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ep3

Huda
Idrees

Dot Health

Huda Idrees is the Founder and CEO of Dot Health, a real-time personal health data platform. With a background in engineering from the University of Toronto and a prolific career at some of Toronto's best known startups, her latest venture is transforming the way people access and control their own health information for good. In this episode we talk about discovery, scaling, and the challenges of healthtech.

Framework: You're listening to Framework, where we dig into the research, planning and building that goes into bringing products to market. I'm Rob Hayes – and I'm Tom Creighton – and today we're talking about Dot Health with its founder, Huda Idrees. For those who don't know, Dot Health is a simple and secure way to access all of your personal health data. Huda, how about a short intro to yourself and your history as a product creator?

Huda Idrees: Yeah, thank you so much Rob and Tom for having me. A little bit about me – I'm an engineer by training, and I stumbled into the world of design when I realized how much fun it was. Little did I know what I was getting myself into, now I've had an entire career dedicated almost exclusively to working at Toronto based technology startups. My latest is Dot Health. What we do is really straightforward. We make it really easy for people to access all of their own personal health information. Typically, all this data lives inside of large hospitals or clinic networks or pharmacy networks. Now you can actually request it, access it, and share it as needed with your care team.

F: Let's dive into Dot Health a bit. Why did you think that that product was needed in the first place?

H: We had one client and we were making a product for that client – we didn't actually think it was a company at the time. It was just something I was doing to help someone who was going through a difficult situation. So, our first client was going through late-stage chemotherapy, and was finding it really difficult to communicate what was going on with his health across multiple groups of people – his care team, and his family, and other care providers who were maybe not part of his oncology team. He was just finding it really hard, and was carrying a binder around with him. He was overall just finding it difficult to understand where he fit into the picture, how this treatment had affected others, etc. So we really made a product to help a single user and realized quickly after that that it actually impacted many more people.

F: So you were able to abstract out from from a single user of this thing you were building into a much larger product. Why were you initially drawn to solving this problem in a product way?

H: I think when you're a product designer – something that you've done for a long time, that could be like, you know, if you're if you're a writer you're constantly thinking about everything as a writing project. When you're a designer, you're constantly thinking about making things easier when you're in the world of product, and that's where that's where I had been. Prior to founding Dot Health, the one thing I was thinking of is: how can I do this so that it's not so painful and so specific and so tailor-made for one person but instead can be productized in a way that can help multiple people who are going through a similar situation, because at the end of the day, this is a product, out of all the things that I've ever worked on, that has the most profound impact on the people using it – and you can't not want that to exist for multiple people. I think that was that was a large part of this.

F: Were you thinking about this as a product problem right out of the gates, or did that come at the tail end of helping your friend with their personal situation? You kind of look back on it and saw – there might be a larger opportunity there.

H: Yeah, I mean initially, I was at a different job at the time, at a different startup, at the time of the founding of Dot Health, so, you know, it was a bit of an accidental founding of a company. I didn't actually think it was going be a company or a product or anything. I was just looking to help someone through a very large life crisis. And I think if I can look back into the problems that I've always wanted to solve and how I made decisions throughout my career, I've – in one way or another – always been looking for something that would fundamentally better the lives of people using it. That has been what attracted me from the very beginning, and on some level even going back to early days of Wattpad, I was looking for something that was in the realm of healthcare that impacted lots of people that was consumer-specific, because I didn't understand why – when every other industry was so far ahead, and was adopting technology consumer technology, specifically – why healthcare was so far behind. So that was definitely the back of my mind, but not necessarily the way that Dot Health started – it wasn't in any way methodical.

F: So at what point when you were developing this for this one person did you realize that you were actually solving a much larger problem? Or that there was a problem to be addressed with the thing you were building?

