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August 4, 2022
What can UXers do to improve health inequity? Here’s how to approach UX research in healthcare and building a practical healthcare app.
Wendy Johansson is a global product experience leader and entrepreneur focused on the intersection of product and user experience and on scaling up high-performing global teams. She is the Co-Founder and Chief Product Experience Officer of MiSalud Health and an advisor for companies like Cerby, adplist.org, and Wizeline. Wendy has a background in design and product, focuses on building equitable teams and products, and supports underrepresented people in tech.
Erin: Hello, everybody and welcome back to Awkward Silences. Today we're here with Wendy Johansson, the Co-founder and Chief Product Experience Officer of MiSalud. We're very excited to have you here today. We're going to be talking about centering, identity, and equity, and health tech research. Thanks for joining us.
Wendy: Awesome. Thanks for having me. Super exciting to be able to talk to other researchers out there about how we continue to make research equitable, and actual practice from some companies like mine.
Erin: Awesome. We got JH here, too.
JH: Yes, I feel like that description implies that our healthcare system can maybe use some improvement, which feels true. I'm excited to see how we can help do that.
Erin: Awesome. Yes, I heard something the other day about the NPS of health care, it's pretty low, so lots of opportunity for disruption and improvement, so excited to get into it. Wendy, you've had a career doing all sorts of wonderful things, and they have led you here to co-found this company. I'm curious to hear about what led you to do this, and among all the other things that you could do. Why MiSalud? Why right now?
Wendy: I'll start with the why right now. Why right now really came with COVID. With the stats out there, especially within the United States, if you are Latinx, you were five times more likely to catch COVID than any other American. Once you caught COVID, you're 3X more likely to die from COVID than any other American. Those stats, they're astounding, but they're also not new. Not new meaning, we continue to see communities, like the Latinx community, being negatively impacted when it comes to health issues.
Things like the pandemic, and we're seeing it again right now, even with monkeypox. For example, I'm in San Francisco, and they just released some stats around the fact that I think they said 15% of the population in San Francisco is Latinx, but 65% plus of the cases of monkeypox are within the Latinx community. That health inequity continues to show itself over and over again, whether it's diabetes, chronic health issues, like hypertension whatnot, but it just became the time and the place to do something about it on the outside.
On the internal view for me, I have been working with teams and building companies and teams and products in Guadalajara, Mexico since 2008. I've spent many years living there, many years going back and forth. At this point, they're friends and family to me. I wanted to bring folks together and actually build something that impacted their friends and family. We got together and we started talking about a lot of the different perspectives that my colleagues, product designers, engineers have in Mexico about health care in the US, and about the US in general, everything's supposed to be better here, right?
In the time that I lived in Mexico, it was incredible how healthcare even as a privileged tech worker like myself, like healthcare, is pretty easy. It's usually covered very well by my tech companies, but when I was sick in Mexico, I could just go to a nice hospital, and get really good care. There's no wait time, but of course, that again was a privilege of my being able to afford that, but coming into the US for a lot of my colleagues, even as tech workers and visitors who have tech jobs, they're just completely blown away by how terrible it is here.
Some of them have lived in the US for a couple of months, or a couple of years as students or workers, and just being able to get care and suddenly getting like a $700 bill, because you walked into urgent care because your kid was sick, that's incredibly shocking. We got together and decided, "Let's help the people that we know, the people that we're connected to, and see what good we can do," especially in this time of need, where the need continues to surface with all the data around pandemic, and as I mentioned, again, like now with monkeypox, and all the multitudes of variants that continue coming with COVID.
Erin: Yes. At the time were you shopping around for an idea of a problem you wanted to identify and solve, or was it more, "This is a problem I can help solve, let's go start a company."?
Wendy: Definitely the latter, because at the time I was also working at Amazon, doing something vaguely related. I had started the Amazon apprenticeship program, and it was really focused on gatekeeping and opening doors for people who didn't have traditional like, "Oh, you didn't go to University of Washington or Stanford with HCI degree, how do you open the doors into UX?" At Amazon, we did that, but the approach ended up to be folks who didn't even have that advantage of doing a Bootcamp.
People who are coming from their Amazon warehouse, hourly worker statuses, or coming in from, "Hey, I've always been interested in design, but I work at a grocery store," or, "I'm interested in design, and the closest I get to it is I'm a makeup artist at Sephora." People with different kinds of jobs and livelihoods, but many of them ended up happening to be BIPOC, and opening those doors. I would say, when I looked back at a thread of all the different things I've done trying to build equitable teams, to build better products for the people that use them has been a thread in that.
