back pain unit, but for that one patient, it's crucial, because maybe if they just lose weight, the back pain will disappear, maybe, so in that case, we can add a nutritionist from an extended network that we have that also knows that clinic and knows the professionals there. And then they join just for that one patient. Our clinic as well has an orthopedist, but for, hopefully, for the majority of the patients, we don't need surgeries. In that case, the orthopedist will be there for the initial assessment but then we'll be out of the team for that one patient. We're in Switzerland, so it's like ski shoes that are customized and you further customize them, okay. I like the ski shoe example. It's much much more sophisticated than this but in the sense it's customized for one patient population. In that case, it's a low back pain. And then there's the extra step of customization of the clinic – to suit your needs. This can be by adding or removing from the workflow.

Alex Jani, X-Health.show: 47:23

So who's referring the healthcare professionals to the patient? Because the patient doesn't go doctor shopping anymore, right?

Basem Higazy, Consulto: 47:34

No. I'll tell you the exact scenario that we would love to have. Someone who started to have pain no longer than, let's say, 12 weeks. They came to us directly or their GP referred them, they ended up in our clinic. In that case, our our aim at that point is to prevent that pain from becoming a chronic pain. It will be actually secondary prevention of low back pain. You already have it, we will help you be better, but actually will help you not to become a chronic patient. When the patient enters the clinic, everything is structured from that point on. They'll be meeting first with the pain specialists who will assess all the condition of the patient. Before you even meet with the patient, you actually have met with their GP or the referring physician, to know the history. You have even around one hour to discuss all of that– paid. So you both get paid for that. And then by the time the patient comes, the clinical intelligence is there not just the files, it's the story of the patient from the perspective of a clinician that followed the patient until they reached that point. And then you had listened to the patient, after all this assessment. Okay, then the pain specialist will say, you will need to visit the neurologist or psychiatrist, or psychologist, and the orthopedist, and neurologist. You go to these stages in your care. It's all predefined in the next three weeks, you will go to all of them. And because it's part of the clinic, you don't actually choose them. Yes, you don't choose them but they are the best in what they do. Because they are working together. And the more they work for more patients, the better they get for you. So you don't schedule. You can have a recommendation of the scheduling, so this date this date, yes, yes, yes. Now we have six appointments already all planned with you.

Alex Jani, X-Health.show: 49:31

You haven't mentioned AI or Machine Learning so far. Are you involving AI?

Basem Higazy, Consulto: 49:37

Absolutely. And it's intentional. Actually I'm very happy with this conversation because it allowed us to talk freely about what we want to do. Most of the time people are hyper-focused on technology. We are slowly going from the culture to the tools and now we can speak about AI because we have developments that we use different machine learning algorithms, rule-based algorithms and deep learning. And they are more to the pipeline of our development. The first is actually designing the model of care. I told you that from the moment you enter the clinic, everything's pre-planned and depending on the patient, can change a little. But the journey is designed so that we achieve certain results. For example, diagnosis within one month max. The normal to be six months. Why? You just need to talk to each other, get it done, do all the tests the right way and it would be good. And also, imagine you visited now one doctor but when you visited them, they tell you, Do some tests and come back to me. Imagine if you did these tests before you go to that doctor. Now, it cut one visit. It is really good for the patient. Good to the doctors because it's not redundant. And it's good for the system because it costs less, right. So there are many, many values for designing the journey of the patient for everyone. Now we do this manually. So us and our doctors, we design this patient journey. We're doing it for the low back pain, we'll be doing it for the next five, six, seven conditions. But in order to scale up, we need technology to help us with this. And this is where we are developing a machine learning algorithm that would learn from all these data points that we're having in designing. And then at some point, we want our AI helper, in that sense, to recommend for the doctor a patient journey. Then the patient journey – the doctor would validate it or change it. It's like someone doing for you the first draft and then you change it. So one another function that I think is incredibly cool is predictive patient journey as well. Let's say I see in your tests that your glucose level increased, then I can send to you, We saw that your glucose level increased and we recommend that you go to see your GP or diabetologists, for example. But not only that. We actually recommend the doctor, we find an appointment with this doctor, he is really good, or he she is really good – now I'm gender biased – and we found these two appointments, would you like to take them? And before you go, you have to do A1C test to know your blood glucose level. So we also will send you a kit through collaboration with this lab to do this test before you go to the doctor. Are you okay with that? Yes, yes, yes. Basically, all of this was prompted by simply seeing that the glucose level has increased. This is not rocket science. It's not really science fiction, it's very, very possible. And we'll be doing it as a feature of our system for every patient. Also, I told you we designed the patient journey in certain order, so that we do the tests before we need the doctors. For example, we group all the tests at one time so that you don't go multiple times, if possible, to meet multiple doctors at one visit. But what happens if you skip one point? You skipped one visit or you don't do one test for whatever reason. Then the whole journey changes as well. And, for now we do it ourselves, but in the future we want to automate this. These are two features. There are other four areas that we're working on but I don't want to bore you now.

Alex Jani, X-Health.show: 53:31

Oh, that's all very interesting. But the question is the timeframe. What timeframe are you looking at? When do you want Consulto to happen? And basically, what do you need to make Consulto happen? Because the vision is huge. Even if you start locally.

Basem Higazy, Consulto: 53:50

I totally agree with you. And the funny thing, when we started, we thought, Oh that's so simple, like, really the most simple thing and it makes absolute sense, it does. But now our vision is executed through incremental achievements. The first achievement that we are working on now is throw out our MVP for the collaboration platform between healthcare providers and enable two things: that they are able to consult with each other and get reimbursed for that. The low back pain clinic – this will be ready next year, sometime next year, like, in the first two quarters. This will be our first clinic, so we're already there. How much we scale that, our work on the low back pain? It will happen so we can scale up by adding more clinics. So we can have another clinic for low back pain and another, another – to meet that demand.

