DoctorNow

Currently, the global healthcare model for providing care at scale is broken. Care is optimized through the lens of creating physical care systems and structures and not focused or built for the patient or provider. Only in mature markets has the capacity for remote care begun the adoption process. Yet telehealth’s value proposition is more profound in developing countries where care (hospitals and health systems) is located primarily in cities, and receiving care means overcoming travel time, wait time, low numbers of physicians, and low rates of satisfaction. Yet expanding economies also offer an attractive regulatory environment that is more open to innovation because the burden of regulation is less drastic. There are over 1 billion people in Subsaharan Africa, with an estimated 150,000 doctors. This is 1:5,500 people, far below the recommended ratio of 1:1,000 by the World Health Organization. So the macro scale problem/opportunity is a less developed healthcare infrastructure and a shortage of medical professionals. 

At a micro-scale, these healthy systems are shaping the relationship to care. Because health systems are relatively new and the current jump is a leapfrog from traditional medicine to health system medicine, the relationship and usage model for many customers is undefined. The current model is that customers avoid seeking care in hospitals and health systems because of the burden this care represents in time, energy, resource, and more. In interviewing and learning from our customers, the common sentiment is - unless I am very ill or in severe danger, I don't go to the hospital I go to the pharmacy and try and receive care in that setting first. So when you look at metrics like the per-capita healthcare spend in a country like Ghana, which is $78 per person, this is an under-accounting because this informal care is not captured. And while some problems may be successfully resolved in this setting, it does reduce health outcomes, and you can see this at least partially in the life expectancy, which is 64 years of age. Lastly, we have learned from our customers the frustration that comes with receiving care in the hospital. When a patient arrives, they have to navigate the hospital bureaucracy to find the doctor they need, often having to pass multiple gatekeepers and lines, only to receive attention for a very short period of time which leaves people feeling under-served with no path for recourse. There are no such things as reviews, feedback, or others. This causes a feeling of dissatisfaction. 

The problems within this system are therefore complex and multi-variate. People don't actively seek care because it is expensive, difficult to get to, has long wait times, and has low satisfaction rates. The question is, therefore, how do you reduce the friction to care to ensure users have access to the care they need when they need it.

DoctorNow is a digital-first managed marketplace. We connect users to medical providers quickly and affordably, and we empower users to select the care they need when they need it. What does this look like - we have a digital application, currently a phone app but moving toward a web app where a user can log in, fill out their information and get access to care. We then have a user flow that helps them navigate what care they need - is this scheduled care, urgent care, home care, or emergent care. Our approach is to build or partner to create the best experience possible. So for the case of emergent care, we have a partnership with the national ambulatory service so a patient or doctor can summon an ambulance. The rest of our services we have built out from the ground up. Our application is hooked up to the local cellular-based payment platforms to render payment for service. If urgent care, we get the patient in front of a doctor in 15 minutes or less. For scheduled care, they join at their selected time. Our tech stack supports video, voice, or text communication with the physician so that if service becomes an issue, contact is still possible. After the consult, we prompt our patients to provide feedback on the experience. A portion of this is used internally to provide feedback to the company and the doctor on the doctor’s performance. The other component goes to public reviews so patients can see and make informed decisions on their care. We are also currently launching what a family profile will look like, which will empower full families to manage their care on our app. After an appointment, the doctor puts in notes, and we have an EMR system so that as a patient interacts with our app over time, they can track their own health, communicate their previous appointments if needed, or select from care providers they have met with previously. Our aim is to provide transparency and ownership to our customers.

Due to the distributed nature of telehealth, we have garnered much interest from a pool of Ghanaian ex-pat doctors who mostly moved to the US and Europe, where they are now doctors. We have worked with the Ghanaian Ministry of health to get a certification process in place to onboard these doctors to provide further supply as we scale. As we hit scale, we are working to develop an inclusive model with a sliding scale wherein we will be able to offer reduced-price care to patients in need. 

