"We are going to settle into a significant amount of our healthcare interactions being digital in the future"

Q. Tell us about Twilio, your role and how you got into this.

Susan: Twilio is a specialist in communications and engagement. Historically, we have been way up high and to the right in all the magic quadrants for communications as a service. So, we’re a cloud platform that enables our customers, typically, to focus on where they bring value and let us handle the communications.

Recently, we’ve invested greatly in CDP (Customer Data Platform) technology. The idea is to not just have communications channels but make that a communication, engagement, and intelligence type of exercise where you really deeply understand somebody as an individual and personalize those communications in a way that is meaningful to that particular person. More importantly, be able to do that at scale and in an economical fashion.

Q. What was the specific need or gap that you saw in the market that led Twilio to get into this in the context of healthcare?

Susan: I would perhaps argue that there are different components of the equation when you talk about engagement. There’s always the data and the companies that are essentially repositories of that data. There are the medical reference systems in our space and CRM which is almost ubiquitous and certainly a critical component across many different industries. But being able to understand first-party data in a practical way and apply that specifically to communications around healthcare issues is the next frontier.

When I think about the strides that we’ve made, particularly during COVID – and you could argue that that was of necessity because we couldn’t see patients necessarily in person as we had historically done — you almost get to a really interesting place where we have digitally enabled the relationship that we used to have way back in the day when the doctor came to your home. They knew your family and your history. They probably brought you into the world and they might take you out of it at the end of the game. So, the notion of really understanding where people are in a more dynamic way is really interesting for health care.

You think about any of the chronic conditions that plague so many of us, and the way we really kind of snap at Chalk Line in a way and say, “This is Susan Collins. Perhaps she’s a compliant diabetic or maybe a pre-diabetic person.” You put Susan Collins on a little box and maybe enroll her in some sort of program. Perhaps, there’s even some care navigation and then, unbeknownst to you, three months, six months or a year later, something else happens in her life that you have no visibility into. Maybe her spouse is diagnosed with something serious, or they get COVID, or Alzheimer’s. All of a sudden, even though you don’t know it yet, she has become a rising risk patient because all of a sudden that spouse’s issue is taking up all the oxygen in the room. She’s not focused on her own health the way she used to be. Under our current approach, that’d be really difficult for our health system to have visibility into.

Technologies like CDP that use first-party data that understand what your activity is, today, as opposed to a questionnaire or survey you might have filled out a year ago, can really give you a lot of insight into the nature of that person’s reality. Now, that can change from day-to-day. I think that’s a really powerful concept but they’re only just beginning to scratch the surface.

Q. Let’s now turn to the core platforms and the products. For the benefit of our listeners, do give us an example, a use case, or a client case study from your work that helps us understand what your product does.

Susan: We think of the product as a communications platform as I mentioned, and that can look different in different environments. One of the nice things about taking a platform-approach to solving communications, engagement, and challenges in healthcare is that you don’t actually need to be able to look around a corner and know what’s coming.

If we think back to what seems like a really long time ago, but was only a little over two years ago before COVID, we had appointment reminder solutions and automated phone services that would tell you to not forget to pick up your prescription, for example. Chemically, somewhat generic in nature, but maybe some EHR would fire off a little notification that would send you an email about your appointment with a Dr. Smith on Wednesday at ten.

Now, we have had so much more experience in extending these systems in a more meaningful way to create dialog with patients and between patients and their providers — certainly of necessity through COVID — where there are basic things you couldn’t do before. Today, I can send you a text message before that appointment that says, “Hey! When you get here, don’t come in, stay in your car. Text “arrived” to this number and we’ll you know exactly where to go. You don’t come into the lobby. Don’t hang out in the waiting room. We’re going to put you right in a treatment room.” It’s a very basic use case now and used by hundreds of health systems.

All of the communications around vaccine availability, handling education around vaccines as well just indicates that we’ve come such a long way and maybe, I guess, better late than never. We’re starting to address some of the disparities in access and in understanding, and in trust in our health infrastructure, by giving people trusted sources of information about issues that were of concern to them.

For example, we work a lot with Penn Medicine and their Nudge Unit. They’ve done tremendous work in this space and recently through a mega trial run just before COVID — actually around flu vaccinations. They found that changing a single word in a text message, for example, “A vaccine is reserved/waiting for you” as opposed to “A vaccine is available for you” could change the uptake of that vaccine by 11%, which is really a staggering number of people when you start multiplying that across large populations.