H: We talk about a couple of a-ha moments in our in our company. The first one came for me when this friend of mine who is going through chemo, one day sat down and explained to me how it was before – before Dot Health. And by the way, it was just like a clunky little app that I built for him, so we didn't even have a name for it legitimately. He was trying to explain how, before we had given him this tool, he would go in he would see his oncologist and they would put two pieces of paper in front of him, and within a two-minute conversation where the doctor would look at a computer screen and this patient would look at these two pieces of paper, that would be their entire interaction. After he was given access to the app, the big thing that started happening was that he shared access to the view that we were giving him, which was really really straightforward. It was basically a historical record of all the health interactions he'd had. His doctors started turning his computer screen around, so that both patient and doctor were looking at the same thing. And that shift in building a product that has a real-life change in behavior, within a setting that was otherwise very separate for patient and doctor, was the big moment for us. We were like, wait a minute – we thought stuff like this existed already. Because I'm a newbie in healthcare, I don't know anything about health-specific software. So that was a big a-ha moment for us, and then naturally like every person who's even a little bit curious, what I did immediately after that was go and talk to every other person I knew who had very high interactions with the healthcare system to ask them if something like this could be useful for them. I remember going out and finding a group of 25 people, and I found that when I was like, oh great, you've had this concern – let me try and help you in the same way that I helped this sample size of one. The other the other a-ha moment was when all of those people started referring other people who needed this. We had to cap it off at 200 people from 25. So that was a big moment. We were like: wait a minute, people are not only willing to use it and and trust a system with their personal information, they're actually trying to talk about it to their friends and we're literally two days old. That was super cool to see.

F: It had to feel good seeing that kind of Interest, to validate a massive and important problem. You touched on some of the existing solutions there. There's the binder full of papers. There's the “stare at the computer screen and don't make eye contact with the patient” – so it sounds, as much as it is creating a solution for the patient, it's also ultimately a problem for the healthcare providers, that you're solving here – to give them better tools to help the patient.

H: Yeah, I think fundamentally – we've started it in one area, but this is really a broader system problem. So the thing that's missing and that's really stopping healthcare as an industry to move forward faster, is that the infrastructure underlying the entire “health ecosystem” is really broken. It's built on a series of old fax machines and lots of paper files. That's what it's built on. And so, when there's no infrastructure supporting a giant several-trillion-dollar global industry, it's very difficult for that system to innovate, or to move forward, or to empower the patient. As we've seen in a lot of other Industries, when you empower the person who is ultimately the one benefiting from a lot of the system, that's when change really starts to happen. We've seen this across the board. Consumerization and disintermediation of a ton of Industries have caused massive changes in our economy.

F: It sounds like in a lot of ways you were coming up against a very analog system and having to initially grapple with that framework. That included, what what other issues did you face to actually get this off the ground?

H: Are we going to talk about this for the rest of the episode? [laughs] Because I could do that. I think coming at it, it's a good thing I knew nothing about the healthcare system going into this, because if I did I don't think I would have done it. So I think a certain level of naivete was really important in this entire story. So healthcare – I think overall as an industry, worldwide, but also in Canada, given the amount of government involvement – is really difficult to understand. There's very little visibility for anyone like me who's a private sector industry person going in and trying to both understand the system, identify the problems, and then pose solutions for it. I think we got lucky in that we stumbled into a problem where our customer was telling us exactly what they wanted. But then what we had to do was super steep learning curve that I feel like we're still on to be honest, a year in. Which is: understanding exactly how the healthcare system works. So everything from how doctors are in fact independent contractors allocated to hospitals, not really employees of the hospital, understanding how the provincial healthcare system interacts or doesn't interact with the federal health system. Understanding all of that is like peeling layers of an onion that we're still very far from the core of. There's obviously the analog system. There was all the politics around it. There was the understanding and visibility into the never-ending list of stakeholders in healthcare, and then understanding the role and the positioning of the payers in this model so – in the United States, which is a a private healthcare market, payers are obvious. Payers are consumers either via their employers or their insurers or both, or out of pocket. But in Canada, payers are really either the provincial government or your insurance, combined with your employer for certain things. So, operating in a system that's not really a universal healthcare system, but that wants you to think that it is, is really difficult. It's a lot of dead ends. It's a lot of talking to a lot of people who you need to convince that they need to see you. Sometimes we joke that it's more that it's more like political endeavor than it is a technological one.

F: And despite that you you continue to move on with this.

H: Yeah, I mean it's a lot of fun too, don't get me wrong, you asked me [laughs] if there are concerns in this. There are so many things that are so much fun. In a lot of ways things have been different than we expected, in a lot of other ways things have been so much faster than I would have ever imagined. The uptick from consumers – I legitimately thought we would still be grappling with how to get consumers to understand why they should, at the moment, pay for the service, but what we've actually seen and what we saw from the very beginning of Dot Health and announcing it is that there are more people willing to pay us for this than we are able to accommodate, even today, with a much bigger team. It’s super surprising.

F: So when you went out of the gates, you had an initial prototype in your hands for your one friend. What did that consist of? How did you come to that as – here's what we want to put in your hands to help you through this situation.