JH: The data you shared is very damning and compelling of 3X to 5X, like worse outcomes in these different dimensions. The problem there feels very real and acute, but I'd imagine as you try to go figure out like, "How do we go help and add value and try to make some progress on this?" Probably a lot of research to unpack because it seems like such a multifaceted problem, there's so many dimensions. How do you actually then go from that being like, "There's a mission here worth doing, and there's a problem here we're solving, to how do we actually help and solve it a little bit?"
Wendy: Yes. Part of that has to do with a unique model we have at MiSalud. That's not part of research, I'm just going to skip over that. We have a unique model that helps solve some of the other data that exists in the US, which is 25% of US Americans basically are of Hispanic origin, so that doesn't mean they all speak Spanish, because you could be first generation, second generation where you're more English dominant, and maybe you speak casually to your parents in Spanish.
I'm exactly that person but in Chinese. English is clearly my dominant language, but when I speak to my parents, I speak to them in Chinese, and have a pretty good conversational. I see a lot of Latinx folks like my generation who have this exact need, where we're still translating for our parents, we're picking up those health bills, those medical bills, where we're helping them understand how to make those appointments.
That need, I guess, my understanding, empathy for it is outside the barrier of I don't speak Spanish to my parents obviously, but being able to have a very relatable empathetic experience of many of us first gen immigrants, we do exactly this for our parents, and we'll continue to do it. Then we're writing this bridge with our generation under us. If our children are bilingual, or monolingual, we continue to be that bridge with our elder generation.
It seemed like something that was easy to approach for me because I have that experience, but when it came to really understanding a lot more of the nuances of our community, in terms of documentation status, needing different medical needs. For example, one of the things we discovered early on, like any telehealth app, here's a list of symptoms you can come in with, or you're just in pain and tell us a level of pain.
Something that actually popped up last fall when we were in our Open Beta was a lot of folks were coming in, they knew what they had, they said, "Look, this is just a cold, or I've just injured my arm. This is normal because I lift boxes all day, I just need a medical note from a doctor to excuse me from work, otherwise I get fired." You and me, we're tech workers. Don't feel good today, let me clear my calendar, email some people, set my away status on Slack, all good.
When we're talking about our hourly wage workers in the community that largely sits in that space, they actually need a medical note to actually prove you're really sick. That actually became one of our top trends in the winter, when a lot of people had colds, potentially COVID, and needed to come in for that quick understandable medical note from somebody who could understand them without having to go stand in line at a local clinic, or try to make an appointment with your doctor two weeks later when you're not sick anymore.
Being able to have access to that in your language with people who were really trying to understand to help you, I think made a big difference initially. A lot of our learnings and how we approached it just came from talking to our community. One of the early things we did-- Sorry, I'm monologuing here, I'm just going for it.
Erin: No, you're good. Yes, keep going. One of the early things you did.
Wendy: One of the early things we did was we actually went out and set up booths in, for example, in San Jose, a large Latino community. There are supermarkets and entire malls that are Hispanic focused. There's one called La Tropicana. It's in San Jose and everything in the mall, from the hairstylist, to the gift shop, to the kid shop, to the giant supermarket there, which is called Tropicana, everything's in Spanish. When you go there, it really feels like you're in Mexico.
Humorously, basically, two blocks down the road, there is the Vietnamese version of that, because San Jose also has a large Vietnamese community, which is exactly the same, but everything's in Vietnamese. There are these pockets. We showed up there, we had a booth inside the supermarket on the weekends, and we're handing out flyers, getting people to come talk to us about MiSalud and many folks, MiSalud means my health in Spanish. Many folks got the idea of what we're doing. They're like, "This is in Spanish though, who are you, and what are you doing?"
We told them, "You can get free consultations with Spanish-speaking doctors here and now, right on your phone, you don't need insurance, you don't need to prefill any personal information. You can just come in and have a call. During those situations we learned a couple of things we already knew about, but really got to get personal with people about, "Well, can I sign up if I don't have an ID," and we're like, "What do you mean you don't have an ID?" Basically people started intimating that they're undocumented.
What's it going to look like if I work with the service and I need a prescription, or I need a lab test? We were able to help alleviate those concerns and show them how, especially in California, you're able to get a lot of this care without identification. Then we started learning more about the actual users and the use cases. Again, you and I are in tech. If we were to design a mobile app, yes, sure. We're going to design it for you and me. We know how to download an app, we know our email addresses.
Some of probably the most shocking things for our team early on are lessons learned where when you log in a healthcare app, you need two factor authentication, email address, SMS code, or email and password and SMS code. Many of the people that we met in the grocery stores, we try to sign up, would struggle with the first step of, "I think I have an email somewhere. Can you help me find it? I can't remember what the email address is," and we're like, "Uh-oh, this is a problem."