We’ve become very sophisticated now around those kinds of use cases where you really deeply understand the audience you want to engage with. We’ve learned a lot about what the content needs to be, the delivery channel, how to accommodate people’s preferences, and how to reach people who are in communities that are historically underserved or have limited access to health care. It’s so heartening to see that progress after all these years in this industry.

You think of what SameSky Health is doing, for example, with a partnership to end addiction and see the tremendous strides they’ve made in communication with patients and how it’s an effective way to reach people where they are.

Q. You’re a communications platform and working at the intersection of technology and behavioral economics. In your space, who do you consider your competitors?

Susan: There are innumerable point solutions, out there and that’s been the approach that traditionally, health care has leaned into. There’s the text message solution for appointment reminders and such kinds of things. However, we think of ourselves much more holistically as a platform especially now, with the addition of Segment, an intelligent engine powering a platform that has a lot of omni channel communication capability.

At the risk of sounding a little arrogant, I don’t know that there are other true platform communications solutions that are cloud-based that we would consider competitors. Sometimes, it comes down to a little bit more of the customer use case and how broadly they think about communications. Is that a kind of a strategic thing that they’re thinking about across the health system or maybe a payer environment? Or, are they just trying to solve for prescription reminders? That must be considered.

Q. Twilio works with directly with clients like Penn Medicine and a lot of technology firms that embed your tool or solution within their own platforms. How does this landscape look to you from a competitive standpoint? How do you help your clients sort through going with EHR first or with the best-in-class?

Susan: We have solutions that work well for the health tech community. For example, EPIC, our vendor is an £800 gorilla in the space and they leverage our programable video product to create the embedded telehealth experience within their product. That was very widely adopted during COVID for obvious reasons. Likewise, we power every other brand that you’ve heard of in telehealth — over a billion minutes a month. That’s on the intelligence side.

For organizations that want an out-of-the box solution but who may not have the development resources or the bandwidth to stand those solutions up in the way that they prefer, those are wonderful options and we’re very proud to support them.

Then, there are other organizations that feel that they do not want to delegate the patient experience to someone else’s roadmap. They feel that often it may be a differentiator, a kind of bespoke patient experience that they want to create. It’s something that they feel strongly about owning a roadmap for. In those cases, they can likewise leverage our technology to build a very unique experience for their patients and providers.

Sometimes, there are workflow considerations and it’s a mistake to leave that to an afterthought. You really want to build something that’s efficient, particularly today, when providers are so challenged and burned out. They’ve worked so hard for so long looking for ways to make it easier and more efficient for them so, this is a meaningful exercise in lots of different organizations.

That said, I think, you can have your cake and eat it, too. In that respect many organizations try to start with an out-of-the-box solution. A World Health would be a great example of that. Powered by Twilio and highly configurable, but it does work out-of-the-box. Sometimes, they get a little bit of experience with that platform and decide they want to take it to another level, so, they might then build something of their own on Twilio directly. And that’s fine too.

Q. Let’s talk about patients. In the last couple of years, with the pandemic on, everything went virtual. Your own messaging volumes went through the roof. But, of late, there’s been a pullback. What are you seeing in your own volumes? What does it tell you about how patient preferences or even provider preferences are changing?

Susan: Some providers were quite surprised, to be honest because we’ve thrown so much technology at providers over even the last decade that meaningful use and the implementation of all the EHR at scale was a big lift for them.

You can argue, on the one hand, for standardization and best practice. You can also argue, on the other hand, that there’s an art to practicing medicine as well. Sometimes, providers may feel that that technology is dictating a particular approach. It was difficult for many organizations to navigate.

There was some technology fatigue as well. Then along comes COVID and the huge burden that that presented. So, we said, “Yeah, this solution is going to be more technology.” I’ve spoken with many physicians who are friends and who just went, “Susan, I just can’t take more technology. It’s really like my head is going to explode.” They then came back pleasantly surprised to say, “Turns out seeing my patient in the context of their home environment, maybe sitting in their living room, maybe with a spouse who hasn’t previously joined an appointment or an adult child who can dial in to a virtual visit has added a dimension to that experience that was not possible in our traditional model where I would just get in my car and drive to the clinic and have my appointment by myself.”