H: The first version was super super straightforward, like version negative 2.0. So, this one client that we had, he would be given pieces of paper that he was carrying around in a binder. All we did – essentially I took the pieces of paper from him, and then I started punching in all the numbers that were on it in sort of like a spreadsheet-like app. It wasn't actually a spreadsheet, but I made a dumbed-down version of it that I gave him access to. And I just put in all the data that he's giving me, essentially just basic data entry, and then I gave him the ability to annotate it. So in this specific case, we were tracking this patient's cancer marker. When you're going through chemo, in a six- or nine-week chemotherapy treatment, what you're calculating, or what your oncology team is calculating, is your cancer marker. Where is your cancer marker at the time, on on a certain week? And what you're tracking is whether it's going down or not, essentially. So that's literally all we did. Instead of his doctor giving him only two data points, we were able to give this person 10 data points. And so we were starting to broaden the context in which his cancer marker information made a lot more sense. That was it. That's that's all we gave him.

F: It's really interesting to me that you are able to extrapolate out from a very tailor-made one-person app into a broader platform that a lot of people are interested in. How did you validate that that solution idea, both with patients and medical professionals as you really started to build this out in earnest?

H: Initially we had thought that our vertical was going to be cancer patients specifically. So this space, specifically, because that is what we had done. In wanting to reach out to more people who had multiple interactions, we started to uncover other types of verticals where maybe it wasn't the exact problem. Maybe it wasn't measuring cancer marker progress, but instead it was measuring something else that had to do with health. So a very good example of this was first-time pregnant women. They just came up as a vertical for us out of the blue. We never thought this would be something that would be applicable for them. It wouldn't be something that would be interesting or useful, but when people who belong to this vertical approached us, a lot of the conversations were very similar. They said: I have a family doctor and I have an OB and oh, I also have separate specialists who I see for some some other concern that is sort of related to my pregnancy, but not otherwise, and so I have multiple healthcare professionals who are giving me multiple pieces of information. Very similar once you start drawing parallels, it's actually very similar to what a cancer patient is facing – who has potentially multiple conditions but is also going for routine treatment for a health concern. So a lot of these, I would say our clients made us aware of it, more than we were pre-empting a lot of it. A very small amount of What Dot Health is is like the brainchild of our team – a lot of it is learning from being in the space and learning from so many people using it, and telling us things that are more or less valuable for them.

F: When you went from your your first user to your first 200 users, did you just basically open up the the doors, and say what are you looking to track? What are you looking to get a better understanding of? Or how did you start to quantify which segments and verticals you could build around?

H: We went from 1 to 25 to 200 and then we capped it off there, for a little bit. That was up until we announced, which was about a year ago. Really what we went to the first 25 people with was: do you have multiple health interactions? And do you have concerns around tracking or managing any of that? The ones that did come forward to say, yes, this would be useful, were vetted carefully against how many times they were going to see a doctor, or what types of information they wanted to be able to capture. If it was something very subjective we knew we couldn't really help them. If it was something like “I need to analyze my doctor's notes over the period of 20 years”, we know we didn't build the platform for this. What we're really good at is stuff that you can chart over periods of time, and data that we can put in front of you in a way that helps you, or your care team, better understand and manage your own health. Subjective data like doctors notes, we're less good at than we are at objective types of data like charts, medical imaging, things like that. Early on we weren't specific with consumers that we were taking on, but we did have certain verticals present themselves to us as very obvious candidates. The cancer vertical was a pretty prominent one, largely because our first client was recommending us to multiple other people – when people go for chemo, they're actually just sitting there for two hours with a group of other people who are also going through a similar situation. So there's a very certain kind of referral and bonding that happens within that vertical that frankly we couldn't have foreseen. The other vertical that presented itself was this first-time pregnant women, who were going for different types of tests and more regular interactions like ultrasounds, and were tracking things like fetal growth. These are things that we would have never known. I don't have kids so I have no idea why or what any of this is, or why it's being tracked, but a lot of our clients were really specific about a lot of this, and very knowledgeable about a lot of it as well. The third sort of vertical that I would quantify is in the category of like chronic or comorbidity? Comorbidity is when you have multiple diseases that you're managing, or multiple conditions that you're managing. For example, you could have arthritis, but you could also be a diabetic. You're actively managing two separate conditions, or maybe you've had an ACL reconstruction surgery, which is a certain period of time, but you're also trying to separately manage something like routine dialysis. These are people where it's very normal for them to be going to multiple healthcare providers all the time. That's the category that I would define those early clients in. Almost all of our first 200 clients fell into one of those categories.

