Latest / StartUp Health NOW Podcast / StartUp Health Fireside Chat: Dr. Ashwini Zenooz, GM and Chief Medical Officer at Salesforce

Transcript

StartUp Health Fireside Chat: Dr. Ashwini Zenooz, GM and Chief Medical Officer at Salesforce · StartUp Health NOW Podcast

• 0:00
  [ on-hold music] Look, I think the more you collaborate with the clinicians, the better you're gonna understand what their challenges are.
• 0:18
  And this goes not just for clinicians, but you're talking also, you know, I was also an administrator, so you have business operations, right?
• 0:25
  So you need the people that you're building things for at the table so that you can understand what challenges you're trying to solve for, so you can have an end-to-end solution.
• 0:32
  But it is very important to not work in a silo, um, or just to read about it or hear about it and start making changes, right? I think it's important to understand the challenges and the nuances. Yeah.
• 0:43
  [upbeat music] Hello and welcome to StartUp Health NOW, the podcast where we talk with the entrepreneurs shaping the future of health and discuss the health moonshots that they're working to achieve.
• 0:59
  I'm Logan Plaster, your host, the editor-in-chief at StartUp Health. On this episode, I have the pleasure of bringing you a conversation with Dr. Ashwini Zoonuz, GM and chief medical officer at Salesforce.
• 1:11
  Before taking on her role at the tech giant, Dr. Zoonuz, who is a practicing radiologist, oversaw the modernizing of electronic health records, EHRs, at Veterans Administration.
• 1:23
  During her time at the VA, she was instrumental in pushing for regulations that allow providers to be able to practice medicine across state lines.
• 1:31
  In her role at Salesforce, Zoonuz is exploring the many ways that the company's relationship management technology can be applied to health, from vaccine rollouts to individual patient records.
• 1:42
  This conversation was pooled from StartUp Health's Fireside Chat series, so in addition to Dr. Zoonuz's voice, you'll hear some real-world questions and comments from founders in the StartUp Health portfolio.
• 1:54
  Want to get more content like this? You can subscribe to the podcast as well as get other health innovation updates by going to our website, startuphealth.com, and clicking on the content tab.
• 2:05
  Now, onto the interview with Dr. Ashwini Zoonuz. [upbeat music] Dr. Ash, you were hired by Salesforce in 2018.
• 2:20
  Uh, you were already having a big impact at the VA, as I just said, in policy. You're a practicing radiologist. I can only imagine the kind of impact that you were looking for in, in an opportunity.
• 2:31
  So, uh, what impact were you hoping to have by moving to the CRM giant, uh, in 2018? Yeah, thanks for that.
• 2:41
  Um, so I've been here about two years, and [clears throat] definitely didn't think that I was coming into a role that I'd be in today. Uh, didn't expect all of the things that we've, like, experienced, right?
• 2:52
  So, but what I will say is, you know, I've spent most of my professional career as a clinician and as an administrator. So, um, you know, at some point, uh, during that time,
• 3:05
  I started c- be-- I became a caregiver for a very ill, uh, family member who happened to be my mom, and I think that's when you quickly realize that what you think healthcare looks like on one side is not what's happening on the other side.
• 3:19
  Um, so for me, um, going into policy and then working within a, uh, w- within government to scale things was more from that perspective. I felt like you needed to have better collaboration tools.
• 3:34
  You need to have, uh, data and insights.
• 3:37
  Um, I want that to be readily available, and for patients to have the opportunity to seamlessly share, uh, their data so that they, too, um, you know, could have a choice and actively participate in their healthcare.
• 3:50
  So definitely lessons learned for me coming from the VA was, [clears throat] you know, technology is a great, uh, accelerator, uh, in so many ways to all of the things that we're trying to get done.
• 4:02
  And Salesforce had this incredible opportunity. You know, right before I joined, they had purchased MuleSoft, um, uh, which is a, an integration tool and, you know, enterprise integration tool.
• 4:14
  And there was a lot of interest, uh, at this company, uh, around health just not being a product, more around how do you add and change things in healthcare, what are the bigger conversations we could be having, not just from building products, but where are we going to, uh, invest, what kind of partnerships are we going to have, and then what are the things that we'll do in terms of like giving a platform for change.
• 4:39
  So to me, those are the things that were really interesting and why I chose to come here. Got it. And I'm guessing that your role has evolved in those two years. Uh, this has been an active two years in health.
• 4:52
  So s- kind of talk us through the trajectory of health at Salesforce from 2018 till now. Yeah, I mean, absolutely. I think, um, you know, just from a...
• 5:03
  Like I said, when I came here, it was an, um, it was more as a, you know, you have clinical and a hospital administration and payer experience, come and help us think through solutions.
• 5:14
  And that has obviously, uh, exploded, uh, because of the digital health transformation and the investments in general.
• 5:21
  And then comes along the pandemic this year, um, where you really need to think about these solutions, uh, and ensure that it's scalable [clears throat] across, across the globe, right? We're in a globalized economy.
• 5:34
  So addressing things for one pocket of the world doesn't work today. So, um, definitely my role has significantly expanded.
• 5:42
  And then from that, I think just as somebody who has, um, healthcare, clinical, and public health expertise to serve as a translator, and somebody who can sit in between the conversations with governments or, you know, other folks, uh, in other organizations who are also, who also have a clinical background, um-To think through how do we take care of our own employees, you know, how do you collaborate between different organizations to think through how they're caring for their employees.
• 6:11
  Um, these are really active conversations. I feel like I have a second job, uh, that is just as, if not more equally, uh, you know, more important in so many ways right now.
• 6:22
  You know, as the vaccines are coming out, thinking through, like, what is the vaccine strategy. There are different types of vaccines, which one's more effective, can you require them?
• 6:31
  These are all conversations that, you know, it's been really, um, I hope helpful for my organization, but definitely for me, uh, to have a seat at the table so I can be participating in these conversations. Yeah.
• 6:45
  Um, how much of a culture clash was there when you came out to San Francisco and you entered tech as a, as a clinician? [sighs] Oh, gosh. Are you trying to trap me? [laughs] Um, you know, so I...
• 7:01
  As a clinician who's, like, gone into tech and tried to lead change management across VA, um, I experienced, I think, large scale what it was like to work between those two areas.