Then we would have people say, "Okay, great. Now we're on the phone number step. I don't actually know my phone number, because I never call anyone. How do I find it on my iPhone?" We would actually have to go through all these extra steps of, "Hey, you're on your phone. Here's how you find out your email. Here's how you find out your phone number. Here is a recommendation of how you create a secure password, uppercase, lower case, numbers, symbols, et cetera."
Honestly, every single person, they just wrote it down on a post note, and put it in their pocket, or their purse. It's a totally different community of tech savviness that we had to learn in person.
Erin: I was going to say, you were learning this in person, was this at the shopping mall or over time? I'm curious about how much learning and discovery did you do before you launched the app, and obviously you're continuing to do a ton since you've launched.
Wendy: We actually didn't do that much learning and discovery before we launched the app. That's always the struggle of a startup. Do you chicken it, or do you egg it? Which one goes first. We made a hypothesis and we built an app that again, works for you and me like normal tech savvy level. We put it out there, and then when we were in-person with folks in the grocery stores, we did this for probably about two months every weekend.
Then we also had some partners and friends who ran restaurants in the Bay Area and LA, where we were able to go in and offer this to their employees, and train their employees about how you install and do these things and answer their questions live. We basically saw the same trend. In lower tech savviness a lot of secondhand phones from the children that were parental locked are supposed to be for your kids. A lot of people do parental lock and give it to their parents.
They're like, "You're not going to accidentally buy or download stuff." We learned a lot in-person, but I think it was super helpful for us to have an initial hypothesis, have built out the first version of the app, and was able to use that in-person with people. This was definitely something with the tech savvy level of our community. We wouldn't have been able to paper prototype them or have conversations about it. We'd actually have to see them struggle.
Seeing how people were poking around their keyboard, like, "Oh, let me go ahead and type this on my phone, one-fingered," folks who continuously dropped their phone because they had arthritis and there was difficult for them to use, certain keyboards or certain elements within the app and having to make things super obvious. I think as a startup, we had to definitely build something to really see the pain that people were going through in utilizing the technology, but also once we did go out there, we just continued to talk to people and continued to observe.
We even had situations where somebody would come talk to us at the grocery store booth, and want to do their health call right then and there, and we're looking around and we're like, "You might want a little more private space, maybe go to your car and do this, and maybe we'll come with you and help you set up and observe," and see how even people, because we're on demand as well as scheduled, seeing how people came into the app and would just scroll through.
Like, "I'm an older woman in my 50s, I'm looking for somebody older as well, who's more my contemporary, because I'll trust them more," versus younger woman in their 20s would say, "I definitely want a woman doctor, but I definitely want somebody more my contemporary, who's not going to judge me, about the things that are going on with my health."
It was also interesting to see that, which is very typical in healthcare, but also see how much more it mattered to our community members being able to see like, "Oh, I'm going to talk to Dr. Liz. She's from Mexico city. I'm also from Mexico city, or my mother's also from Mexico city." There's an affinity there already.
JH: You touched on this a little about like, "Hey you're about to have a sensitive conversation, maybe go to the car," or something like that. Just more broadly as you were doing research here, how did you make sure that you were handling the sensitivity that comes with health information correctly? Did you have to get consent, or how were you doing that with people to make sure that it was something that was comfortable for people, and allowed you to get the insights you needed?
Wendy: Everything that we were doing was HIPAA compliant, so the way the platform was built, we would not involve ourselves when those consultations started. I remember actually going with somebody to their car, helping them set up and choose the consultation saying yes to camera and mic permissions, and then they're still there, they're like, "Oh no, don't leave." I'm like, "Oh no, I'm going to close your car door. I don't need to hear this."
Make sure our team understands that boundary of personal health information, and where we need to step away. We also see the same on our customer support side. You would think it's clear customer support is your tech issues, how do I get a subscription? How do I get help if I'm in a different state other than California, instead of coming in through our helpline a lot is "Hey, here's a photo of this condition. Can you tell me what it is?" It's like, "Oh, no, we don't need to see that."
For example, in our research we found a lot of folks just wanted to drop in, and have that text conversation right here and then, they don't always want to be on a video call. They don't always want to do an audio call, but a text is a nice, safe place to start for them to build trust. We actually ended up launching earlier this year, a chat directly with our coaches and doctors. You can actually start the conversation there. Our coaches and doctors found that there were many simple things that they can help address.
Like, "Oh I have this headache or I have this sinus issue." "Okay, well you should go get some over the counter and try it for a few days, come back and let us know if it gets better if or if it doesn't." There are just some things where somebody might be talking about a rash or something like, "Hey, can you just go into the app and actually start a video call? I need to see that. I can't continue texting you about it."