F: It's really interesting that referrals and people talking about this with other people in similar situations accounted for so much of that early customer base. That's really amazing. One of the things that I have to imagine you were really concerned with was the barriers around working with something as personal and confidential as your health record. I'm really interested to know how you dealt with that, especially as the product really took off.

H: So even today so we've spent no money on marketing to date, and on average each Dot Health client refers six other people to the system. Our customer base is built on referrals and it's built on word-of-mouth. When when we look at how it grew from working with very small groups of people and working in a very sensitive area, I think a lot of that is trust-building in smaller groups before it gets to larger groups. A lot of people always question why we would cap it off, or why we would put a waitlist up, instead of just letting anyone and everyone sign up and give us money. I think a large part of that is around trust-building – if I can't treat you with the dignity and respect that you deserve from someone dealing with your personal health information, then I also can't expect you to refer me to other people because I will undoubtedly create a negative experience for you if what I'm accommodating for is purely the number of users that I get in, versus the quality of experience that I provide. There's the famous adage and the product world around getting 100 people to really love you versus a thousand people to kind of like you, and that definitely stands true for us. From the very beginning client experience around a lot of this has been and always will be a massive value-add for what the Dot Health service provides, because in a lot of ways all of this information is technically available to you. You could technically take half a day off and go downtown to some hospital on University Avenue, and stand in line at the health records office in the basement of UHM, and you can fill out a form, and you can go home and wait for 3 weeks for your information to come in the mail for you. That doesn't mean it's a good experience. A lot of that is understanding what we're looking to provide and trying to stay really true to it, while also recognizing the fact that I mean this information that people are trusting us with – there really isn't any other information that that is any more sensitive than this.

F: It sounds like people, if they have the problem, they're very willing to provide this information. Were there any specific challenges and validating a health-based technology products that you wouldn't have with other types of products? I know you've worked in financial services a few times. Does it provide a unique category of challenges?

H: Oh, totally. Healthcare as an industry on its own is so unique, it just carries so many more nuances with it than any other industry I've worked in. I like to joke that like financial data wasn't like hard enough or sensitive enough, so I picked the other harder challenge.

F: Where you go from here?

H: Yeah, I know right? [laughs] So I think when we look at establishing both trust in us as a company, but also trust for people in this in this type of ecosystem, there's again multiple stakeholders. I think we got lucky in that we stumbled upon our customer from the beginning, but I can tell you about all the dead ends that we came up against. So very early on, we actually thought we would build a system for doctors. So we thought: well, why don't we build something that allows doctors to look at multiple patients’ information, and then track it for them and then tell them, you know, blah blah blah – and then we tried selling this to doctors, and that was when we realized that doctors are literally the hardest people to sell anything to. No traditional sales technique works on doctors.

F: Why is that?

H: Their motivations are so different, especially in Canada. I can't speak for other industries within health, like the United States for example. Actually I can speak to that a little bit, because we thought about launching this in the United States briefly, before ultimately deciding against it. In the United States doctors act more like business people, they make business-based decisions. In Canada, because there's really largely only one payer, that payer being OHIP in Ontario, provincially otherwise, doctors don't care! Their motivations are very different. One quote, and I will leave the name of the person out of this, that I think is a really good example of how healthcare professionals react to technological solutions – I remember speaking with this one healthcare provider, very well regarded in the space, and he said “You know, I don't want technology companies coming in and telling me that they can save me money, because I don't care about saving money.” Now, put that in context with literally any other industry you can think of. Anything that you're trying to sell, it doesn't fit. It's completely backwards. That's when we started realizing that we were faced with a very different type of person. The other thing that we realized in conjunction was that we shouldn't be selling to doctors in the first place. Today all the health technology that is built – EMR's (electronic medical records management platforms), adjudication systems, or health information exchanges by the government – they're all built for physicians. So there's 80,000-some physicians across Canada. There's 36 million people in this country. The market size when it comes to that, given all the all the solutions that exist, all of the solutions are actually targeting a very tiny portion of the population. The people that have been completely ignored are the ones that are desperately looking for a solution. I think that really helped us move away from that dead end, stop trying to sell it to doctors, and do the reverse. Sometime in the future, does this become important for healthcare professionals? Or healthcare professionals using it in some way or another because their patients are sharing information with them? Absolutely. But I think it matters for the kind of company that we're building, the kind of product that we're building, for us to be very specific about who our customer is and that will always be the end consumer or the patient.

