[00:00:00] Joy Rios: Hello, and welcome back to the HIT Like a Girl podcast. I'm your host, Joy Rios, and today we continue our deep dive into techquity, our five part series focused on digital health equity. Each episode, we'll explore different facets of how technology can bridge gaps in healthcare to ensure equitable outcomes for all.

I’m here with Janna Guinen from the HLTH Foundation. Today we're going to keep it simple. One thing we have not covered about the Techquity for Health Coalition is how to get involved. Can you talk to us about that? And hello again, Janna.

[00:00:43] Janna Guinen: Hello again, Joy, and also to our listeners. Yes, true, we have not told anyone how they can get involved. In the Techquity for Health Coalition.

So here we go. We're not hiding. I promise. We actually have a lot of work to do this year of publishing and doing outreach and planning another case study competition for this year. So we definitely want to need others to get involved. Here you go. Please reach out to me if you're interested in the Techquity for Health Coalition at info@hlthfoundation.org. So HLTH Foundation is HLTH, HLTHfoundation.org. So that's where we are.

And then I'm gonna do a quick catch up for anyone who may be joining us for the first time. Today we are here talking about HLTH Foundation's Equity for Health Coalition, which is focused on how to effectively harness digital health and data for people underserved by the healthcare system. The goal is to overcome health disparities and to do it consistently and effectively and successfully. So in this series, Joy and I are teeing up interviews with winners of the Coalition's Techquity for Health case study competition that winners just announced at the end of February.

So today's episode is actually a really personal one for me. So one Saturday last fall, I was reviewing case studies and I learned about a free app that could help my own mother and I want to tell you this was a moment of high emotion for me in all of this. This is a project that was submitted by a digital design agency called WillowTree and it concerns an app called Vocable.

Which was designed to enable nonverbal people to communicate. And a lot of people might remember Stephen Hawking the astrophysicist who had ALS and he used a device where he could speak by using his eyes would be looking at the letters and he would look at the each letter to spell out words that were then vocalized by a special device.

And I also want to say I've learned since learning about Vocable that there are just so many reasons why someone may be nonverbal. And in many cases, devices like Stephen Hawking had are just not affordable. So the Vocable app uses a newer technology that's more affordable than what Stephen Hawking had.

He had a different type of technologies, eye tracking technology. On top of this, WillowTree has made this app entirely free. This is a project that was started by someone on the WillowTree team for personal reasons. It's a personal thing to me too, so for me, it was an entirely different experience, like being a reviewer on this and thinking in such an intimate way about the impact that technology can have when it's well designed and well thought of and made accessible, available, all of that.

The personal story for me is that my mother is now almost completely non verbal, but her mind is intact. So I can just say that creates a lot of suffering for a person who isn't able to communicate their needs or their feelings. So I've tried Vocable with her. We had some success with it off the bat.

It takes some learning though, but we're going to be working to help her use Vocable and it really is just not an exaggeration to say that it could change her life. So that's my story, but what I want you to be listening for to for the listening audience is how willow tree continues to involve patients and communications experts as they learn and expand into new patient populations.

And the ways that they've given consideration to affordability to accessibility, not just of their particular app, but across mobile devices and also the way that they manage privacy. So I hope that this interview drives home the importance of transparency. And also of collaboration when it comes to digital health equity.

So let's take a listen and you're going to hear from Rachel Starnes, the group vice president and managing director at WillowTree and then Kylie Kalik, Vocables app and the Vocable app product owner. And then the guest host today is Dr. Tanisha Hill, who is the founder and president of the Digital Health for Equitable Health Alliance and also a Tech Equity for Health Coalition advisor.

[00:04:49] Joy Rios: Janna, thank you for sharing your story and for teasing up this interview. Let's jump in.

[00:04:56] Tanisha Hill: Hi, I'm Tanisha Hill. I am the founder and president for Digital Health for Equitable Health Alliance. And i'm also an advisor for Techquity for Health for the HLTH Foundation. So i'm excited to come to you all today to the listeners to join me in a wonderful conversation with Rachel and Kylie who are going to introduce themselves from WillowTree.