We take a human-centered approach and have mechanisms for feedback to learn from our customers what their needs are to inform our product roadmap. These communication lines include active user interviews during our design and test process, an open WhatsApp contact where users can interact with our team, and on app surveys to garner live feedback. We first launched with scheduled care and quickly got feedback that there was an immediate need for urgent care, which we built into the application within the first few months of launch. More recently, there was growing momentum around home health to assist older family members perhaps living un-supported to be able to receive care. This interest was especially acute among a large group of Ghanaian ex-pats who are living abroad and were interested in ensuring their family back in Ghana was receiving the care they needed. We launched our home health platform on Jan 21st. Today we have 1000+ customers on our waitlist and have been testing out operations with the first five paying customers launching for general use in the coming month. We see our product roadmap as expanding services to provide full care continuum support.

Many communities in Ghana do not have the same modus operandi concerning the utilization of healthcare services. Here in the United States, there are options and flows that patients experience - perhaps you fell and hurt yourself, you may start at an Urgent Care, escalate to the ER, before going to a specialist. In Ghana, the system starts with pharmacies and the next option in the hospital. The degree of inefficiency when there are no options and channels to right-size the care needed to the consumer's experience is immeasurable, especially when focusing on a community already experiencing acute medical professional shortages. Our solution does no less than change the whole operating model of care - helping governments and national systems of care adapt to the 21st century and provide flexibility into systems plagued by shortages of medical professionals. For patients, this flexibility also means a 100x experience improvement as they are able to get the care they need when they need it. For family members living abroad paying monthly to send money back to Africa, remittance payments are a black box with no accountability. By providing a direct means of payment and support, we can also provide insights into the successful care and treatment of family across the world.

The goal is to build a solution that addresses the needs across age and income levels in Ghana and beyond. Defining a new product for a market requires meeting these communities in their existing channels. To do this, we are taking a multivariate and data-driven approach to community outreach using new media (social and web advertising) and conventional outreach (church groups, campus groups, tv, and radio). Our beachhead market centers around 3 core customer personas:

1. Female 24-32 with children

2. College students generally without kids

3. Middle age- 32-42 both genders

Our diverse team embodies skills across the continuum needed to create impactful change through our product. The company was envisioned and brought to life initially by two Ghanaians, Kwabena and Bright. 

Kwabena Tuffour, who goes by Kwab, has a deep technical background, having worked in innovation across consulting companies building and deploying new and creative solutions. Utilizing this deep knowledge, Kwab brought the technology platform to life himself over a period of 6 months as he worked in stealth, driven by the need to help communities. 

Bright Agyei is a Ghanaian ex-pat who has worked in accounting, finance, and operations. Bright has been running operations and partnerships, helping to keep the momentum going while building vital connections across the target markets. Together Bright and Kwab’s deep connection and network across Ghana have been essential to creating a dynamic product vision that combines technical and community needs. 

They have been joined by a diverse team of builders and designers from around the globe from Central America, the Caribbean, and Africa. Our central ethos is human-centered design. We build with and for our users and have worked extensively to develop channels of communication with our users to gather and utilize their impact. This includes dozens of user research interviews to build empathy with various communities and test designs and approaches, to a Whatsapp channel to create a space for dialogue, to user surveys built into the flow to gather live feedback.

We have experienced the highs and lows of building and launching a new product in a complex market. We launched our beta and quickly scaled to 10k users before experiencing technical degradation from our third-party developer group, which had used predatory practices. We re-designed our platform and have worked to rebuild led by our in-house developers, and during this process built and launched our home health service, which now has a waitlist of over 1,000 people. We have figured out the legal hurdles to onboard Ghanaian physicians living abroad. We have learned from our users and launched medical professionals who meet the requirements of unique cultural needs. Our biggest challenge has been breaking into the international venture funding market. US and European investors tend overwhelmingly lack the knowledge or interest to invest in Africa. African investors tend to require valuations that make investment impossible with any investor outside of Africa. We need help developing the business acumen to break into the global venture market. We further need business support as we look to grow internationally to gain a foothold in nations that tend to attract outsized investment in Africa, such as Nigeria or South Africa. We are here to learn and improve, and we are hoping this challenge will help bring our team to the next level. 

