Episode cover featuring a picture of a foot in a boot. Background color split between orange and white. White Aboard logo at top and episode title in black at the bottom: Paul Breaks His Foot and Observes Enterprise Healthcare Software.

When Paul injures himself and is advised by his wife, Rich, and ChatGPT (seriously) to seek emergency medical attention, he goes to the urgent care and marvels at their utterly Byzantine technological set-up, from parallel, disconnected patient portals to being handed a literal CD-ROM with his X-rays. What can we learn from systems built for the captive user—and how does that apply to enterprise software more broadly?

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E15

Paul Breaks His Foot and Observes Enterprise Healthcare Software

February 13, 2024

Rich Ziade: You know, Paul, this is just one of those days. I intentionally took an extra walk today. It was sunny, I’d say 50 degrees. New York City. Everything felt brighter than usual. There was a spring to my step. How was your day?

Paul Ford: The opposite.

Rich: Where are you? Are you not in New York City? What’s your problem?

Paul: I’m home. It is a beautiful day. I broke my foot.

Rich: Oh no.

Paul: Yeah. I broke it in a very middle-aged way, which is, I was walking down the stairs, and then I heard a thing go crack.

Rich: Oh no.

Paul: So it turns out that that bike accident that we haven’t really talked about, that was pretty bad a month ago?

Rich: Yeah…

Paul: I probably actually did a little more damage to myself than I thought, and so I have—

Rich: Oh no.

Paul: Oh yeah. And it’s really good, like I went, I went—it’s a good break. I will be on one of those little kneely rolly carts for a month in a boot, and then I can wear a normal boot. So I’m sure you’ll have positive, encouraging things to say to me throughout that entire process. I look forward to that.

Rich: [laughing] I’m going to get you cool hubcaps.

Paul: I got the little basket to put in front of the rolly cart. [laughter] It’s coming from Amazon so that I can deliver mail around the co-working space. Yeah, no, I have had, I gotta say, a day. Although we also have to look at, there is a bright side in general, which is I have a job that—I don’t work in construction, right?

Rich: Yeah, yeah.

Paul: I can work remotely. I can come to the office for meetings. We’re going to be okay. But I’m going to have a crappy month. And then if I follow all the rules, I don’t have to get surgery. So there’s that.

Rich: Okay. All right. Well, that’s the better way to feel better, which is, it could be worse. We do have workers’ comp at Aboard, if you’re feeling it.

Paul: Do we? Great. That’ll be really good.

Rich: I think you have to—I don’t know for sure, but I think you have to, by law, have workers’ comp insurance. And if your pinky toe doesn’t let you type on the keyboard, then, uh, you should file a claim.

Paul: That’s a shame I wasn’t injured at work, right? [laughter] I should have limped into the office and fallen down in the door. “Oh, Rich! What’s happening?”

Rich: No, I don’t think you have to be injured at work.

Paul: Oh, really?

Rich: I don’t know how it works. I’m not exactly sure.

Paul: That’s like—

Rich: So let’s not talk about workers’ comp, because neither of us know what we’re talking about. That’s not what this podcast is about.

[intro music]

Rich: Are we going to talk about your foot for an hour, Paul?

Paul: No. First of all, no podcast should be an hour.

Rich: Fair.

Paul: But second of all, and this one should be short because I’m in pain in a boot. So if I yelp or just call out a name in the middle of this, that’s all that’s going on? No, so what happened, you know what’s wild with this, because we’re supposed to record the podcast and I break my foot, is that I kept thinking about all the systems I was interacting with and how fundamentally broken they are. So let me just actually narrate in a minute what happened. So, right, I’m in pain. And then my wife is like, “You should go to urgent care.” And I’m like, “Nah, it’ll be fine. I’ll just ice it.” And she’s like, “You should go to urgent care.” And you said, “You should go to urgent care,” because you’re my other wife. And then—

Rich: For our listeners that aren’t in America, urgent care is essentially walk-in storefront emergency-room-light.

Paul: Yeah, they’re all over the place.

Rich: Yeah.

Paul: So then I asked Chat GPT, and it said I should go to urgent care.

