Notable Health | Modernizing the Medical Experience

Hey everyone, this is Heather Mack from Greylock. You're listening to Gray Matter, where we share stories from company builders and business leaders. A quick word before we get into today's episode. Like most things these days, Gray Matter is currently being produced virtually. That means no soundproof studios or extra fancy audio gear. So in addition to great stories from some of the most talented tech entrepreneurs in the world, you might also hear the sounds of everyday life, like passing cars, construction crews, or the occasional impromptu visit from dogs, cats, babies or housemates. Please bear with us. We're doing our best. Okay, today we're talking with Pranay Kapadia. Pranay is the co founder and CEO of Notable Health, which has created software to automate one of the most outdated, costly and time consuming parts of healthcare administration. No Noteable partners with health systems to replace manual in person workflows like billing and clinical note taking with automated digital tools. Like the other health tech startups we've had on Gray Matter recently, Notable has seen an uptick in business ever since the coronavirus pandemic hit and shifted most healthcare services to virtual experiences. Before Founding Noteable in 2017, Pranay was VP of Product at fintech startup Blend, which developed software to reinvent the mortgage and lending industry. Prior to Blend, he led product teams at financial platform Intuit. So finding ways to innovate in complex, heavily regulated and technologically outdated industries is kind of Pranay's thing. Let's hear more from him.

Pranay, thanks so much for being on Gray Matter.

Thanks for having me.

So I thought you could just start off by giving us a brief overview of what the company does. And I know you started off a little bit different than where you are today. And so if you could just walk us through that journey. Also kind of put in context what was happening at the time. In health tech and also in startup.

Land, it's important to just start with what do we know about healthcare? And often people look at healthcare from the lens of, well, we're a patient, we've seen the experience or know a loved one that's actually been through that experience and it's been terrible or there was something that went wrong with it and it does start there. The way to think about healthcare really is around patients, providers or health systems and payers or insurance companies. And when you look at all three of those, what we actually found when starting the company was patients actually had an abysmal experience. When you had to go into a doctor, you'd have to pick up the phone, call someone Talk to them, schedule the old school way, go in, sign forms, hand over insurance documents. Somebody on the other side is actually transcribing those documents and then asking the provider to have more information. The providers are physicians. There could be other levels of caregivers as well, but they were spending majority of their time on taking notes, trying to figure out how to ensure they've captured everything about Pranay as a patient, such that they can actually charge for it, such that they can actually be covered for malpractice. And then all that data is packaged up and sent over to the insurance company that says, yes, Pranay requires that care. We're going to pay for it, but we're also going to ask Perne to pay his fee. And all of that data collection that workflow is, is convoluted. It actually costs the industry anywhere from $600 billion a year to $1 trillion a year in this country alone. That's the experience at notable, when we looked at that, we said there has to be a better way to bring machine learning, design, and data together to build a platform for the future that could actually power workflow in an intelligent way. We call it intelligent experience automation that brings together machine learning, just beautiful design for workflows, as well as robotic process automation to really automate so many of those manual, mundane tasks. Because imagine a world where we could actually go into. Instead of spending a trillion dollars on administration, healthcare could actually be about the patient and provider experience, the best care you can possibly get, and we can actually channel those dollars to be more preventative. What if you actually could get something that was a wellness yoga course, or it could be something around this is the right nutrition plan for you. And all of a sudden healthcare is now preventative versus where we are today, but that's where we're spending the money. And so at notable, we're tackling that administration, eliminating it by improving the patient experience, the provider experience, and seamlessly transferring data between all those parties involved.

What made you want to try to fix these problems? These. These huge problems that have been going on for so long and that other companies have tried to tackle and have either only gotten just a little bit of the way or failed. What made you want us to do this to yourself?

