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For Black History Month, we’re recognizing pivotal Black leaders in healthcare who’ve paved the way forward for our country and the Black community.

Services that reduce travel and encourage social distancing are now more essential than ever, not only for vulnerable populations but all of us as members of our communities. Alto’s free same-day doorstep delivery ensures you have safe and reliable access to medications in this time of uncertainty. 

Hear first-hand from members of the Alto technology teams.

Alto / Blog

5 Black Healthcare Leaders to Know

At Alto, part of our work is to redefine the modern pharmacy to make sure patients from all backgrounds have reliable, affordable access to the medications they need. This extends to fostering a culture of inclusion in healthcare and honoring the Black leaders who have transformed the medical field. For Black History Month, we’re recognizing pivotal Black leaders in healthcare who’ve paved the way forward for our country and the Black community.

Black Healthcare Leaders Who’ve Paved The Way 

Dating back to the 19th century, there have been many Black individuals who, despite discrimination and prejudice, have made a profound impact in healthcare. From hospital bedsides to the front lines of the abolitionist and suffragist movements, here are five Black pioneers in healthcare you should know.

James McCune Smith: The first Black doctor in the U.S. 

When James McCune Smith showed potential and promise at a young age, his parish collectively raised funds so he could afford to attend university. Because of his race, he wasn’t allowed to attend school in the U.S., so he earned his baccalaureate, master’s, and medical degrees from the University of Glasgow in Scotland. 

Not only did Smith become the first Black doctor to practice medicine in the U.S., but he was also the first Black physician to publish articles in U.S. medical journals. In addition, he penned and edited articles for abolitionist newspapers including “A Lecture on the Haitian Revolution” (1841) and “The Destiny of the People of Color” (1843). He worked closely with Frederick Douglass and the two founded the National Council of Colored People. As a highly-educated Black physician and scholar, Smith was a key figure in not only abolishing slavery, but also in helping make its success credible.

Mary Eliza Mahoney: The first Black licensed nurse in the US

Mary Mahoney, born to freed slaves in 1845, learned the importance of racial equality at a young age. This became her reason for pursuing nursing school: to fight for and serve women and the Black community.

After years as a janitor, cook, and washer woman at the New England Hospital for Women and Children, she was accepted into their nursing program. The program was so demanding that only four of 42 students finished—Mahoney was one of them. And with that she made history as the first Black woman to become a licensed nurse. 

She earned many accolades in healthcare, became a member of the American Nurses Association (ANA), and co-founded the National Association of Colored Graduate Nurses (NACGN), where she was an elected leader. The NACGN was later absorbed into the ANA in 1951. Mahoney spent her days caring for those in need at the hospital and her nights campaigning for women’s suffrage. Her efforts were so influential that after her death, she was inducted into the National Women’s Hall of Fame alongside her fellow suffragists in Seneca Falls, NY. 

Dr. James Hildreth: President & CEO of Meharry Medical College 

A leader in immunology, Dr. James Hildreth leads Meharry Medical College in Nashville, Tennessee — one of only four Black medical schools in the country. Their mission is to create more opportunities in medicine for the Black community. Hildreth is renowned around the globe for his decades of influential HIV research as well as his work to fight the global COVID-19 pandemic. He was recently appointed to the FDA’s COVID-19 Vaccine Review Committee.

Hildreth earned his Bachelor’s at Harvard, his Ph.D. in immunology from Oxford and became the first Rhodes scholar from Arkansas who was Black. He joined the Advisory Board at Alto in August to help reimagine the pharmacy experience as one of its two anchor members. 

Phill Wilson has lived with HIV for over 30 years and lost his partner, Chris Brownlie, to the virus in 1989. Ten years later, he founded the Black Aids Institute (BAI) to ensure Black communities receive the information they need for prevention and treatment. The BAI has been leading the fight to end HIV in Black communities for over two decades and is the only national HIV/AIDS think tank focused exclusively on Black people. 

In 2010, President Barack Obama appointed Wilson to the President’s Advisory Council on HIV/AIDS. Over the last three decades Wilson has amassed countless national and international accolades, including the Ford Foundation’s award in Leadership for a Changing World.

Anna Louise James: One of the first Black female pharmacists

The daughter of a Virginia slave who escaped to Connecticut, Anna Louise James grew up in Old Saybrook, Connecticut, where she became the first Black woman in the state to earn a pharmacy license. She ran her own pharmacy and, when her brother-in-law—one of only two Black pharmacists in the state—was drafted in World War I, he asked her to run his pharmacy. 