We’ve now had enough experience that we’re not treating digital as just a poor replacement for an in-person encounter. There will always be a need for face-to-face encounters in health care, but there are so many times when the convenience and the access that digital health provides, has added to the experience. We can certainly bring other resources to the conversation. We can share documents, visuals, change the waiting room experience and make it more engaging. You do see some really innovative solutions being developed.

Sometimes, they’re just around the administrative function in health care, which we know can be substantial, and concern, for instance an easy way to pay your copay in a cashless environment. It happens everywhere else, in every other industry that you can think of. Now, we’ve brought that kind of ease and simplification to health care, as well.

It’s a very interesting time and while I don’t think we’re finished evolving in that way yet, I think we are going to settle into a pretty significant amount of our interactions being digital. It’ll be interesting to see what happens with reimbursement and workflow discipline among other things but we’re not going to go back to a time when even a simple question like “My kid’s skin in the ear has a rash” that can be handled easily over video will go away.

Q. Switching to underserved populations, I want to ask, are these new technologies really serving them? Your broad comments on that, specifically in terms of what you’re seeing through the usage of your own tools and platforms.

Susan: That’s definitely a huge problem to wrestle to the ground. It’s one that’s so important and honestly, a bit of a passion of mine to work on. We’re interested in and invested in the space along with others.

I do think we’ve started to think a bit more out-of-the-box, which is great and again, not treating digital as just a poor substitute for face-to-face, I’ll give you an example. We were talking about that Nudge unit from Penn Medicine. There is a great study on their website that they ran around handling hypertension and pre-eclampsia in pregnant women.

As you probably know, this very disproportionately affects women of color and can be an extremely serious problem. It often happens in the context of a busy young mom who might have other kids and a job she can’t get time off from. She feels okay so, getting her to come into the OB-GYNs office to get that blood pressure monitor can be a real challenge. The rates of compliance with those programs can be quite low, and you have all of the usual impediments to transportation, time-off, childcare etc.

It turns out that you can send to these women’s homes a very inexpensive blood pressure cuff that possibly costs 20 bucks at your local Rite Aid. You can send a text message that says, “Hey, you get us a reading.” It’s a simple thing and not particularly intrusive. It doesn’t really interrupt the course of her other activities during the day, and the compliance is sky high. The patient’s satisfaction in such cases is off the charts. It’s extremely cost effective and a text message is a fraction of a penny.

Solutions like that think a little about solving the problem in a way that’s very patient-centric. They get us the information and insight we need to serve that patient well. It really provides a lot of hope for the future. We’re just, again, scratching the surface in these kinds of programs but that’s an example of how you can really leverage technology effectively to serve folk who are historically maybe underserved or lack access to health care resources.

Q. You’re no longer a startup but there’s a vast ecosystem of startups that are just as innovative as you. However, they’re very early on in their journeys. Many are reliant on VC money to pull through but the VC environment has changed over the past few months. What do you make of this current environment? What should a startup founder in an innovative startup think about now?

Susan: There’s so much incredible innovation today, that it’s hard to keep track of it all. Actually, we do our best and we have programs at Twilio, such as a venture program and an incubator, for instance. So, sometimes, we have a little bit of a front row seat to some of these startups. One of the best parts of my job is actually seeing how people are thinking about change and improvements.

I think focusing on real problems is key. I have a very practical bent, so the theoretical is sometimes a little lost on me. When you can show, even in maybe a limited way based on resources and ability, how you can impact other humans’ experience of care, it’s likely that you will have a pretty receptive audience in the venture world. Certainly, there has been incredible growth in digital health investment and we’ll probably see a little bit of a pullback given the current economic realities.

However, I don’t think digital health is going away anytime soon. I don’t think the funding for digital health is going away either and we’re talking about 20% of our economy. It’s a massive market that everyone can relate to. All of us have had health care and we’re going to continue to need health care. So, it’s a simple thing to explain.

However, when we talk to founders, where we see sometimes a bit of a gap is that practical application proof points to a real good grasp of an MVP from a solution perspective and the ability to articulate that in a clear and concise way. That is always compelling. I’m not trying to take on the entire world at the outset, so my advice would be to have a very straightforward path to where you want to get to. Wherever you are on that path is where you are and I think, that’s okay. One bite at a time, right? It’s hard to think about and I’m just being really practical that it is wonderful.

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Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity