How A Small Digital Health Startup Won a Statewide Contract (and the T-shirt Story)



How a small digital health startup won a statewide contract… 

The Patient Portal for New Yorkers will be launching soon and I am proud, as a native New Yorker, woman in digital health, and a NYS-trained and licensed physician, to have been a part of it -especially the design process. Just a little less than a year ago, we were all nervously awaiting the results of the rfp process and here we are, excitedly awaiting the patient portal’s prime time debut.

It’s interesting, 90% of startups just don’t make it. So how does a small and relatively unknown startup without revenue or clients win a statewide contract over competitors with revenue, a board and clients? I think it has to do with a small group of people getting together at the right time, in the right place, and for the right reasons. It also has to do with the foresight of people who live and work in a pioneering state like New York.

I first met Christopher Bradley, the CEO of Mana Health, as a referral from a friend who had seen me at a number of technology events. Entrepreneurs, MD’s, students, MPH’s, MBA’s, PhD’s, etc., often come to me for clinical input, strategy/advice, or to learn more about the digital health landscape -especially in New York. At the time, Mana Health was set to be more of a clinical decision support (CDS) company and there was no portal or any bold-faced names. I even remember the first MVP of the CDS product, it was a tree diagram of some circles, lines and words and a bit of a built-out back end and that’s about it.

I decided to help because it’s part of the doctor in me to help people and I’ve been privy to how hard it is to run and be in a startup (Super, super tough!). I also saw the coming wave of mhealth, clinical decision support/data analytics (there’s no way one person can practice medicine AND read literally hundreds of millions of research articles a year, and sadly info in books can sometimes be 2-3 years behind) and tech’s ubiquitous integration into medicine. I had finished my Internal Medicine residency and gotten my license, and having always had an interest in technology, had been educating myself on what was happening in the field as well as its intersection with my own field. Also, over the past 10 years, I had always had ideas about how I thought technology could be integrated into the industry and in some ways improve access to information, workflow, and both patient and provider education. I also definitely had opinions in terms of what the interface and the experience of the tech could be (we spend so much time at work, so why didn’t the tech at work match the smartphone in my pocket?”). “No more spreadsheets!”, “Some consumer elements, please!” and “Mobile, mobile, mobile” were my battle cries.

We started to work on the CDS tool and then the opportunity for working on the Patient Portal For New Yorkers came up, run by the New York E-health collaborative (NYeC), which is composed of the major healthcare leaders across industries in NYS and who are doing amazing work when it comes to pioneering projects in digital health for the state. I thought this was a great pivot because it was the opportunity to build something for the people of New York that would help at both the individual and population level. Also, because it is a solution for a problem that has always been a hassle -getting your medical records from multiple providers from multiple institutions at any time (and not just M-F between the hours of 9 am to 5 pm vs on weekends or that midnight to 7 am emergency). In addition, personally for me, it was the opportunity to pay it back and pay it forward for a place that has given me an incredible education and an incredible life.

There were certain requirements that needed to be met to build out the portal but the competition to win the RFP was mostly about the design. I thought this was great, as a proponent of STE(A)M, and because design seemed to be missing from a lot of the technology used in the medical field. It was the opportunity to really make something that was nice-looking, friendly to use and that would be practical and useful for people. We had an amazing team of designers, Jin and Justin (I called them J^2 because they worked together in a way that was almost telepathic), who really made things come alive visually when it came to going from paper drawing/only-in-your-head-thus-far idea to physical product, and we had hard-working developers (one of which was Dmitriy, also a Mana Health co-founder) who really loved developing something that helped simplify aspects of a very intricate multi-player system. We also had med students who were part-time and mainly worked on the CDS, but who were super excited about the portal.

As for me, as in most startups, I wore many hats, but I’m proudest of my contributions related to overall design and design features. Many features of the design come from real life experiences, both clinical (inspired by specific patient encounters I’ve had) and non-clinical (the flip side of being a patient). Raise your hand if you can relate to any of the following: How many people are tired of endless drop down lists? How many people often forget some of the things their doctor said at the last visit? How many people have visited the emergency room or an urgent care center on a weekend or after 5 pm? How many people know all of the medications and procedures that their loved ones have had over the past 5 years? How many people speak English as a second language? How many people prefer universally understood pictures/symbols over words? How many people want to know who has access to and has been accessing their information? How many people want to make sure that their healthcare providers have the correct information about them and their loved ones?