• 7:14
  I think, you know, I think in our industry, like, people go in other industries and talk about, like, move things break fast, you know, or m- move fast, break things. [laughs] Right? Is that what they say? Yeah. Sure.
• 7:26
  Um, uh, I'm blanking on his... Zuckerberg. I found that often, because I think we're so-- we want to be resistant to that as clinicians, right? We don't want to disrupt, we don't want things to be broken.
• 7:38
  But I think for somebody that sits at the intersection of the two, you recognize, like, you need to be able to do that without breaking things, or improving things.
• 7:48
  So there's definitely always a culture clash, and I think what's happened is, at least in, in healthcare, people would come to us and say, "We know what you need, and we're gonna tell you what you need to do."
• 7:57
  And I think that needed to change. It's something I learned when I was at the VA.
• 8:01
  You need to have your frontline providers, your schedulers, et cetera, at the table when you're making workflow changes and you're doing, you know, large implementations. Um, so
• 8:13
  I feel like it's been less of a culture clash here in, uh, at Salesforce, because I'd experienced that in my prior roles, right? Yeah. Um, but yeah. I mean, I think there's always a...
• 8:25
  You know, you need to, like, walk the halls together and spend more time together, instead of just an hour a week in a, in a conference room. That's what I would say. Yeah.
• 8:33
  Just to sort of bring it home, uh, for the founders on the call, what's your advice in terms of bringing that balance to your decision-making?
• 8:41
  Uh, how important is it to have clinicians as part of your advisory board, et cetera? Yeah.
• 8:49
  [laughs] Look, I think the more you collaborate with the clinicians, the better you're gonna understand what their challenges are.
• 8:56
  And this goes not just for clinicians, but you're talking also, you know, I was also an administrator, so you have business operations, right?
• 9:03
  So you need the people that you're building things for at the table so that you can understand what challenges you're trying to solve for, so you can have an end-to-end solution.
• 9:11
  So whether you have an in-house person or you have an advisor or you have a design partnership, um, I think any of those or all of those will work depending on how large you are.
• 9:22
  Um, but it is very important to not work in a silo, um, or just to read about it or hear about it and start making changes, right? I think it's important to understand the challenges- Yeah... and the nuances. Yeah.
• 9:34
  Um, thinking more globally, I mean, how would you describe, how would you paint how Salesforce thinks about health today? Um, v- is it just another vertical? Is it more foundational than that?
• 9:47
  Kind of what's the ethos around health at Sa- Salesforce? So I don't think we ever thought about it as a vertical necessarily.
• 9:55
  Um, definitely we've seen that over the last 20-plus years the company's been around, um, we've done really well just as a horizontal, uh, set of products to build out solutions across different, um, you know, subverticals within our healthcare space.
• 10:11
  Uh, we do have a verticalized product in the space, but I think as a company what I would say is [clears throat] we, especially today, I don't think a company that has a healthcare product like us can think about what we're doing from just as a vertical.
• 10:28
  Um, you know, I talk to companies, you know, I talk to folks who are in the grocery business, I talk to people in the manufacturing plants, I'm talking with people in the finance industry.
• 10:37
  Every company is a healthcare company today, and I expect it to be for the next, at least the next few years, you know, um, until we have equitable distribution and herd immunity, um, understand how long vaccines are going to actually provide the immunity.
• 10:52
  There are so many things that are happening in the space that I think we need to be providing tools for people to, to work from, uh, anywhere. We need to provide tools for people to collaborate.
• 11:03
  We need to provide tools for people to come back safely to work. Uh, we need to provide tools for people to travel safely. So I think there are so many things that are needed from a health perspective.
• 11:13
  Uh, I think we think about it much more globally, uh, or much more q- in a comprehensive way, uh, in addition to just thinking of it as just a vertical. What does that mean for your job as CMO?
• 11:25
  If, if every company is a health company, what does that mean for the scope of your work and kind of the, the challenges that you see coming down the pike? Yeah, I mean, it's been...
• 11:35
  Look, it's been really, really fun to just build out solutions and, uh, adding, adding things for our subverticals, and I will continue to work with those product, uh, teams and, you know, our team's gonna continue to help with that.
• 11:50
  But I think right now, like I said, over, at least for the next couple of years, um, we have a bigger role to play, uh, as we think through, like, how are airlines gonna get up and running? What are the things they need?
• 12:02
  How do we get people back into the movie theaters or stadiums and, you know, have it safe?Um, the future of work. Like, these are all conversations and solutions that we need to think about.
• 12:12
  And, you know, I'm not say- I d- I actually don't think that Salesforce can do this alone. It's going to require a lot of partnerships, a lot of collaboration, um, big and small. And so we need to...
• 12:24
  You know, that's sort of where I'm at. I'm thinking bigger picture. Uh, I wanna think through the larger strategy of these sort of things with the leadership here, and, uh-
• 12:34
  So, so, so- Yeah, it's-- I'm gonna have to balance.
• 12:36
  So, so you really see your role and the role of Salesforce as having a hand in, in these areas, uh, like getting back to movie theaters, getting a- airlines back up and running, getting back to work, et cetera, which is a, which is a big global vision.
• 12:50
  Absolutely. I mean, we're pretty active on a global front, uh, not just from a.org or a government perspective.
• 12:57
  Um, for example, today I was just on a, um, a, a, I was just, we were just releasing news that we have a collaboration now with Gavi, the Global Alliance for vaccines, to have equitable distribution of vaccines.
• 13:09
  Um, this is really important because Gavi, the whole purpose of f- uh, forming that vaccine alliance is so that, you know, you don't have countries left behind, but you have at least, uh, some per- you know, tr- transparency, right, across, like, who has what and what the need is.
• 13:25
  And technology can do that, and we intend to play a role and partner and collaborate wherever we can, right? So we are thinking much, you know, much bigger than just sort of solving for point solutions. Interesting.
• 13:39
  Very interesting. Um, shifting gears slightly, uh, you recently penned an article for the Harvard Business Review titled Telehealth Is Working For Patients, But What About Doctors? So I'll put it straight to you.
• 13:52
  Uh, what about doctors? Is it? Yes and no. Um, you know, I talk to a lot of my colleagues who are telling me that they love having, um, some flexibility in their days when they have telehealth, right?
• 14:06
  So you, you're able to not only provide flexi- flexibility for your patients and give them more access to off hours, but you can provide care and take calls, for example, you know, after you put your kids down to bed, right?
• 14:18
  And you can provide and collaborate, um, for specialty care during your downtime. So I think it allows for a lot more flexibility.
• 14:27
  But I think in general, a lot of these solutions, like I said, haven't been designed with providers in mind.
• 14:32
  And, you know, in the past, as, you know, I think everybody on this call knows how painful it's been for clinicians when we've had to work with the EHR and EHR modernization, right? It-- We actually went backwards.
• 14:45
  I mean, I went from having people helping me, um, with my notes or filing them to, and, you know, hanging up my radiology studies to a pack station where I had to hang things myself.
• 14:56
  I had to dictate things myself, correct things myself. So the burden of, uh, that amount of work fell to the providers, uh, and the clinicians, you know, that are providing care. So,
• 15:08
  you know, with telehealth, we're hoping... I think it's still in its infancy. Telehealth, I, you know, I know it's had rapid adoption, and we're having 100, and, you know, I, I've seen all the- Sure...
• 15:18
  uh, statistics, 175X, et cetera. But telehea- telehealth is in its infancy. How we care for people and the way it's going to change is going to look really, really different a few years from now.
• 15:29
  It's been-- The pandemic has accelerated those types of changes, and I think this is a perfect opportunity to sort of think through what's a different way of working, and involving those clinicians will be important.
• 15:40
  Now, you know- Yeah, y- I say hoo-ha to people who say that older people, you know, will not use telehealth. That's been debunked, right? Mm-hmm. People are willing to use it if it's easy to use. That's right.
• 15:51
  That's right. Same goes for clinicians, you know. If you make it easy and it's, like, few clicks or n- you know, very few clicks to get to what you need to do, and you get the data at the point of care,
• 16:00
  anybody will use it, right? But it does require some education, change management, training, et cetera. Make it simple.
• 16:07
  So, so what are those practical strategies then for a health startup that wants to make sure they are making it work for, for providers? You know, you say take, take change management seriously.
• 16:18
  So, so what does that mean for the innovator, um, wanting to catch that problem on the front end? Yeah, I mean, I think you have to have focus on what you're solving for, but also understand what you're connecting to.
• 16:31
  And I say this knowing how difficult this is. We've had an interoperability problem in this industry for over, like, two decades, and we've been talking about it.
• 16:40
  So, you know, I say anybody that's building something that, you know, works with clinicians, don't have us go to, like, five different screens to get to, like, where we need to get to.
• 16:49
  If you have, like, workflows that directly integrate into the EHRs, um, or
• 16:56
  can be accessed through the EHRs, or can be accessed so that the data is bi-directional, right, where you have, uh, that data going back into the EHR. Like, take away the extra clicks that are needed.
• 17:09
  Um, pull in the information that's needed. Now, again, we're gonna have to have a different conversation around what I think is needed, uh, for that interoperability framework.
• 17:19
  What I think exists today is not functional, and so, you know, that's a, that's a whole another conversation. But I do think if you're, if you're building things, uh, you want those integrations.
• 17:31
  You want integrations into the IoT. You don't want us to get overburdened with all of the data coming in. You know, have a way to manage those so that we're only seeing, like, aberrant numbers.
• 17:42
  You know, uh, we only need the data that we need to see rather than all of somebody's, you know, uh, steps that they're walking. It's not relevant. Um, so it needs to integrate into billing.
• 17:54
  It needs to integrate into the EHR. It needs to integrate into the IoT. You know, perhaps, like, thinking about,
• 18:01
  uh, an ethical way to look at social determinant data so that you're having the appropriate data at the point of care.
• 18:07
  So if you think somebody is not gonna come back in for an appointment, you know, having that available so you can take care of that with a telehealth visit with a different provider while you have them.
• 18:16
  These are all, like, challenges healthcare has, so if you can make it easy, you'll have rapid adoption, uh, and people will use it.Nice.
• 18:25
  Um, let's take a break from my questions and I'll take a question from the founders on the call. Uh, Alan Gale from Aimee Health, uh, why don't you come off mute, uh, explain briefly what you do and, uh, ask a question.
• 18:39
  Hi, thank you for, um, the great talk so far.
• 18:42
  So, um, we provide a personalized nutrition platform working with nutritionists and doctors and coaches to very easily identify and fill gaps in a person's, uh, diet, addressing chronic diseases and various health goals.
• 18:59
  And so my question has to do with sort of the two-sided goals that many practitioners have expressed, um, as well as yourself just today.
• 19:12
  One being the desire to have a scalable solution that can work across many different populations in a, you know, fairly easy way to implement,
• 19:22
  um, as opposed to a more personalized approach with nutrition or even precision medicine or various other approaches using that personalized paradigm, but which may not scale as easily.
• 19:37
  So the problem to me seems that, a- a- and the crux of my question is, to what extent,
• 19:44
  um, are you able to evaluate personalized solutions in light of any evidence of their support when the marketplace itself doesn't often fund that kind of clinical research in order to provide that evidence? Thanks, Alan.
• 20:02
  So that's a lot of questions in one, so let me think through how to answer that. [laughs] And if I don't, if I don't get it right, uh, ask me again. But I think, you know, here's what I will say.
• 20:15
  I think all of us know that personalized medicine is where we're going, and, uh, a lot of the information, the types of, um, innovation that we've had so far has been for scalable and/or billing, right?
• 20:27
  So if you think about the EHR, for example, uh, in my opinion, I think the reason that Flatiron was so effective is because most of the, you know, oncologists did not have what was needed in the basic EHRs to do the things that they needed to do, and they couldn't get the insights that they needed.
• 20:43
  Uh, doesn't mean that you could operate in a silo. You still needed to connect that back to the EHR to get the remainder of the data, right?
• 20:51
  So I think personalization, even for chronic diseases, uh, by disease state, like certain things do not have the capability in the current, uh, system of innovation to do what we need to do.
