This article was initially published on SeedToScale

Rare are the instances where a deeply personal experience, subject knowledge and interest intersect to result in a startup idea. Onco.com’s is one of these rare instances. I got to interact with Rashie Jain when she spent a few months in 2014 at Accel as an intern,  who helped us frame our healthcare thesis, before flying off to Wharton for her MBA. An engineer from IIT Kanpur who specialised in Biological Sciences and Bioengineering, Rashie has spent all her working life in the healthcare sector. A close family member’s struggle with cancer showed her first hand how broken cancer-care is in India. She put all this together to co-found Onco.com, an end-to-end online driven cancer care platform, with oncologist Dr Amit Jotwani in 2016. Today the Bengaluru-based startup has 1,500 oncologists as part of its network and has 30,000 active customers.

We at Accel are privileged to be part of the Onco.com journey even before inception. As part of Accel’s healthcare thesis, we identified multiple gaps in the healthcare ecosystem in the country and looked at how digital could provide solutions. One gap was the lack of specialists in India and the resulting impact on quality and delivery of care. Her intent to disrupt and improve cancercare through digital interventions was the right fit and so Accel came on board as an investor.

Onco.com is still an early-stage startup and is attempting to reimagine the manner in which treatment and support is offered to cancer patients and caregivers—as tough a challenge as any in India right now. Yet, Onco.com’s journey offers key insights into how a startup can tackle a large and complex problem by reconfiguring the entire ‘consumer’ process, creating solutions for each segment of the value chain and by keeping the ‘consumer’—in this case the patient—at the heart of the solution. ‍

The problem: Reimagining Cancercare Delivery in India

The Challenge:

• Patient and caregiver/family are effectively on their own from the time of diagnosis
• Extreme lack of usable and relevant structured information on everything from treatment options and quality of hospitals to avenues for second opinion and follow-on care
• Not patient-centric
  

The ‘Simple’ Solution:

• Build a consumer-facing digital platform that offers end-to-end information
• Use technology to improve quality of cancercare and bring in transparency
• Build an entire oncology system that is patient-centric and ensure all-round guidance‍

A Complementing Team

The quality of Onco.com’s founding team has played a key role in its early growth. Rashie and Amit bring distinct skill sets to the table. With her healthcare, business and technology experience Rashie is the big picture, vision setting founder who keeps pushing for scale. Amit, an experienced oncologist, understands the patient’s cancer journey inside out and also has a strong understanding of the practice of oncology in India. He is the pragmatic medical doctor who not only provides first hand insights into the doctor and patient experience but also provides the ballast of realistic goal setting.

Clarity of Vision

The challenge they were taking on was immense, but Rashie and Amit had a clear vision of what needed to be done.

The goal: build a virtual cancer hospital

They broke this down into the various moving parts that needed to get built for the whole entity to work with precision. Sure, some of the assumptions and early iterations needed to be re-examined along the way. But, this crystal clear clarity ensured their eye remained unwavering on the ultimate goal.

Typically, the patient faced the following challenges:

1. They have not found the right treatment provider
2. The treatment is not going well
3. They don’t have information on how the treatment is proceeding or what needs to be done
   

While a digital platform could solve many of the challenges that arise out of these three points, the question was “will the patients trust what they read on the internet?”

On the doctor’s side, the main question to be answered was whether they would opt for a different digitally-focused path, especially considering the low number of oncologists in the country.

Building Step by Step

The main feedback that the team got from the patients was that they needed guidance and support during the treatment journey and needed help connecting with the right doctors and hospitals. This is why offline partnerships with doctors, hospitals and diagnostic centres were given a priority. Starting with partnerships with oncology hospitals in Mumbai, Bengaluru and Delhi, today Onco has covered about 65% of the supply available in the country!