She renamed it James Pharmacy and was known to everyone as “Miss James.” More than a place to pick up medicine, her pharmacy was a central gathering spot for the community. Miss James ran the pharmacy for 50 years and today, the building still stands and is listed on the National Register of Historic Places.

Our work to redefine the modern pharmacy begins with recognizing and honoring past and present Black leaders in healthcare. The leaders who’ve not only advanced the field of medicine, but who continue to break down barriers to help ensure equal access for all. Interested in making a difference at Alto? Follow us on LinkedIn to learn more or visit our Careers page for open roles.

Justin Moy, Senior Software Engineer at Alto, explains how the engineering team developed a staging environment strategy that could keep up with our growing organization.

Creating Sandboxes: How to Make It Easy for Your Engineering and Product Teams

When we formed our Infrastructure team in 2020, our charter centered on scale, reliability, and the developer experience. Our first priority? Developing a staging environment strategy that could keep up with our growing organization.

Initially, we had a set of command-line tools for staging environments that could be run from an engineer’s workstation. However, this approach required significant manual effort to create and manage an environment which led to inconsistencies like outdated data and lack of full application coverage and integration. The required workstation dependencies and maintenance added to the overhead. These tools were also different from the ones used to create a production environment, causing drift between the two.

To address these issues, we focused on improving our tooling to create consistent and reproducible results for both our staging and production environments. Here are the five steps we took to get there:

Luckily, we were already here. Our deployment process involved creating and deploying Docker containers and using a Procfile to run specific parts of our applications (think separating out web and workers). Packaging our applications as immutable Docker images allowed us to ship consistent and portable code. These images are run as containers which can be executed on separate hosts and scaled independently of each other.

We wanted to increase our observability, mature our internal monitoring, and maintain our infrastructure in a more consistent and reproducible manner. Kubernetes, and its automated container orchestration (deployment, scaling, and management), allowed us to accomplish all of the above goals.

It was easy for us to get started in Kubernetes thanks to Kind, which allowed us to run clusters locally. This increased development speed and reduced the friction of learning a new external provider.

Helm makes it easy to manage packaged applications in Kubernetes. Some community-provided applications include: NGINX for load balancing and reverse proxying HTTP and other traffic; Prometheus and Cortex for metrics, monitoring, alerting, and dashboarding, Loki for logs; and Sentry for exceptions.

In order to ease the integration with other infrastructure components, enable rapid deployment, and, most importantly, provide us with the consistency and reproducibility we wanted, we created and deployed Helm charts for our applications.

From here, we could stamp out our applications for developer use in sandbox environments: complete end-to-end environments, separate from production, that enable engineers to rapidly develop and test their code. And if an engineer is working on multiple features, they can spin up multiple sandbox environments and manage their applications and data independently of each other. Victory!

We had already created pipelines in Concourse to automatically deploy and upgrade our infrastructure Helm charts. To eliminate the manual toil of spinning up new environments and to reduce the friction around sandbox adoption for our engineers, we extended these automated pipelines by building a Git-driven continuous deployment pipeline. When an engineer created a commit to a repo defining the state of a sandbox, our Concourse job would apply these changes.

At this point, we could deploy environments that resembled production but were separate from production and other sandbox environments. They connected to the rest of our observability stack, including metrics, logs, traces, and exceptions.

As we prepared to scale to the rest of the product and engineering organization, we focused on the following ideas: further reducing manual toil, removing barriers to entry, reducing cost, and optimizing the development workflow. The diagram below shows our sandbox architecture.

In Kubernetes, an operator acts on custom resources in order to automate a task or set of tasks. The custom resource allows us to create a well-defined entity and extend configurability options to users. The operator allows us to customize individual sandbox environments based on changes to the custom resource.

We utilized Kubebuilder to create our operator and CRD (custom resource definition). Kubebuilder was a great starting point and provides tools to ease rapid development of a new operator.

Using this pattern, we could easily perform CRUD operations (create, read, update, delete) on a custom resource using standard tools like kubectl, and the operator would handle updating our deployments in Kubernetes. These updates could include: updates to application configuration, deploying a new Docker container, injecting different secrets, etc. This flexibility allows for testing of many different scenarios like: developing a new feature, reproducing a bug, upgrading frameworks, and security and load testing.