F: It sounds very much like the thing that you were creating was really very amply validated on the patient side, and very enthusiastically so. Even with what you just said, were you looking for a champion for this on the on the hospital or healthcare side, or did you think the patients themselves would would really allow this to sort of bubble up in their in their normal interactions?

H: That's a really good question, because I think when it is multi-stakeholder management, you do in fact need champions from every angle. For where we've gotten with Dot Health in the span of a year, we count ourselves really lucky. There's a lot of roadkill in healthtech in Canada and beyond, and we have had champions every step of the way. We have political champions, we have media champions, we have influencer champions. We have physicians who are champions, we have pharmacists who are champions. Frankly, we wouldn't be able to do what we're doing without them because they’re a very necessary piece in helping us understand the broader ecosystem. Dot Health in a lot of ways is disintermediating a lot of healthcare communication, but what we're not trying to disintermediate is healthcare. We're not going to try and get in the way of a person trying to get care, and what that means is we're always going to be managing the communication between two very different parties. In order to do that successfully, we need champions and important stakeholders in all of those areas. It's taken a lot of work for us to find a lot of those champions, but they have been instrumental – some of them sit on our board, lots of them who are non-patients also sit on our advisory board. So you have both patients and non-patients on our advisory board, but we do have representation from a lot of these groups and I think we need to.

F: In terms of where the product went from when you hit those first 200 users to where you are today, how did you really plan out what your what your roadmap looks like, what your deliverables look like, once you've got through that initial validation from your customers?

H: When we when we first went from being fairly under-the-radar, and having just these two hundred clients, to actually announcing our service and going a bit broader, we started to better understand the types of information that we were getting. It's very different to have 200 users total to having 200 users every day. Those are two very different ends of the spectrum and it helps you understand things that we were doing that could scale, and things that we were doing that could never scale, that we needed to be able to automate in some fashion. In terms of prioritizing a lot of the work that we were doing, we've been very focused on ensuring that our core workflow is fast, and that it is valuable as quickly as possible for the people looking to access it. Our core operational workflow is getting some kind of a request from a person to access their data, actually pinging the data sources that have that data, communicating with that data source, and bringing back that information to our system to then the exposed to the customer and that never changes. This core workflow stays as-is and if there's anything disrupting this workflow, that shoots to the top of our prioritization list always, so we’ve been very true to that core operational workflow – and everything else is sort of surrounding it. Features like sharing your information are secondary to the core workflow – if we can’t actually get your data, there's no use trying to build a sharing feature for it. They kind of go from there. Who are we looking to serve first? If there's anything that's getting in the way of the patient getting the information that they need from their own health systems, we need to be focusing on that first. Like any early-stage startup, a lot of priorities shift based on some of the consumer behavior that we're seeing, and based on some of the value that we never knew was going to come out of this. An example of this is young parents realizing that they needed to be able to show their children's immunization records to multiple different places, including schools and camps. We started getting these requests for like children under 18, and their immunization schedule. Dot Health, when it was originally built, did not accommodate for handling information for minors. As we looked at what was important for a person to manage their records, but also for families to be managing their records, it started to add different layers to the core operational workflow. The core of it never changes, but we're actually adding another layer on top of it, that is doubling this work for a single consumers use – for a parent’s use for example. Family profile sharing was a direct suggestion from a large group of our users that helped us realize that this could be important. That's where the shifting priorities come in. We have a multi-faceted business. We both have to attract consumers while also building partnerships with large hospital systems or data sources, and there's a fine balance between that and completely turning one way and ignoring the consumer, and that's why I think it was really important for us to learn those early lessons, and failing at selling to doctors, for us to really know who our true customer was. Our customers and our users have been our north star in this entire journey.

F: We could talk about the space that this product sort of lives in honestly for the rest of the of the show, it's super interesting – but at the end of the day you you are building a product to answer these unaddressed needs, and you already touched on a building layers on top of layers and and discovering these needs that you hadn't really conceived of. How has the product really evolved as you move from from that the negative v2.0 the actual product that you that you launched with? And a year on where you're at now?

