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The Voice of Healthcare - Episode 5

Co-hosts: Dr. Matt Cybulsky (Principal, Ionia) and Bradley Metrock (CEO, Score Publishing)

Guest: Ilana Shalowitz, Senior VUI Designer for Emmi.

Duration: 29 minutes, 51 seconds

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Bradley Metrock: [00:00:12] Hi, and welcome back to the Voice of Healthcare for August 29, 2017.


Bradley Metrock: [00:00:19] Very thrilled to be joined once again by co-host Matt Cybulsky - Matt, say hello!


Dr. Matt Cybulsky: [00:00:23] Hey, everybody! Good to be back.


Bradley Metrock: [00:00:27] Really looking forward to talking with our special guest today, who is Ilana Shalowitz. Ilana, say hello!


Ilana Shalowitz: [00:00:33] Hello, everyone.


Bradley Metrock: [00:00:35] Ilana, thank you for sharing your time with us and sharing your insight with us. You've got a very interesting background and I'm looking forward to diving into that. Before we get into that ... at the top of the show I do want to say the Alexa Conference registration is going on right now, and listeners of this podcast in particular should take note - because there is a healthcare panel that is part of the Alexa Conference, where we're going to have some very interesting guests be part of that panel. It's on Saturday afternoon, January 20th; it's part of the Alexa Conference. A lot of interesting companies will be part of that. If you're in the healthcare space and getting into voice technology or already into it, you should pay attention to that. We'll be talking more about it as we move forward.


Bradley Metrock: [00:01:23] Ilana, thank you very much for being part of this with us today. And I guess my first question for you right off the top is - you do voice user interface design for a company called Emmi -


Ilana Shalowitz: [00:01:37] Yes, we were just acquired by a company called Wolters Kluwer.


Bradley Metrock: [00:01:42] Interesting. So what does your company - and then perhaps the larger company that you've just gotten acquired by - what do you do?


Ilana Shalowitz: [00:01:50] Emmi was just acquired about a year ago by Wolters Kluwer and we're part of the division of clinical effectiveness. Clinical effectiveness focuses on how can we reduce medical error. That's a huge burden to the medical system. I've heard it quoted on the order of billions to trillions of dollars that it costs the medical system. Sometimes if patients make a decision in the clinic, or it can be on the patient's side where maybe they're not taking their medication. So when Wolters Kluwer and Emmi joined, Wolters Kluwer brought the side that supports the physicians so their program is up to date, and what it does is it provides physicians with a way to quickly reference what the latest literature says on how to treat a given problem so they can make better decisions in the office for helping their patients.


Ilana Shalowitz: [00:02:52] At Emmi, what we do is - there is just not enough bodies to support all the care that's ideal for patients. Ideally you would want somebody sitting right with you to talk you through everything - everything medical that comes up, to make sure that you have the support to stay healthy. But there aren't enough resources for that in hospitals. And so we really help extend the reach of the care team.


Ilana Shalowitz: [00:03:16] We have two main products: we have multimedia programs, and we also have automated outbound phone calls, which is the product that I work on. But beyond the preventive screenings side, we also help during care transition - and those can be really rough times for the patients. They're just discharging, might have been inundated with information, and they might not know left and right, much less pay attention to the complex information that they've gotten. And so what we do with the transition series is we'll call patients at a pace that we set, and we'll give them information that their care team will want, and we also communicate back to the care team about how they're doing. Their care team is receiving a daily report on exactly how they respond to our calls. And we'll mark for them if there's anything that they would like to follow up with. So instead of calling thousands of patients every single day, they can focus their resources on those patients that really need help.


Bradley Metrock: [00:04:18] And how do you figure out which patients to prioritize? Or do you just simply call them all? What's your sort of process to decide "OK, we're going to ..." Is it just you wait 60 days past where they were supposed to show up at an appointment to call them? Or there's other criteria? Can you share with us something about that?


Ilana Shalowitz: [00:04:38] Absolutely. For a prevent solution, we work directly with clients. We'll sit down with clients and ask them what their needs are. I'll ask them what the patient experience is like coming into this call, and they'll provide the list to us of the patients that we'd like to call. We can do some really interesting things if they give us more complex data. For example, for a medication adherence call that I wrote, I was able to pull in from the data exactly the name of the medication that the patient was missing. So it wasn't just "Hey, have you been taking THAT medication?" I could actually name it for them, and so they were able to think about that particular medication in that time.