One of the key challenges was the sheer complexity of cancer. There are over 200 types of cancer and each cancer has different stages and patient journeys; you need to overlay different types of treatments for each of the types of cancer. The number of scenarios is mind boggling. Just mapping this out was time consuming and here Amit played a key role. He gave a realistic picture at every step, from understanding the patient journey to creating the product experience.

To build out an all encompassing platform, the team needed to offer solutions at every stage of a cancer patient’s journey:

• pre-cancerous, where they have symptoms,
• recently diagnosed, where they have met or are looking to meet an oncologist,
• already undergoing treatment, where treatment is a combination of therapies, from radiation to surgery, and
• remission, where monitoring continues and interventions need to be planned
  

At Onco.com, over 50% of patients fall in the first two stages. The intent is to keep the process simple for the patient but comprehensive. The patient or caregiver has to share their data, which includes reports and other details and based on this personalised guidance is offered. In case, the patient knows exactly what they need, they can opt for just that service, like getting an online opinion or speaking to an oncologist or booking a diagnostic test online.

The patient can use the proprietary technology platform that generates treatment guidelines for multiple types of cancer based on the inputs provided by the patient. Once the patient feeds in their data, the platform does a preliminary assessment, followed by connecting with the right oncologists, coordinating the tests and follow-on appointments and other such services. A dedicated care-manager is assigned to the patient, who is the single point of contact for the patient offering all the support and assistance. From the patient perspective this is an extremely important service as sometimes new symptoms develop or they might have doubts or concerns and may not be able to call up the doctor each time. The care-manager helps the patient in each step of the journey, including coordinating emergency care when required.

An important innovation here is the “Tumour Board”, a concept prevalent in the West but seen very rarely in India. The tumor board is a panel of doctors who collaborate and review a case so the right treatment is identified. This ensures second opinions are considered and an all-round approach  is followed. This helps the patient access higher quality care no matter what their location.

Customer Buy-in

In the initial days I was worried that the team was over-engineering—was focusing on building out all components of the product and team before really reaching out to the market. But, looking back I believe that was the right thing to do. Healthcare overall is a sensitive area and cancer-care even more so and the team could not afford any breakdown in the experience. Even one bad experience gets amplified and has a great impact on the patient.

The response from the patient community is heartening. Right from the start we could see that stickiness was strong. From helping patients get onto the right treatment plan—83% of patients on Onco.com have changed their treatment with support from doctors on Onco.com —to helping reduce cost of treatment and getting specialised therapies, Onco.com has been able to offer the right help to its customers. Every month 12,000 new customers come to Onco’s website and the startup serves 2,000 patients, both free and paid, every month and is currently serving 30,000 active customers. With the NPS consistently at 65 over the past six months, it is clear that Onco.com is on the right path.

The Covid-19 lockdown and the continued restrictions in movement between areas for months meant that the Onco.com team was able to offer even more support to cancer patients. Many patients were worried about going to hospitals or travelling to receive care due to fear of Covid-19 infection. Onco was able to offer virtual consultations and also help them plan better. Typically, cancer-care is about going to where the best treatment is available, which is why patients travel to big cities for treatment. This was not possible in the past few months and Onco.com has ensured local healthcare support for patients across the country.

Future Outlook

Scaling up further is the obvious next step and Onco’s ambitions are global as the challenges are similar to that in India in many international markets. However, the supply side challenge is significant. This is not an e-commerce business, where inventory and supply can be quickly scaled up. There are a limited number of oncologists available and Onco.com needs to maintain a balance between demand and supply so they can ensure the highest quality care and support at greater scale.

The other challenge is replicating the excellent online Onco.com experience at the offline third-party service provider’s. If the patient gets great support from the care-manager but has to wait for hours at a hospital to meet the top oncologist, the experience is subpar. The intent is to scale, but not scale at the cost of the quality, and to ensure they have a greater say in the patient’s overall experience even at the partner premises.

The ambition is big and so are the challenges. But with a strong team and processes that have been built out with significant thought, Onco.com is well poised to help a larger number of cancer patients get the right care in their journey to get better.

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