We're talking about Vocable. We're excited about the technology that they've developed and we're going to dive into some really wonderful discussion. But before that, how about I start with Rachel? Rachel, would you like to introduce yourself?

[00:05:30] Rachel Starnes: Yeah, thanks, Tanisha. Hi, everyone. I'm Rachel Starnes, Group VP of Design at WillowTree.

And at WillowTree, I oversee and lead about 100 designers focused on partnering with clients, delivering some world class design experiences that hopefully impact our users and businesses.

[00:05:44] Rachel Starnes: And Kylie, how about you introduce yourself?

[00:05:46] Kylie Kalik: Sure. Thank you. My name is Kylie Kalik. I'm a Product Lead Director at Willowtree.

In my role, I help our clients understand and dig into what their problems are and what we can do to solve them. And I'm also the long term product owner for Vocable AAC.

[00:06:04] Tanisha Hill: I'm excited to chat about this project that you all have been selected for. So Kylie, I'm going to start with you. Can you describe the project for us, for our listeners on the podcast?

[00:06:13] Kylie Kalik: Sure. Vocable AAC is a augmentative assistive communication app for folks that are non verbal and may or may not have minimal use of hands, other extremities, functions, so they are able to communicate via head movements using facial tracking and touch if need be.

[00:06:35] Great. So tell us a little bit about your origin story.

What made you all come to this conclusion that we needed this type of technology?

[00:06:44] Kylie Kalik: Absolutely. So our origin takes us back to actually about 2018. We had a teammate in WillowTree whose partner came down with Guillain Barre, which is a essentially a very sudden shutdown of most of the body systems leads to paralysis and very commonly lack of verbal skills.

And at that time, and even now still in hospitals, the technology is using talk boards. So having boards with letters, symbols, words, and for asking folks to blink, point, use a finger in order to communicate. So her teammates said there has to be something better. We have to give credit to Mr. Matt Kubota himself.

He said there has to be something better. So he started bouncing some ideas around in the office. And this is when ARKit came in to play in Apple. And this is allows all that head tracking and some of the kind of laser eye movements that you may see. And we were able to come up with some small prototypes of having ways to use head tracking and use a keyboard for folks to verbalize and put communication together.

There are some similar technologies out there, but they cost thousands and thousands of dollars. And for folks that are using them long term. They have to go through months of adjustments, months of approvals from insurance. It's just not readily available at the time of need. If somebody is going through which is sudden car accidents, any things of that nature that are very quick and day to night.

So it's, we are looking for something quick, easy, free that can be picked up. So we've been iterating ever since on having something that is free, readily available and easy enough to pick up on the time of incident.

[00:08:28] Tanisha Hill: Great. And I wonder if you had any partners when you all were developing this technology.

Who did you partner with?

[00:08:37] Kylie Kalik: Yeah, we've had a lot of partners. So I mentioned Matt Kubota. He was our teammate. We've had a huge array of teammates that have worked on this over the years. As this has been a passion project for WillowTree. So cute shout outs to Chris Stroud, Steve Gordon, Casey Lomas, Nick Cook, a huge array of folks.

In addition to that, we've had partnerships at Duke. The team that was mainly working on this was based in our Durham, North Carolina office. So we had some partners at Duke in their digital health and assistive technology regions, the NC and North Carolina digital technology for health coalition, who works directly with the department of state health services.

We have probably about 20 or so speech linguist pathologists that we've directly worked with and done user interviews with to gain actual patient insight, user insight, general feedback as we make content, things of that nature. And then John Costello, who's the director of augmentative communication program and ALS augmentative communication program at Boston Children's.

He's become a very recent in the last couple of years champion of our technology and use, and we meet with him probably every six months or so, if not more frequently to get his feedback on the latest and greatest technology in a, and what's really needed in these really quick onset, as well as an ALS community of those kind of rapid decline of folks that are really literate that need a little bit of that kind of ramp up time.