Bradley Metrock: [00:05:26] I want to ask you sort of a question about your own background. I'm fascinated in general in the voice technology space about all the different trajectories that people who are in the space have taken to get there. You've got people with all sorts of liberal arts backgrounds. But you also have plenty of computer scientists and folks with a little bit harder skill set. And I'm fascinated by that. As I look at your background, I think that it's exactly that whole premise. Share with me, and Dr. Cybulsky, and the audience how you got into doing voice user interface work and what got you interested in doing that.


Ilana Shalowitz: [00:06:07] I've always been interested in people and this sort of system that governs their lives. I studied both anthropology and psychology in college to better understand how people interact with each other, but also about their their internal world with that psychology. And thinking about where I wanted to move forward - I really wanted to be in communication for behavior change. I loved design. I loved figuring out how people interact with things and the idea that humans have it in their control to shape this world around them. We could make things better for people. I had to learn what sort of vocabulary translated from marketing to design. I knew that I had the skills, the research skills, because that's heavily emphasized, especially in anthropology and design values and ethnography. But there's still a vocabulary that you have to pick up. For example, in marketing: customer-centric becomes user-centered, or human-centered, design. It's the same concept but still to be considered an outsider in the new industry you have to have to learn the insider terms.


Ilana Shalowitz: [00:07:26] Finally I got this contract in design research and I loved it. The tradeoff that researchers always think about is ... do you work client side? meaning you have an in-house agency and then you may get to see the product through; or do you work at more of a consulting agency where you just hand off your research? And my experience working at the consultancy solidified for me that I really wanted to be involved in the product design.


Dr. Matt Cybulsky: [00:07:56] Yes, I'm always fascinated by these ... I guess I would call them "AHA!" moments that people have in formal circumstances ... sometimes it's them sitting in a lecture hall and they're listening to someone speak and they have an "AHA!" moment. Or like you, they're having a casual conversation with somebody and there's a synthesis, a connection that's made. Really curious - what was that connection that you made, and how does that motivate you now?


Ilana Shalowitz: [00:08:28] There's so much nuance involved in voice design. And right now designers are having to defend their place. What is the place of a designer in voice design? Can't you just have anybody do the design? I've thought about it because it's a valid question and because a lot of what we see out there is transactional: "Hey, what's the traffic like? "What's the weather like?" "Can you play music?" And for that, those principles can be learned by a lot of people. But the art really comes in when you start to think about conversations over time - when you start to think about "OK, now I'm dealing with sensitive health information. How do I best convey this to to the listener?"


Ilana Shalowitz: [00:09:22] For example, one of my clients - they were up here, they're an insurance company - and they wanted to talk to their patients about - they wanted to send out a health risk assessment. And those health risk assessments ask things like: Do you live alone? Do you have trouble with your memory? (And I actually have a clip of that I can share with you in a moment.) But the beauty and the challenge is figuring out: how do I possibly frame that conversation? They want to send it out to their new members, and it's just going to be a terrible jarring experience. Nobody will want to answer and it will feel intrusive. So, how can I as the designer smooth over that experience, so it seems natural and people want to participate? And as I said, it's really the nuance and the beauty that brings it all to life for me - and also context is another big part of that.


Dr. Matt Cybulsky: [00:10:23] What are a few things that are standing out to you as really having an influence, or as really having a positive effect, when it comes to using these voice-driven tools with your product? Maybe focus on the post-discharge care management focus of your work.


Ilana Shalowitz: [00:10:41] Sure. One of our most popular series is the heart failure series. Say you've just been discharged from the hospital with heart failure, and we address the emotional sides of it as well as the very practical: you have to weigh yourself every single day. And so we call patients every single day for 40 days. And we ask if we can call the patient back. And actually the wife of one patient had gone through the whole series, and she said how appreciative she was that we did call every day to remind her to get her husband's weight, and how we really talked her through the whole process of that care transition.