• 21:02
  But what we learned from that is, uh, now, like in order for us to do oncology the way we'd want to do it, we also need to connect proteomics and other genomic data, et cetera.
• 21:14
  So it's becoming more and more focal for that particular industry.
• 21:18
  So if you look at nutrition, I would say for a particular chronic disease, having, um, you know, pilots with folks that fo- you know, concentrate in that area at different medical centers is a great way to get data.
• 21:30
  So, you know, I would recommend design partnerships, uh, in the space. Um, second, I mean, I think there's something to be said.
• 21:38
  You know, I think you can have two different types of innovation, one that's completely scalable and more horizontal across the healthcare industry, and one that's more focused that integrates in, which to me, uh, what you're talking about is the latter.
• 21:50
  And companies like Flatiron, Livongo, and some of the other ones that are on the market, uh, Virta, uh, Steady Health, et cetera, are showing the need for more focused, uh, disease-directed solutions, and I think they're gonna do really, really well.
• 22:05
  I think that, you know, like I said earlier, there's definitely a need to think about integration and/or interoperability and think through whether you want to build that or you want to have a partnership with a broader company that provides that fabric of interoperability.
• 22:21
  So how would we go about incorporating much of this really valuable nutritional information which presently is really not included in EHRs?
• 22:31
  You know, there's very high level macros in, in some of them, but not micronutrients or a vast amount of data that could have been added or could, and eventually will be added, in my opinion, but which presently isn't.
• 22:43
  So how do we bring that into the fold in that setting and workflow, to your point about what's important in managing a practitioner's time?
• 22:52
  Yeah, I mean, I'm definitely not an expert on this, but, um, [laughs] sounds like you might be.
• 22:57
  Uh, but what I would say is this is similar to the other types of data that we can't get into an EHR, or it sits in an unstructured format, right?
• 23:04
  Like, uh, where people live or whether they're caring for somebody who, uh, happens to be, uh, on a Medicaid plan and if they don't get their medicine, they're going to give it to the person living at home.
• 23:15
  So, like, the socioeconomic conditions.
• 23:17
  These are all things that we are thinking about, and I think whether you build software that incorporates that and transmits it into a location in the EHR, whether you have partnerships with EHR companies, or like I said, you know, we could have a discussion for an hour on what I think the interoperability framework should look like.
• 23:35
  Uh, those would all work.
• 23:37
  So just to make a comment on that framework, I think it's really important to have, you know, sort of like not just an integrator, but an integrator plus a developer platform that's built for, purpose-built for healthcare, right?
• 23:50
  So that you don't, you know, you can have structured, unstructured data. You can have all different types of data that are moving bidirectionally in real time so that you have that data at the point of care.
• 24:01
  So if you, you know, if a provider is taking care of somebody who ha- is a diabetic or a heart failure patient or, you know, certain types of chronic diseases or an oncology patient that can only be on a restricted diet, et cetera, that information is coming, um, at the point of care so that they can make decisions actively without having c- to cull through pages and pages of data.
• 24:24
  I, I personally believe that nutrition's very, very important to whole health for both preventative and for treatment.
• 24:30
  So, you know, I'm with you.I don't have all the answers, but I look at it just like, you know, data on where somebody lives or data on their socioeconomic status or homeless status. Thanks, thanks for the question, Alan.
• 24:44
  Uh, we've also got a question in the chat from Imran Kronk from Ride Health. Imran, if you can come off mute, explain what you do and ask your question. Hi. Um, thanks for the, the talk and opportunity.
• 24:56
  Um, so Ride Health works with, uh, hospitals, health plans, societies and foundations to coordinate, uh, transportation for patients and members who face barriers to care.
• 25:05
  Um, and my, my question, uh, relates to, uh, and the reason why I was interested to attend is, is we have some clients who are, are also Salesforce, uh, clients who are...
• 25:15
  They, they've kind of taken on a lot of development work and expense and effort to build Ride Health workflow integrations into their Salesforce environment, and that kind of took us by surprise because, you know, a few years ago we thought mainly about EHR and, you know, uh, the, the payers using their care management platforms that are kind of classically designed for that purpose.
• 25:35
  Uh, but then more and more people seem to be adopting Salesforce and using it kind of almost as their system of record for managing relationships with, uh, patients and members. And so it seems to be a growing trend.
• 25:45
  We're seeing more interest from other clients who also happen to use Salesforce. Um, so I'm curious if you s- how, how you see that kind of activity evolving, uh, with your healthcare industry customers.
• 25:56
  Has that been, like, an intentional strategy that you've been pushing, or is this something that's also kind of taken you by surprise, you know, how, how people are adopting it? No.
• 26:05
  I think we've seen a lot of different use for Salesforce. Now, let me just go back to Alan real quickly, 'cause you helped me think through something.
• 26:12
  I would say people are adopting Salesforce for taking in this kind of data, Alan, so this could be a collaboration tool.
• 26:19
  I'm happy to talk to you offline, uh, to explore if that's something that we could work together on. Uh, but just to come back to, you know, to what Imran said, yeah, I mean, I don't... It's not that we're surprised.
• 26:30
  I think, you know, those of us that have been working with CRM data, those of us who are working, uh, in the space, uh, know that, you know, we're not a system of record, we're a system of engagement.
• 26:41
  We definitely take data point, you know, data from all different places so we can have it on a single page for whoever's taking care of the person.
• 26:48
  Um, particularly for those of us who work with vulnerable populations who don't make it to their appointments on time, right? We started noticing that if we provide them, uh,
• 26:59
  the ability to, for us to schedule rides for them, and they ha- they come in, you know, you're assuming that they're gonna have better outcomes.
• 27:06
  So we've been talking about this for years for, you know, people who work with the VA population or Medicaid population or, uh, folks who are older and living in remote areas.
• 27:16
  So coming into Salesforce, uh, we've had a partnership with Uber.
• 27:20
  Uh, we do have, uh, partnerships with companies like Uber, uh, Lyft, et cetera, and now that's expanded to beyond that, um, to other coordination, coordination sites, and we do that through, like, call centers, for example.
• 27:34
  Not that we're doing it, but we're providing the ability to have call centers schedule these, uh, rides for... Clinical call centers should think through these things when we know people are living in certain ZIP codes.
