To Bangalore and back: Resident leads software design effort at Indian heart hospital

A nurse at NH works with an EHR on a tablet

A nurse at NH works with an EHR on a tablet

I was carrying little more than a phone number when I boarded a plane to Bangalore, India, in August 2012. After a day of flying and a memorable first encounter with India’s traffic, I found myself sharing lunch with one of my heroes, cardiac surgeon Devi Shetty, MD, founder and chairman, Narayana Health (NH). The media, including the Wall Street Journal, have compared Dr. Shetty to Henry Ford, and NH has been called the Walmart of hospitals because of their shared mission to mass-produce heart surgery at prices most Indians can afford.* I would have the privilege of spending the following year helping Dr. Shetty and the staff at NH design a software product that is now being used for patient care at NH. In addition to the project management skills I learned as a result of this experience, I also came to understand some of the difficult realities—and surprising benefits—of operating a health care institution on a limited budget.

A unique opportunity

Many surgery residents spend a year or more doing full-time research. At Stanford University Hospital, CA, we refer to this time away from clinical duties as “professional development” because the program is open to residents pursuing unconventional learning opportunities, rather than strictly conducting bench research. Instead of joining a traditional lab, I went to India.

NH administrators and Dr. Shetty have developed a growing worldwide reputation for providing sophisticated cardiac surgical care at a low cost. Dr. Shetty founded NH with a vision of expanding access to heart surgery to India’s medically indigent population. Seeking a professional development experience that would build on the business administration degree I earned in medical school, I decided to help Dr. Shetty build a customized electronic health record (EHR) for heart surgery patients. I wanted to learn something from his organization that I could bring back home.

During my initial discovery trip to Bangalore, Dr. Shetty and I agreed that I would help create a smart EHR. At this stage, the product existed purely in our imagination, and starting from scratch sounded like a fun challenge. Because this task required deep knowledge of postoperative patient care, I was well-suited to the job.

Between August 2012 and June 2013 I would make half a dozen trips to India, ranging in length from a week to a month. I did not seek outside funding for this endeavor, although NH ultimately reimbursed my travel expenses. During that eventful year, I had the rewarding experience of overseeing the project’s progress from a concept to a working pilot program implemented in the cardiac surgery intensive care unit (ICU) at NH.

The “Silicon Valley of India”

From Dr. Shetty, I became aware of an imminent collaboration between NH and a large technology company that had agreed to supply an experienced team to build a pilot of the clinical software. My first month-long trip to Bangalore involved two main activities: learning how the city’s ICUs functioned and meeting our technology partners.

But first, I had to work out the logistics of life in Bangalore (known as the Silicon Valley of India). I rented a “serviced apartment,” meant for frequent business travelers, with private security and staff available to cook and clean but cheaper and more low-key than a hotel. I selected a neighborhood called Koramangala for its proximity to shops, restaurants, a gym, other educated young professionals, and relative proximity to NH’s 1,000-bed cardiac hospital, where I would be working. From Koramangala, my daily commute was a 20-minute taxi ride on a privately operated toll highway; it was well worth the $1 each way to avoid the traffic gridlock.

To learn how the ICU functioned, I integrated myself with the residents and fellows in the adult cardiac unit. I rounded each morning with the team. I attended the weekly cardiac surgery mortality conference, finding it remarkably similar to our morbidity and mortality conferences. I took note of practices that differed from what I was used to and tried to absorb them so that our software design would reflect the local environment at NH. These differences ranged from basic terms and drug names—they call epinephrine “adrenaline,” in the British tradition—to more fundamental issues like scope of practice for ICU nurses.

At the kick-off meeting with the software engineers, we established objectives and a timeline for our collaboration. I remember feeling intimidated by all the software jargon, but the engineers probably felt the same way about the medical jargon the health care professionals were using.

After that meeting, members of the software team began shadowing health care providers in the ICU. They would stand at a patient’s bedside for an afternoon, watching nurses administer medications, measure vital signs, and remove tubes and drains. This was all new to the software teams, and they found the experience intense. One morning, I had to tell our young business analyst that “his” patient—the one he had been shadowing—had died overnight. It was an emotional but important task for me to break the news to him and debrief the event.

Negotiating what to build

On my third trip to India, NH administrators gave us an office. I arranged desks and chairs in a converted hospital room, with a wall oxygen supply and a sink in the corner. We had to walk through a pediatric ICU to reach our office, so the sounds of the hospital were all around us.

Many other people, departments, and projects were competing for resources at NH, but I figured out ways to get what we needed. It helped being a surgery resident; I could enter the operating theatre and, during a lull in the operation, ask questions of the senior surgeons and anesthesiologists.

Part of my role involved working with the NH clinicians to develop content for the software. As a first step, I documented all of the data we needed in an electronic medical chart. This task was much easier for me than it would have been for the technology team. Using my clinical knowledge and a surgical textbook, I wrote a list of the vital signs, lab values, and the basic items and services necessary for the care of a postoperative cardiac surgery patient. I cross-referenced my list with the paper ICU charts at NH and entered the information into an Excel document. It likely would have taken months for nonmedical personnel to elicit that kind of information from local physicians.

Later, as we began to incorporate more complex medical content, I would gather a group of senior anesthesiologists, surgeons, and medical intensivists to decide what clinical data values should trigger warnings in the system and other key features that should be included in the software.