The problem that the healthcare market in Ghana and much of Africa faces is the shortage of medical professionals. Due to this deficit, any wasted resources (medical professionals’ time) come at great expense to the rest of the system. Our key innovation is expanding that ratio by using a triage system with medical professionals appropriate to deal with each circumstance. We have registered nurses for low-risk patient interactions, Physician’s assistants can encompass the low risk while also doing more moderate and high-risk interactions, and Doctors can manage and participate across the spectrum. Using the patient intake flow and the type of care, we can then provide the most appropriate care for any circumstance and can escalate as needed. This will provide a tectonic shift in nations' abilities to increase care capacity while simultaneously reducing friction in receiving care for patients.

Creating the intake system for care at a national level also provides aggregate data, unlike anything health systems have been able to utilize in these communities. It allows for better modeling and predicting community needs and can be vital input to resource planning or pro-active care in community-level health events like an illness outbreak. Creating strong community ties that value truly goes up and down the stakeholder groups from customers to governments and everything in-between.

Secondary innovation is around the connection of international resources. Family support across the diaspora and improved remittance payments using our family care model. Also, working with the governments, we have been able to get approval to utilize Ghanaian ex-pat international physicians who are eager to provide support back in their communities.

Our impact goals center around the health and well-being of the communities in which we work. 

• About 40 percent of the population has policies available through the National Health Insurance Scheme (NHIS), but these only provide limited coverage with few options. It is our goal to create an inclusive system that can help facilitate care no matter a patient's insurance coverage. Removing the need for insurance to get high-quality primary and urgent care. Expanding healthcare access beyond the insured will improve community health and economic output. At launch, we do not accept insurance, and our model is priced to be well below conventional care rates in the hospital setting.

• 81.4% of the population has some degree of access to primary healthcare in Ghana. 30% of the population has to travel far to access primary facilities or see a specialist. Our goal is to reduce the burden of travel time to receive care, increasing the rate of utilization and access. Our goal is for customers to receive care on average within 20 minutes or less, greatly reducing the burden of care for our users. This is done by using our telehealth and home health services.

• Perception of healthcare quality is low (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5770037/), which we feel is a proxy for trust in the healthcare system. By providing more choice and ownership of the process as well as providing a channel for feedback, DoctorNow aims to improve the perception of healthcare in Ghana. This will be measured through traction and maintaining a net-promoter score of 70% or better - if more people are receiving care by creating logins, utilizing care multiple times, and maintaining utilization, then we know we are positively impacting our users.

• Healthcare in Ghana, like much of the world, does not provide the same level of support for low-income communities. DoctorNow aims to create an inclusive model of care and hopes to increase health engagement for all socioeconomic strata with a focus on including low-income communities more effectively. We aim for 30% of our users to need discounted or free care.

• Knowing that diversity is an asset for our organization internally and externally with how our customers view us. It is our goal to develop a team that represents the communities we serve and which empowers the communities we work in with opportunities. By becoming a value add for our customers' communities, we will establish DoctorNow as a positive force beyond our healthcare offering. We are working to expand our local offices and to hire resources from across our community.

Tracking our interventions at a patient and population level while utilizing demographic information is central to our model. As we work to re-develop our application, we are actively working through how to best arm ourselves to track our impact and business metrics. Our goal is to build measurement purposefully into the system and not as a byproduct (the beauty of having a data scientist as a CEO). We are working to fine-tune our ability to track impact while reducing noise with our current capabilities. This has proven to be fairly limited, given our application development issues. Our current metrics that we are using to talk through the narrative of our progress are traction, early adopter demographic information, and repeat customers. Another interesting dynamic is around the social sharing of technology usage within many of our communities - so metrics around organic growth represent positive views of our users because it's common for people to share their favorite apps amongst their network and social network

Beyond quantitative measures, we also try and capture qualitative measures. Our application designs have functionality for users to provide experiential feedback, which will be used by our organization to provide feedback to the providers. It will also be provided to users to empower their choice. Healthcare, when done well at scale, provides choice, and that is what we want to work to build into the system - we want our users to know they have agency in this process. Currently, we capture these qualitative dynamics through our WhatsApp and email feedback mechanisms.