• 27:45
  Because we have the ability to take in data from different places, analyze and say if somebody's at risk, we can offer these types of, uh, insights, um, through AI tools to people scheduling, um, um, these se- types of appointments.
• 28:00
  So it's been... You know, it's definitely an evolving strategy. We've learned a lot, but, um, we definitely knew this was a use case. Any quick follow-up, Imran? Yeah. Imran? Just I, I, I meant to share the examples.
• 28:15
  Uh, one of those is, is Genentech, uh, so not far from, I guess, Salesforce's HQ, and they've...
• 28:20
  they brought in Mulesoft to do a pretty ambitious sort of next gen, you know, uh, uh, kind of 360 degree, you know, uh, trial participant engagement platform, and they've got, from what I understand, a, a book ride button that's, that's a part of that system that their, uh, patient engagement team is using and, and so they've, they really invested a lot in that.
• 28:41
  The other one is the HealthWell Foundation, uh, which works with people who need, uh, financial assistance, uh, including travel assistance.
• 28:48
  Um, and they've used Salesforce as their system, and, and they're now using it to kind of, uh, administer their, their Ride Health program.
• 28:55
  So, um, would love to, to follow up and just understand more about how we can make it easier for other Salesforce customers potentially to, um, to do similar things, uh, in life sciences- Yeah, I mean-...
• 29:05
  or, or healthcare provider world or payer world. Yeah. I was just gonna make a comment on that.
• 29:10
  I would just say, um, the other thing that we're seeing is health insurance companies, both government and non-government, are thinking through the strategy as well, obviously with reimbursements and follow-ups, et cetera.
• 29:21
  So, um, we're looking at how do we integrate or look at, uh, companies that do integrate, uh, into this type of data.
• 29:29
  Uh, the other thing we're also looking at is there are employers that want visibility into what's available as a, a, from different insurance companies as a benefit. So having visibility into, um, let's say, you know,
• 29:45
  insurance A, United Health, whatever, offering these benefits to their Medicare population or Medicare Advantage population, if that's visible through Salesforce, it makes it for an easier booking and to offer, uh, when somebody's having these booking conversations.
• 29:58
  So these are all things that we're thinking about as well. Thanks for the q- thanks for the question, Imran. Um, let's shift slightly, and, um,
• 30:07
  you know, one of the commonalities, uh, between your roles at the VA and at Salesforce, uh, is that both made you a pretty coveted gatekeeper for health innovation. People, uh, wanted to get your attention.
• 30:19
  Uh, people, uh, you know, companies would wanna run pilots at the VA, et cetera, and I'm sure that's even more the case w- with Salesforce. Maybe we can talk a little bit about partnerships, what they look like.
• 30:30
  Um, you know, how do you currently find and test new solutions in the market?Um, yeah, so we, uh, so we have a couple of different, uh, routes for that.
• 30:44
  Um, uh, definitely we have, because our, our, uh, leadership is so engaged in the healthcare space, we definitely see a lot of, um, folks reaching out to us, uh, asking, you know, from all different places, saying, "We're thinking about X, Y, and Z.
• 31:01
  We wanna explore a partnership with you." Uh, and those partnerships can go a couple of different ways. We can have an OEM relationship where you can build on top of a Salesforce platform. Uh, Veeva's done this.
• 31:13
  Uh, Guidewire has done this in, in the insurance space. We have several companies that are building tools on top of Salesforce.
• 31:20
  Um, we also have integrations, um, and so ISV type of relationships, uh, with the company where we have a lot of this.
• 31:29
  Like, if you look at the insurance space, because we provide information for Interqual and MCG guidelines, right? So we have, um, a direct integration into Catalyst, right?
• 31:39
  Or we have integrations into Cerner for, um, pulling data for, uh, uh, for population health, et cetera.
• 31:46
  So we have a lot of different types of those relationships with both, uh, smaller startups to big established companies.
• 31:53
  Our app ecosystem is, I believe, one of the largest, uh, of all tech companies when you look at all of the different ways that, uh, people build on top of or integrate to, uh, the different Salesforce platforms.
• 32:05
  Um, we also invest quite a bit. Um, [clears throat] uh, definitely since I've been here, uh, that has ramped up in the healthcare space. Um, we focus quite a bit on, um,
• 32:20
  all, all verticals that are, uh, that are startups in the space that we think are important for us, uh, where we identify white space.
• 32:28
  Also, where we think it's outside of our white space, but we think that it's a much needed area and there's going to be growth for the company from a revenue perspective, right?
• 32:36
  So we do both those types of investments, uh, through our ventures team. Uh, and then we also invest with the impact fund.
• 32:44
  If we think that there's populations that are at risk and you have scalable solutions in the Medicaid space, for example, uh, we will invest.
• 32:52
  Uh, we will look beyond the seed round to see if there's something interesting that we can invest in. I wonder if you'd, uh, be able to flesh out any of those areas.
• 33:00
  You mentioned, uh, white space, uh, areas in the market, greenfields, uh, areas of need, areas of high impact. Could you sort of, uh, add some, give us some examples of some of those areas that you would be investing in?
• 33:16
  Um, [laughs] so I, I think that, you know, the, the best way to get something like this is to reach out to me so that we can review our blueprints to see if there's a space for what you're working in.
• 33:29
  A lot of times we'll get, uh, founders, you know, again, I'll get a lot of, like, really, really interesting companies that are working in, like, the maternity space, for example. Sure. And that's too narrow.
• 33:41
  Uh, that might be something I'll forward to our benefits team to see if they wanna provide that as a benefit to our employees and not as just an integration, right?
• 33:48
  So, uh, but that doesn't mean there, there isn't, like, robust investment in that space. So I wanna just, like, clarify that. We definitely do invest, but it's more so for where we're going. Gotcha.
• 33:58
  We're an enterprise company, and so we provide, [clears throat]
• 34:01
  we provide, um, uh, services for businesses to, like hospitals, uh, insurance companies, pharmaceutical companies, governments, and medical device companies to do their work so that they can take care of, like, patients and members, right?
• 34:18
  Yeah. So if you have things where, um, you know, we're really, really focused going into the next year on life sciences.