Rich: That’s what did it. My advice or your wife’s advice…?

Paul: And my wife said, well, thanks for listening to the problematic robot.

Rich: Yeah, exactly.

Paul: Yeah, so I was like, three for three. All right, I better get in. I got in a car service, and off I went. And there’s one about a mile away. And I go in and a very brusque man from Russia—a very nice radiologist, et cetera, et cetera, and he’s just very tender, and then the brusque doctor comes in and is, like, [Russian accent] “You broke it.” And so that’s what I found out. [laughter] So now I’m in system one.

Rich: Okay.

Paul: So I go there, and so they’re like, okay—well, first they forget to give me my crutches, so eventually my wife had to go back and get them, God bless her. She’s kind of been a champ through this last two days. Then they hand me a referral on paper, as well as access to a system that doesn’t connect to the system of my regular doctor, which is called MyChart.

Rich: Mmm hmm.

Paul: So I can log into that and find out all the sort of experiences I’ve had in urgent care, which include I once had a Q-tip come off of my ear, and a lot of strep throat over the last ten years.

Rich: Okay.

Paul: That’s all in there. So that’s, like, doctor system one. I have a piece of paper that says that a man with the, you know, a doctor has said I’m in pain, or that I need a cast, that I’ve broken my foot.

Rich: Okay.

Paul: And I have a compact disk read-only memory device. I have a CD-ROM—

Rich: …what?

Paul: [laughing] Yeah. With my x-rays on it.

Rich: All right, for the young listeners of this podcast. [laughter]

Paul: Exactly, right? Like, everyone is just kind of staring at it. So I take—

Rich: Let’s walk back.

Paul: No, no—

Rich: What is a CD-ROM?

Paul: I mean, that’s the thing. It’s a portable hard drive that you can slot in and out. It’s also what, it’s a data version of the audio CD. So there’s that. No one has CD-ROM burners outside of the medical industry. All right, so now I go home—

Rich: Okay, so you got a little kit, you’ve got your little story. You got a CD-ROM, a couple of pieces of paper.

Paul: Yeah, crutch—

Rich: —and then you, yeah, okay, okay.

Paul: Okay, so now I go to system two, which is called MyChart, and it’s part of the giant hospital system I’m in, Mount Sinai, and I log in to that, and I try to call the doctor’s office, and it’s, you know, the endless phone tree. And I always find—I don’t know about you, but I find negotiating my own healthcare really depressing. I always need my wife to help me because I just find it bleak. I’m just like, you’re sitting there in pain—

Rich: Yeah.

Paul: And it’s just, “Hit 45 if you are in…” Just like, it’s endless. “Call 911!”

Rich: Yeah, all of that is terrible, people—especially people who are, I mean, you broke your foot, not to diminish that, but sometimes people are going through some really, really hard circumstances—

Paul: No, it’s fair to diminish that—

Rich: And then they’re dealing with insurance and just being put on hold, and it’s kind of awful. It’s actually, in a way, not to sound overly dramatic, kind of inhumane, in a sad, terrible way.

Paul: Our healthcare system overall is pretty inhumane. And what happens, I think, you and I are middle-aged guys. You find parts of the system where they listen to you and pay attention, and then you hold on to them. Like, we have the same GP because he pays attention.

Rich: Yeah. Yeah.

Paul: Right?

Rich: Okay, so you’re on hold.

Paul: So I’m on hold. We call the doctor’s office. They’re like, okay, that doesn’t work. Then they’re like, look for a callback in the morning. Can’t get through again in the morning, doesn’t come through. So then I file a ticket, essentially, a ticket asking my GP for help. And then—

Rich: Wait, what do you mean file a ticket? You logged into your GP’s…

Paul: Yeah. You can’t send him an email—

Rich: …portal or something?

Paul: Yes, yes, I sent him an email through the portal.

Rich: Okay.

Paul: So just to upshot, that’s not going to work. I call a few more times. I call the office. I call back to the urgent care because they’re like, we’ll get you a recommendation, and I call a 1-800 number. Five, six, I finally do get told that I can be seen on Monday.