Increase adoption by removing barriers to entry (admin web UI)

We built a web UI so users would be able to deploy sandboxes intuitively and easily without extensive knowledge of the underlying tools. The web UI interacts with our custom resource and lets the operator handle updates. It allows our teammates—both engineers and non-engineers—to easily spin up their own environments for development, demo, or training purposes without modifying production data.

In addition, we show helpful information about a sandbox to a user. This includes links to each of our applications; pre-filtered logs, metrics, tracing, and exceptions; and commands to connect to specific applications to ease debugging.

Because the sandbox environments are integrated with our monitoring stack, we have the full metrics and logging that we expect from our applications. We created an autoscaler service that performs queries against this information and scales our sandbox environments up and down. We’re able to decrease our costs by over 90% when these environments are not in use and are able to quickly scale them back up when they are being used.

Optimize the development workflow (image updater)

An additional feature we built into our sandbox environment is the ability to follow a feature branch in our applications. When an engineer pushes a commit to a pull request in Github, a corresponding sandbox will automatically update to this commit. This reduces several manual steps in the development workflow and allows engineers to test their code in near-to real time.

Sandbox environments have made an impact on the engineering organization and beyond.

Engineers can quickly desk check new code in a production-like environment during code reviews.

Shared sandboxes reduce the blast radius of bug bashes.

Non-engineers can spin up sandboxes to demo or provide training on features without impacting production data via the Admin UI. This has proven particularly useful for Product Managers and Designers on the team to be able to play with product features and better understand how they work in order to suggest improvements.

Teams have built use case scenarios into their applications. This allows easy reproducibility of critical paths and functionality.

With these five steps—Containerize, Kubernetes-ize, Helm-ify, Automate, Optimize—we’ve laid the foundation for deploying all of our environments in an automated and consistent manner. In addition to applying many of our learnings to improve our production environment, we successfully built core infrastructure that our engineers, product managers, and designers use each month to test their changes and reduce production downtime.

Interested in learning more about engineering at Alto? Follow us on LinkedIn. 

In this post, we'll share how we identified the problem of failing cypress seeds, what the culprit was, and three ways to make seeding test data more robust.

How to Debug Slow and Failing Cypress Seeds

End-to-end test failing before it even begins? Here’s how we timed, debugged, and sped up our seed data.

At Alto, we use Cypress to test our Rails application end-to-end. As our application grows, so does our end-to-end test suite — along with the seed data it requires. This led us recently to a perplexing problem:  when run in CircleCI, our end-to-end tests would mysteriously time out during the seed step, causing them to fail and block deploys.

Seeds can be painful to debug. They’re typically set up through a single request and, depending on how thorough the tests are, call upon most of the models involved in the application. If a model throws, say, a validation error because of bad seed data, you'll see it in your Cypress logs. If a model hangs, the request often doesn't show up in the logs at all. There's no status code, no error message—all you know is that somewhere, somehow, some process is failing to finish.

In this post, I’ll share how we identified the problem, what the culprit was, and three ways to make seeding test data more robust.

To Identify the Problem, Focus on Your Logs

We started by comparing logs from our failing CircleCI runs with those from local test runs. Turns out, our CircleCI logs in failed runs stopped after a specific log message. 

For example, when our test runs succeeded, the logs looked something like this:

...
LOG: creating model
WARN: foo with id=123 not found
WARN: foo with id=456 not found
WARN: bar with id=789 not found
ERROR: Invalid parameter to function `foobar`
LOG: model created
... rest of logs

But when they failed, they instead looked like this:

. . .
LOG: creating model
WARN: foo with id=123 not found
WARN: foo with id=456 not found
[end of logs]

This let us know where to focus: after the function that looks for foo, but before or during the one that looks for bar. Of course, this only works if you have enough log statements scattered around in the first place. I’d recommend logging the time it takes to create each model in seeds, which has the added benefit of telling you where to start if your seeds are becoming annoyingly slow. 

At the top of our file in db/seeds, we declare the following function to add timings to our CI logs:

@last_time = Time.now
def log_time(label)
    Rails.logger.info("Time [#{label}]: #{(Time.now - @last_time)}")
    @last_time = Time.now
end

We then call the function after each create statement in our seeds:

Product.create!({...params})
log_time(“Product Create”)

This prints logs in the following format:

...log metadata message=Time [Product Create]: 12345
...log metadata message=Time [User Create]: 1102
...log metadata message=Time [Address Create]: 105
...