Ilana Shalowitz: [00:11:29] Another thing is our new series - it's diabetes smart series. This one takes into account all sorts of variables for a much more tailored experience for the patient. If the patient is new to diabetes, or if they've been managing it for a while, we'll speak to them differently, based on their experience. We also know that patients are going to have trouble during certain times of the year. It's what people in anthropology would call "feast holidays," like Thanksgiving, or there's a lot of candy around Halloween or Valentine's Day. So our system pulls from the date to address those those topics, knowing that it's going to be a difficult time. And that sort of personal attention is invaluable, and also couldn't be replicated using normal staffing by the care team.


Dr. Matt Cybulsky: [00:12:32] With the staffing and the care team, are you experiencing with healthcare collaborators that there's a shortage for patients in need?


Ilana Shalowitz: [00:12:43] Sometimes there's a shortage but sometimes they're not able to reach the ideal support. If you think of a quick example, returning to maybe a diabetes eye exam - it would just take so many staff hours to call thousands and thousands and thousands of patients. Instead, they can send out an Emmi call and have them transfer right into schedule. And that staff is then freed up to do more skilled tasks.


Dr. Matt Cybulsky: [00:13:19] I agree with that completely. One of the things that I'm coming across quite a bit is this conception that patients are only in your hands for a very short period of time amongst the years that they're alive and well, or not well, during the year. So, these hours that you can't touch them - having a resource or a medium that can modify how they typically take care of themselves is really important for outcomes in recovery. Now, one of the things that I've also come across is there's sometimes an asymmetrical intent. Even if we keep them out of the hospital (and that's good), or if we keep them out of an inpatient stay or coming back for an outpatient stay and taking care of themselves at home (that's fantastic) - there's a loss of revenue that the hospital has to deal with. Have you come across any sort of asymmetrical business intention when it comes to how effective your product's been, from the voice side of taking care of patients?


Ilana Shalowitz: [00:14:22] I'm really glad that you brought that up. I haven't seen that there's an asymmetry. Everything that I've written over the years has been of benefit to the patient. But what you will see is that clients will pursue different products based on their reimbursement models. So if they're still fee-for-service, then they might focus more on the preventive side of things, because we can collect all those people, or they'll give us the the data file, but reach out to all these people that are overdue and help motivate them to come in. But it's also important for our clients who are beholden to quality measures because we can do things like call them about the flu and collect data on who's gotten the flu vaccine already so they can they can report it for their documentation.


Dr. Matt Cybulsky: [00:15:26] That's an excellent example. What other tools within Emmi from the voice perspective are you proud of or excited about? Or perhaps ... maybe there are some voice interaction tools that you think might need some work in that the technology isn't really there in a supportive manner quite yet.


Ilana Shalowitz: [00:15:45] We still define all of the grammars; we don't use natural language processing or understanding. It's both a good thing and a bad thing. And the good side of it is that we're very strong on design, and we have been able to come up with really creative solid solutions for our clients. And the example that I used about context by referencing the date - that's a strong design decision that I don't think that other people have had to think about, and I haven't seen anybody address that well before. Something else innovative that we've done is we've come up with a tutorial walking patients through stress relief techniques that they can use on their own. I haven't seen much of that either. And so because we have these boundaries, we've actually been able to innovate on the design side and that makes for a really wonderful patient experience.


Dr. Matt Cybulsky: [00:17:04] That's an interesting comment you've made: the cost of being wrong. I imagine, though, that with your interface there are some things that cannot be captured. When you look at a focusing of your portal or your medium that you're working on with the patient, are there any feedback/commentary you're getting from clients that say "Hey, wish we could also pick this up" or "Wish we could integrate into this into our EMR in such a way that it would be apparent to me"? Are there issues with providers having to look at your portal versus seeing everything in one space, or do you guys integrate with EMRs?


Ilana Shalowitz: [00:17:48] I don't know exactly how the integration works. I do know that we're integrated with our clients to varying degrees. And I do know from the design side we set up the reporting structure and we do think about things like "Does this go on one page or two pages?" And "How do we display this information so that the provider doesn't have to dig through to get the information?" And for the diabetes series we have, we collect blood sugar at any time of the day through texting, and that goes into their port. And we purposely put it all aggregated in one area so that the provider can quickly glance over it to see how the patient's been doing over time without scrolling, scrolling, scrolling to see this day, that day, this day.