H: It’s been through like a million iterations since then, like all good products. I think we've seen it move away from being a pretty a pretty basic viewer, if you can call it that, to becoming a true ‘product’ where people are able to do multiple functions within it. Because my background is more focused within web development personally, rather than mobile development, actually started as a web app, but now most of our use – over 70% of it – is on mobile. We always knew that would be the case, but never really knew how much it would shift to mobile. This is always a surprise, I don't know why it is, but it’s always a surprise. I worked in like on multiple projects where this has been a surprise to me. I should just learn now, but every every time it catches you off guard. Noticing the different aspects of it that a mobile platform can help with versus a web-based platform has brought about a lot of different changes. Sharing and permission-based data viewing is a very very very huge part of the platform of Dot Health, and I would have never imagined that at the beginning. I would have thought it would be a single use of some sort, and it's just evolved into something that is, in fact, a more useful product than just me or the team had envisioned it to be.

F: How do keep iterating as you work through this? Do you get fairly regular consistent feedback from your customer base on on the product and the product experience?

H: Yeah [laughs] we get a lot of feedback all the time. Every Dot Health client has my personal cell phone number, so that makes it really easy and they do they use it. It's not like it's there for show. They do use it. So we do hear a lot from them. We also have very frequent touch points from our end to check in on people who had maybe asked a question, getting back in touch with them and specifically talking to them about a problem or concern that they’ve come across. We do get regular feedback, and then on the other end, we get lots of feedback from our partners so, you know organizations that are in some kind of a data-sharing agreement with us based on explicit consent from the end-user are a large part of this feedback loop for us as well. They are seeing the effects of it on some of their end users who are using our platform now to access this data, and so not a day goes by without one of our partners or one of our users getting in touch, to either say something good, bad, or mostly in between about our product. That definitely shapes the direction of not just the product, but the company.

F: It sounds like you've got a lot of feedback, it's actually a very constant stream for you. How do you manage that and make decisions on what to act on, versus what to wait and see if you hear more of, versus what you ignore?

H: A lot of it for designers, product owners, entrepreneurs, is filtering through a lot of the feedback and advice that you will get – and so on our end, the thing that we'll look at is again going back to: are we serving the primary need for which we have built this platform? If there's if there's anything that interrupts that, that comes first. All the other surrounding features and functionality go through the exercise of the internal team figuring out how much work it is versus how much value we believe that it can provide. One thing that we do really well is that we never do traditional focus groups or questionnaires that have rhetorical questions in them. We actually just establish a lot of trust with our clients, and check back in with them – not about the product specifically, but rather about what they're facing in the real world that the product can help solve for them. That's the type of qualitative feedback that really helps us narrow down what people are really looking fo. It's not like we get product we get product feedback like “I wish you would move this button there”. Throughout the the process of talking to a lot of our clients, we've also trained them in a way to tell us stories, rather than throw feature suggestions at us. That's often the kind of feedback that will get. They'll talk about an incident that happened, rather than a specific product suggestion. I think the collection of all of those incidents, and noticing patterns in that and filtering through that is really the job of the internal team. That's what we do and we get together for that very frequently. This is something that we're constantly talking about, we're constantly shaping and shifting our roadmap from the three weeks to the three months to the six-month to the nine-month – where the 9-month is super fuzzy, and the three weeks is super solid, and everything in between is a gradient. It allows us to move some things that we feel will provide more value to more of our users further up on our product roadmap, versus something that sounds like a good idea in theory, but actually to implement it would take us a year. That's not unheard of in healthcare.That's again referring back to a lot of healthtech roadkill – it's difficult to make some of those decisions when you can totally envision how amazing it would be, but it would take you a year to get out. That is too long an iteration cycle for a startup that is as young as we are to be able to bear. That's an automatic vetting system for us.

F: To that point exactly, and you already kind of touched on this in terms of of your customers bringing you stories about how they want to interact with their own health information, but how much is your roadmap driven by these sort of gaps that you're discovering versus, you know, maybe a more traditional kind of feature-level planning?

H: As an organization, we do have a broader vision for this that is specifically targeted towards fixing that system-wide infrastructure gap. We've always known that that is what we're moving towards. If you can zoom out for a bit, what Dot Health is really doing is building a bottom-up network. If you look at any predecessors of this type of solution, they've all built top-down network. Provinces have tried to get all the hospitals to talk to each other, and then eventually many decades later that trickles down to the patient. We're doing the opposite, and we've always known that, we've always known that we're building a network effects business that starts from the consumer. When we look at a lot of feedback suggestions that we get, some of them are shaping the way that we think about network effect businesses, and a lot of the team has been involved with network effects type businesses in the past. We know that’s where we're headed. If a future suggestion completely takes us off-track – like one thing we get all the time now, ironically enough, given what we talked about a little while ago, a lot of the suggestions that we get now is from healthcare professionals saying that they want to manage their patients care. I'm like – you've got to be kidding [laughs].