Rich: Okay…

Paul: But the problem is I have the instinct that Monday isn’t a good idea. Meanwhile, my wife went to the doctor, just by coincidence, and she’s, like, “Hold on, let me see what I can do.” So she went upstairs from where she was going to the doctor, because we all go to the same place, and she said, “Listen, my husband broke his foot, and he’s having trouble getting an appointment before Monday.” And they’re like, “Okay, he actually needs to go to the emergency room if we can’t fit him in.” So no one has communicated this to me. They’re like, “He can’t be on a broken foot all weekend or it’ll get worse. That’s just how it goes. So he needs a boot and he needs to deal with this.”

Rich: Yup.

Paul: So this information—and then my wife looked him in the eye and said, “Listen, I’m about to have—have you ever dealt with a man in pain over a weekend? Because—”

Rich: [laughing] Over Super Bowl weekend?

Paul: “Yeah, if there’s anything available, I could get him in a cab and he could see them,” and they looked at her, and they kind of know us there, and they went, “Let me see what I got.” [laughter] So seven different channels, multiple systems, CD-ROMs. And then, so they called me like a minute later and they’re like, “You can come, but bring the CD-ROM,” because there’s no way to get the radiologist, right?

Rich: Okay. Okay.

Paul: “So if you have the thing where I can see the break, I can do this.” So long story short, I did get treated. I took the cab in—and I mean, you got to understand, it’s New York City, just start dinging up, like, $50, $100 charges with everything I’m saying, right?

Rich: Yeah. Yeahyeahyeahyeah.

Paul: Like, ding ding ding. And, upshot is my foot is broken, I’m wearing a boot, et cetera, et cetera.

Rich: Mmm hmm. Mmm hmmm.

Paul: I watched them, I watched them try to load the x-rays from the CD-ROM. It’s all there. It took, like, three people to work on that because they’re like, “When they come in from City MD, they’re in the Z folder.” It was stuff like that.

Rich: You’re kidding.

Paul: No, no, no, no. So it was just—

Rich: Okay.

Paul: As I’m watching, because this is all we talk about and all we think about.

Rich: Mmm.

Paul: I got to tell you, Rich, here’s where I’ve ended up with this. I accept this friction because I’m a person of a certain age. I kind of know, you know, HIPAA vi—there’s HIPAA rules in the hospitals, and IT buying, and we used to sell IT services and blah, blah, blah, blah, blah. I know why, actually, all the friction and all the fences are in there. But at the same time, if I wasn’t—I’m a person with flexibility who speaks really good English, has a wife who advocates for me, right?

Rich: Yeah.

Paul: I’m as lucky as you can be in this system. And it took eight tries to get active care that wouldn’t make my situation worse.

Rich: Okay, so you’re saying a few different things here. I want to unpack it, right?

Paul: Okay.

Rich: We’re not going to have a podcast about, you know, health care in America. That’s not what this podcast is about.

Paul: No, that a little out of scope for these two guys?

Rich: Little out of scope for these two guys. I do think you’re saying a few things. One is the experience you had—here’s the funny thing, I want to contrast this. There is a whole profession that has actually sliced itself up into multiple professions called product marketing, or user-experience design, or user-interface design, or…funnel journey, user-journey design. There’s a million of these. And the reason those exist is because they are seeking a particular outcome, and that outcome is usually some sort of transaction, and that could be, I got your phone number and I can upsell to you, or that could be you checked out the cart and you took your credit card out and you bought the thing.

Paul: Sure.

Rich: And so there’s immense, immense investment and energy has been made on the consumer side of using tech. Technology.

Paul: No, let me break you with an anecdote because it’s relevant. I remember talking to somebody once about, they knew the team that worked on the Amazon homepage.

Rich: Mmm hmm.

Paul: And somebody was like, “Hey, I think we can do something really cool with the shopping cart.” This is like 15 years ago.

Rich: Okay.

Paul: So they did something cool with the shopping cart and they lost $2 million in revenue in about 30 minutes. It just didn’t make people click on “check out” as much as they had before.

Rich: Yeah.