I always wanted to be a doctor. Funnily enough, I couldn't afford to go to med school at the time. And so the next best thing that I loved was engineering and coding. So did computer science. Had a terrible financial situation, wanted to know how to manage money and really lear about how you could use software and technology at scale in highly compliant regulated industries to improve people's lives. And had a wonderful stint at Intuit where I learned a lot in you're helping run mint.com, quicken, working on products like TurboTax and QuickBooks and then had a terrible mortgage experience. And then you had the fantastic experience working with the entire team at Blend, also a great lock portfolio company where we were able to tackle a similar data problem, a workflow problem, but in a very different industry, the underbelly of banking, if you may, mortgages. And as we were working on that and streamlining Nima, the CEO would always talk about what is a one click, one tap mortgage look like? And we really called it self driving mortgage, Self driving fintech. And as we were doing that, my wife actually came home complaining about how we've been working on that problem for self driving fintech for the last 12 years of my life. But nobody's working on autopilot for healthcare. And she's a physician and she spent 70% of her time doing paperwork, trying to collect data from her patients and share it with her insurance companies, make sure that that flow is working, not actually focused on patient care. And so that's what got us interested. But when we first started, and this is just so important early on, people look at it as here's a pain point and the patient experience sucks. Let's just come up with a new patient experience. Great. I think with these highly regulated industries, people really need to understand, and I would say the tenure Blend was incredible from that perspective. Really need to understand not just the workflow, the compliance, but also the incentives of the market and then find the right partners that are willing to work with you to think just different. There's so many times where we've found situations where the industry would say, well, this is how it's done. We need a wet signature and a wet signature. Well, what is a wet signature? Well, it's actually where you print out and actually sign a document. That's what the compliance team needs. Great, Can I fax that document back to you? Yes, you can. I was like, great, so if I sign it on, on an iPhone and fax it back to you, it's considered a wet signature because you can't tell the difference. Like, oh yeah, I guess that rule was written in 1982 and nobody's actually updated it since. But yeah, that should actually resolve the issue. And so finding the right partners that will actually ideate with you on those workflows early on is just so crucial. And then the other part with healthcare, probably more so than any other industries, but we've seen this enough times now. The marketplace is just ridden with point solutions. The number of point solutions that you will find in the industry are amazing. And you put yourself in a provider's shoes. My family of physicians, they just want something that works, something that they could turn on and it should work. We don't want to have to stitch together a whole bunch of solutions. Then you talk to CIOs and enterprises and they will say the same, which is it needs to work with my system of record. I'm not going to switch, which is really, really important. And I would rather work with a platform partner that can scale with us through the continuum of care versus a point solution. One for check in, one for voice documentation, one for billing automation, one for schedule. It's just a nightmare.

I just want to touch real quickly about when you first launched and what your initial like first quarter, few quarters were like and then how you've really leaned into the rpa.

Sure. One of the other interesting things about legacy stacks and enterprise software in particular that I picked up over the years that I think founders and entrepreneurs must, must think about and know about is you can fall in love with the AI, you can fall in love with the design, you can fall in love with the solution, but it's only as good as the integration. And there's no enterprise software, no cio, no, that is willing to just rip and replace everything. It doesn't work that way. And one of the earliest things that Jerry taught us at Greylock was just about being the system of engagement and the system of intelligence that actually sits on top of the system of record. And I call it sedimentation of the enterprise, just actually having better and better layers. The funny story I like to tell is we actually had a green screen COBOL system at Intuit that ran a lot of our payments. A small business could swipe a credit card on their phone and not know that it's actually going over a COBOL system where you couldn't find somebody to write that system or code in that system anymore. And so it really is sedimentation of these legacy systems. In some cases you can replace them. That's great, but doesn't happen overnight. And so we started to look at, when we came into healthcare, we just thought, okay, there's data standards, everyone talks about interoperability. This is going to be a piece of cake. It's just going to be that easy. And we tried to go Live with our first group of 10 providers, 10 physicians using our platform. And the integration timeline that we got in the legacy way of integrating with them was 10 months. And even with that 10 months, it was, well, we don't have an API to put that field in here, so you're going to have to put that as a PDF document and tell the physician they now have to contort their bodies, click in one additional spot and know when to do that. And the workflow is just going to suck. And I remember talking with Jerry and I very quickly, we discovered, and it's true. Across all enterprise software, I believe the road to purgatory in healthcare is driven by integration. It takes too long to roll things out, to do things and iterate in order to make sure that you're delivering something of value.

And it's expensive.

It is. Every integration costs a healthcare system a million dollars to integrate. And they're always thinking about, well, if I choose to do that, then I have to doing something else because I need resources against it. And to their credit, that is true. That is how things have worked traditionally. And so I jokingly say every other industry might have an API as we know it, Application Programming Interface. In healthcare, the P stands for person, not programming because you'll just add more people to copy paste between systems instead of having an API. And so yeah, I was talking to Jerry about this timeline and he's like, well, you've done this before, you've done this at Intuit. This is how. Mint.com I was just like, yes, RPA. Hey, let's actually think about how we can build our platform. And so three years ago, we actually started to build our RPA platform to really tackle this. And it's been transformative. We've actually been able to go live in very controlled ways. We like to go through, it's important to make sure that you go through HIPAA guidelines, you have your privacy and data standards, you're looking at data retention encryption, you have your SoC2s done, your high trust certifications. All of that is important to get done. But once you have that, you want to minimize the time it takes to go live. You want to minimize the feedback cycle loop time with customers. What's been incredible is with one of our partners at the enterprise level, we went live with them in 13 hours on a system that traditionally they will tell you their minimum go live was about 12 months for any integration. And what that allows us to do is focus on iteration of workflow versus integration. I encourage founders to think about how do you actually integrate the coolest, sexiest solution that you might have, the best AI in the world into their existing systems such that it's really easy for them to adopt, because if they can't adopt it, it's useless. And so that's kind of like our way of learning quickly and trying new things. And I remember the first time we actually talked about this. I've talked to a number of phenomenal names in healthcare on RPA and they're like, you're doing what? That's crazy. Just wait for the industry. And interoperability standards are coming. And the way we saw it was there's three potential futures ahead of us. There's one where the industry just keeps layering on more people and people and people and the cost of healthcare just keeps going up. There's another where we just hope that there will be rules that will be passed in Washington that will make this possible in our lifetime. And they are moving there to all of their credit. I think what CMS and HHS are doing is incredible. It's just going to take five to 10 years to actually see through the industry or we find innovative new ways that might seem crazy but have worked really, really well for us.