However, after compiling all of this information, we faced a major challenge in defining the scope of our pilot software; we could not do everything immediately. We had to choose which pieces of the medical record were essential to include in the demonstration project—enough to convince NH administrators and our technology partner that it would be a good idea to build a full enterprise product, and to implement that product at a new NH hospital scheduled to open in a year. Multiple factors made narrowing the scope difficult: we measure a significant amount of data in a cardiac ICU, most of which is essential. Additionally, all of the stakeholders—physicians, nurses, engineers, and managers—had ideas about what the software should include. Somewhere, we had to draw the line.

The central event of my fourth sojourn to India was a series of meetings we called “close week.” We organized all of the stakeholders into the NH boardroom, where a sign that reads “Healthcare is all about Process, Protocol and Price” hangs prominently over the head of the table. Our entire team remained in the boardroom until a consensus was reached regarding what to include in the pilot, and, perhaps just as importantly, what to leave out. At the end of close week, the team had compiled hand-drawn illustrations of every screen that we were committed to building. For every screen, we also had an Excel spreadsheet describing each piece of clinical data that would be represented and how the users would interact with those data to perform various tasks.

Determining the scope of our pilot design marked a major accomplishment. From that point forward, the software developers could write code and test it without their clinical partners changing their minds about what to build.

The developers went back to their offices and completed a remarkable amount of work in a few short months. Meanwhile, I turned my attention to planning pilot implementation. Working within the NH facility gave our developers the opportunity to expose the software to real-world clinical demands right away. We wanted nurses using it at the bedside so they could “break it” and give us feedback to make the product better.

The pilot takes off

NH nurses unwrap their new tablets

NH nurses unwrap their new tablets

We identified a cardiac anesthesiologist to lead pilot implementation during my fifth visit to Bangalore, and I helped him outline an action plan. He selected a core group of nurses as “trainers” for the pilot, and one memorable afternoon, I stood by as he handed out tablet computers to the trainers and began their preparation.

By my sixth trip, an early version of the software was ready. We demonstrated it to Dr. Shetty with guarded enthusiasm. A few nurses were trained to use the software, and a few ICU patient stations went live with the system. As expected, it initially crashed, the nurses pointed out errors, and the engineers came back with fixes. We were extremely pleased.

One goal charged our efforts with excitement. We sought to make the software ready in time for the opening of the new NH hospital on Grand Cayman Island, the first in the Western hemisphere.

As we made final preparations for the pilot, I started to make arrangements for my return to clinical residency. The timing worked out well. I had facilitated the design process, but the coding, testing, and implementation would carry on without me. My final trip to India that year centered on ensuring that my successors were fully capable of taking the reins on this project as I transitioned back to clinical residency.

A year later, after a successful pilot, the scaled-up version of the product was available, and it now serves as the primary chart in a Bangalore cardiac ICU. The new NH hospital is open, and we all anticipate the software will be operating there soon, as well.

What I brought home

We had dreamed about a “smart” EHR, debated and determined how it should work, revised our plans, made compromises, and then, finally, built a product. My greatest reward was seeing our creation put to use in patient care. Surmounting the day-to-day challenges of creating a definitive product that started out as such a nebulous concept provided me with my greatest learning experience. I also learned a great deal watching firsthand how Dr. Shetty managed his organization.

One major challenge was actually the mirror image of NH’s biggest asset: the leanness of the organization. NH is extremely disciplined about containing costs. There is essentially no waste, no unused resource. As a result, finding personnel and money was difficult, and we succeeded because we had Dr. Shetty’s active support. I do regret, though, that we did not have resources for an impact study to determine whether our software measurably improves patient care. This may be a goal we can pursue in the future.

Eighteen months later, what stands out about working with Dr. Shetty is how a surgeon’s leadership can comprehensively influence the service a hospital delivers. For example, during close week, Dr. Shetty’s main contribution was to simplify our design. He repeatedly asked such questions as, “Do we need that feature? Is that piece of data necessary?” One of the most powerful things he did as a leader was to streamline the process and remove unnecessary and superfluous information and ideas. Dr. Shetty is relentless about cutting processes that require time and money but which fail to enhance patient care. At the same time, he selects important projects like the hospital’s infection control procedures and dedicates his own time and influence in order to advance them. His dual role as chairman and an active surgeon who operates and sees patients on a daily basis enables Dr. Shetty to make these types of decisions.

I believe surgeon leadership can make hospitals better. I have noticed that in addition to his personal leadership, Dr. Shetty selects senior physicians and surgeons to lead new hospitals and other key business units, which I believe is important to their success. Excellence in hospital management boils down to overseeing thousands of details that experienced clinicians uniquely understand.

That first day in the NH boardroom, I took note of the sign mentioned earlier: “Healthcare is all about Process, Protocol and Price.” In the following year, I learned that these words do not signify that NH is perfect. Rather, they keep the organization’s purpose front-of-mind for its leaders, as an aspiration to be pursued every day.

It might serve us well in the U.S. to be similarly focused. The lesson my experience at NH taught me about successfully running a low-cost hospital is that it requires extreme discipline and attention to detail.

I am grateful to Dr. Shetty and to Stanford General Surgery for affording me this opportunity to build a new product and, in the process, to observe NH operations at every level—from the ICU to the executive suite. I anticipate that as a result of this experience, I will be better prepared for a career of shaping organizations to deliver excellent, affordable health care.

*Anand G. The Henry Ford of heart surgery: In India, a factory model for hospitals is cutting costs and yielding profits. November 25, 2009. Wall Street Journal. Available at: Accessed January 30, 2015.

Rai S. Indian surgeon known for Walmart-izing heart surgery brings affordable health care closer to Americans. Forbes. February 2, 2014. Available at: Accessed January 30, 2015.

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