Paul: So they turned it off. You have an environment with commerce, with millions of users, where you can learn incredibly quickly.

Rich: Yes. So I want to introduce a notion to this podcast.

Paul: Okay.

Rich: And I think maybe this is, I think this is said in other ways. Do you ever go to a concert? Like Tool, or Rush? I’ve been to those.

Paul: Oh, yeah. I just saw somebody running down the street in a Tool t-shirt and it was not a man. I was shocked.

Rich: Wow.

Paul: Yeah. I mean, we’re all just flabbergasted.

Rich: Wow. This was a dream or this actually happened?

Paul: No, this really happened. It definitely was…it definitely made sense.

Rich: When you go to a concert and try to buy a bottle of water, it’s $7.

Paul: Sure.

Rich: If you leave the concert venue, it is a dollar.

Paul: Well, in Rochester, New York, but, yes, I know what you mean.

Rich: Yes. That’s what’s called, essentially, a captive consumer.

Paul: Sure.

Rich: Like, they don’t have options. Actually, they don’t even, I don’t think they let you bring water in, so you can buy more stuff. Movie theaters do this.

Paul: Yeah.

Rich: $12 for a bucket of popcorn.

Paul: I mean, do you remember there was a period, I’m assuming, like, class-action lawsuits happened or something, where they would check your bag every time you came into a movie theater?

Rich: Yeah, it was insane. It was insane.

Paul: They’d be like, “Ah, you can’t bring Raisinets from outside in here!”

Rich: So I want to piggyback that idea of a captive consumer.

Paul: Okay.

Rich: And I want to call you a captive user.

Paul: Yes.

Rich: And what you are is someone that—they don’t need you to get to the end of a journey and buy a thing. You’re going to do the thing, because your foot’s broken. And you’re going to do the thing because the payment didn’t go through for your homeowners insurance. And you’re going to do those things, and they don’t need to make good technology for you, because you’re going to do them come hell or high water. You will sit for 20 minutes on that phone.

Paul: Is it a moral fail—I feel sometimes childish, because I actually see that as a moral failing. I feel that the industry should try harder to serve people where they are. But sometimes I think that I’m a child for thinking that.

Rich: No… Keep your moral coins for other causes. Paul Ford.

Paul: Really?

Rich: I will say that I’m going to take a different view of it. I do think it’s a shame. Look, I think when people are in a high state of stress, like in a medical situation—

Paul: Sure.

Rich: The experience should be good. I do think you’re now treading into moral failure. Waiting 20 minutes with your bank around a payment? That sucks. That’s bad customer service. I’m not going to really get into a moral discussion about that. But if someone is really, really, really stressed out about their dad’s illness, and their dad doesn’t speak English because they’re a first-generation immigrant, and the kids are handling it all, and they can’t seem to get anyone on the phone that cares about anything they’re going through? That is terrible, and sad. And that should not be the case—that’s not a technology issue, that’s a larger issue. But I will say this, though, let me take a different angle around it, around your experience, Paul. It’s bad for business. It’s not good. Usually it means that down the road it’s more expensive to deal with you that way.

Paul: Mmm hmm.

Rich: But these systems take hold and nobody bothers to change them. So it’s actually bad economics. Not only bad morals, but bad economics, right? You’re in a spot, and it’s a funny thing, because if you go to a hospital system like Mount Sinai, which is vast and it’s big, and you say, “We really want to improve the experience for people who have, you know, ambulatory conditions that just need some attention,” they will look at you [laughing] like you’ve lost your mind.

Paul: Right.

Rich: They just will. They will. And that is the case for a lot of industries. And what we’re wading into here is non-consumer software, which is what a captive user is. A captive user, the UX people love to tell you that they care about that captive user. That it’s very stressful to get a mortgage, and it shouldn’t be stressful, but that’s not where the money flows.

Paul: No, it’s true. I don’t buy this software. I buy health services, and they are delivered—and my insurance, I buy insurance, the insurance buys health services after being told it must.

Rich: Yes. That’s right.

Paul: And the software is kind of somewhere in the middle. So all those incentives and structures, they do kind of get boiled in the analytics and dashboards. But there’s nothing like that moment at Amazon where they went, “Turn it back, because we just lost $2 million.” [laughter] That never happened.

Rich: No!

Paul: Yeah—

Rich: It becomes a satanic voice coming out of Bezos. [satanic voice] “TURN IT OFF.”

Paul: Yeah, I mean, instead of sending you a single question mark and email as he does, it’s like an exclamation point. [laughter] No, but if you think about those incentives, right, and you think about, like, they didn’t buy it versus they did buy it, and here we’re in this zone where it’s like, I exist as a single database row in a monthly summary that gets emailed in PDF—

Rich: Yeah.

Paul: To a CIO inside of a giant hospital system.

Rich: Yeah.

Paul: I’m so, so tiny in there. I’m one of millions and millions of rows.

Rich: And they’re not going to lose you.

Paul: No, they’re not.

Rich: They’re not going to lose you.

Paul: There’s very little risk.

Rich: You ever see people throw tantrums at, like, the front desk?

Paul: Aw, so sad.

Rich: Of anything.

Paul: Yeah.

Rich: And the people look at them like, “Wow, you’re really upset. And my God, we don’t care. We don’t care one bit.”

Paul: Well, it’s also—if you want to know, people, I remember when I first moved to the city. If you want to know what differentiates, like, I always was like, when will I be like a New Yorker? And it actually turns out you just kind of have, you stop think ever asking yourself that question. That’s when it happens.

Rich: Yeah, yeah.

Paul: But if you want to know the difference between the person who has still kind of got out-of-town roots, like, the New Yorker who gets upset at customer service has failed completely.

Rich: Yeah. Yeahyeahyeah.

Paul: Because you have to always be like, “Mmm. mmm. Yeah, I know, but I am not—” The New Yorker, the one rule that you learn here is you just don’t leave. You’re like, “Well, I’ll just sit right here.” [laughter] And they’re like, “Well, no, doctor’s not here today.” “Yeah, well, if he comes in, I’ll be right here.” “Well, I could get you down to talk to somebody downstairs.” “Oh! Well, if you could, that’d be really great. Thank you.”

Rich: I want to talk about another kind of captive user, which is sort of where I want to eventually take this, and I think this is going to be the beginning of a bunch of conversations around this. Software you use at work, if you work at a desk and you’re using certain tools, it’s sort of the same disincentives. They don’t have to be great. You started a job and you have to use the tools that they gave you at the job.

Paul: This is ENTERPRISE. That’s the word.

Rich: It’s enterprise, right. And even today’s quote-unquote “modern tools” and modern products—look, they don’t have to be a source of pleasure, but they also don’t have to be a source of pain. And what’s funny about it is the damage it does, not just to the experience of the user using it, but it’s actually probably suboptimal in terms of productivity. If the thing worked better, you’d work better. If I don’t have to train you for four weeks before you use the thing, that means I get to save four weeks of your productivity time.

Paul: Let me actually simplify this. Bosses walk around and they’re, like, “Why isn’t Rich at his desk? You know, I never see him at his desk, never see him working,” and they freak out and they talk to the manager.

Rich: Yeah.

Paul: But if they saw Rich using the expense-tracking software, which he has to spend three hours a week just doing expense tracking, [laughter] they don’t think of that as a loss because he’s, quote, “working.”

Rich: That’s right. That’s right. By the way, if I’m not at my desk, it’s because I’m crying in the bathroom about the software I have to use at work. [laughter] This is an old story, and it hasn’t changed. And the truth is, the amount of money spent inside of hospital systems, inside of large organizations, is massive. It’s actually massive. How do we know this, Paul? You and I visited a lot of those big companies in our former lives as agency leaders.

Paul: We did.

Rich: We saw the tools that people use and how they work and how they wanted them. And look, there are well-intentioned people inside those companies. But my God, the big machine is the big machine. [laughing] It’s hard, it’s hard to pitch it, and say, “Look, we got to make things better for our people.” It’s like, “What?”

Paul: You know what’s always sad about that? Everyone, when you say enterprise, everyone assumes there’s a magical force somehow, that it has secret knowledge.

Rich: Yeah.

Paul: And sometimes I think that’s true, like, an ERP system that understands the Azerbaijani tax code, because that’s where you get some of your textiles. [laughter] Okay, fine. But the part where they move the boxes around and put stuff in the database is the same in every system. It’s just different salesmen.

Rich: It is. It is. And some of our proudest work, we did some innovative things at the agency, but some of the best work we did was actually delivering really good, usable systems inside of these places, because design was a core part of how we thought about software at the agency, at Postlight, our former agency. And it’s very satisfying to see that actually matter and work for people.

Paul: So bring it home. I’m pain-addled. What are we telling people here?

Rich: I think we’re telling, well, first off, I hope you feel better.

Paul: Thank you.

Rich: And it is the Super Bowl. You should just watch the Super Bowl this weekend.

Paul: It’ll take me about a half hour to get to the basement, but okay.

Rich: [laughing] What I worry is you’re going to drop a drippy buffalo wing.

Paul: Yeah. And I reach down to get it, and then suddenly I’m in the hospital for three weeks.

Rich: No, it’s just out of reach. It just stays there.

Paul: Oh, yeah, that’s happened today. I couldn’t drink the coffee. It was all the way over…

Rich: Paul. This is the Aboard Podcast, and we’ve built a really good consumer tool around collecting information and managing it with Aboard. But our eye is towards those captive users.

Paul: It is. We want to make their lives better. And I think I have to calm down because I think that this is, like, a moral urgency, but I think it’s a professional thing. Like, let’s save time and save resources and not panic about it, and just, like, let’s get into organizations and help them make better software.

Rich: Consumer software is world-class, and that bar has not come near what happens inside of large organizations—by the way, it’s not just people who work inside them, but it’s their customers, too. Logging into my term-life-insurance policy is bizarre. Logging into my health-insurance provider because I’m trying to get prescriptions mailed to me is one of the most surreal—it’s like taking acid.

Paul: Rich, I’m going to do something. I am going to give us permission on this podcast, and a warning to the listeners. What people don’t know about us is that we used to close the blinds in the office at work that we shared. Usually we kept a pretty open-door policy, and we would put on a video and we’d watch it. And what would the video be? It would be like SAP intro tutorials, and we would talk about enterprise software as we watched people demo it. That was our secret life.

Rich: [laughing] The most uncool confession ever.

Paul: No, but that’s the old, other trillions of dollars that nobody hears about are spent that way.

Rich: It’s fascinating.

Paul: I think you and I, after we’ve moved on from the agency, I think we kind of pretended that we didn’t care, but we still really care.

Rich: Yeah.

Paul: We’ll use the opportunity of me breaking a bone to lean back in and talk more about enterprise.

Rich: Yeah. It’s one of the most unorthodox marketing campaigns that Aboard, that has ever been initiated. Essentially, let’s fess up, Paul. I busted your foot so we could open this conversation. [laughing]

Paul: One of those bad scenes in the movie where I need you to beat me up so that they think that we’re not on the same.

Rich: Right, right.

Paul: Do it, Rich! Yeah, you hit me in the foot. All right.

Rich: We didn’t introduce ourselves, so I’m Rich Ziade.

Paul: I’m Paul Ford. We’re the co-founders of Aboard. It’s a great data-management tool that lets you save links and do all kinds of research. Highly visual, highly good. Great new features rolling out soon. We’d love for your friends to sign up. You’re probably already signed up if you’re listening to this. And we’d love to hear from you. Hello@aboard.com. We really do like to know what’s going on, and we like to see if we can help. We still like to help out anybody who gets in touch, so let us know. Yeah.

Rich: And exciting announcements coming soon, so…sign up for the newsletter also. It’s pretty great. Thank you, Paul. And hey, godspeed, my friend..

Paul: Yeah, no, no. I’ll see you in the office. Soon on my rolly cart.

Rich: All right. That’s right.

Paul: And I’m sure you will only say appropriate things about my rolly cart.

Rich: [laughing] Have a lovely week, everyone. Stay safe.

Paul: Bye!

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