These logs will help you figure out problematic model create calls, but each model may have a lot going on in its callbacks (before_save, before_commit, after_save, etc). You can follow a similar approach to time those callbacks:

# in the model file
Class Model < ApplicationRecord
	
...

before_save :foo

...

def foo()
   start_time = Time.now
   [ ... things that happen inside the function ]
   Rails.logger.info("Time [foo]: #{(Time.now - start_time)}")
   [ function return statement, if applicable ]
end

It’s important to note that the most time-consuming statements in your seeds often cause the most trouble, but that’s not always the case. If your seeds are hanging due to external API calls, it’s entirely possible for those calls to usually take a short time to complete. If you have hanging tests, I would recommend logging test runs in CircleCI, since you may not be able to find the problem locally. 

Through timing our seeds, we narrowed down our search to five of our most time-intensive models. We were then able to time the individual callbacks within those models. One callback  in particular—containing a call to an external database—raised the most suspicion. It took up most of the time it took to create the model, didn’t return any information needed in our test, and was not mocked or stubbed out. 

Requests to this test database would usually work, however, since we call on it multiple times on every CI run, with concurrent CI runs, these requests would sometimes take a long time to complete, leading to a test timeout. 

In our case, since we were making calls to a hosted database in our tests, we changed our test environment to create and refer to an isolated instance of the database. While this was the best approach for our specific issue, we also explored some other ways of stubbing out API calls and skipping callbacks from your seeds file, which we describe below. Use these approaches with caution, as the more you stub, the less true-to-life your tests will be. 

Ideally, you would have already stubbed out third-party API calls in your code using environment variables. An example approach:	

def do_the_thing()
    if Rails.env.production?
    	[ ...do the thing ]
    else
	[ ...do some fake thing if needed ]
       Rails.logger.info("We theoretically would have done the thing.")
end

However, you can also use Typhoeus to mock third-party api calls in seeds, similar to how you might in a test. Imagine that your Product model makes a call to "https://slack.com/api/foo”. We can then mock that call out as follows:

mock_response = Typhoeus::Response.new({code:’500’, body: {
    “ok”: false,
    “error”: ‘not_authed’
}.to_json})
Typhoeus.stub("https://slack.com/api/foo”).and_return(mock_response)
Product.create!({...params})

Again, I would advise you to stub check for environment variables in your code rather than stub out individual API calls in your seeds and tests. But if for some reason you need to do the latter, it’s possible!

Similarly, you might want to stub out a function you’ve written if it takes a long time to run and doesn’t affect the outcome of your tests. This can’t be stubbed out in the ways we mentioned above since (1) you might need it  for — and hopefully are testing it in  — other tests and (2) it doesn’t have a url. minitest has a tool for this. Imagine you’re trying to stub out some functions from a Photograph model.

require ‘minitest/autorun’

Photograph.stub :fetch_product_photo_url, ‘’ do
   Product.create!({...params})
end

This will return an empty string when Photograph.fetch_product_photo_url is called within the Product model’s callbacks. You can also replace the empty string with anything else you might want the function to return.

Last but not least, it’s possible to skip entire callbacks and validation. I wouldn’t recommend skipping all of them, as that can cause models in your tests to stray very far from how your models actually work, but you may find it useful to skip specific callbacks.

While all the methods that I’ve suggested above are possible and can be useful, remember that stubbing and skipping from your seeds may just be band-aids for issues you have elsewhere. In our case, we could have stubbed out a model function or created an isolated database for testing. While both methods would have been functionally the same, doing the latter allows us to have to worry less about that database in the future—if, for example, we write more functions that depend on it, or update the mocked functions to do more than they currently do. Keeping tests in line with how the product works also keeps it more in line with the actual user experience: if it’s taking a long time to create a model in your seeds, it probably takes a long time for your users, too. 

Since adding timing logs and creating an isolated database to our end-to-end tests, we have a regular source of truth for the efficiency of our models, are able to develop more smoothly with fewer spontaneous test failures, and have more confidence in our ability to quickly pinpoint and resolve seed timeouts in the future. 

When the pandemic hit, we were thankful to already be in the position to make a meaningful difference for Alto’s working parents. Our Working Parents & Allies Employee Resource Group (ERG) was formed at the beginning of 2020. 

Supporting Working Parents at Alto

With the COVID-19 pandemic forcing the shutdown of schools, offices, and daycare programs this year, working parents have been expected to accomplish Herculean feats of focus. Many parents spend their waking hours with one eye on their computer screens and the other on their children, all while coordinating remote learning, nap times, and video conferences. 