So we've had some really incredible partners in addition to leadership is a huge champion for Vocable and voice in general. And that's what Vocable is all about is giving folks a voice who need it the most. So really great partnership with everyone at the leadership level.

[00:10:17] Tanisha Hill: That’s exciting. In my role as president for the Digital Health and Equitable Health Alliance, we try to put patience first, right?

And I think partnerships are one of the key aspects of our group is that we partner and it's partners, you wouldn't expect. We have pharma. We've got universities and it's what you all have been doing. I think partnerships are very important to really get to a tool, a digital tool. It's usable for basically everyone.

So I'm excited to hear how many partners and how thoughtful you are in terms of the development of the technology. So Vocable AZ represents a significant step in assistive technology. Can you talk to me a little bit about the initial tech design and how you may have had some design challenges, if any, and in while you were creating this sort of intuitive interface that could be used by people with communication challenges?

[00:11:06] Rachel Starnes: Yeah, so I'll take that one. Challenges started with creating a really strong design system. And so with a design system, you have to be very focused on creating a simple, creating it easy to use, reusable, and especially a design system with a new medium, which is using head tracking, which some designers were less familiar with.

And so when establishing a design system, we also need to consider a great user experience. So how do we use minimal UI? How do we take away unnecessary steps and make it as quick as possible to really get down to the answers that we were seeking? So the UI decisions of designing for head tracking is completely different than designing for touch type.

It's got different qualifications and it really makes a challenge, especially for those designers who have never designed for this type of medium. And Vocable really relies on the ability to quickly read, to quickly understand answers, to have recall on what icons mean. And so for this reason, Vocable uses a lot of the native iOS and Android iconography patterns where audiences are really familiar with understanding the normal, simple icons that audiences can understand.

So some of the additional challenges that we faced were everything needed to be very well spaced and organized. So when, particularly thinking about a device and thinking about head tracking, we had to have a very consistent grid. And so getting into the details, even though it's my nerd alert hats going on, because I'm a designer at heart, sticking within an 8 pixel grid, making sure we had consistency in the layouts for predictability. Not only for the audiences who are consuming this product, but also we needed to develop really rapidly and at a quick pace and allowing that consistency with our audiences and the developers to have that shorthand and for us to be able to get out features quickly. Additionally, the app I mentioned previously, the app uses a lot of system icons, particularly for iOS and Android.

We like to stay away from any custom bespoke icons, but we also established a path because we know there down the road, there might be additional icons that we need to introduce and creating a pathway to do that. But just ensuring consistency, I would say, was the biggest design challenge that we faced.

Especially in designing this new medium.

[00:13:37] Tanisha Hill: So I had a chance to download the technology of the app. I was pretty excited about the fact that users could actually add what they needed into the app in terms of communication. They could have their own phrases or words, for example. And so can you tell me, you touched on UI, but can you tell me a little bit about the user experience?

How would, how did you use user feedback to shape the final product?

[00:13:59] Rachel Starnes: Yeah Kylie mentioned earlier that we have great partners in the system that we're relying on. We're talking to speech pathologists, but what's also really unique is it's an open source project. So we have designers who can come into our files from all over the world and make input on to the type of features, the type of designs that we are going after, and it's a, there definitely is some ground rules. It's a campground rule of leaving it better than you found it, but also taking into the consideration of feedback based on some of the comments people are emailing in.

We're seeing some data, even though it's very light data, making sure that people can download it, but strategically, it's open for everyone, and we seek a lot of feedback, but we also need to prioritize that feedback in a meaningful way, and that feedback is prioritized for our users and then also prioritized on feasibility for us to be able to get out the features.

[00:14:56] Tanisha Hill: Wonderful. So I pride myself on in making sure that all patients have access to digital health technology. So that's what we do at DHEH. That's what we advocate for. And I think one of the greatest parts of what you all are doing is the access, the ability for access and affordability. And I know that Kylie talked about how other technologies tend to be pretty expensive.

