Healthcare’s Digital Accessibility Problem | Ro’s Plum Ertz

0:00I love Ro because we put the patient at the forefront. on everything we do and everything that we're working on is built around how is this solving a patient problem? Like if anyone said anything about the blockchain, I would straight up walk out of the building. I've told every person at the company, like you say blockchain, I'm out. Like that's not what we're here for. We're not here for the AI, the, you know, technical innovation for the sake of technical innovation. We're here at technical innovation for the sake of how can we make patients' lives better? How can we make it easier? At Dev Interrupted, we work to give engineering leaders actionable ways to improve their teams.

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1:09Welcome back to Dev Interrupted. We are live in New York and we've got Plum Ertz with us. Plum, welcome to the show. Howdy. Thank you so much for having me today. I mean, anyone who comes on the show with sparkly red heels is absolutely a hit in my book. It's a casual Tuesday shoe. I like it. And you're the director of software engineering at Roe, which is a direct telemedicine startup. Would love to dive in on a topic I know you're very passionate about, which is accessibility. And I know it's for the work you're doing here. Yeah. Yeah, absolutely. I mean, there's so many different ways to define accessibility when you think of healthcare and telemedicine.

1:42You know, I'm based in New Jersey, New York, whatever you want to say. And I can find a doctor. There's a million doctors, a million specialists. For a lot of folks, you don't have that opportunity, even the United States. It's not a choice of, oh, do I go online or do I go to a doctor? It's do I get health care or not? So putting health care on the internet is how we make that happen. And it's not just enough to put health care on the internet. And that's where digital accessibility comes in. Just because something is online on a website doesn't mean you can access to it because you really have to build it in a way where folks, regardless of what technology they're using, what network they're using, what ability or disability they may have, they're able to use that.

2:20And that's not the responsibility of the person to try to like figure out the Konami code to use your website. That's the responsibility of the people building these sites, building these experiences to make it accessible. And sometimes that really gets lost in the build, especially weirdly enough in healthcare. I don't know if you've ever gone on like your insurance website or any like digital website. You probably had some of the less good experiences in those spaces because so much attention is just brought to the functions of getting the insurance and the form fields and everything and not enough on just making it usable.

2:52Does the website work? Can users effectively navigate to find the care they need? Just an example for my personal life, when I was trying to switch my primary care physician, I couldn't figure out how to do it online. I looked up the documentation like, oh, here's how you do it. Didn't work. I don't know if it was just because I was on Google Chrome or what it was, I had to call in and say, hey, I really want to switch my PCP. How do I, you know, can I do that? And they switched it for me. But this is a process that should be easy online, at least was presented as easy. And I am a fairly able-bodied, despite if anyone watching, I currently have a cast on my arm, but normally able-bodied person.

3:29The challenges for others who maybe have further accessibility issues, I know can go deeper. And it seems like not just in healthcare, but broadly in software engineering, we often optimize for just like, oh, you know, we're getting 80 % of people, 90 % of people. And the edge cases really get ignored. Yeah, because it's, and I mean, even you're the perfect example right now, because it's 80 or 90 % of people because folks are thinking about permanent disability. They're thinking about, oh, well, we can't get the blind people or the deaf people or whatever have you. But the problem is disability is a spectrum.

4:00It's the kind of thing where in a given day, in a given situation, someone might have a limitation. They might have just had shoulder surgery and only been working with one hand. So there are now a set of interactions, maybe on a mobile device or a touchscreen device, you can't do right now. And maybe you've already encountered and we need to be able to build for that. My typing needs about a third of normal. Yeah. Exactly. Exactly. And that's the sort of thing when you think about things like one-time passwords and security codes where they have that sort of time sensitivity element to it, that's something that if it isn't built in a way with the proper alternatives to accommodate different abilities at a given time, you're not going to be able to do.