Bradley Metrock: [00:18:41] Ilana, you were saying earlier ... you were commenting on the fact that you had thought about: do we really need to invest in a lot of thought, in a lot of psychology/philosophy in maximizing voice design? And it's just interesting ... and of course the answer is yes ... but it's just interesting to me to think about how if you take literally everything ... the earliest buildings: people said "Oh, you don't need that. Someone just lives in there. Who cares? You don't need to do anything." And of course that was rejected and we got modern architecture. Or thinking about something like a mobile phone: people said "Oh, you don't need to design that. You can just make calls. Who cares?" And of course someone made a lot of money - named Steve Jobs - saying that that wasn't true and that there needed to be more design brought to it. And voice is going through that same thing.


Bradley Metrock: And this is the theme that comes up from time to time on VoiceFirst.FM podcasts: there's all this questioning that goes on. Do we really need to care a lot about this? Or is it just OK to put something together and we'll still be fine? And the answer is that, like everything else in human history, we don't have any idea. We're only beginning to find out the difference between intelligent voice user interface design and the absence of any design. And we know there's a difference. We're just beginning to understand what it is. So I heard that, and what you were saying earlier, and I just wanted to come back to it because that fascinates me and it's a theme of our podcasts.


Dr. Matt Cybulsky: [00:20:41] Yeah, I'm going to piggyback on you there, Brad. I think it's really important that we recognize that in the past, we a lot of times manufacture trends economically - we can reduce funding, for example, for streetcars - and then open up funding for building roads so that gas automobiles become the norm. We're starting to make that same shift towards battery technology and gasless vehicles, which is another shift in economic focus which you can argue largely is somewhat manufactured. That being the case, the ease with which people can utilize interfaces with their voice, I think, is what's captured a lot of venture capital attention and also design attention, similar to what Ilana's talking about today. And without a doubt, because of the momentum and the evolution of these tools, it's not going anywhere and it's probably just going to become even more embedded in our day-to-day - not only in healthcare, but I think just about everything.


Ilana Shalowitz: [00:21:40] I've seen a lot of people focusing on speakers and in-home assistance, and a lot of companies saying "Let's get our speaker out." But seeing what happened in marketing where everybody said "Oh,let's have a TV ad!" and "Let's have a newspaper ad!" ... eventually it became all integrated and all one, and I think that the industry isn't there yet. So what I'm looking out for is - how can we use voice for what voice is good at, and how can we be platform-agnostic? It doesn't need to be a speaker. It doesn't need to be a refrigerator. We have an enormous amount of data on the user, and then it becomes sort of like a buddy that you can take around with you because it has all this data on you, and you can take it to the hospital. What if you had just a small USB drive with your assistant on it, and you were able to take it to the hospital and see all the information that your doctor wanted you to see. And it can update you, communicate with your doctor also, on any of your vital signs and things like that. So that's what I'm seeing, and seeing a lot of people being very excited about it - but their focus very much now on certain devices. They haven't gotten into how all those devices connect or the one lived experience that each person goes about during their day.


Bradley Metrock: [00:23:14] So you've got an exercise for us, right?


Ilana Shalowitz: [00:23:16] I mentioned earlier that part of what I see the power of voice in the future is: can it walk you through? can it help you get through the day and not just return information to you? So I pulled one of our stress relief exercises and I thought it might be nice for the listeners to end on that.


Bradley Metrock: [00:23:38] Absolutely, and I could use that myself. I know Dr. Cybulsky could use it. All of us could use it!


Dr. Matt Cybulsky: [00:23:43] Definitely.


Bradley Metrock: [00:23:43] Sign me up, please!


Ilana Shalowitz: [00:23:43] This comes at the end of every call in our diabetes series, and the patients have a choice to do this exercise or another one. It's completely optional. We start it off by saying that it's called diaphragmatic breathing, I'm not sure if you've used that term - diaprhragmatic breathing is known to lower your blood pressure. And this is just a snippet from that. Feel free to follow along.


Exercise: [00:24:17] This may be the first time you're trying something like this out. Even if it seems strange at first, try and be patient with yourself. Give it a chance to be relaxing. OK. Let's start by getting comfortable. Turn down any music and try to find a quiet spot to sit or lie down. You may want to use headphones or put me on speaker phone for this exercise. All right. If you're ready, say "START." If you need a second to get set up, press the star key. Great.