F: Well now it looks fun and cool! I want that!

H: What's super neat is having gone down that path, understanding why that was wrong for us, then coming back and realizing what the broader need of the system is, we’re recognizing that our first stab at it was actually completely wrong, and exactly what everyone who has failed before us has done. Sometimes we'll get product suggestions like that that completely take us away from the grander vision of all of this, and I think those ones are the ones that we ignore completely, and then some of those stories are the ones that make their way into some of the hunches that we already have. Some of the very rare ones, like family profile sharing, are the ones that fundamentally change our minds when it comes to what will have and a profound impact on a network effects type business. If you think about family profile sharing, you're actually getting a two for one deal. From Dot Health’s perspective, you're getting one person signing up, but they're actually asking for information for multiple people. So we’re actually building a stronger richer network that way than we would be by going one by one. As we have that that broader vision that we're constantly communicating internally and externally, that remains the guide or the sherpa of our roadmap.

F: When you put that release out to your 25-person audience, and then to your 200-person audience, did you have milestones set for what success would look like? Or what you intended to learn that would allow you to move to the next tier and open it up to more customers?

H: A big part of it for me, knowing how many health technology companies had failed to either find a revenue model or engage customers – those were two very obvious ones from the very beginning. I've worked in a lot of companies that didn't really have a revenue model or didn't really make money, and I refuse to believe that that is the way to do business. I'm old school that way, and I think that a business should make money. We were profitable month one. We were making money month one. That was a big part of this – is this a big enough pain point? People hate paying for shit, so could we get them to pay for something? Because if we could get 25 and then 200 people to pay for something, we've really hit on something! Then the other bit was maybe they've paid for it because they're in a desperate situation, but are they actually engaging with it? Those two were quite intertwined for us. Engagement was a really large piece, and then quickly followed followed up with that, which was a surprise for us, was referral factor. How many people who were now engaged, and paying, were now referring this thing that they were engaged and paying for to other people, because they found it useful. The usefulness was a big piece of it, and it wasn't necessarily like a traditional “monthly active users” or “daily active users”. It was more, when you have a health interaction with the healthcare system, are you using Dot Health to help you better communicate a health condition or a health event? That is what we're more interested in, rather than are you logging in every single day to, say, check your cholesterol level. Well, we're not getting data for you every single day, so that almost doesn't matter. What we do care about is: are you getting the value that you signed up for? Are you continuing to be with the system? We are a SaaS product, so people pay us nine dollars a month. Are you consistently paying and nine dollars a month, or are you canceling out of the plan? Because you can cancel at any time. Obviously retention and churn is a large part of it, but in early days honestly we were looking for like will people pay for it, and will they actually find it useful.

F: You talked about whether it's helping them communicate their health better. That's a very qualitative measure. How were you going about validating that, or quantifying that qualitative?

H: Again, we started with tiny tiny groups. We started with with a sample size of one, and we were in very close contact, of course, that with that sample size of one. Then we went to 25 people, and they were all on my speed dial, I would talk to them all the time about any new health attractions. Remember, these are all people who are going to hospitals and specialists and doctors very frequently. So my touch point with them is “what happened when you went this time? What was your concern? How long was your appointment with your doctor? Did you feel good coming out of it? Did you ever need to know did you need to bring up something like Dot Health? Did they ask you certain questions that you didn't know the answers to?” These were all questions where I want to understand what is in fact useful in a health interaction for people, and then where our product is actually fitting in. The same thing for the two hundred people. To this day, there's actually 15 questions, you still have to go through a certain onboarding and learning for the system to understand who you are as a client before we can start serving you, because healthcare’s so nuanced. Learning that very early on was so important for us, and then capturing a lot of that information and making sense of it. So we'll hear maybe like 50 stories in a day. What are the parallels between all those stories? Maybe someone who's pregnant for the first time and someone who's going through an ACL reconstruction surgery are actually talking about the same problem – and that's when you start to figure out the commonality across all of these, and then how to better build product surrounding those commonalities rather than designing for the specific.

F: I think it's been really interesting, and you've touched on this quite a lot, that your process around validation and value of the product has been very customer-driven. I'm really interested to know how collecting that data and that very personal feedback will scale as you continue to grow. How do you think that that process is going to evolve?