4:33And that's locking people out of whatever they're trying to access, which in my case, close to my heart is health care. Where are most of the pain points as far as accessibility for health care? From, I mean, there's kind of the digital, general digital accessibility, which also applies to health care. And then I think from regular health care, a lot of it is just being able to get in touch with someone who is a specialist, get in touch with someone who is a clinician, you know, you can scale doctors to a certain point in a physical space, but then you have to move to a digital space. And that's where a lot of folks have issues finding that access.

5:10There's also an issue, and especially with Roe, we deal with a lot of sexual health. You know, we deal with erectile dysfunction. We deal with semen analysis. So these are words that I say every day at work, and it's not as weird as you think it is after a while. But those are things that are really uncomfortable for a lot of people. So a lot of access is creating that safe space and that comfortable space. And that's why digital healthcare can be helpful because someone can sort of do that whole onboarding experience without having to say, I have to drive somewhere and go to a doctor and say that I have a really embarrassing personal problem and I don't know what to do.

5:41And we provide that place for people to be able to have those conversations. And it doesn't necessarily have to be a synchronous conversation where you have to say that to someone, but you can still get the information you need in a way that can help you move forward in achieving your healthcare goals? The work you're doing, I know, is really important to just provide that general accessibility across, you know, all care functions worldwide. I'll say to bring it back to another personal example, during the COVID-19 pandemic, I did therapy online and that kind of access was really important to me in the time as I was going through some personal challenges in my life.

6:16And I know that's true of a lot of other folks, but some folks I'm sure listening are saying, well, you know, like I have access to care. This isn't a big challenge for me. Like, why is this relevant to my software engineering team? Like, why is accessibility like that important? Like, what's your pitch to the folks who are listening and kind of having that question in their head? The pitch, you can always throw a lot of the like larger statistics of number of people who have a disability. It's something like one in four Americans have some form of disability. So if you want to play the pure business route, it's like take 25 % of your potential customer base and just drop them off a cliff because that's what you're doing.

6:50Yeah. But the way that I found resonates the most with engineering teams is having them see someone struggle with the experience. It's the kind of thing where, and if you've worked in any kind of startup, you know, a bug could hit a bunch of people and no one really notices it. But then like the CEO's second cousin like texts him and says there's a problem and suddenly like the entire world is stops to fix this bug. Yeah. It's that kind of personal connection. It's seeing one person, maybe someone they know, maybe someone they've just met, go through the experience in a way that they haven't seen before using a screen reader.

7:21There was an example when I was working back at BuzzFeed prior to this in media where we brought in someone who was blind, who was our partner in our accessibility testing. And he just went through the website with a screen reader, like one pass. And all of the news editors, the people who wrote this content were just floored because they were hearing their content in a new way for the first time. And they didn't like it. They didn't like the way it sounded. Like we're not presenting this right. Yeah, we're not presenting it right. So it's about really having that personal connection. But here is a single person who is struggling because you didn't put in the effort.

7:52And when I say effort, a lot of digital accessibility is free. It's this weird thing where accessibility is both hard and very easy. Like you don't have to if you just had straight up HTML, like forget frameworks, forget everything. You have an HTML page and you put a form on it. You use the correct markup, semantic markup. It's accessible. we spend like 90 % of our times as engineers throwing all this javascript stuff on top to like put accessibility at risk and so it's about going back and actually making the right choices using the semantic html using the things that have been in browsers for like 20 or 30 years now which doesn't take a lot of time unless you've spent all this time building this product without it and suddenly you're sitting the day before launch running through a checker and it's like Like, oh, and now we have 700 accessibility bugs.

8:39Like whatever technical debt, I'll deal with it later. Yeah. Yeah, whatever technical debt, you'll deal with it until, you know, you're creating negative experiences. Or I hate to say it, but a lot of times it's like a lawsuit-based thing where that's when the impetus comes for companies. Which I hate. I hate that people can't just go in and be like, hey, we need to build the right things. When you're building for folks for disabilities, you're really building a general user experience overall. You're reducing the risks of bugs overall, all of those things. But sometimes it literally takes the legal aspect to give people that kick in the pants.