There are different ways to get people comfortable with sharing the information, and then as you build that trust of, "We're talking about something I visibly have to see, can we do that video telehealth call now?" That was the little bridges we had to build of, you've heard about the service, you can chat with somebody who seems like they're a real doctor, you don't know if they are though, and then as they continue to diagnose and work with you, you can actually jump into those video calls. A lot of our folks actually just start with a video call, but there are definitely folks, for whatever reason, privacy, security, lack of trust, always want to start with chat.
Erin: I'm curious because you have what chat, SMS, video, on demand, not on demand, all these different modalities of interacting with care and you on the business side, on the research side, can't be there, as you said, in the car, there are moments in the journey you're not allowed to be there, part of, how do you close the gap on that journey and understand where you're improving, where there are opportunities not being able to be there as part of all of it?
Wendy: That is where we have a unique advantage. All of our health coaches and doctors work for us full time. We're able to have conversations internally with our medical team to really understand what are you seeing and hearing when it comes to ease of use? Are you seeing a lot of people doing that video thing where it's like, "No, my finger's like writing the video because I'm holding it on my phone," or are you seeing people constantly accidentally dropping off?
In the early days we did see a lot of people accidentally dropping off their calls. What we learned was, they're going to tap on that WhatsApp message that's popping in, even though they're in the middle of a video conversation with you, and once they move to another app, it actually hangs up on the call, so then we had to continue to learn and adjust from there of, we keep your call continuously open for two to three extra minutes if you leave the app, and then you can come right back in, and your doctor is, or your coach is still there waiting for you.
We had to learn on the go, but it wasn't just experiencing it from talking to people in-person at the grocery stores, or actually talking to our coaches and doctors to see how this worked out. We actually did some dedicated research twice, I would actually say three times. Three times within the first year. The first was me talking to friends, neighbors, and then at some point I live by a grocery outlet. I live in a heavily Hispanic neighborhood here in San Francisco.
I went to the grocery outlet and I basically bought $10 gift cards and stood around and said, "Hey, you're leaving the grocery outlet. If you talk to me for five minutes, I'll give you this $10 gift card." I would just ask them, like, "Do you go to the doctor? How do you go to the doctor? What do you see them for?" Having these casual conversations in person. I was doing it in Spanish in a parking lot. I think that bought me a lot of credibility, because they're looking at me like, "Why does this non Hispanic person want to talk to me about something?"
Being able to do that in person, it built credibility. Actually a couple of the ladies that I did speak to coming out of the grocery outlet, one of them actually insisted on taking me home with her. I was like, "Okay." It ended up because she wanted me to read her medical bill and help her understand it. [laughs] She actually showed me some of the things that she did have at home. She had her Amwell which is a big telehealth service sticker on the magnet on the fridge.
Then she actually had written out directions that one of her children had written out for her like, "Open your phone, click on the app that's yellow and blue, and then do this and start the consultation, make sure it's in Spanish." It was really interesting to see how people addressed healthcare, and some people who didn't. What all of this research did for us was it helped us create an a axis, and the axis that we did was on the X-axis side.
We had basically put the range of English dominant to Spanish dominant and where each user was on the range. Then on our Y-axis, we had something called reactive and preventative. I think you and I are probably more attuned to what preventative care is. We understand the concept. We've grown up with the idea of primary care providers. You do your annual exams as a male and female, and you have those normal things that you go check for like, pap smears, breast cancer, 40 plus, they're pretty common to us.
We know this growing up, and when we're not super attuned to healthcare, but when we're talking about our community, which has very much been underserved, they go to the emergency room in urgent care when something is super wrong like, "My arm is bleeding, I've been out of work for four days now, this is really bad. I need to go see someone." Once they go there, it's very much a reactive condition of, "There's something wrong with me right now," but they never address the preventative because it's expensive. It's out of reach.
Maybe it's not in their language, or they just don't know how to, with either the insurance they do or do not have, or in the locations they are. It becomes this axis that we ended up seeing on this quadrant, a lot of people were sitting up on the reactive side. When we took a look at what we would need to build based on reactive and looking at other telehealth platforms, those telehealth platforms are for the usual.
I use One Medical, I guess now Amazon, and with One Medical, I just go in and everything is geared towards, "Are you here for your annual exam, refill a prescription, a cold, a pain, or did you receive some viral infection, or anything else going on, or do you need vaccines?" Those are my options when I go to One Medical, but what we need to do to really encourage a less reactive and more preventive shift in mentality is when you go into our app now, you can see everything from big to small.
Your chronic health conditions, medications, whatnot, but also you can come in for something as simple as allergies. Like, "My nose is running all the time. I don't think it's COVID. I think I have allergies. I didn't know I could treat and prescribe for that." A lot of folks that we've talked to don't know that they have allergy medicine that actually resolves the itchy watery eyes. They hadn't ever thought to talk to somebody about that, because it wasn't that big of an issue.