Yeah, and all of those make a lot more sense to be able to do those things. Especially now when we're dealing with a public health crisis. And not just like public health safety and personal health care, but really everyone's seen how messed up the healthcare system really is. Everyone already knew. It wasn't exactly a secret, but it's just every aspect has changed. And so it seems like it's kind of like finally the moment for companies like yours to really be able to shine and say, like, well, look what we can do. Like, let me help you. This is what we've been. This is what we've been telling you. So what's that experience been like for you guys?

Yeah, I'll just talk about all of the stakeholders, patients, providers and payers. Pre Covid and post Covid. Pre Covid. It was, you know, patients for the most part. There are some pockets of efficiency and design, I would say. And I've had a chance to talk to and work with many of those people. For patients, for the most part, it was a very old school front door, very painful and lots of paperwork, lots of touching things. When you come into the office and everything was in the office, everyone that you talk to would say about 3% of their visits were actually virtual for providers. They actually were focused on efficiency. They're running at about 6 to 10% margins and trying to figure out how could we actually optimize that. But life was good. For the most part. They were just trying to think of how can we see more patients. And then for payers, they were looking at innovative new ways to collect data so that they could segment their population so that they can manage risk better. Great. With the pandemic, it's fundamentally been transformed. And the first thing, patients don't feel safe to go in to see their provider, let alone should they. Actually, the leading health system in San Francisco, their chief of medicine, said, I don't understand where my cardiology patients went. I just, how do you stop having a heart attack? How do you not need to come in anymore? But it just stopped because people don't feel safe. And the reality is it didn't stop. They just didn't go in anymore because they didn't feel safe. And that was transformative. Which then led to a complete crash. Probably the first recession ever in health care where providers are scrambling to figure out how should we retool? How should we rethink what our workflows need to look like in a touchless environment? How do we make our patients feel safe and how do we make our providers and staff feel safe because some of them aren't even coming in or we need to furlough them. And then for payers, there's an interesting incentive structure for them where they are only allowed to make a certain percentage of profit legally, per the government regulation, and therefore they must spend on patient care. But a quarter worth of patient care just vanished. And so that money is just there, and they're trying to determine ways to actually spend it to collect better data. For the following year, it's been fundamentally transformed where patients are now demanding virtual and touchless experiences. When we first started, I remember our first contract for a patient experience, the healthcare system leader said, well, even if 5% of patients do it before they show up to their visit, that will be transformative. We currently are seeing 95% of patients actually checking in on their own device before they even show up to their provider or doing it virtually 60% of the time, which has been transformative for providers. We grew 2 1/2x in three months the first quarter of this year. And what we saw was they all want a touchless experience. They don't want to use shared computers anymore. We're actually getting calls from hospitals currently that are filling up saying, can you strap on my nurses to be touchless so that they can actually document things on the COVID floor without having to share computers with folks. It's that, I mean, it's crucial. We always talked about what would a touchless data transfer look like from patient to payer. And it's just being accelerated. And then for payers, they're thinking about how can we actually engage and activate the right patients to come in and let them know that they're safe to go see their provider for the A1C or their mammogram, or to fill what's considered a care gap traditionally. And so it really is this transformative period of an acceleration of virtual and thinking about what that's going to look like, optimizing for volume to make sure that you're seeing the right patient in the right way and then really refining your value going into next year, which is, am I actually taking care of these patients the right way? Because what they're actually starting to see is I might not need all the staff that I traditionally had because technology is enabling a more seamless experience. I might not. Or I can redirect that staff to other kinds of care and actually do at home care and not need the patient coming in. And that transformation has been, it's here to stay through this pandemic. And we're lucky that we were skating to where the puck is going. Boy, has it been accelerated.