9:08It's really interesting because I think a lot of us think about disability and accessibility as this thing that's kind of far away from us. If you're in that 75 % of the population that doesn't have to deal with it. But there are going to be periods, I mean, to point to my personal example right now with my shoulder, or just as you age, where you're going to experience this. And particularly with telemedicine and access to health care, this becomes very important as maybe you need to access more health care services while starting to have maybe it's hearing disabilities as like a very common example or simple eyesight issues.

9:41So I love that you're zeroing in on this because particularly in your field, it's very important. Where are the other challenges that you're seeing as far as the health care vertical today? I mean, there are so many challenges just in terms of there's so many things that have yet to move online. I think one of the things that I'm really excited about when it comes to the industry is how much we've been able to start moving online, moving to be sort of an in-home thing. So at Rowe, we're basically the only company in the U.S. that does pharmacy, physician, in-home lab testing, diagnostics. All of that is something that someone can get without sort of being able to leave their home.

10:16This is actually really, and you brought up the pandemic earlier, like post-pandemic or I guess during the pandemic. I don't actually know if we're post-pandemic. That's a topic for another time. That's a big question. Yeah. Other podcasts. But the pandemic brought forward telemedicine so, so quickly. And so maybe that's actually the challenge is the fact that a lot of people got online really quickly. And I was definitely looking at Pew stats yesterday, Pew Media Research, because I studied comms and economics. And so they were my go-to for things. And it was something like in 2021, 40 percent of people surveyed use the Internet in a new way for the first time during the pandemic.

10:49And so now you have this whole new population of folks who are coming onto the Internet who are potentially becoming more comfortable with things like health care online, whereas before they weren't, even though telemedicine has been around since the 1960s. Right, but it doesn't have this focus on it, to your point. Yeah, but it hasn't had this focus. And now it's like we've maybe in, you know, three years brought ourselves 10 years into the future in terms of what folks are looking for. And so part of it is catching up. Part of it is actually bringing all those experiences online in a good way.

11:17And part of it is helping people catch up because, you know, it's not just like everyone who's a teenager went online for the first time. It's folks who never grew up with technology or grew up with a different type of technology who are now trying and in a lot of cases struggling to use these applications to get health care in a way that should be available to them. And so working to make that more available to them. I think it's also one of those areas where once you experience the convenience in a successful way, it's hard to go back. Let's say I had an eye infection and normally I'd have to drive in or take the bus or whatever into a doctor, spend all this time.

11:51And maybe instead I'm like, well, I have work meetings all day. Can I set up a telemedicine appointment this afternoon? Hop on, doctor can look at my camera very quickly over, you know, Zoom and say, oh, yeah, like, yeah, here's the antibiotic, go pick up for your pharmacy or even we'll ship it to you. And so I think this is where your points around access and having it go beyond simply the folks who maybe have challenges reaching access, but also just the convenience you could reach on this population are huge. And I really liked the way you described this when we were talking earlier about what Roe does.

12:25How would you define the success of Roe and what you really do for people? It's goal-oriented healthcare. And I think the important part, and I guess sort of the secret sauce to our success, is the fact that Roe is backed by a lot of people. people who care. I mean, I go into work, I didn't go into work today, but I go into work most days. I'm in standups with physicians. I'm in standups with pharmacists. I'm in standups with our legal team. We're not just building a technical product, like fully in our React world, arguing about how we want to use TypeScript to define, I mean, we do argue about TypeScript, but the problems that we're trying to solve are way less technical and more about how do we take the parts of the clinical process and put them online in a smart way.

13:05So, and I mean, I'll say this up front, we're not using AI. There's AI and chat GPT and like the alphabet soup of different algorithms right now. We're not using any of that. We're just putting clinicians online in a smart way. The technical problems we're solving are not these deep algorithms where we have to do all this, you know, difficult. We're using things that have been in existence for a while, but just using them to automate healthcare. And it's a focus on value to customers, which is what I love, where, you know, folks may hear this and say, oh, I'm not in healthcare. Does this matter?