From the patient perspective: DoctorNow works by reducing the friction and frustration around receiving care by facilitating doctor consults either through our application or our home health platform. This care is rendered at prices below what receiving care at a hospital or facility costs and eliminates the travel time, wait time, and difficulty having follow-up. It is also more efficacious than going to a pharmacy and working with a pharmacist to receive drugs or treatment options which is the general first-line approach for people. Empowering patients with a means to receive affordable, high-quality care and data on their conditions (digital EMR) will increase utilization and improve outcomes - reducing morbidity and mortality and increased quality of life and faster recovery. The outcome of this shift to more active participation and access to care will be improved health and wellbeing for communities as people will spend less reacting to expensive care needs when conditions become exacerbated, ultimately leading to improved economic outcomes. 

Evidence: we are still working to develop our data capturing mechanisms across our application which will allow for a longitudinal study of patients. But anecdotal evidence is rich with patients reaching out to us to share their stories- like the mother of a young child who feels accessing our application and getting help on stabilizing the child until she could get to the hospital during the day. Or we had a patient who had severe jaw pain and needed help figuring out what his options were and who he should talk to. Or one of our first home-health patients who signed up not just for an initial consult but paid the first 2 months up-front to help them as they had more challenging health needs and had trouble reaching the clinic. 

Assumptions:

Reducing friction will increase utilization

• That we will be able to track and ensure high-quality care that matches or rivals clinic-based care

• That having access to their own data will improve ownership and use of care systems

• That improved access will improve long-term outcomes

• That an improvement in health will improve communities' economic status 

From the physician's perspective: DoctorNow works to connect physicians to patients efficiently and provides a better means of extended participation in a patient's health. Physicians, therefore, get to spend more time with patients and having interactions and less time dealing with all the moving parts of clinical settings. This also allows them to meet with patients whom they may otherwise not be able to reach because of more remote settings. This holds true for both physicians working within Ghana and those Ghanaian ex-pat physicians working abroad. The outcomes of this new approach to providing care offer physicians greater access to providing care that, from our interviews, they find valuable. It helps to reduce burnout by anchoring physicians on providing care that many feel is of higher need but hard to do. 

Evidence: Again, much of our evidence is anecdotal. When we launched our beta we had over 20 physicians local in Ghana sign up even though we had no payment mechanism to offer them. They signed up to do pro-bono care, even opening their schedules to night shifts. In talking with them, we learned that many felt limited by their clinical practices. That they got into care because they wanted to help people, but they felt that their current capacity was limited. When the Ghanaian ex-pats reached out to us they were highly interested in finding a channel to help provide care back home. They wanted to engage with us and work with us as we worked with the government to get approval to utilize their expertise.

Assumptions:

• That DoctorNow is able to sustain the efficiency of physician time and able to quickly and easily connect them with patients.

• That patients will engage with their health portal and re-contact physicians they have already had contact with

• That providing new channels of patient access will improve job satisfaction.

Beyond this theory of change, I think its helpful to think out past horizon 1 and into the future horizons of innovation. We see these dynamics fitting into a flywheel which one turning will shift the model from which people receive care. If you can provide a high-value first stop in the care you can facilitate access and improve efficiency at a system level. In a country where there is a shortage of physicians as well as hospital beds and resources - each asset must be used to its highest efficiency. Being the main artery of intake and building out all of the components for providing support across the care continuum changes how the health system will grow and evolve. This is the change we wish to bring to the world.

Our core technology is the building blocks of mobile applications and web apps. Our platform is currently an application that is accessible on Android and iOS, but we are moving toward a web app that is more universally accessible. Our platform supports video, voice, and text-based communication between patients and care teams to more readily support the rendering of services. We use APIs to connect payment platforms of various wallets to facilitate ease of use. We are developing our solution as our offerings mature. For instance, our home health is primarily facilitated by WhatsApp communication, but as we scale, we are working on automating this process within our solution. Our underlying focus is on data collection and processing because of the future value this represents for our customers and their countries. We imagine a world with close government relationships from which we can help facilitate population-level care. By being a primary source of care we will have early data on potential population threats such as disease outbreaks which otherwise may go un-defined for days or weeks and therefore slowing the ability to stage a defense. 