Coming back to that conversation, or probably many conversations with your wife about how difficult it was to just do her job and not be totally burned out, how did you figure out how you were going to actually start a company? To answer that, we've always had this.

Theory and I've been fortunate enough to work with my co founders now for seven years. And the theory was always when you think about these vertical industries, you actually can think about them as a data workflow and a data stack. What everyone's trying to figure out in these verticals is how can you collect the highest fidelity data in the most seamless of ways that is the most accurate either to manage risk or to manage money. And so simple examples of that would be you're actually doing your taxes. The old school way was paper, very, very painful. And then with Intuit, we actually thought about how could we redesign that experience where you could take a picture of your W2s on your, of your taxes and actually make doing taxes function. People thought we were crazy. It was the same thing with depositing checks. When it came to mortgages, we actually pulled together what would a seven minute mortgage app look like? And people thought, well, nobody's actually going to do a Mortgage on their phone. But the reality was, if you could actually think about what are the banks thinking about, what are the checkboxes that they're trying to check off and how can we create a beautiful experience upfront to get high fidelity data? We could transform that entire data stack. And it turns out healthcare is actually very similar to that which is everyone, my wife included, Physicians are actually trying to figure out what is the insurance provider now, what would they reimburse me for, how do I take care of this patient to the best of my knowledge. And all of those three things are then pushed onto the patient. When you're coming in to say, Heather, can you answer these questions? Can you tell me about how you're feeling from the last time you showed up? What medications are you on? Can you please chicken scratch them on the sheet of paper and then hand them to another individual to then type them into my emr, which then I have to work in. So that's the data stack that we saw and we learned about in health care and it took us a while to figure out the right wedge. How do we actually start in that data stack? We started originally with, hey, what if we just had a profoundly beautiful patient experience and we quickly found nobody in healthcare cared about patient experience.

You mean none of the people who are administering healthcare.

Yeah. And they were like, this is beautiful, beautiful, that's awesome. But it doesn't actually solve anything for us right now. Now that has changed given Covid and we'll talk about that, I'm sure. But that was a big aha for us. And so then we started to look at how could we actually do a high fidelity data capture for providers so that we can actually make their experience touchless using voice. And we're known for that. And it's net promoter score of 74 for providers. And it's just absolutely stunning. But what we found was we could actually collect more and more data from patients before their visit with a provider. That would actually save providers even more time and streamline the back office administration. So things like we've actually built models where we intelligently reach out to patients when we know they should schedule an appointment. We then ask them for how they're doing from the last time they were in. We collect all of their insurance cards, which is of kind. Take a picture. We use machine vision to extract all of that information so that we can send that data to the right spot. And you don't need people looking at this information. And then we write up majority, about 60% of the provider's chart is written up for them to review just like they had an army of residents at their side without them actually having to do any work. And so we've seen patient sat score of 97.4. We actually collect a thumbs up, thumbs down from every patient that goes through our app. And it's been amazing as we designed that where I love to tell the story because it happened a few weeks ago. We had a patient go through our entire front end experience before they were about to see their provider. It was for a Medicare wellness exam. This is a once a year exam that Medicare requires people to do if you're over the age of 65. And this patient checked in, finished their entire wellness Exam in under 20 minutes on an Android device. Gave us a thumbs down at the end of that entire experience saying I don't technology and later we heard from the physician that he absolutely loved it because he saw somebody else doing it on paper in the waiting room and he heard that it takes 40 minutes to do so even though he doesn't technology. We've actually had to think about how can we make it accessible. How can you use voiceover if you're 80 years old on your own device to check in in a way that is transformative for the entire data stack. So long story short, we had to look at the entire data flow and the workflow for why administration exists in healthcare and then start to think about how could we use experience, how could we use technology, how could we use machine learning to solve that problem versus let's find a point solution that we just try and stick into the healthcare system and it doesn't actually change much.

Yeah, that's really interesting because as you know, in my previous life I was a reporter and I really focused on health technology and some of the earliest exposure I had to how healthcare was finally getting digitized somewhat was okay, we're digitizing everything. We have all this data but like now we don't know what to do with it or we're creating all these new data streams but we don't know how to use it. So it was kind of. That's why there's been all these false starts or added complexity. But you were just talking about how you figured out right away how to use it. How did you do that? Were you talking to patients? Were you talking to doctors? And also maybe this is a good way to talk about your first iteration of your product with the watch.