H: I think a lot of the best things about early-stage companies don't scale. So, you know when I have 200 clients, it's easier for me to get in touch with them and ask them for information than when I have 20,000 clients. A lot of what we're focused on is ensuring that as we scale, the ways in which we make it easy and okay for clients to get in touch with us scale with it. When we announced the company, we made sure that we had more tools that solicited feedback from people that weren't calling them every day, that were different than that. Maybe when they were onboarding we had specific call-outs to collect information. If we put a questionnaire in front of them, there was always a little feedback tab that let them enter really anything that was on their mind and just press enter, and not worry about attaching an identity or a name or anything to it. Making a lot of this really friction-free for people. We do have to be careful around that, and ensuring that we manage it – and there are a lot of companies that do customer interaction, customer feedback, really well. We really look up to a lot of these companies and startups and organizations to see how we can do that similarly as we scale and grow. Finding other representatives, new stakeholders that we've come across. We've started working with some primary care data – family doctor data instead of just hospital data. So: do we have representatives within family or primary care that can help us scale some of this feedback? Can we find people that are playing the role that I was playing earlier out in the community, and can we get them to tell us how their customers or constituents are feeling, and what they're saying? So developing a lot of those relationships, and then scaling some of the ways that we collect as solicit feedback from customers, it’s super important.

F: Was there a kill switch built into the into the product that you're building? That you'd know: we're way off course, or this isn't valuable?

H: Like have we done stuff that we've later regretted, and cut out?

F: Or was there ever anything in your mind that would tell you that you're on the wrong path, or that this whole product endeavor wasn't going to be successful?

H: Yeah! I think I think a lot of a lot of what we've learned is that health is hard and lots of people have failed at it. We've also studied a lot of failures and done a lot of post-mortems with the people who have gone through this. One thing that we knew right off the bat is that if we're trying to kill two birds with one stone, so to speak – I should have used a better metaphor–

F: –heal two birds

H: [laughs] Much better. If we're trying to use one feature that we develop for multiple users, and the the our primary customer – the patient – falls at the very bottom of that of that pool of people, then we know we've gone astray essentially. Staying true to the customer, and then always thinking about the top-down bottom-up really helps. This is the way that we describe a lot of what Dot Health is, it’s a bottom-up network. If at any moment, we are going down a path that is maybe super lucrative, or has a huge positive impact in the media or anything else, but that is in fact a top-down approach, one that has either been been tried or is the de-facto way of going about a solution, then that's where we know we're not serving the the primary audience. Other than that, we're a really straightforward product. We don't have a ton of feature bloat. A lot of the work that we do is in ensuring that the number of places that we can get your data from is always increasing, and we're putting in less effort for greater returns, that we're always delivering really excellent customer value. At the intersection of those two are where most of the things that we work on lie, and if they don't, they're very obvious and they stick out like a sore thumb. I'm saying this now, ask me again a year when we're a lot bigger and maybe I'll say differently, but right now it's so obvious and so easy and I wish it could stay like this forever.

F: You've dropped a lot of knowledge on us today in terms of of starting and scaling and discovering where a business needs to go. Are there any parting thoughts about building a product in the healthtech space that you want to share with us?

H: I think healthtech is the place to be, in a lot of ways. It is an industry that impacts everyone alive, and it is so far behind. We need not one, not five, not ten, but thousands of companies like Dot Health looking at the gaps within healthcare because it literally impacts every single one of us. It can be daunting coming in, I think that's why lots of entrepreneurs don't even try it, but it is doable. The most important part of all of this is that there are so many efficiencies to be made within the healthcare space that it actually creates a really interesting and valuable space for entrepreneurs to come up with solutions that not only positively impact the the health and lives of so many people, but can also be great businesses that can fundamentally shift the economy that we live in, specifically in Canada. What I’ll say is: we have all the ingredients. We’ve looked at and researched so many markets, and in Canada we have this perfect intersection of talent, of the right level of fragmentation and consolidation, and the demand from consumers to be able to really pioneer this industry that nobody, to date, has been able to crack.

F: That's awesome! We wish you continued success with the with the product endeavor that you’re spearheading here. Just want to give you a big thank you for joining us today, and a big thanks to all the listeners out there.If you're interested in signing up for yourself, you can at dothealth.ca. If you enjoyed this episode of Framework, it helps a lot if you leave a review or rating on iTunes or recommend this podcast to a friend. And if you'd like to hear someone else's product story on Framework, or tell your own, we'd love to hear from you and our contact details are on our website. We'll see you next time.