• 34:25
  So if you're thinking about, uh, tools for decentralized trials that you're working with or clinical trial management, uh, that we can coordinate to, um, or in the provider space where we, you have more robust telehealth solutions with integration into remote monitoring, uh, these are all things that we are thinking through as a strategy, but would also be a great place to, uh, to have an integration.
• 34:49
  Interesting. And I could go on and on, but we are such a broad company- Yeah... and do so many things that we definitely have a lot of, like, white space beyond what we wanna do for the next year or two.
• 34:58
  Uh, how big of a challenge is that? It's just the scale and scope. You know, I ask you this question, it's like there's almost n- no answer because it's almost everything. You're moving in so many different directions.
• 35:09
  Um, how challenging is that? You know, it's interesting you ask that because, I mean, on one hand, I would say when I first got here, [clears throat] and this is, like, the beginner's mind/beginner's challenge, right?
• 35:22
  You come in, you're like, "There's all this white space. Let's go do it all."
• 35:25
  And you start, like, trying to push for things, and you quickly fail because there are checks and balances at Salesforce that say you can't do that.
• 35:32
  But what I've learned after being here for two-plus years is you have to choose wisely in what you're gonna focus on and focus on the markets that you think you're gonna win in, right?
• 35:40
  So we definitely look at, like, growth, uh, beyond just the AMER market. Like, where do you think, where do we think that there's opportunity for us in what we build?
• 35:49
  Um, but I think the success of Salesforce has been because we are so good at partnerships. Uh, 99% of our deals have an SI partner.
• 35:59
  We work with those integrators to make sure that we help them understand, you know, our roadmap, our products. We have lots of tools, you know, for, for those types of companies.
• 36:08
  And we have a really robust ISV ecosystem, and that's because we don't want to build in everything.
• 36:14
  So if we think that you're gonna extend our products or you're going to be a Salesforce ISV developer, or if we think that you're, you know, uh, really understand our integration points and can help with that, we invest a lot of time into those companies and make a commitment to say at least for the next two, three, X number of years, we're not going to go into that space.
• 36:35
  So when I get companies and I see that there's an ISV relationship, we have a team that's dedicated to doing that.
• 36:41
  And their job is actually to protect the com- you know, the companies, to give you clarityUh, on what we're not going to go into, and that you have direct relationships with our product team so that they know you exist and that you're building and integrating, uh, so they're not going to go into that space.
• 36:58
  Gotcha. So... Uh, Richard Hanbury, uh, from Sana Health has a question in the chat. So Richard, if you wanna come off of mute, uh, tell us what you, what you've built and ask your question. Oh, thank you. Yeah.
• 37:11
  Um, so, um, my name's Richard Hanbury, Sana Health. Um, we have a, um, device which is an audio visual neuromodulation. Um, we're going through two FDA trials for fibromyalgia and neuropathic pain.
• 37:23
  Um, but essentially the device produces a very deep relaxation effect, um, on, uh, with every use.
• 37:30
  Um, and so we have applications across all sorts of, uh, well, almost every area of mental health where anxiety is an issue.
• 37:37
  Um, my, my question was around, so what of your, um, vast 50,000 employees is it, um, what, what are the largest mental health challenges and what are your go-to solutions?
• 37:49
  Um, and I, and I guess sort of, um, this is, this is not on the data side, this is on the sort of, you know, looking after your own people side.
• 37:55
  How do you, how do you look at, um, uh, trialing things that might be of help to your people? Yeah, I mean this has been a challenge definitely during the pandemic.
• 38:06
  We see obviously an increase in, um, the need for mental health services, um, across, you know, not just our employee population, but the communities that they live in, families, et cetera.
• 38:17
  So, uh, I don't have a good answer for you on the trials, honestly. We're just trying to like keep up to make sure we keep our employees safe and that we're giving them benefits, right?
• 38:26
  So, uh, we do invest in telemental health. We do give benefits, you know, for different, um, digital tools. Uh, there are benefits on, uh, the types of providers that they can go see.
• 38:37
  We do a lot of things outside of like the direct care space, uh, by giving people time, uh, you know, having, uh, employees, um, attend concerts, et cetera.
• 38:48
  There are a lot of other things that we do outside of just giving clear space. Um, but I'm happy to connect you with our benefits folks to see if they're doing any sort of trials. Um,
• 38:58
  you know, like I said, I think this is another area for innovation that's needed, um, definitely in the employer insurance space.
• 39:06
  I do see a lot of startups that are doing second opinion/price transparency/uh, thinking through like star ratings of the different services, right?
• 39:16
  But there's no comprehensive solution that kind of looks at all of the above, and I think, um, it's, uh, it's ripe for innovation in my opinion.
• 39:25
  Um, but yeah, at least on the Salesforce front, uh, we, I don't think we've looked into particular devices, but I could be wrong 'cause I, I do have, uh, I, I have all those conversations, I send them to the benefits team.
• 39:38
  So I'm happy to do an intro so you can have those conversations. Thank you. I appreciate that. Thanks for the question Richard. Uh, we've also got a question from David Haddock from Psych Analytics.
• 39:48
  David, if you wanna hop off of mute and share your question. Sure. Thank you. Um, [clears throat] Dr.
• 39:55
  Ash, we're a company specializing in screening patients for behavioral health and coaching physicians into understanding the patient's whole person characteristics. I'm curious, um, if
• 40:12
  Salesforce has done anything to support an individual patient health record.
• 40:18
  I know that, you know, we had Microsoft Health Vault, we've had Google Health, we've had all kinds of, of false starts in this area, but Salesforce might be just the right company to finally make it attractive to people to start managing their own health information.
• 40:38
  Yeah. Um, so I think [clears throat] look, we've had a lot of discussions over the last 20 years we've been around on where we wanna invest.
• 40:48
  [clears throat] Everything from do we wanna be in the EHR space to the patient portal space to the- Mm-hmm... you know, to sort of the enterprise B2B, B2B2C space.
• 41:00
  And at the end of the day, our core business I think is focused on being the layer of engagement, and we've done that so, you know, predominantly with enterprise customers, with our customers, right?
• 41:12
  So we have not been, uh, engaged on anything with the patients.