Alex Jani, X-Health.show: 54:49

You mean another in a different location or with a different team?

Basem Higazy, Consulto: 54:55

With a different team. To break down

things to the basics actually: 54:58

a clinic is a space and people that work in that space. So if we have more demand, let's say our first clinic has a maximum capacity of 20 patients to serve, and now we have 50 patients. What happens classically in the healthcare system is waiting lists. We hate that as much as everyone hates waiting lists. So how are we going to act? We simply make another clinic for low back pain by connecting other five or six doctors to work together, to have certain capacity. What happens when you exceed that capacity? The same. That's the vertical scale-up by simply putting more teams together in one condition and scaling up on that one condition. We can also horizontally scale up by making another clinic another condition and when we reach the demand – the same. All of these clinics will become connected together in a distributed network. Alright, so now you have these different clinics on these different conditions and they are connected together in a distributed network, meaning, that they are connected by functional links, not hierarchical or organizational, and they are fully autonomous and independent at the same time. So you can do a new workflow, you can do a new patient journey, but you're all bound by the same outcome measures. For example, if you're in low back pain, are you able to tie your shoe comfortably. If you do something different, for example, to decrease the patient journey length, fine, do it, that's nice, but at the end of the day, we will have the same outcome measure. By this, we can learn from each other. It's not about I'm older than you are, you know, I know better. It's about, we can try new things. And if I'm better than you, it doesn't matter if I'm younger, with lesser experience, this is what will prevail. Another effect of these functional links is to also help doctors be committed to their work and still have a life. So for example, I'm a pain specialist in one unit, I can replace my colleague, who is now having a kid who is sick, or they want to go for vacation, I can simply cover for them just for this time. I'm not actually in the same organization, as you were both independence, I'm not going to replace you and take your work. I'm just going to replace you now. And knowing that you can do the same for me as well, when I need it.

Alex Jani, X-Health.show: 57:31

That's kind of sensitive. Again, the question is, would doctors want it?

Basem Higazy, Consulto: 57:36

Again, I think if we speak about younger doctors and what motivates them to go to medicine and continue in the profession, they are very different from the past. For example, this idea of graduating and as soon as possible you have your own clinic and work 80 hours and make a bunch of money, have nice holidays – most people couldn't care less about this now. They want to work 45 hours, 50 hours, have a decent salary, and be able to have a life. Think of all the women who are unable to balance a career – and men, it's a gender issue but in fact the society is still having the norm of childcare...

Alex Jani, X-Health.show: 58:18

Especially here in Switzerland, yeah, it's true.

Basem Higazy, Consulto: 58:22

Why? Like, why can't you have both: a very fulfilling career in medicine and at the same time having a thriving family life? That's possible. But if you are working within the constraints of the current system, it's impossible. If you are in a residency or you're working in a hospital, you're expected to work certain number of hours that are very hard to balance, if you have a life. So yes, so

the answer is: 58:49

Yes, for sure. There will be the ones who are jealous, the ones who are protective of their patients. It's fine. That's normal, no worries, they exist. But at the end of the day, you will be offering an alternative for those who can imagine a world where doing medicine is possible while having a nice life.

Alex Jani, X-Health.show: 59:13

Okay, so thank you very much for a very interesting conversation, looking into the future really about what it can look like. Good luck with your ambitions, I'd say plans. Because tech is not that difficult. The culture to change – that's the most difficult part here.

Basem Higazy, Consulto: 59:35

100%. And I want to just finish with two thoughts. Just came to my head now. If you noticed, we started to get the patients, we started speaking about the doctors and how to work on the incentives for them to work together. We built together the clinics. So the units, we connected them, so there's distributed networks. The overall picture is decentralized healthcare that we want to achieve, we want to build, so that we bring healthcare closer to the patients. And we make healthcare human. Not just for the patients but also for doctors – to be able to maintain their full independence, entrepreneurial career in medicine, while having bonds and while having system structure that actually listens to them and supports them on the journey and delivery of care. Technology is very, very important. The first steps are rather the simpler ones that we use to achieve better communication, sharing of data, and going to the other functions in our AI roadmap. But no technology will

be developed out of like: 1:00:40

We have a technology, let's see what to do with it. It will be rather to solve an immediate and exact problem, we know exactly how we want to solve it. So it will be as a tool, a suite of tools that we will be using to build our decentralized applications.

Alex Jani, X-Health.show: 1:00:58

Alright, so thanks again.

Basem Higazy, Consulto: 1:01:00

Thanks so much.

Baher Higazy, Consulto: 1:01:01

Thank you so much.

Alex Jani, X-Health.show: 1:01:02

And for you listening: Thank you. And if you want to learn more about Consulto, please head to consulto.care. [POST-ROLL STARTS] I'm totally impressed by the audacity of researchers turned startup founders, doctors turned entrepreneurs or ordinary parents turned healthcare innovators. People battling the battles that no one fought before. For the eXtra health of the future. So if you see a startup posting on LinkedIn, show them some love, hit Like, comment, That's fabulous. If you have a couple of drops more of that altruism, follow the X-Health.show, leave a review here. I'll be able to bring more of these visionaries to you. So a big Thank you. You're awesome. See you next week.

SPEAKER: 1:01:48

The information in this podcast is for informational purposes only and should not be considered medical advice. If you have any medical questions, please consult your healthcare practitioner. The opinions on the show are Alex's or her guests. The podcast does not make any responsibility or warranties about guests' statements or credibility. While the podcast makes every effort to ensure that the information shared is accurate, please let us know if you have any comments, suggestions or corrections.