Those who continue to work outside the home must navigate the unpredictable availability of childcare services. Anything from new shutdown orders to a caretaker forced to quarantine can mean a lapse in care. A recent study found that 33% of working parents had no access to childcare at all, a percentage twice as large as in pre-pandemic times. 

At Alto, we serve thousands of working parents, including many who are juggling caring for their children and aging parents. Just as we support them by delivering a better pharmacy experience, we also want to support the hundreds of heroic parents working at Alto and caring for our customers every day. 

ERGs are meant to empower community groups within an organization by directly linking decision makers and implementing policies that support the group’s specific needs. The groups often center around a shared identity or experience and focus on building community, providing support, and contributing to its members’ personal and professional well-being. By creating an open forum for employees to come together, discuss challenges and opportunities, and foster a sense of belonging, ERGs help both individuals and organizations thrive. 

“Now more than ever it’s important to uplift and advocate for parents,” shares co-lead and mother Lidia Valdez. “The parenting landscape has shifted dramatically in 2020 but with the continued sense of community at Alto we can lean on one another for advice and support.” 

For more on how Alto fosters an inclusive culture and company, we invite you to read Diversity at Alto. 

The Mission of Alto’s Parent & Allies ERG

Alto’s Working Parents & Allies ERG came into being just before the pandemic began placing unprecedented demands on parents. It aims to provide an inclusive space for parents and allies to discuss how they’re feeling, speak openly about the challenges they’re facing, and request what they need from Alto. The ERG also helps parents remain informed and up-to-date on the policies and programs that are in place to support them. 

While the ERG’s first initiatives have centered upon providing pandemic-related support—from child care services to remote learning opportunities—these initiatives will continue to grow and evolve along with the needs of working parents at Alto. 

It was quickly apparent that Alto’s working parents—like parents everywhere—were overwhelmed with trying to manage the sudden shift to full-time, in-home childcare and schooling. The ERG responded by launching forums co-hosted by parents and the ERG leadership committee. These support groups were designed to create a safe space for parents and allies to share how they felt amidst a return to virtual learning in the Fall. Following the discussions, we launched a pilot program to offer immediate, tangible support. 

We began by inviting parents to opt into a program facilitating childcare services through UrbanSitter—a site that connects parents with trusted caretakers from their local communities. Interested parents received a stipend to cover membership fees and in-home or remote care costs. Whether parents needed support during a video conference or last-minute care after finding out their child’s daycare was closed, UrbanSitter could provide some relief.

We also rolled out a program with Outschool—a marketplace of live, online classes for students ages three to eighteen. Participating parents could access five hours of classes per week for free, allowing their children to explore interests ranging from math and music to filmmaking, coding, painting, and writing. With over 50,000 classes available, Outschool helps parents focus by keeping their kids engaged with fun, enriching activities. In the words of one Alto parent, “I really enjoyed Outschool for my kids. It’s such a good help; they are engaged and learning new things. Both my children and I love it!”

In addition, parents that needed hardware support for at-home distance learning were provided laptops at no cost. 

After a few months, we asked parents to provide feedback on the pilot program. We found that 71% of parents participated in the program, and 47% felt that the resources had made a positive impact on their lives or increased their ability to be productive and engaged at work. We’ll use this feedback to continue initiatives that have made a difference in the lives of Alto’s working parents while introducing new programs that can provide further support. 

The ERG leadership team also identified opportunities that would spark joy and support parents outside of the Alto community. “Working remotely can often feel isolating so we wanted to create instances for parents and their children to be recognized,” notes co-lead and parent Sandy Obeji. “In addition, we knew it would be important to extend this acknowledgement beyond parents at Alto.“

In October, we hosted a Halloween costume contest aimed at encouraging fun and creativity. Alto parents were invited to share photos of their kids in costumes, and prizes were awarded for the most unique, scariest, and funniest getups. Both adults and kids participated in choosing the winners, arguably providing more fun than a night of trick-or-treating. 

We also coordinated a Holiday Giveback Program to raise money for supplies and gifts for children and families in need during the holiday season. Alto employees were able to donate items to seven organizations—one for each Alto pharmacy location—virtually with the help of You Give Goods. In the end, we exceeded our fundraising goal and Alto matched the total donation to help make the holidays a little brighter for families across the country. 