One of our core values is childlike curiosity and we always keep you hear us ask why a lot As a company, and often our customers and partners or someone at the team, as forward thinking as they might be, might prescribe, hey, can you make this optional so that some patients can provide it and others can't? And we'll push back. Why do you need that data? What are you doing with that data? How could we possibly get it for you in a better way? And it might take us a week longer, it might take us a few iterations to figure that out, but we always like to ask why. And so when it started with my own family of physicians complaining about how long it takes to to chart, we didn't just say, how do we make your charting faster? It was like, why are you charting? What are you trying to accomplish? How do you know if your charts are any good? And the answer was, well, I'm charting because I just have to submit this to billing and for recall purposes so that I can remember something about my patient the next time they come in. I'm charting so that my notes look great, so that when they get sent to other physicians, they know it was for me and my brand is sprinkled into the words that I use so they'll send me more patients. And so that's why they were charting. The next jump to that is, well, if I'm charting, I can chart using voice faster than I can chart using keyboard. Great. Yes, that is faster. Yes, we enable that. But when we actually identified why they were charting, we figured out ways to collect that information from the patient in an automated way, from other caregivers in an automated way so that even the provider doesn't have to do it. And we always talked about it as front to back, back to front, which is think about the most seamless way to collect data in any industry at the front end, but then do it in a way that's actually satisfying the back end system's rules and incentives and use that to your advantage to then identify ways to simplify that experience on the front end. And it's really hard to do, but it's similar to what we did in mortgage, it's similar to how we actually work on TurboTax or even in accounting. We would actually think about what is the accounting logic at the end of the day that we actually need to satisfy. Or in credit cards, how do we make sure that we're actually capturing the right data at the right time to make sure that this credit card is not fraudulent and make that as seamless as possible on the front end. And so it's very similar, yet there's a lot of nuance, as one would imagine. And so every day, we're fortunate enough to learn from some of the industry's best, be it Bob Wachter of ucsf, who's an advisor, or Zeke Emanuel, who you've probably heard of, who is, you know, part of the founding team for the American Care Act. And so they teach us every day about these incentives and more and are part and parcel of how we actually build the platform to deliver the seamless experience that we want to see.

How do you craft the right messaging, not just from a marketing perspective, for existing customers, for any new users? Like, how do you do that over.

This time with the downturn? Actually, there was a particular day where I remember calling my team together, just saying, stop everything. This is not business as usual. And it was jarring. The team's like, well, you've got this Sprint plan and we've got to push out this marketing message, or we got to do this role. I was like, just stop everything. We need to come together to identify what does this mean for our current customers. First, how do we make sure that they're actually delighted? Do we need to slow down on collections from them, Give away some product for free just to make sure that they're solvent? Because if you see As a provider, 75% of your patient population just stops showing up tomorrow, but you still have to pay your staff and you still have to pay your rent. It's jarring. And so we had to rethink all the way to the core and then start to look at how does this impact our product roadmap not six months from now, but today? What are we going to do differently today? How do we double down on touchless experiences for patients and providers in a way that has never been done before? And then how do we actually start to share that with our customers and with new prospects? And it's been incredible to see how our partners actually vouch for us and want to see us succeed. They're like, we've seen what you can do on the provider side. We now need a touchless patient experience. Can you extend into that, or we know what you're doing on the patient side. I now need a touchless experience for my providers because we can't have shared computers anymore. And so you are going to see that shift. But there are moments where you actually need to hit reset and make sure that everyone on the team is aligned. And it was jarring for the team to think that through. There were some decisions that we made earlier on, always imagining this touchless autopilot for healthcare administration that served us well, but it did require hard boot. Let's reset, let's make sure that we actually do it with a sense of a bias for urgency. And we'll talk about that a lot at our company, which is we can't wait for the world to evolve around us. We need to be the catalyst that creates that evolution faster. And so we keep pushing for that.

How have these strategies affected your customer acquisition or even your relationships with existing customers?

What's been fantastic to see is our customer adoption. I mentioned the first quarter. We'll share more on the second quarter too. And it's just been amazing. We've actually had new partners like Intermountain, which is one of the leading health systems in the state of Utah, and they actually saw our platform and just immediately got it. Thinking about how this could radically profoundly change the workforce of the future, change the patient experience and provider experience, and to be able to roll out a patient experience with them that then powers clinical workflow, that then helps ensure that their staff are actually working on care, not administration, is just magical. And to then have them and other partners then start to evangelize what's changed, which is very interesting, is healthcare and vertical based industries for the most part tend to work around conferences and that usually is the best way to acquire customers. I've seen it work with mortgage before as well and it is fantastic. We've had to double down on word of mouth with the advocates that we have currently. Reid Hoffman, his advice was tap into your network and we've had to do that and make sure that our current customers are advocates that can actually share you work with notable, your patients will love it, you have a 7-10x ROI in the first year. Your providers aren't going to be burnt out. You have to do it and now is the time. And so it's been more than once have I heard the quote, never waste a good crisis. And when people actually think about it now, there's this time in healthcare to reset, rebuild. Ensure that your patients feel safe, ensure that your providers are safe, because if they aren't, the whole system comes crashing down and therefore cities and states shutting down makes sense. And make sure that your payers can get as much data that's relevant for them and their patients because there is more that they can do at a population level than any individual provider might be able to. Funnily enough, when we first started working with patients, we created this beautiful prototype where I showed my family the ability for my Family physicians to monitor their population of about 2,400 patients in real time. And we kind of got smacked on the head. Wow, this is awesome. I never want to see it, because if even one of my patients was at risk and I don't do something, I'm liable for it. And I can't Keep tabs of 2,400 patients at any one given point in time. And it is fascinating, but payers can, and there are people that actually do population health very well. And so that data is still important, but you have to have it at the right fidelity for the right person.