• 41:18
  I do think there's a, there's an opportunity that's not our, uh, strategy right now, only because, um, we are still actively thinking through, um, sort of patient privacy and ethics and how, how do we wanna be engaged from that perspective with, uh, storing and handling patient data and, you know.
• 41:36
  So I- I think a- as a company right now, we don't have that in our roadmap.
• 41:41
  That's not to say it won't change, um, but at least right now we collaborate with Apple and other EHR vendors to help provide, uh, the engagement.
• 41:52
  But we just have a lot of unanswered questions on how we wanna approach or how we think, you know, states and governments will wanna approach like privacy issues, et cetera.
• 42:02
  So we're not, we're not headed there anytime soon. Well, I just suggest you might have the kind of credibility and reputation that wouldn't put people off. Yeah. Ex- And we definitely wanna maintain that.
• 42:15
  [laughs] So we wanna be more thoughtful, so yeah. Thank, thanks for the question David. Um, Dr.
• 42:21
  Ash, I wanna ask you about the pace of innovation, because in an interview at Startup Health Festival last January, uh, you made sort of a side comment about, uh, the pace of innovation at the federal government, uh, about how i- it might be a good thing sometimes when it moves slowly, that when so many lives are at stake, um, a, a, a slowness to innovation that, that steps needed to be, uh, gone through the, the gates that have to be gone through can be a good thing.
• 42:49
  So, uh, I wanted you to just sort of comment on the pace of innovation now a year later.
• 42:54
  Uh, w-You know, a year of, of COVID later, uh, what you sort of think about that in terms of Salesforce's pace and just the, the people on this call?
• 43:05
  [sighs] I think in healthcare, pace of innovation is a double-edged sword, and I'll definitely eat my words from StartUp Health.
• 43:12
  I think we should have, you know, we should definitely go faster given what we've seen with this pandemic. Um, but look, I think we still have to be careful, right?
• 43:20
  We are dealing with patient- people's lives, and we're transmitting information, so if we miss, like, an allergy and someone has an an- anaphylactic reaction, it's a life lost.
• 43:29
  If we don't, uh, flag a pre-suicidal, uh, patient and a life, that's a life lost. So we have to be really, really careful and thoughtful.
• 43:38
  So I'm all for innovation, and what COVID has shown is we need more innovation and more collaboration. But I definitely, I don't think we should just go fast for the sake of going fast, right? Mm.
• 43:52
  So, um, I think federal government is realizing that they need to invest in more public health infrastructure and public health innovation. That's definitely a space that's ripe. Um, we definitely need to...
• 44:03
  I mean, talking about interoperability can't just be a conversation for the sake of it at these federal meetings. Um, so they are, they're...
• 44:12
  The Blue Button conferences, the conversations we're having have been much more focused and holding our feet to the fire, saying, "Are you moving along in adopting standards?
• 44:21
  Are you, you know, innovating along FHIR standards?" So I think there are different types of innovation, some that has to go really fast, like adopting standards, for example- Right... or building on a platform.
• 44:32
  And then there are things that you have to be careful. So yeah. It- I sh- probably should've been more clear even last year.
• 44:38
  [laughs] It, it goes back to your initial, uh, you know, comments about working with practicing clinicians, you know, having somebody at that decision-making level that's really, that really has patient care at the forefront of their mind,
• 44:52
  which might, might slow you down a little bit. Uh- Absolutely. I, I wanna ask you a, um, a management question because, uh, 2020 has thrown some interesting management curve balls.
• 45:02
  Um, Richard, uh, alluded to the fact that Salesforce is pretty big, uh, 40, 50,000 employees.
• 45:09
  And, um, 2020, in 2020, Fortune magazine ranked Salesforce as number six on its list of 100 most, uh, uh, best companies to work for, uh, a coveted spot in the top 10, uh, during a time when, uh, managing large teams has been really challenging.
• 45:25
  So, um, since it's a challenge for everyone on this call, um, what are some of the strategies you've employed this year to manage teams well? I think my management strategy has, I don't think it's changed.
• 45:39
  I've managed big teams, um, and managed through influence for a long time now. And so, um, I definitely think collaboration is really important.
• 45:50
  I'm not a hierarchical manager, but I am very data-driven, and so I think that, to me, um, hol- holds true today in this, in this era. Um, I've always loved, uh, having remote collaboration in the VA.
• 46:05
  I had a lot of employees I never met in all the years I worked at the VA, and, uh, we had a lot of remote calls. You know, we used phone calls more than this forum, right, where you can see people and get to know people.
• 46:18
  Um, so I have a remote management style that I've always, uh, enjoyed.
• 46:23
  I feel like people should be given more flexibility, and if you have flexibility in the workplace, you're much more engaged, and, uh, you will prioritize time for the things that need to happen at work.
• 46:33
  Um, so I think all of these sort of things, like, I'm really glad the pa- the pandemic, uh, while it's really unfortunate, um, has sort of brought to the forefront to say these are things, uh, from a workplace, uh, that matters to employees.
• 46:47
  Uh, so from a management perspective, that's all been fine with me.
• 46:51
  Um, I definitely believe in, like I said, having more collaboration tools at Salesforce, for example, being able to quickly, uh, navigate and have conversations or chat, like the omni-channel component has been great to have as a manager.
• 47:07
  Um, yeah, but at the end of the day, like I said, as a manager, you're responsible for your output. And so, uh, to me, that's more important, and having a good team culture is really important, and, uh- I, I like it-...
• 47:23
  that continues to be important. Yeah, I like how you said manage through influence. I wa- I wonder what that phrase means to you.
• 47:31
  I mean, it just means that you don't need everybody reporting to you or you don't need control over everything to solve for problems.
• 47:37
  I mean, uh, I guess unless you're, I don't know what, you know, not even king, I guess, um, back in the day, like, you just can't, you cannot have control over everything.
• 47:48
  So, uh, [clears throat] I think having a strategy that you can get people behind and get people excited about is a better strategy.
• 47:56
  Having a path to execution of that strategy so that people can get excited every time you achieve, like, those metrics is really important.
• 48:06
  Um, calling out failures early and saying, "I'm okay," like, "We did this incorrectly. If we were to do it again, let's do these things the right way," uh, are also important.
• 48:18
  And all that adds to people kind of getting behind what you're doing and getting excited about what you're doing.