13:34Yes, this is like a key focus on providing value to customers. And so many organizations lose this in the alphabet soup you mentioned, where they say, oh, well, you know, our CTO thinks we should innovate this way, or our VP of sales said he heard this on a call. And instead, they need to be focusing on what's the actual outcome for customers instead of just using anecdotes to inform it. because that kind of laser focus is what great companies succeed off of. And I find that a lot of products and engineering organizations have challenges with aligning the work they're doing, the features they're delivering back to the customer.

14:09So I love that that's kind of this focus for you. And I'm curious in your past work, how have you had that same customer obsession, as some folks will call it, and brought that to the engineering and product doors? In my past work, it's definitely been very different because my past work was very focused in agency, in media. And so a lot more of that is around just sort of the cell and the users are more of eyes. So, you know, when I worked in a purely agency, I did some contract work for Verizon like years ago and there was never any connection to the Verizon user as a customer. It was just like, here is this thing.

14:42And so working in healthcare has been a totally different experience for a lot of reasons. One, just obviously the regulatory aspect of it and all the due diligence that you need to do. And the second is just really caring about people And from various media stories, there are certain health organizations who don't put that at the forefront. And that's why I love Roe, because we put the patient at the forefront. Everything we do and everything that we're working on is built around how is this solving a patient problem? Like, if anyone said anything about the blockchain, I would straight up walk out of the building.

15:11I have told every person at the company, like, you say blockchain, I'm out. Like, that's not what we're here for. We're not here for the AI, the, you know, technical innovation for the sake of technical innovation. We're here at technical innovation for the sake of how can we make patients' lives better? How can we make it easier? I think that's a really apt point that we sometimes forget. And I have to admit, I'm guilty that sometimes I got all excited. I get to have these conversations of people talking to me, these like amazing technologies, blockchain and AI and all these things. I'm like, yeah, that's really cool.

15:40But remembering that delivering value to customers is so important. So it's interesting to see how entering this vertical as your focus last couple of years has really informed that viewpoint. Because like I said, I think it's something where the best engineering leaders I talk to say, we are so focused on delivering value to customers. Here's how we do it. So I'd love to hear that and that kind of focus. I'd also love to dive into something that we talked about briefly before this show, which is we like to ask this question of leaders who come on sometimes and say, what's a screw up you've had as an engineer or engineering leader that you can share with us?

16:11How much time do you have? I have lots of time for this. As much as you need. Oh, goodness. I mean, I've made screw ups at every level of my career, which is excellent. I think it's like a rite of passage at a certain point. You have to break something. And there's a couple of reasons why you have to break something. One is because it shows that you're really digging in. You're learning your application. You learn from it. And you also learn how to fix things and work together and save it the next time. So a specific example, my favorite one is from my last job. I took down BuzzFeed. I took down the entire...

16:39You took down BuzzFeed? I took down BuzzFeed. I took all of the articles. super you know we were doing a full relaunch like fully accessible relaunch of the article pages which are you know the most traffic pages on the site and we had spent so much due diligence it was the first time we were using next js and that's like node-based back end all the champs there we got that all set up and we had scaled everything except that bold little reddish cache that we had been using in staging and it was like whatever the smallest aws reddish cache is and we flipped the switch to turn the site on and sent all buzzfeed's traffic which is like i don't know how many hundreds of thousands of views, like straight at this little Redis cache.

17:14And she just fell over. She's immediately. She's like, what? Close and down. And I just, it was the kind of thing. And again, like at this point, I was a staff software engineer. I was the engineering leader. I was managing four people. I was the one leading this. And I just completely knocked it all down. And the thing you do, you don't panic. You very quietly type out a Slack message. You have a little panic. I was a little panic, yeah. Very quietly type out a Slack message to our DV admin. Shout out to Policia. And I'm like, hey, Policia. Can you just set up a new Redis cluster for me? 15, 20 minutes, we're back online.