First of all, that's awesome about Intermountain. Super amazing system. It's super progressive. That's a good one to have, and especially with word of mouth. And so I wanted to talk about a couple things here. Like, first, like, how do you identify the customers who you wanted? I mean, I know you have a family of doctors and we all use healthcare, but, like, sometimes it's still hard to figure out, like, who is the equivalent of like, you know, like a Wells Fargo and some of your other jobs, or how did you figure out who to go after?

Yeah, I think the rep and learning with Nima and the team at Blend really helped in this place. And the way to think about it was, especially in the early days, there's good customers and there's bad. In the enterprise world, the bad ones are the ones that actually believe they can bully you around to get you to do something. And we've been, from the get go, always trying to identify who are the right partners to actually work with that are thoughtful about a partnership that are willing to actually try new things and listen to new ideas and collaborate with you on those things. You know, great example that I'll give you is Common Spirit, which is the largest nonprofit health system in the country, which is one of our partners. As this crisis came about, we actually rolled out a Covid screener triage process for patients, if you may, to know before they're actually supposed to see a physician. Should this go to a virtual visit? You shouldn't even come in. Just talk to your provider or a virtual visit visit, and we'll set you up with Zoom and we'll do all of that and we'll help you through that all virtually without, you know, somebody having to call you or if you should actually go get tested immediately, and we'll actually route you, set up the test, and everything is done for you. Or if you're low risk and this actually does need you to come in there's a physical, there's a lab, something needs to happen. And we shared that with them. And in a period of three days they got executive buy in and we just started to actually light that up. And because of our integration with their systems, we were able to roll out across five EHRs, over 1200 providers and just continue that momentum. And they've helped in return to actually say here's some areas of suggestion, here's what we would actually do to make it better, or here's how we're using the data. Can your platform also do X, Y and Z so that we can actually eliminate that need? So that's how we've actually been, you know, looking for partners. We like it to be more of a collaborative approach. Here's what we provide, here's how the technology works, here's what we see from a patient perspective, here's what we see from a provider perspective. But we also have the configurability of the platform such that the health system can tweak it to make it theirs. And that's really been the key. And then we also like to do something where we tend to roll things out with smaller groups to make sure that the platform is stable and then roll it out to the bigger groups, which really, really helps. And then often we actually talk about it as we can utilize the our childlike curiosity with a framework called Learn Deskill Automate Enhance. And it's very similar to how we learn as human beings, but to actually do that in rapid cycles. So an example would be learning about how do you make sure that you have the right patients coming in at the right time? Well, how do providers do it today? Can we take that on and learn how to do that ourselves? Can we now de skill it to the point where someone with a $15 an hour salary can actually do it? Because it's just following systems. Can we then automate it and then can we sprinkle in ML or AI to really enhance it where now it's actually radically, profoundly different, different and then do that as fast as possible, as many times as possible. And that has been transformative in how quickly we've been able to actually build product in healthcare in a safe environment.

And I know that core to that is the people you have working with you and advising you. And it's like other regulated industries. It's like not only do you need someone who understands the landscape you're selling into the regulations, but also you need someone who understands enterprise software. You need someone who understands how to fundraise it's. Just how do you build these teams? And we've seen some health tech companies have like a great idea before, but then they hire a bunch of generalists and they can't actually build the product. Or, you know, they have a wonderful physician on board, but they don't understand how to work with startups. You know, it's just all these different things. So if you could talk a little bit about team building and advice, that'd.