• 48:26
  And, you know, for me, at least in this company, it doesn't matter what anybody reports or what level they are. It doesn't really matter. We all just sort of work across teams, and that's how it was in the VA.
• 48:37
  We had, uh, 360,000 people. There's no way, if you think you can tell anybody in the VA what to do, that would never happen. You need people excited, right? 'Cause they're there for a mission. Mm.
• 48:49
  And they have to be excited about the mission. And to me, that is really, really important as a manager. You're gonna be more successful when your team's behind you.Wise words.
• 49:00
  Um, Jim Feng from Fixable will get our last question. But before I, I take him off of mute, uh, a reminder that when he's, uh, when he's done, we'll have our opportunity to reflect back to Dr.
• 49:12
  Ash, uh, insight from the call, something we do at the end of, of expert office hours every week, uh, something that stuck with you, a, a high point to kind of, yeah, share back with the group kind of what you heard that was valuable.
• 49:24
  So, uh, Jim, uh, Feng from Fixable, come off mute, uh, tell us what you do, and ask your question. Thanks for this. It's been really, uh, uh, really, really informative. I'm Jim from Fixable.
• 49:36
  We're a, a employee pain and prevention solution.
• 49:38
  I just kind of wanted to know, um, um, what's your take on, um, the current state of value-based care and where we are currently at, like where we're currently at, and what, how and how does the employer maybe and insurers play into the model of care, maybe some high level stuff where you see it currently, where you see it going?
• 49:58
  I don't think we're at value-based care. Um, [laughs]
• 50:01
  I think we're still at a fee for service model, and I'm really, um, I, I'm very excited that we have more, uh, MA plans, uh, thinking through how to provide better value.
• 50:12
  We've got a lot of startups in the space that are thinking through this, and I think that's fabulous.
• 50:17
  Um, I think everybody should take on risk so that you're motivated to do the right thing, and that you're looking for better outcomes. Um, I think those models are all eventually gonna work.
• 50:27
  Uh, what I also think is super exciting is that now our government, which is one of our biggest payers, is also on board and understands that, uh, paying for value, uh, might actually matter in the long run, and paying for prevention, uh, might be really, really important.
• 50:44
  So these are all conversations I'm hearing, uh, as I'm listening to CMS, CMMI, and other, uh, congressional delegations that are thinking through these things and asking the right questions. So I think that's great.
• 50:55
  [coughs] I also see that CMS, you know, for example, with, um, Viz.ai, they, uh, approved, uh, payment for an algorithm that's, you know, able to detect strokes early, right?
• 51:08
  So I think, you know, it's not necessarily just value-based care, but it's the value of early detection, uh, prevention, early treatment.
• 51:17
  These are all components, I think, for value-based care, and I think the conversations are getting faster in this space. So I think that's really important.
• 51:25
  Um, where I'm not seeing a whole lot of progress is, um, people focusing on the Medicaid population.
• 51:31
  I think if you look at where the payments are made, there is significant amount of, like, a lot of the insured patients are sitting in that population. So we need scalable solutions there.
• 51:42
  Um, uh, I would also love to see, like I said earlier, employers account for a significant portion of, you know, bearing the burden of, uh, paying for healthcare.
• 51:54
  And I think healthcare is getting more and more, it's exponentially more expensive. You know, when we look at, like, how much we're
• 52:01
  not only paying for people who are sick, but all of the other benefits we're giving to people, there's really no way to tell if all the things we're doing is just to retain people and give them a list at the beginning of hire to say, "Look at the 50 things we do versus the 40 things that the company down the street does."
• 52:18
  Like, we have no idea if it adds value or not. It just costs a lot of money.
• 52:22
  Um, so I, I actually see that, you know, for the employer-sponsored space, I know Haven tried to do something like this, but I expect more and more, uh, in the next, you know, I would say two to three years, where there's going to be an explosion of transparency, uh, startups that are gonna start to show, like, you know, is, is the provider A versus provider B, who provides better care?
• 52:48
  How's the system rated? Uh, what's the cost of care at these sites? And employers incentivizing people to go to better star rated, lower expensive sites or flying people places or giving benefits, right?
• 53:02
  I think these are all conversations that employers are gonna start getting involved in, in my opinion. I totally agree.
• 53:07
  And we're already seeing that on the paramedical side with a lot of products coming out and services, so why isn't it on the main, uh, main verticals?
• 53:14
  And, and that outcome measure and that, that data piece I think plays a big part.
• 53:18
  You just, you know, spoke quite a bit on, you know, being data-centric and making decisions on that, and I think a lot of that has to go back to history of that position of the medical, of the doctor, right?
• 53:29
  And, you know, me seeing my patients, there's still that power differentiation, and I think we need to kind of, you know, bridge the gap a little bit so the patient democratizes that care. But thanks for that.
• 53:39
  That was great. Yeah.
• 53:40
  I mean, I don't know if it'll extend to everybody yet, but definitely the really expensive specialty care stuff where you're getting, um, stem cell transplant or you're getting, you know, hip or knees or those- Yeah...
• 53:51
  sort of things, we'll start to see more and more data very quickly. Thanks for the question, Jim. Dr.
• 53:57
  Ash, the way you talked about the power of a collaboration platform, uh, really made me think of this idea of kind of a, um, a- an ethos of abundance.
• 54:07
  You talked about how many, uh, partnerships you're involved in, how many companies are building on the platform, and there's almost a- an unending list of potential collaborations, uh, when you think about y- building the tools for collaboration.
• 54:22
  So I thought that was awesome. Well, first of all, Dr. Ash, awesome to have you on a Fireside Chat with us. Um, your, your experience is kind of unparalleled coming from the VA into this- into Salesforce.
• 54:36
  You gave some fantastic advice. So we are grateful for you taking the last hour with us, so thank you. Good to meet all of you.
• 54:44
  [outro music] StartUp Health invests in health transformers from around the world who are committed to achieving audacious health moonshots.
• 54:58
  If you want to learn how you can join this community of entrepreneurs, or if you want to connect with one of our 330 companies, go to startuphealth.com. Thanks for listening to "StartUp Health NOW."
• 55:08
  We'll be back next week. [outro music]