It's just, "No, that's just something I live with." Being able to offer this range of topics all the way down to, "You're just in pain. You don't know what it is. You don't have to know what it is. It's our job to know what it is." You just have a pain, give us your pain scale and come talk to somebody, and then we'll go figure it out together.
Erin: It sounds a little bit there like you're actually trying to be interested to hear the vision, the mission for your company in your own words, but trying to actually change behavior not necessarily to meet a stated need. I have a bleeding arm, and I want to get back to work, and we're going to make that easy for you. Also we think this would be in the best interest of the community we're trying to serve if we brought up some awareness here and made it easier for them, is that the case? Is that exactly part of your mission?
Wendy: Exactly. Yes, our mission is to help the community evolve their current understanding of health, whether it is on the more mature side. You're already in preventative care, because you've always had a great salary job and great health insurance, or if you're new to healthcare, maybe even new to the US, and you need to figure out how am I supposed to get care for these things. We want to offer that range, and meet people where they are, and slowly educate them forward.
We think that's incredibly important back to the original stats of diabetes, hypertension, all of that is super pervasive within the community. Especially if you're Latinx you have a lot more chance of getting diabetes in your lifetime than an average American. How do we change those habits from the beginning? I have mentioned health coach a couple of times, but haven't clarified that. We actually have the model where we do work with health coaches.
Our health coaches are actually licensed physicians in Mexico. This model for us wouldn't work, because the US has one single problem, which is 25% Hispanic, 6% and less of doctors actually speak Spanish. There's no way that we'll ever close that gap. We have to look for folks who can meet them where they are in terms of language. That for us resulted in hiring Latin physicians who are licensed in their countries, and working with our US based in this case California based patients as health coaches.
We call them health coaches, coach de salute, because they're clearly not licensed in the US, so they're not going to be doing medical diagnoses, but we're seeing about 75% of people coming in with situations that can be addressed with take some over the counter medication, in improve your diet, or your sleep, or your habits in this way. We also offer mental health services. When people come in, and there's a big stigma still with the community, when it comes to mental health, nobody's going to come in and actually say, "I need mental health help."
They do resonate with seeing, "Hey, I'm having trouble sleeping. I'm really nervous about things all the time. I'm super stressed out by work. I'm having relationship issues." Those are typically signs and symptoms where we can bring them into a mental health conversation with our mental health coaches, who in a similar way are fully licensed psychologists in Latin America. They chat with our patients here as Mental Health Coaches.
A lot of it, when we think of coaching also, we're thinking of lifestyle medicine, which is, let's help you build healthier habits to change that. You can manage your diabetes, and help lower your A1C level for diabetes with better habits in eating, in sleeping and exercise. I'm not saying, "Oh, you can make your diabetes disappear without medicine," but you can help manage it, and make it much more manageable and livable in certain modalities with health coaching.
JH: Nice. That's clever. You mentioned earlier about in the dynamic of wanting a doctor or health professional that has some commonalities with your identity. Maybe age or background, or where they're from. That being really important to building that trust and feeling comfortable. Then you also called out when you were grabbing people outside that supermarket and earning credibility because you knew Spanish, and were there and being honest about it.
What would your advice be to researchers who are doing research with the population that has a different identity than themselves and is maybe talking about sensitive stuff? How do you build that rapport and build trust in those types of situations?
Wendy: One of the things that really worked for me, even though I spoke Spanish initially people were super wary. I actually had one lady say to me within the first two or three sentences of our conversation, do you work for the government? Are you just here to find out if I'm documented? I was like, "Woah," like, "Okay, I need to back up and find a new way to approach." One of the things that I found helpful was just to really start with talking to folks about like, "Hey, so I used to work in this company in Mexico and during that time I've been all over Mexico and clearly you're also Mexican, where are you from?"
Somebody might tell me something like, "Oh, I'm from Cuernavaca." It was like, "Awesome, I've actually been to the mines in Cuernavaca." Start talking to them and really trying to build something relational right there. I might try to really queue in on they're walking out of the grocery outlet, what have they bought? She's clearly here, and she's going to make enchiladas tonight. Let me talk about enchiladas with her, and ask her for her [unintelligible 00:29:25] recipe.
It's really going to be situational. I think at core, when I look at my teams and talk about research, I'm looking for somebody who has curiosity and empathy, and can lead those conversations. Also they can read the room, they can read the situation, and they know how to redirect that. I think that's probably just as important as being able to be scripted and prepared, because you can have everything check-listed out for you.