17:47Oh, man, that's a great story. And I love these kind of stories because it feels like every engineer has one. And everyone who's worked at engineering for a while is like, oh, yeah, I forgot to send me a call and took the whole site down. Oh, I did that too. You did that too? Both at BuzzFeed and at Ro. Awesome. Awesome. This is a great transition because I'd love to dig into your career at BuzzFeed because we actually haven't had a lot of folks from media on the show lately. So what's different when you're working as an engineer in media? What was interesting about it? Ooh, I mean, working for, and I worked for BuzzFeed, I guess, from like 2018 to 2020 to set the stage because the first thing that everyone asked me was like, oh, did you know the Try Guys?

18:27No, I did not know the Try Guys. They were gone by that time. Sorry. I have no good spicy stories from there. Working with media, I actually, when I started at BuzzFeed, I worked with BuzzFeed News. So I started right around the time they launched BuzzFeedNews.com. And that was a cool experience because you get to work. I sat directly in kind of like the news pit. So you get to see folks working day to day. And that's where you start to, you know, you don't build as much connection to, I guess, the BuzzFeed reader audience. But you build a lot of connection, at least I did, to the news team and really understanding, like, they're putting a lot of effort into these stories.

18:56There's some Pulitzer winning stories. How do you build the technology, the experience to support getting that information out there and getting that work into the world? So building that kind of connection was really fun. I covered the 2018 midterm elections, which was cool. Also broke something then. Accidentally called an election like five hours too early. It was fine. You got to tell us about that. Okay. So we were using a third party API that was sending back the results like as they were coming in. Yeah. And I guess at some point, I forget it was either. They were putting test data in production and we had pointed to production too early or we were still pointing to staging.

19:33So anyway, I called Texas for Ted Cruz like five hours. I have never seen the editor-in-chief or not the editor-in-chief, one of the senior editors like materialized behind me. Because this is when we were sitting in the office and she saw the website and she's like, how do we make it go? I'm like, one moment, please. I'm sure someone screenshots it. It's on Twitter immediately. People are like, oh, BuzzFeed's calling it. I think it might have been early enough that we were okay. Okay, okay. But because it was like we were pointing most traffic to a couple of specific like article pages on the homepage.

20:04So like fingers crossed. Oh, man, that's a that's a hectic day at the office for sure. And it's it's interesting to see the kind of switch you've had in your career where you've worked on this like very high pressure front facing piece. And then you have a lot of like extreme customer service work that you're doing today where it's like, how do we align directly to customers? But to draw it back to your accessibility point earlier in the conversation, I think it's really crucial to understand the importance to have this accessibility for both companies. Because, I mean, you mentioned this stat, 25 % of Americans have some sort of accessibility challenge.

20:39And with media, that means like a massive portion of your audience is gone. So you brought up the screen reader example earlier. How did BuzzFeed bake into their user testing and exploratory plans around new features, et cetera? that approach accessibility to ensure they weren't cutting out a large portion of the audience. I mean, a lot of it was just building in the rules of tools, technology, Buzz, I don't know how much I'm allowed to say about BuzzFeed, but it don't work anymore. So, you know, they have their own internal CMS. And so a lot of it was actually, that CMS powers a lot of the content that's being built out there.

21:13So there's two pieces. There's making sure that the render, which is the piece that I built a fair portion of, is accessible. And obviously, two years down the line, so if there are any accessibility issues now, not my fault, I promise. Look, you've been gone for a while. But no, they still have a really great team there who's still really focused on accessibility. And then it's building into the actual tools. We built things into like the quiz editor. So if you had a color on a background, it would give you an approximation of like, hey, this might be a contrast issue. Like doing as much as possible to surface that.

21:41The best way to build accessibility is to build it as hurly into the funnel as possible. So when you're literally talking about initial feature spec or a new quiz format or something, you want to think about, well, how will this work with a keyboard? How will this work if someone has a screen reader? What are the alternative content options for it? And moving forward from there. And honestly, the same thing we're doing at RoNow when we're looking at both sort of landing pages and ways to explain to folks. And as we're getting into more complex treatments, you know, we're working on GLP-1s now, as I'm Becky Gobi, which are in the news for a whole bunch of things.