Be great for us. It started with my co founders, who I've worked with now for seven years. Just having a common vocabulary was tremendously important. Us knowing where we're strong and not and being able to fill in in a very honest, open environment has been really helpful. And then one of the earliest things that you discover in any new vertical is you have to speak the vocabulary of a customer. So if I would come in and say, wow, look at this beautiful mobile friendly patient experience it actually is using. You could go all out and be like, okay, we're using React and it's mobile friendly and it uses a modern stack, great. But it actually doesn't talk the value, it doesn't talk to them in how it actually helps them. And so we had to very early on find partners, if you may, on my team that would actually be augmentative and really help in us magnifying how we speak and how we learn. And so the team that I've been fortunate enough to build is actually one where we have people from insurance companies, they know how that runs and they know what the incentive structure there is. We had to work really hard to find the right physician or providers to actually join that also were engineers. So they actually know how to build stuff and not just here's how my workflow would work and let me pontificate what the future could look like with AI.

Yeah, you could just bother your family constantly with questions.

Trust me, we do daily testing. There's daily testing in my house of pretty much everything that we build, which is really helpful. But also people that have actually deployed software within the health systems and finding those people takes time. And maybe it's easier to just say, I'm going to. I found someone. They've got the title, they've got the name, they've got the brand, let's just toss them in. But they have to be good with ambiguity. They have to know that they're the ones that will create these systems and playbooks for how we'll actually roll things out. And so it's taken us a while to build that executive team. But we've been very explicit as a team, continually talking about here's what we're good at, here's our gaps. How do we fill that gap with either internal DNA or advisor DNA in some which way so that we can continue this learning journey? Because it's not a one year endeavor to really take the trillion dollars worth of expense and administration and drive it down 95%. It's a mission worth going after. It has to happen, it's inevitable. We have to be the catalyst that can make that possible faster than ever before.

That's such a huge amount of money to be operating in and trying to show ROI in the time of like you're saving money, you're saving time and how do you show new customers or prospective customers how you're going to be able to do that?

Healthcare is an interesting industry where almost every other industry actually functions a lot on growth. Whereas healthcare is one of containment. When you start to think about that containment, you start to think about how can you actually build things at scale that really, truly drive out wastage and yet have a competitive, durable advantage. It's really hard. And that's one of the reasons why, you see there's 10,000 companies trying to tackle diabetes and there's probably 15,000 companies trying to tackle CDC and they're all trying to do this little niche and every niche is massive. But it's a race to the bottom. We've had to think through what is the virtuous network that you can build, how can you actually utilize data across customers in a way that the product keeps getting better with every use, such that we can then automate so much of it at 10 cents on the dollar like Amazon, we want to actually provide as much value to our customers for a price like prime that really, truly transforms the industry.

It's interesting because that's a very real application of automation and AI machine learning in healthcare versus what we think of like this thing's gonna diagnose cancer by looking at me real fast on my phone.

When we looked at it from a naive perspective, we ideated on what could we do with genetic data and mobile data and financial data and bring it all together. And could we actually help you understand how your body would actually metabolize drugs? And it's possible those things are all doable, but then you actually talk to the people in the industry and the first thing you'll hear from any physician is I don't trust a black box. Where's your randomized control trial? RCTs are a known thing now thanks to Covid. But where's the rct? And even once you do have an rct, there's a lot of skepticism around them. And you know, the best quote I heard on that was in fundamentally how we actually think through things is we don't have the right to talk about how AI will replace what doctors do and diagnose better if we first can't use it to eliminate the jobs that people don't want to do.

Right.

So let's start there. Let's eliminate that, do humanity good because they'll actually then naturally start to pay more attention to us as patients. Naturally, we will then get better care at a lower cost. And then we should actually start to look at all of those. Now. It will be, you know, there are certain places where machine vision will likely help and you will see, you know, machine learning driven use cases. But again, they should start small and then be embedded at the point of care. Eliminating these death by a thousand clicks, as providers tend to call them.

Absolutely. Yeah. Let's start with billing and then we can move on to cures.

You know, it's just, it's funny that people talk about that. The stat that I learned about we spend or health systems in general have 8x as many resources for every billion dollars in revenue as compared to any other industry. And so all of those dollars are being spent on things like billing, on things like scanning an insurance card, on things like doing a prior auth, which is checking with your insurance company if you can get this operation or if you can have this medication. And now there's people on both sides of that equation having phone calls, trying to talk about can Heather actually get this operation? And so it's just really expensive and so much that needs to be automated away that we couldn't be more excited to be a part of this change. And it really is a transformative time to be in healthcare and healthcare technology in particular. I don't think they get out of bed and think about how do I make this computer screen as confusing as possible so that somebody misclicks it and impacts a life. We need to take healthcare seriously. I think that that is important. But there is this moment in time where the way we think about it is it's not about redesigning the screen. It's about rethinking the paradigm completely and using the right interface, whether it's voice or it's touch in some which way to streamline that versus let's actually go redesign what your computer screen look like and hope that we'll have the right usability. So it is easy for people to dis EMR companies. It's actually so easy to get out at. But I do know a lot of good people that are trying really, really hard. It's just. It's the COBOL problem all over again. When your stack is actually built 20 years ago. It's really hard to make the changes when you can't actually iterate and move at the speed that you would like to move at.