Until you walk into the real situation where I was incredibly taken aback by, "Are you with the government?" Like, "Let me see your ID." I was like, "I will happily show you my ID, you don't need to show me anything." Like, "I'm just a weird, normal person who just wants to talk about healthcare in Spanish with you in a parking lot." It's reading the situations and how to approach that. I certainly had several people turned me down, that I'm not saying I was successfully talking to every single person I tried to stop.
I would say, what I noticed is several things. Women wanted to talk to me more, men just in general, we also noticed this throughout all of our research, men just didn't want to talk about health. They're like, "Yes, I'm not worried about that." Like, "My mom takes care of it, or my wife takes care of it, and then somebody schedules for me." It makes me wonder about the young single men who aren't living with their moms, because who's taking care of it for you?
Basically, women want to talk to me more. Then we also put together small groups where we had some of our male colleagues go out, and yes, men talk to them more. You have to see and meet people where they are, and with who they are and the mentality.
Erin: You talked a little bit before about the importance of building equitable teams. What does that look like at your current company? How have you worked to do that?
Wendy: Yes, our current team, we are a bilingual app and service. Everybody has to speak Spanish in English. That's a start. A large portion, because I have worked in Mexico in tech for a long time. A large portion of our engineering and design team are coming from Guadalajara or Mexico City. What we have found super interesting. This is not because we tried to, this just happened so to turn out this way, is a lot of our engineers are married to doctors. Their partners are doctors.
They come in with not only an affinity of like, "Oh, yes, my aunt, she lives in Los Angeles." This is totally going to be helpful for her, but also like, "Oh, but my partner is an ophthalmologist, or a surgeon, or a pediatrician," and would be really interesting to bring them in this model, because I hear from them about how the platforms they use when they're doing telehealth are incredibly painful. It's not helping the right people, and all these other things.
They're already coming in with the things they've heard from their partner like, "Oh, I have ideas about how these platforms work," as we continue to build them. That's been really interesting. On the equitable side, a lot of what I intend to continue hiring, we are a startup. This is the economy that is the current economy. As we continue to grow and scale, what I would like to do is continue to hire more folks with that lived experience in the US.
Our Head of Marketing and growth is Latino, he moved here from Mexico 20 years ago, and one of the first things I saw in his resume when we had a conversation, an interview was, "Hey, you went to the University of Guadalajara, that's really exciting. I've given lectures there on UX." Like, "I totally know that school, it's so awesome that you went there." He told me as a Latino living in LA and having been a professional here for so many years, he's like, "You're the first person who's actually seen my having a degree in Mexico as a positive."
Everybody else is like, "I've never heard of that school. It's not a US school. Your education doesn't count." Trying to find people with lived experiences, and the journey that they have is incredibly important, because they can lend a lot more to us, that helps us get ahead of the research, helps us get ahead of what's coming next. For example, I know his father is probably one of our early promoters, he was always coming in the platform.
He would always tell us how happy his dad was utilizing MiSalud. He would actually have to do the same thing, which was, "I had to set the app for my dad, get all the way in the call, and then hand it off and walk away."
JH: That's cool. You touch on it a little, but the reality feels like our system or healthcare in general at the moment, is it the people working in healthcare, the doctors, everyone else, and also have a tough time with some of these platforms, and the way the system works. Then the people who won't care, and it's this unfortunate mismatch. Are you also doing research with people like the providers on the platform, and getting their input and stuff?
How do you do that? It feels a little different, you can't just go to a supermarket, and find doctors who are using your app. Are you going out to them in a different way? What stuff do you hear from them?
Wendy: Yes, before we started building the platform, we had several advisors and investors who were doctors, are doctors, I guess. We actually asked them for their experiences on other telehealth platforms. Of course, they're all confidential. Some of them were able to just tell us about things that were useful. Others would point out things that were missing that made their life pain. That gave us our first initial ideation on what the other platforms look like out there.
Then the next step we had was because we have all the coaches and doctors that work for us, we actually just set up regular, it's on the calendar, we just rotate through the staff, and just go in and basically, I'll call in as a fake patient. Then the Design Team is on Zoom screen share with them looking at them in the doctor portal, and just observing, almost ethnography, except we can't really be in their environment, everybody's still remote and COVID-y.
We just see how they use the platform. I'll actually just go through some of our fake health conditions, and talk through it with them. Just seeing interesting things like, "Hey, we noticed that when you were screen-sharing, you made your window really small, why do you do that?" They're like, "Oh, because I have a Google doc over here, of the over-the-counter medications that are available in the US. I want to be able to look at that list when I realized that you had an allergy. What can I tell her is over the counter, she can pick up."