Initiatives like these are just the beginning, and the Working Parents & Allies ERG has been collecting feedback that will guide our planning for 2021. In addition to extending access to several of the resources mentioned above, we are also exploring workshops for parents centered around current issues and events. 

There are plenty of reasons to believe that parents are superheroes, but that doesn’t mean we can expect them to perform superhuman tasks. Alto’s Working Parents & Allies ERG was created to help parents find much-needed balance and support during a tremendously difficult time. We look forward to seeing the group grow, aiding ongoing and future initiatives, and continuing to foster a culture where everyone feels included, valued, and supported. 

Interested in learning more about the Working Parents & Allies ERG? Reach out to parents@alto.com. 

Last year, we built a feature to show patients all of their medication pricing options, including when paying cash might be cheaper. Here are two surprising trends we've discovered since.

Two Engineers Crunch the Numbers: When Is It Cheaper to Pay Cash for Your Medication?

Tom Cahill and Ashley Qian, Sr. Software Engineers

In 2019, we launched a streamlined flow in our patient app to handle a surprising scenario: when the out-of-pocket price for a medication is less than the insurance copay.

Since launching our price selection feature last year, we've saved thousands of patients money by bringing this disparity to their attention. On average, patients save 30% off their total copay when their out-of-pocket price for a medication is cheaper than the insurance copay. The average savings per prescription is $23.30. 

While several factors impact how drug pricing works, here are two trends we’ve seen in the data so far.

These Two Therapeutic Classes Are Most Likely to Be Cheaper Out of Pocket

A therapeutic class is a method of categorization that groups medications based on the conditions that they are intended to treat. Here's what we found when we aggregated prescriptions by therapeutic class:

Across the 394,367 prescriptions we examined, roughly 0.5% had lower out-of-pocket costs. Comparing different therapeutic classes, anti-parasitic drugs (example: permethrin) appear most likely to have a cheaper out-of-pocket price by a fairly wide margin at 2.94% of cases. Cardiac/cardiovascular drugs (example: rosuvastatin calcium aka Crestor) and blood medications (example: tranexamic acid) stand out as well with over 1% of cases.

Looking at the results in terms of median percentage savings, a few classes stand out as having a fairly high disparity between prices: anti-histamines, contraceptives, anti-neoplastics and anti-infectives. 

Brand Medications Are Less Likely to Be Cheaper Out of Pocket

You're up on Family Feud, and Steve Harvey asks you to name some differences between brand-name and generic medications. The first thing that probably comes to mind is cost: In general, one expects generic medications to be cheaper than their brand-name alternatives. We might expect brand name medications to incur higher copays and thus a larger opportunity for Alto to provide savings. However, we see a surprising trend in our data:

In fact, only .01% of brand name medications we've delivered since shipping this feature had lower out-of-pocket prices (compared to .6% for generics).

So what gives? The cash price we’re able to offer for a medication is mostly determined by the cost we paid a wholesaler or manufacturer to buy it. The copay set by insurance plans, however, is often impacted by behind-the-scenes negotiations between the drug manufacturer and the pharmacy benefit manager, or PBM. As a result, the cash price isn't always strongly correlated with the insurance copay:

Among a set of equivalent products, the one with the cheapest cash price might not be the one with the lowest insurance copay, and that difference can be significant enough to make it worthwhile to forego using insurance.

As engineers who are tasked from time to time with investigating issues with our billing system, we've experienced our fair share of bewilderment at the surprising outcomes we sometimes see. The complexity of pricing is why we've invested so heavily in making sure both our internal tools and patient-facing applications present users with the information they need to understand their options and make well-informed decisions.

We have countless opportunities to help our patients achieve better health outcomes, save money, and be more informed about their choices when it comes to their medication. There’s a lot of exciting work to do, and if this sounds interesting to you, please reach out to us on LinkedIn. We’d love to hear from you!

We are building a pharmacy where every patient matters and is included. To do that, we need to foster a culture and company that is committed to challenging existing racism, injustice and prejudice, in order to create a culture and service that is inclusive. 

Diversity At Alto: Building an Inclusive Healthcare Company and Culture

At Alto, we are redefining the pharmacy experience which has been part of a very old, broken way that has fueled systemic racism. We are building a pharmacy where every patient matters and is included. To do that, we need to foster a culture and company that is committed to challenging existing racism, injustice and prejudice, in order to create a culture and service that is inclusive.  Our team consists of committed and passionate individuals who champion to effect positive change on issues related to race, injustice and prejudice.