Can you guys talk to us about how you balanced access and availability and any ethical concerns that you all may have come across? As you were developing this technology?

[00:15:31] Rachel Starnes: So strategically, as far as the ethical concerns, there are no analytics collected and that's on purpose for safety and security reasons.

And it's a little bit of a double edge because double edged sword as a designer, I want analytics. I want to see what people are getting tripped up on. I want to see the type of users I want to see what's behind the curtain, but for safety and security. We want to keep it free. We want to keep it where we're not storing any data associated with any individual user.

And so what that means is there's no analytics and no data collection. So additionally with, as it pertains to how we can create it accessible for everyone. We're on top of all the OS updates. So when you think about the operating systems that Android and iOS have, especially Android, that might have more access to different countries, we want to make sure that the, their phones and devices, whatever device they're on, it works.

And so that means that we have to make sure that all the devices help me out. Kylie, I don't think I have a note on this. We have a lot of different devices that we do support. It's particularly not just the brand new, shiny iOS 15, we need to support older devices and devices that might not be in more common in other countries and particularly Android.

And so maintaining both systems of iOS and Android at the same time are really important just for accessibility reasons and for folks to, to be able to download it and use it. Kylie, was there anything else on that one?

[00:17:04] Kylie Kalik: No, just a tip, on Android, in particular, Android has a much larger global reach as a platform in general, so we had some issues with Android for a bit and actually took it down from the Google Play Store to ensure the greatest amount of safety and accessibility and usability, and we recently put it back on earlier this year and got it back up and running in the Play Store to make sure that it was supporting it.

Essentially, as far back of OS versions as possible that are still in high use in areas like China, India, areas of the Middle East, so that we have as much accessibility as humanly possible for folks that need it as we've to your point about feedback. We've gotten a lot of feedback of folks asking. Can you please scale back?

For this version, and we go and look at the analytics in terms of downloads and the versions and making sure that we have that coverage.

[00:17:55] Tanisha Hill: It sounds like we'll actually had to do quite a bit of work to make sure that these that the technology was actually accessible across devices, which is sometimes a challenge.

And to your point, you mentioned different devices. Some folks may have older devices and not have the most updated software applications or Whatever it's functioning behind the scenes on their technology. And can you talk to me a little bit about how you guys continue to make sure that you have the high quality functionality that you're just describing a little earlier?

[00:18:25] Kylie Kalik: The biggest thing is we treat Vocable as we treat any of our client projects, which means that the quality testing that goes into it is just as high of a standard if not higher.

So we will take not just emulators and simulators. On our computers, we will get actual handsets and make sure that everything is up to snuff. Everything works. Everything is responsive as it needs to be. We do testing to make sure it's performant and that it actually downloads. They're not getting any errors. We take, we really do take the time to go through those layers of tasks to make sure that it's working.

[00:19:00] Tanisha Hill: So you guys are going to take a step back and talk a little bit more about collaborations because the case study, this award is about techquity, right?

And I've talked to you all about digital health for equitable health. And we talk about making sure that these technologies are accessible for all. I'm just wondering, we've talked about giving technology this accessibility for people who aren't vocal. What about different populations of people in underserved populations, for example?

That's where we are, the nonprofit that we serve. Can you talk to me a little bit about how you, how any nuances or considerations or experiences with people with other disabilities or people in underserved populations or people in different age groups, any discussions or considerations around those topics?

[00:19:45] Rachel Starnes: There is a grading system of accessibility that all products are assigned, and AA is a pretty standard accessibility standard that is applied that we aspire at WillowTree all of our products to be AA. However, with Vocable, we sought out AAA, and if anybody's listening in, that is a really hard feat to do.

AAA accessibility is not only taking a look at color. It's keyboard access, it's displaying ARIA labels and making sure that everything is tagged appropriately, but in particular, color is a part of that. There's a lot of different spectrum of color blindness, like protanopia, people have different type of color blindness that affect their way of viewing the application.