They're like, "I just made the window smaller so that I had another window with the medication list over here." I'm like, "Interesting. We should build that into the app, rather than having you squeeze the window, and have the video of you that we're all having of parts of our faces." Able to really see them utilize it, in this real-ish way. While also hearing from our coaches and doctors, the types of-- I guess, types of questions that they're also hearing from the patients in terms of, "Okay, what's next?"
Like, "Where do I see that prescription in the app for somebody who's not super tech fluent?" Like, "Okay, after this call ends, it's on the bottom of the screen." We were thinking about things like, "Are there ways for us to be able to have push notifications that the coach, or the doctor can trigger, so that the user has an easier time." Like, "Okay, you get the push notification, prescriptions ready, tap on this, it's going to deep link you into the app, on where your prescription pharmacy is."
Being able to do things a little more manual, that if you think push notification, you would never think that we should allow coaches and doctors to have that power. We're thinking that could be really interesting, because they can really help the patient complete their health journey in that situation by offering that deep linking, or call out through push notification.
Erin: Yes, especially an audience that's having some challenges with tech, just tap tap and--
Wendy: It's not just the patients, I'll throw out one other thing. The patients and doctors, they're not tech workers, they're not tech savvy. This is also something where we have to meet them. The way I like to think about it is our goal should be to develop an invisible layer of technology that just helps two people get together and improve their health. In the backend, our technology should not be in the forefront blocking anybody, it shouldn't be difficult to navigate.
One of the things that we've learned in talking to my co-founder, he's also an ex-surgeon, is everything in our current medical system today, when you go to the doctor, or the hospital, it was built for billing your insurance. It wasn't built for your care, Erin, or your care JH, it was built for, "How do I line item, every single thing I just did here, when I give you a vaccine, from opening the needle package, to disposing the needle, to disposing the vaccine little vial, and then even putting a band-aid on you?"
Everything is a line item, so I can bill your insurance for it. It's not built for the doctor to say, "Hey, this is going to give me the most holistic care for Erin, so I can help her into the future manage what vaccine she needs to take, when she travels to whatever country." It was built just to make money. One of the things I would like to have, continue to have pride in as we go forward is we don't work with insurance. Many of our community, they're underinsured anyway.
We would rather just build something that helps enable the doctor and patient care and not worry about how we're making money. Of course, that is a privilege we have as a venture-funded startup. That's something that we'll continue growing to, and figuring out as we go along. Like, "One day, we'll work with billers and payers, but that is not today." Today, everything we've built is for that doctor and coach to speak to that patient, and have a holistic view about their care, if they keep coming in with the same symptoms.
Erin: Yes. I'm curious along the lines of how do you monetize eventually, which is a problem for tomorrow is a great VC backed company, as you mentioned, we talked about the matrix earlier. You have the matrix of Spanish-English fluency and then the reactive/preventative, and we've talked a lot about from what I gather more the Spanish speaking, reactive, and may be lower on the economic scale as well.
Do you have many customers outside of that? Customers that would be willing to pay, that speak a lot of English that are more preventative on the other side of things, and if so how are you serving them at the same time as these other customers?
Wendy: Yes, and that's always going to be a fun situation for us to consider as we build forward is exactly what basically any other designer has to deal with is, how do I build for the Pro user and how do I build for the new user? In that case, that's basically the same mentality, new users being lower tech, Pro users being like, "Just get me in that consultation video call, I don't need to worry about all this other stuff." We do have users like that.
Actually, one segment of that group is super interesting. It is actually tech workers in Mexico. We actually offer our service to companies in Mexico, and they tend to be tech companies, because a lot of their employees traveled to the US, and maybe when you're in the US, you get food poisoning, and then you want to call a doctor, but you're not from the US, how do you actually get care? We offer MiSalud for that contingency as well.
It has been super useful for them, but it's also something that we continue to consider as, how do we research and balance their needs? For example, when it comes to our lower tech-savvy patients, they come in, and they do their username, password, and then their two-factor authentication. When it comes to our more tech-savvy users, they want to use their Google or their Facebook or their whatever single sign-on, and just get it over with and have that ease of use.
We do see people come in and continue to sign up through their Google off, it's like, "No, this time use your work email." "No, that time use your personal email." Now you have two different medical records, how do we help you merge those? Those are things that we're learning from our users is when they sign up, for example, one of these Mexican tech companies, they all signed up with their work email, because you're enrolling, and you're enrolling through your company.
Then when they all came in to actually do their mental health consultations or health consultations, they use their personal email. We realized there was this mental gap for them of just like, "Yes, I don't want to log in with my work email, because I didn't want my work to somehow access this." We were like, "They wouldn't access this." Even if you're tech-savvy and you understand the system, we find that people are still concerned about security and privacy of information.