This passion for equality is what we strived for when we first set out to build a team with a broad representation of diversity. Our goal was to create a community that reflects an inclusive culture regardless of age, education, gender, race, ethnicity, religion, sexual orientation, socio-economic status, or other dimensions of diversity. Yet even with the best of intentions we recognize that there is more work to be done to dismantle the systems and structures that fuel racism and inequity.

2020 has been a year like none other for so many.  HR professionals around the globe have stepped center stage to support our organizations, teams and communities in ways many of us could not imagine.  I wanted to write this post to share my personal journey on this topic while supporting others in capturing this moment.  I am a white gay cis man.  Many of my identities provide much privilege.  I am committed to educating myself. I am building an environment where our teams can push past their fears to learn and grow.

Read more about Why We Prioritize Diversity at Alto.  

In 2019 we initiated our focused DEI (Diversity Equity Inclusion) work with the goal of ensuring employees felt safe, and included, and ensuring that candidates and employees have equal access to opportunity for advancement in the organization. We learned a few things during the early days of this work including balancing listening while creating the right structure to move to action.  Fast forward to early 2020, in the midst of the global COVID-19 pandemic and the murder of Ahmaud Arbery, Breonna Taylor, Tony McDade, George Floyd, and Jacob Blake, we like many other organizations did not want another moment for action to pass by.

Read more about Alto’s Mission and Values. 

The week after George Floyd’s murder we hosted a series of listening sessions for Altoids.  We began them with a simple statement:  “We are holding this space for you.  Tell us how you are feeling.  Share your experiences.” The results were powerful moments of revelation, pain and heartbreak.  Black, Asian, Native and Latinx Altoids shared experiences of racism, sexism, and prejudice in their lives.  As a leadership team, we started to wake up to the enormity and urgency of the work we had ahead of us.

In reflecting on these tragic murders and Altoid voices, we realized we needed to expand the building blocks of our 2020/2021 DEI strategy. We recognized that we didn’t want to rely on the members of our underrepresented communities to lead us on this journey.  We do not expect underrepresented professionals to teach us, especially cis white men, about the history and experiences that led us to this moment. 

We made the decision to find a partner to help.  What struck me about Pathfinder and Trier Bryant, is their ability to push our thinking on this critical work while meeting us where we are (each one of us). Trier is a strategic leader with distinctive Tech, Wall Street, and military experience spanning across 15 years. Pathfinder has an unwavering commitment to advise leaders on how to create a more equitable, inclusive, and thriving culture to produce prosperous companies. I appreciate many aspects of Trier’s support including that she too is a Chief People Officer, she wears these shoes.  Given that experience plus Pathfinder’s work with clients like Equinox, Compass, SoundCloud, Gusto, and eBay, we gain perspective and lessons learned.

Our first half-day session with Trier focused on educating the group about the language of diversity (e.g. Is it okay to say Black? What makes up the LGBTQIA+ community?).  Next we spent time learning about key historical events starting from 1619 that have shaped our current society with respect to race, oppression, and white supremacy in America.  We watched videos displaying more covert forms of white supremacy [see Ellen Tuzzelo’s Pyramid of White Supremacy]. 

These are actions I could recognize in myself (i.e. not challenging racist jokes when told by my family members, not always believing the stories of Black victims).  I felt sadness and shame. Sharing these feelings and our part in the current state of our nation is an important step. We took time to process and walked away with an epiphany.  

Over the past decades, America and specifically Corporate America lulled itself into thinking that we’ve been fighting bias.  Our aim up until this moment was to reduce or eliminate bias.  We were wrong.   Our fight, our work is to eliminate racism and white supremacy in America. This work is neither a marathon nor a sprint; we’re committed to doing this work all our lives.   

With that realization in mind we got more specific about what diversity meant to us and where we wanted to focus our teams at Alto. Diversity by nature is very broad and inclusive. We used individual characteristics, experiences, and abilities consistent with our values and mission that includes but is not limited to:

*Sexual Orientation and language abilities will begin to be captured with Workday, our new HR system.

As a part of the above education, we learned that while we all have various identities and intersections that represent our Altoids, intersectionality is a term that must be clearly understood to comprehend unique modes of discrimination and privilege that occur in the workplace.  