And thinking about the design system, our design system ties color to actions. So we use calm navy as a main color background color to inform more informational pieces. We use that hot, active green in order to really showcase active and success states, but also touch targets. There's a broad range of people who will either be touching and interacting or using their head tracking for the very first time and under very different circumstances.

And so when thinking about different type of audiences that may need different accommodations, definitely taking a look at touch targets and also visual timing so everyone reacts in a different time and just how we all read a different pace and time. And so making sure that we're always allowing for additional time for achieving a specific goal.

But additionally, making it, I think I touched on this earlier, making it open source for other individuals to come into the files, to be able to speak and address some of the languages that we use. Kylie might have mentioned this in the beginning, but Vocable is being used all over the world, and particularly in regions of China and the EU, and to get those nuances is correct.

We need to rely on those local to make those design decisions and to have that input. And so it's really key when thinking about accessibility, not just thinking about designing it for myself or a friend, but really thinking about those who are in different communities and different locations and different age, different demographics, and being able to accommodate one product for all of these individual users.

[00:22:12] Tanisha Hill: That's really exciting. Kylie, any additional comment?

[00:22:13] Kylie Kalik: When we initially launched Vocable, this wasn't intentional whatsoever, but around the second week of March 2020, and some may or may not remember, around the third week of March 2020 is when the world shut down. Our initial actual huge use of users were COVID units in China and Italy, and that's where the localization initially came in.

So we had users of all age, all demographics, all levels of socioeconomic status, trying to find a way to communicate with their loved ones, maybe for the last time. So we had a huge grasp there. And as we continue to develop in addition to COVID units, we were getting a lot of use in ALS and stroke units.

And over the years, we've also grasped folks in schools, public schools in particular, especially those in lower SES areas that have really limited use of devices for children with IEPs that Just need something that they can use out of the box. When they get to school, they may not have a device that they can take home with them, but they have one that they share with a classmate.

So having that customization that can be shared across on a single device is huge for them. And that's allowed granted a lot of access for folks in schools. In addition, we've had a lot of big grass. Excuse me, from folks with autism on the spectrum that have verbal and nonverbal days. We get emails about weekly from folks saying that their feedback saying that Vocable has increased their life and their ability to go out and socialize with folks a little bit more because they have a way to do that now.

And a lot of the, oftentimes It's because of that low price barrier. They're the only price barriers there, whatever device they're on. So they've said they've looked at other options and they just couldn't afford it. And now that affordability is there and they have that option, which is incredible to hear about.

[00:24:12] Tanisha Hill: So I’m so excited that you shared both how the technology made an impact during pandemic, which we as a world weren't really prepared for. And I think we're more prepared in the future, but it really shows how digital health technology can really transform communication, especially people who are nonverbal.

And then you also talked about how it affects different populations. Those with lower socioeconomic status. I think I was really excited to hear from you. The examples about patients, people with autism and just. It moves me to see the impact that this technology can have on different people in different places, different races, different experiences.

It really talks about what we really want to focus on, which is techquity, right? It's a true example of techquity. So I'm super excited that you shared those examples with us and that Rachel, you gave us sort of the design. from a designer's perspective too. And I will tell you it's exciting to talk to designers.

I don't normally get to do this in the realm that I'm in digital health. I'm talking to HCPs or for us, it's more political. We'll talk to folks on the Hill. So people are a little bit excited, but also concerned about the future in terms of AI. So I wanted to ask you my last one of my last questions for today.

It's around the AI, the integration of voice technology and AI, especially chat. GBT is has become highlighted basically as a game changer for enhancing vocals, responsiveness and user experience.

Can you guys talk a little bit about how your team approach to incorporating what's your team's approach to incorporating these types of technologies?