Data is collected and stored within our HIPPA compliant AWS run ecosystem. The key regulation we face in Ghana is around patient data security so we have worked from day one off the most extreme model - the US HIPPA compliance system. The system collects data directly from customer inputs and store it in the cloud.

10 of the 11 members of our team are either from potential target markets or within 1 generation. We represent 5+ countries, including across Africa and Central America, with countries of origin that have a similar need for this product as their economies grow and the healthcare markets develop. We are human-centered innovators who feel strongly that to be successful in building a product, you have to do it with and for the communities which will use it. Part of this is also building local teams. We have an on-the-ground team in Ghana, and as we build out our development team, we plan to locate teams across the continent. Success without impacting local communities is a blunted success. 

Diversity goes beyond national origin and also gets into the various identities. Going back to one of our impact goals, we hope to mirror local communities in our representation and we strive to include all identities within our team. This includes race, gender, sexual identity, religion, and more. We look forward to the opportunity to execute on this vision.  

Our business model is a path to providing full care continuum support to our patients/customers and an effort to provide the medical resources which can create a sustainable business. Our end goal is to have a digital-first care application that can help facilitate all types of care a patient may need - similar to Amwell in the US but with a customer base who needs our services far more. We are starting with home health and telehealth as the cornerstones of our model. Home health because it is a premium service that generates a higher value transaction and is also readily requested by Ghanain ex-pats trying to facilitate care for families in Ghana. To maximize value for home health customers, we must offer a wide variety of specialties which, until we are able to scale the home health customer pool, will be difficult to support maintaining the critical mass of doctors to provide the breadth of expertise. Our telehealth is a much more widely applicable service that is needed in home health, but the lower price for using this service also expands the customer pool rapidly, which provides that critical mass to keep doctors on the platform. 

Our goal in centralizing care into our digital-first platform is to reduce friction in the system. The value we provide is drastic when it comes to convenience and cost. We are able to provide these services at prices far below brick-and-mortar care facilities and without having to leave your home and commute to the facility and wait in line. Furthermore, we offer ownership and control over the process with the ability to provide feedback providing a degree of agency in the process to which the system is unused to. Our application re-design also focuses on our customer needs, and so we are providing first of its kind in market phone-based EMRs and patient management which can be used not only by individual members but by family units. 

The other side of the marketplace is the challenge of right-sizing the supply pool of physicians. It is our goal in phase 1 to utilize flat rates for consults. But as our business matures and we better understand the demand we hope to roll out physician-determined pricing. Our goal is to create a model which attracts medical talent for the impact they can have but also for the income they can generate. With the limited supply of physicians, while we assume at some point there will be doctors using DoctorNow to replace the entirety of their income - we also appreciate that the national health is best served by keeping doctors engaged in their day jobs, supporting hospitals and clinics and working on our application to supplement their income. To help us scale this side of the equation, we also have a pool of ex-pat Ghanaian physicians who are more interested in providing care in Ghana than generating income. This also allows us to provide services for free or heavily discounted for low-income communities.

Our goal is to develop a business model which supports not only our continued growth but also the welbeing of our stakeholders. This means having an inclusive model which does not price out low-income customers and having a strong revenue stream to provide resources to our care teams. Our business model is currently centered around re-occurring revenue in the form of a subscription for our home health product as well as a-la-carte services for our telehealth. Home health pricing is at a flat rate of $35 which covers the home nurse visit and a telehealth consult. Our telehealth a-la-carte services are also currently targeting a flat rate of $5 but as our model matures, we plan to make this dynamic pricing set by the physicians. We hope to offer a low-margin model on a sliding scale for low-income communities which will gain access via physician prescription and those on government support. 

Furthermore, these prices provide DoctorNow with a strong margin with which we can re-invest in growth while also providing above-market rates to physicians and nurses. At the starting rates stated above our take rate is roughly 40%. As our business matures, there are many avenues for expanded revenue to support our financial sustainability. As we gather more data, we could potentially offer our own health insurance plans. We can develop corporate partnerships to provide fast response care. We can offer hardware products. Again, the value of becoming a trusted partner in the care journey for our customers is that there are so many parts of that process that are inefficient and could provide a new revenue stream if we were to move into them.