Dr. Matt Cybulsky: [00:24:45] START!


Exercise: [00:24:46] Start by taking a little siiiggghhhh ... to relax your shoulders and your back. Now, close your eyes ... and breathe in and out normally. Whatever's comfortable for you. As you continue to breathe normally, try breathing in through your nose and out through your mouth ... continuing to breathe normally, in through your nose ... out through your mouth ... put one hand on your stomach, right over your belly button. Notice your hand move up and down with your breath. Let's practice: Breathe in through your nose ... fill your stomach up with air ...


Dr. Matt Cybulsky: [00:25:37] I'm already asleep. This is great!


Exercise: [00:25:38] ... in through your nose ... fill your belly up with air ... breathe out through your mouth ...


Dr. Matt Cybulsky: [00:25:45] This is an example of circular breathing.


Exercise: [00:25:47] It sometimes helps to say SHHHHHHHHHH ...


Exercise: [00:25:54] ... air out ... so the air comes out of your mouth ...


Exercise: [00:25:57] Breathe in through your nose, filling your belly up with air ... breathe out, SHHHHHHH ...


Exercise: [00:26:03] Breathe in through your nose, filling your belly with air ... breathe out, SHHHHHH ...


Exercise: [00:26:03] One more time:


Exercise: [00:26:03] Breathe in through your nose, filling your belly with air ... breathe out, SHHHHHH ...


Exercise: [00:26:03] Just like that.


Dr. Matt Cybulsky: [00:26:33] I love that! Do you know how many patients finish that when they start it?


Ilana Shalowitz: [00:26:38] This product is just being released, so I don't have that data quite yet. But I am optimistic. There's a lot that went into that, including my testing it with people and I saw what sort of pacing, on average, people liked - what sort of breath lengths they were taking. We did a lot of research into how exactly to frame that so that it falls accessible to the widest range of patients.


Bradley Metrock: [00:27:12] Thank you for sharing that with us. I think that's a great example of technology and exactly what we've been talking about: using voice design - and just simply, as Matt likes, to say nudging people just ever so slightly in the right direction.


Dr. Matt Cybulsky: [00:27:26] How would I play that - through my phone? The web?


Ilana Shalowitz: [00:27:29] It's a part of a series of phone calls. The patient would get a call and it'd say "Hi, I'm calling on behalf of your doctor for Ilana Shalowitz. Is this Ilana Shalowitz?" - I'd say yes. And then it would ask me some check-in questions, for example: "Have you had a chance to schedule your follow-up?" and then I would say yes or no. And "Last time we talked, you didn't have a ride - do you have a ride now?" It has all these check-up questions that go back to the doctor, and then it'll go through educational tips, maybe how to conduct a foot check - and then it'll finish the call. After it talks to you about all these maybe stressful things, it finishes each call with a stress-reducing technique.


Bradley Metrock: [00:28:14] Very cool.


Dr. Matt Cybulsky: [00:28:15] Yes, awesome!


Bradley Metrock: [00:28:15] Thank you for sharing that with us. And thank you for sharing your time with us today, Ilana - your expertise - you're fascinating, and what you're doing is fascinating - and we appreciate you being part of this with us.


Ilana Shalowitz: [00:28:33] It's been great. Thank you for having me.


Bradley Metrock: [00:28:35] Ilana, for someone who has been listening to this podcast and wants to reach out to you from a business standpoint, to engage with Emmi, or just to talk with you further - what's the best way for them to do that?


Ilana Shalowitz: [00:28:48] They can find me on LinkedIn or they can just send me an email. You spell my name with an "I" - so it's I L A N A - and my gmail just has a dot, and then S H A L O W I T Z ( - I'd love to hear your listeners' thoughts and start discussions.


Bradley Metrock: [00:29:09] Excellent, excellent. Well, thank you very much. And Dr. Cybulsky, thank you as well.


Dr. Matt Cybulsky: [00:29:15] Always a pleasure, Bradley.


Bradley Metrock: [00:29:16] For August 29, 2017 - The Voice of Healthcare. Thank you for listening. And until next time.

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