[00:25:53] Kylie Kalik: I can take that on as a digital agency, we want to be on the cutting edge of all things. But as Vocable is a big part of our org and our culture, we wanted to include, we want to make sure that we were including that and taking all use cases into consideration. So a few years ago, we actually started working on listening mode, which is where we put our AI for folks that are unfamiliar with it's a mode within Vocable where somebody can tap listening mode and other folks within the room can ask it ask questions and prompt invocable will prompt potential answers for the individual to use to answer as well as an ability to create their own custom answer as well.

Where this came into where AI comes into play is the use of large language models and other things like ChatGPT to better inform those potential answers. We started with a really slim modeling tool that we were using for a pizza app actually, and it's formed that to be a little bit more inclusive of greater variations of questions.

And when chat GPT came out, we were able to pull in some more of those language models were able to increase the breadth of scope and breadth of potential language to be used in the app. So that's where we're steering right now. And then, in addition to that, we have expanded into vision OS, and we're able to bring some of those pieces in as well with ARKit and AR and AI interfacing together.

[00:27:21] Tanisha Hill: Spectacular. So I have one final question for you both. It's really just your final comment really on you're passion and I hope folks can hear your passion. I'm excited that I got to talk with you today. And I'm just wondering if you have any last few last comments for the listeners.

[00:27:39] Rachel Starnes: Yeah, I'll go first. What I love about Vocable is focusing on the problem and the need that it serves. And so when I think about addressing health disparities, I think about innovation, innovative solutions. But I also think about that solutions are only good as the problem that it's serving. And so I love that Vocable is focused in on the problem that it's serving and that we are iterative and adaptable, especially there's a lot of different solutions that we could apply and different features and functions that we can roll out, but at the core of it, we have a mission and that mission is to give a voice to those that don't have it.

And so I guess my takeaway would be focusing in on the problem spaces, because if we focus on the problem, we have a high, more high likelihood of success than if we just focus on the full solution. I love this step. That Forrest says that 86 percent of innovative ideas are successful if you're problem led and user focused versus just being solution oriented and solution focused.

And so I love that with Vocable and my takeaway is like really focusing in on the problems and needs that it serves and that will spark the innovative ideas and lend itself to, yeah, disrupting heath disparities.

[00:29:07] Kylie Kalik: Thank you, Rachel. To expand off of Rachel's point, my message for all is that Vocable came out of a singular problem, and we've been able to expand to help solve for more as we learn more.

My encouragement to everyone is to download Vocable, keep your eyes and ears open in the community, and if you see an area where you think Vocable could help, send us a message. That's how we innovate, that's how we iterate, that's how we create our future solutions. We can't do it alone in a silo and we want to be able to help as many folks as possible.

So if you hear something, think of something, please let us know.

[00:29:43] Tanisha Hill: I personally have downloaded Vocable. I encourage others to do the same. I'm excited about the work that you all are doing. I hope you continue to do it, stay the course. And one of the things that I want listeners to take away is what Rachel said.

Techquity is going to be advanced when we become more user focused, not so much product focused, but problem focused. And as long as we continue to keep those two areas top of mind, I think we can really advance the space of techquity and make sure that digital health technologies are available and accessible for all.

So thank you both for sitting and chatting with me today. I'm glad I had the time and the opportunity to meet you and talk with you about the exciting work that you're doing. And I hope that the listeners feel just as passionate now that you've inspired me as I feel right now. So have a great afternoon and thank you very much.

[00:30:37] Rachel Starnes: Yeah, thanks so much for having us.

[00:30:39] Kylie Kalik: Thank you so much.

[00:30:40] Joy Rios: Thanks for joining us as we've explored this winning techquity case study. To learn more about the amazing work being recognized by the Techquity for Health Coalition and see all the incredible winners we've featured throughout this series, head over to the dedicated Techquity landing page on the HIT Like a Girl website. You'll find it linked in the show notes.

Before you go, remember to like, follow, and subscribe to the HIT Like a Girl podcast. And if you've enjoyed this episode, please share it with a friend who might be interested in digital health equity. Alright, thanks! See you

Rachel Starnes

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