To put it this way, and righteously so, because I'll use this word because I feel this way. I'm paranoid about where my health information goes, especially as a woman in this country in [unintelligible 00:42:09]. I would have the same concerns is, I want to use that one private personal email, and not have anything linked to my work emails, even though work pays for my insurance.
Erin: Well, forward-looking, you have a mission, and you're early days in your app, and you've got some users and some research, and moving forward, what are you excited about? What do you hope to contribute to health tech?
Wendy: There's probably two things I'm most excited about contributing to. As we continue to grow and get more patient information, and we can drop that in a mega data lake and anonymize it, nobody's ever actually come out with a Hispanic Health Index report, nobody's actually come out with a wide range of information about, for example, Hispanics in California, and what conditions we're seeing, how we can continue to improve care, and if we can measurably have made change through shifting the mindset and mental model towards more preventative rather than reactive and what that looks like.
I would love to over time, have data to be able to show that and prove that, and interest other practitioners in that model of, "We're not just here to be reactive, and solve people's problems, but how do we actually take the preventative measure forward and change the mentality of how doctors approach their patients? Help them with everything beyond the right now issue that you're trying to build for." I would love to be able to one day provide a report that shows that this works, and have folks be able to approach communities this way.
On the other side, I am incredibly excited about our opportunity to reach out to large employers of large Latinx employees. For example, there's a lot of agriculture in Florida, that happens and I would love to work with those employers to offer something to their employees, rather than "Hey, I'm going to give you something like Kaiser, but you have to pay $1,300 a month yourself for it." Being able to offer something a little more low costs, that's much more accessible and culturally appropriate to the care that people need.
I think that's going to be something that hopefully translates well, when it comes as an offering from an employer, not just right now we're B to C, and you can find us in an app store, you can find us at the grocery store. If we can work with these employers who are offering something that can actually shift in impact their employees' health, and of course to the employers, their productivity, I think that is a positive add, that It becomes a norm that your employer should be offering services that meet you at where you are.
Erin: Wendy, what did we miss? What do you want our listeners to know?
Wendy: Well, I'll point this out, I realized that I've talked a lot less in deep dive about research and how we do it, and we're touching on people. I think the important takeaway here is we didn't approach this as a research project, we really wanted to understand our community. When you approach in particular underserved communities, and you're trying to do research with them, you have to really meet them where they are.
We wouldn't have succeeded with one of our studies, which was based off Dscout, because with Dscout, all of the people we talked on there, they were already on Dscout, ready to get compensated, and ready to use the technology to have a conversation with us. If we had only run with that Dscout study, which we ran, we would have assumed everybody was tech-savvy, and we would have just built that forever.
You have to actually meet people where they are, do the real ethnography, go to the places that people are living, in the environments they're doing the things you need them to do, and get to know them, and build that trust. You don't need to talk to 200 people. Honestly, I've only been in five people's homes at this point, who invited me to come help them or learn more, mostly help them, but those relationships live on. They're all in my neighborhood, and these ladies still call me and I'm like, "I'm traveling a bit, just take a picture of the letter for me, and I'll tell you what it says."
I think I've pseudo-gotten adopted, because I also get a ton of tamales all the time on my doorstep because of that. Meet people where they are, and just be real, and you could actually build really great relationships that extend beyond the research. For me, I'll continue reaching out to the ladies in my neighborhood, because they're ones that I want to talk to when we build a diabetes program, and when we build a menopause program. I think these are relationships worth considering beyond the, "Here's the interview, we're done."
JH: Totally. I thought what really came through in the way you spoke to all this was, you had so many examples of a thing you learned, and some of you could improve as a result of it that just felt so tangible. I think sometimes as you flag some people, when they come to the research, they lean into telling all about the methodology, or the tool or whatever, which is also interesting and important, but I'm really cool to get the stories of, "We found the right people in the right situation, and we learned this nuanced thing, and we fixed it." I think that's really the reason for doing it in the first place. It's great to get those stories.
Wendy: Exactly. Work with your designers. In our case, all our designers are also researchers, so we have that hybrid. If you have dedicated research teams, get close to your designers, figure out how you can actually ideate solutions that will meet the people with what they need.
Erin: We'll also post your LinkedIn and Twitter. Anyone listening with medical bill questions can just ask you directly, Wendy, because they know that's your new side hustle.
Wendy: Exactly. I'll trade for tamales. I'll translate for tamales.
Erin: Sounds good. Thanks for joining us, Wendy. It has been great to have you.
Wendy: All right. Have a good one.
VP, Growth & Marketing
Left brained, right brained. Customer and user advocate. Writer and editor. Lifelong learner. Strong opinions, weakly held.
July 21, 2022
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