In the entrepreneurial world, there are lots of words that overlap with medicine, such as viral, problem-solution format, and pain (which is now the fifth vital sign). It’s really important to address pain and pain points. That’s what we concentrated on. What irks people? What frustrates people and is a real inconvenience and hassle for them? It’s also really important to know who you are building for and understand and anticipate what their needs are. What was great as a New York-based team was that we were building for New Yorkers, as New Yorkers who live and work in the state, it was a product made for the people and by the people. Proudly, I was born here and every level of education and work experience for me has been in New York. I think it matters that the people who are building a utility have some connection to it. It makes it really personal and gets rid of technology being created in isolation from the people who will actually be using it -something that definitely irks me.

One of the really great things that NYeC included in the design competition was a public voting portion, besides also having both an Upstate and Downstate expert judging panel and public showing on demo day. All of the finalists uploaded videos that would show elements of what their design submissions would look like and the general public would have the opportunity to vote for their favorites. I saw demo day and online voting as great ways that non-techie and non-health people could get involved and I knew it would provide great feedback on what people liked/didn’t like/wanted. In a way, it was the democratization of design.

As a whole, I saw it not as just another demo day or competition but as the opportunity to really showcase how different our design was and how different our approach to building the portal would be. All of our hopes for it, all of our passion for what it would mean for people around us (our families, our friends, our patients), all of who we were and our experiences went into it. To me, design/technology/products, aren’t just the sum total of form and function, they also are about the feeling and environment that are created when you are using them. I often find that I like using things that I find aesthetically pleasing, have a funny wink or nod in them, are device agnostic, and that solve some sort of problem for me in a convenient, engaging, productive, and cost-effective way.

Besides clinical input and leading the overall thought framework for our approach, I was really involved in the social media aspect of the company as well. It was a way of engaging with the expert community and being able to talk to members of the general public. I tweeted not as a physician, but as “Mana” or well, a hu”Mana”, who was working to build the change that we wanted to see in healthcare and also shared some of the latest news and innovations that were happening in the exciting field of digital health. It was fun to interact with people not just in New York, but from different states and even from places like Ireland or Australia. It also was about asking people and organizations to vote not just for us, but as a whole, so that as many people as possible could take part in deciding who the winners would be.

And now the T-shirt story…

When you’re a startup, you’re often extremely resource *cough* -CASH”-*cough* poor. You know, fueled by ramen and all, so you really have to be mindful of what you can afford to spend, that is if you have any money to spend at all.

Demo day was rapidly approaching and the subject of what we’d be wearing came up. It was decided that we should get t-shirts made, and having gone to TechCrunch and a number of demo days (over 100), I really liked that idea because they are fun to look at and as a team, it’s very cohesive-looking and makes you identifiable in a crowd. Only issue was that for 6-8 people, the T-shirts would likely cost us $100-$200 which would be better spent on things we really needed -like getting to Albany to present to the judges upstate. Also, we needed shirts in different sizes.

Necessity is often the mother of invention, and sometimes limited resources ($0) can force you to become really creative. So what does a crackerjack team do but roll up their sleeves and come up with a cost-effective solution. I went to every dollar store, discount retailer, chain store to find t-shirts. Was really happy that white was one of the company colors cuz those shirts were the most wallet-friendly. I ended up buying 2 shirts at one store and buying the rest of the shirts at a store where I definitely hit the motherload. There was this one store that was liquidating white t-shirts that were all irregular with black lines through their tags and they were in this huge pile. I dug right in, picking over ones that were stained, had holes in them or were the wrong size. All in all, I was able to buy all the shirts we needed for a grand total of $12.

The shirts looked a little bit dingy and wrinkled, having been in that pile in that dusty crate and they were a little stiff, so I went to the laundromat and washed them at a cost of $2 for the wash, $1.50 for the dry and “free” detergent, bleach and fabric softener (a brand-name borrow of the good stuff from my parents). Then I took the shirts to the incubator space after asking my sister for her iron.

Kevin the med student had been in charge of getting the special t-shirt screen paper and he was able to get some for $12 from Office Depot. We printed out the company logo sans words onto the paper using the co-working printer. (The reason for this is that we didn’t have enough supplies if the words came out backwards or if something went wrong). Then, we set up a factory line where I pre-ironed the t-shirts and laid them on chairs in the space and Kevin steam-ironed the logos on and hung them to dry. And TADA! There you have it folks, t-shirts printed for an entire team for a little bit over what it would’ve cost to professionally print one team member’s shirt ($27.50 total out-of-pocket cost).

I personally think that whoever looks over the incubator’s security video probably had a chuckle that day and thanks to the innocent bystanders who didn’t bat an eyelash as we set up our little pop-up t-shirt factory.

If you want to see our t-shirts, head over to the NYeC Facebook page, entitled “NYC Patient Portal Finalists Demo Day”. Picture 7 of 19 is pictures of some of the team members on stage and picture 11/19 is me with the guys in our shirts.