Right, yeah.

And the other problem that I'll just call out, and this is not just healthcare, this is every vertical is one of productivity with enterprise software, which is. I remember when we once redesigned QuickBooks and we came out and we're like, this is amazing. We've redesigned the entire interface. It's beautiful. It's Mac like. And our Net promoter score dropped 25 points because people are used to working with a QWERTY keyboard. They're used to. They have muscle memory on where different buttons are. And so it's really hard for EMR companies to actually suddenly transform and change their UI despite providers wanting it, because that's their muscle memory. And so we often think about how do we actually pull them out of it so that their data is still in their emr, their system of record is still updated. That should be the case. It serves a great purpose for that. But then power the workflows in a very, very new way.

Yeah. As a CEO, I don't remember the exact years when you were at your other jobs, but like leading teams through challenging times. Sure. Your role is always expanding and you guys are like in the thick of it. Like, you can't even really, like, escape into work and not think about everything that's going on with healthcare. That's what you do. So how have you been helping your team deal with uncertainty, deal with just the general stress of being a human right now, being an employee. How have you seen your role expand?

I'll share what I've learned and what I do fundamentally. Actually was probably one of those CEOs and teammates that hated working from home. And it's something that I despised. I was against it. And with the shutdown, it's proven to me that I was completely wrong. You know, we've actually gone from everyone must be in Silicon Valley in the office to we can actually hire the best and brightest wherever they are and figure out how to communicate with them, which has been transformative for us as a company. But amidst that transformation, we've had to make sure that the Team is still cohesive, the team is still together and knows each other and that trust still exists as we do things because slack as a modality is not the most friendly. But when you actually are able to still build those relationships, when you're still able to drive up and say hello to colleague of yours from the driveway just so that you can actually make that face to face interaction or do a socially distanced picnic, if you may. And what I mean by socially distanced there is it's still 20ft. Just so you can say hi actually goes a long way.

I'm a big fan of those myself.

Yeah, it isn't intuitive. It's not the first thing that comes to mind. And then I do like to check in with team members every so often. I'll check in with them all in some which way if I can over the course of a month. And it's just, hey, how's it going? Is there anything I can help with? Are there tools or things that are getting in the way that we actually can improve? It's been great to see that cohesion exists. We call it this week at Notable and it's a Friday. All hands of sorts, but pretty much everyone on video. We encourage people to keep their cameras on so you can actually see it. I think it's pretty normal now, but those are the little things that, you know, make a huge difference. And then people like Bob Wachter will show up randomly to actually talk about. Here's what he's seeing at the pandemic at UCSF and here's how it actually will impact us, what it helps us with. And we're fortunate enough being at the center of it all is we get to see everything that we do daily impact patients lives. Every single day. We'll have hundreds of patient feedback verbatim streaming into our slack for the team to see where it's like, I'm so glad you're doing this in a touchless way. This is amazing because you care about me as a patient and your staff and just to see that streaming in is just incredible. And so I think that making sure that the team actually knows the value that they're actually building at this point in time has been incredible. So all of those things have helped me learn you don't actually need everyone in the office at the same time.

But it will be nice. Pranay, thank you so much for joining us today. Is there anything you want to add before I let you go?

Heather, thanks so much for having me. I think working with Grelock through the years now has taught me so much in dealing with enterprise tech. Working through some of the frameworks and the incentive structures that we've talked about and then really just tackling some of these hard problems that aren't just product or technology related. How do you actually build that right team? Who are the right people to have on board? Those are the conversations that have been invaluable from the first day of us forming notable and talking with folks at Grelock. And we're just incredibly excited to be partnered with you guys. And I'll say this because I truly believe it help. Tech is the next frontier. I know people are all streaming in from all walks of life. All of the tech companies are coming in, and everyone's realizing that it's a massive, massive opportunity. And I would love nothing more than to have more people from other industries take this podcast and maybe really understand the incentive structure, know how to actually tackle enterprises, and think about how to productize their vision.

Yeah, thank you so much for sharing. I really hope that all happens someday and we're thankful for people like you fighting the good fight, making it happen.

Oh, we're going to do it.

It's got to happen.

Thanks, Heather.

Thanks so much. Take care. All right, everyone.

That concludes this episode of Gray Matter. You can subscribe to our podcast on soundcloud.com greylock partners or you can find new episodes and blogs on our website, greylock.

Com.

You can also follow us on Twitter at greylockvc. I'm Heather Mack, and thanks for listening.