Demo day…

Finally, demo day came. I styled us and we were dressed in our team t-shirts with blazers and nice slacks/skirt and shiny shoes. I also had a bright orange Mana-cure as a nod to the team colors. We wanted to look professional but approachable and even a bit playful because that is what our approach was. At its core, medicine/health is about people and I really feel that you can be both personable and professional. Laughter is often the best medicine, no?

There were about 8 demos in total and it was interesting to see the variations in terms of design and features, some of which were later integrated into what will be the final version of the portal before its official launch. I sat in the audience because I really wanted to hear what people in the audience had to say in an unfiltered way. It was really helpful.

I think that there were several things that really differentiated us from the competition:

  1. Visually, we were the only ones that had t-shirts and looked like a team. We also looked much younger than our competitors which is different because there is often a level of gravitas that people associate with healthcare. (But I’ve worked in every single borough in some capacity from hospitals to community centers to health fairs and 10 years is a long time to be in any field).
  2. We were a company based in New York. (Hometown pride).
  3. Our tile design was different. It was meant to be so. It was meant to get away from the spreadsheet look of previous tools. It was meant work to well on mobile. It was meant to be accessible and device agnostic. It was meant to be aesthetically pleasing. It was meant to be a nod to apps on smartphones and the Windows desktop. (There are actually a lot of nods to things we already do, or are familiar with in the portal from stoplight color schemes to how info is presented). It was also designed to enhance those nuances that help providers and patients at the point of care.
  4. Spanish version. Living in New York means living in an international urban metropolis where people from all over the world live, work, play and converse and it was important to incorporate that diversity (and very practical element) into the design. There are hundreds of languages spoken in New York and we chose Spanish because it is the #1 non-English language spoken in New York. Communication and understanding are at the crux of healthcare and it was really important to build in elements that facilitate that. (Personally, I love learning languages and I think people really appreciate it when you are able to speak to them in their native tongue and I think that taking Spanish in college really helped me become a more effective communicator, and thus a more effective doctor when I worked in areas where Spanish was the predominant language that people spoke).
  5. Integration of the Quantified Self. Wearables are incredibly popular, but even more so, we recognized that we are entering the Information Age/Internet of Things and were aware of sensor technology and data streaming. It was about building with the future in mind.
  6. Our approach was different. It was about changing the healthcare experience from what it was to what it could be. It was about trying to eliminate as much jargon as possible (sometimes if you string enough jargon together, it actually makes less sense than plain, vernacular language). It was about taking a whole-listic approach to health and to people. Often times people segment health and healthcare out as an industry but people don’t fit into boxes and we don’t live in isolation. What we eat, where we live, what our socioeconomics are, all affect our health. We also really wanted to meet people where they are, provide access, convenience and education (it’s not enough to just collect data, it’s also about sifting out what’s important for you and to you and helping you understand what you are being presented with).

I want to take a moment out and really comment on how great it was that NYeC (which BTW is a non-profit), took this crowdsourcing approach to securing winners for the rfp contract. It bypassed the traditional procurement process and really emphasized participation by the people who would be affected most by the portal. I also think it says something about them that they took a chance on a small unproven company to do something that at times seems incredibly daunting. But innovation is about doing something different, doing something that has never been done before and for a greater purpose, for an improved experience and for a greater good. On the flip side, when one wins a contract, it is about making a commitment to serve the people using your public utility -even if you are a for profit company- continually striving for innovative excellence, and not being complacent about anything.

I think that the portal is very much a first step in the continuum of digital health and is an evolving entity. Its purpose is to help people access their information without being tethered to any one service or system. However, ultimately what I hope it does is improve the quality of people’s health so that they are healthy enough to do the things that they dream about doing. It’s not just about blood pressure or heart rate, or lab values, it’s about better health outcomes so people are able to live meaningful, joyful, fulfilling lives and spend time doing the things they love with the people they love. That is what this is about, and that to me is the ultimate health outcome.


Author Bio

Charlene Ngamwajasat

She is a NYS licensed physician. At 18, she decided to forego traditional college education and opted for a 7 year combined BS/MD program because she wanted to help people stay healthy and/or mitigate the effects of their health problems. She chose a program that focused on providing care to underserved communities because she come from humble means and I believe that everyone deserves good quality care regardless of where they come from.

After residency, she decided to take some time off to travel, discover new ideas, meet interesting people, and delve into the dynamic changes that were occurring in medicine–especially those related to the use of technology.

Reprinted with permission.

Photo Credit: CC by Tabitha Kaylee Hawk

About the author: Dr. Charlene Ngamwajasat

Dr. Charlene Ngamwajasat is the creator and writer of the blog Just Curious. She practices in New York City, specializing in internal medicine. She describes herself as a physician who loves to travel, read and experience new things.

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