Identity - the fact of being who or what a person is; affinity (i.e. Hispanic/Latinx, Black, Male, Female, Nonbinary) 

Intersections - a point at which two or more identities  intersect (i.e. Hispanic/Latinx Gay Male, Black Heterosexual Female)

Intersectionality -  the cumulative way in which the effects of multiple forms of self-identifications intersect, overlap, or combine to create unique modes of discrimination and privilege; intersectionality identifies advantages and disadvantages that are felt by people due to a combination of factors

While Alto recognizes a broad and inclusive definition for diversity of various identities, there are strategic priorities for underrepresented groups at the company. After benchmarking current tech and health care demographics, we decided to focus our DEI work for Altoids including our leadership, managers and independent contractors on the following underrepresented groups at Alto: 

Women in STEM (Science Technology Engineering Math)

The following month we read So You Want to Talk about Race by Ijeoma Oluo. What an incredible read! This engaged us in thinking about and naming our privilege.  In the next half-day session with Trier, we discussed the book to name our privilege and explored how it influenced our personal and professional development.  

We learned several lessons from Ijeoma and Trier including that we’re going to make mistakes and say the wrong thing; that is part of the journey yet we still must do the work.  Also that microaggressions are as damaging as overt racism and we must do better at calling these detrimental behaviors out everyday. 

Lastly, non-white people fear retaliation most when the topic of racism and prejudice comes up; we must create a space for everyone’s voices and perspectives to not only be heard but respected.

As I reflected on our second half-day session together, I saw the journey for our leadership team through four stages.

Stage 1: Self-Awareness-doing the personal work regarding racism and privilege

Stage 2: Awakening-acknowledgement of role of racism, privilege, and gressions,; doing the work in our professional life

Stage 3: Empowering-identifying the work to be done with our team, team members and building more inclusion on our teams

Stage 4: Advocating-taking our roles as a senior leaders at Alto to change behaviors and lead change at the company and our communities 

For the last round of workshops we split up our senior leaders into smaller groups so that we could focus on the work needed to be done with each of their teams.  In these sessions, we learned more about identities.  How do we identify?  What do we learn and acknowledge about our team members identities?  We discussed specific examples of how intersectionality shows up in the workplace and the role it places in each other’s experiences.  This pivot allowed us to move into Stage 3.

As we embarked on taking this work to our team, we felt more prepared and comfortable because of the time spent educating, processing and doing our own work ahead of time. This allowed each of us to live one of our core values “start with empathy.” Being empathetic is hard when you haven’t done your own work.

As a result of all the foundational work we’d done as individuals, as a team and as a company, in July, our leadership team committed to a bolder, crisper DEI plan that includes four strategies with clear goals:

Hire - ensure we have diverse teams and insure all are valued

Include - increase inclusion and community 

Develop - educate our leadership team and all Altoids

Invest - support initiatives with money and time  

This new DEI plan rallied the team and catalyzed us to make some significant changes with clear alignment, commitment and clarity around the problem we’re trying to solve. For example, one immediate change we made was to focus our executive search process on underrepresented talent. I’m excited to share that only a few months later (most searches take 6 months), we were able to hire several outstanding candidates from underrepresented backgrounds. 

Before, we had just been “hoping” for diversity and thus looking in all the wrong places.  Once hiring diverse talent  at the executive level became a critical mandate, that forced us to really seek the right kind of strategy. I’m excited to share some more of the significant changes we’ve made, over a series of posts over the next few months.

We are far from perfect.  We have work to do to meet our goals.  These are our first steps.

In January, we will share our first DEI Report including workforce demographics, success stories, lessons learned from 2020, and aspirational goals for 2021 and beyond.

We condemn the violence and systemic racism that has harmed marginalized communities, specifically Black communities, for far too long. At the same time, we commit to look inward and educate ourselves to continue to create safe spaces for Altoids and to act on what we learn. 

This will be a lifelong journey and we will continue to share updates on our progress. Our actions must be sustained and focused on keeping the momentum of enabling change now and for future generations. 

Last, personally this work is the most fulfilling of my career. There are days I am exhausted.  There are days I need help.  Yet there are many days I overflow with pride in our team.  I am most hopeful about the work ahead and seeing the early fruits of this work while challenging us each day to do more.

For an inside perspective on sales at Alto, we sat down with Craig Thompson, our Vice President of Sales, to learn about his experience at Alto and his advice for qualified sales professionals looking to join the team.

An Inside Look at a Sales Career with Alto

Why Our Sales Team is Central to Our Mission at Alto

Like so many big ideas, Alto began with a question: what if we reimagined the pharmacy experience to make people happier and healthier? Improvements were begging to be made: not only were most people and providers frustrated and dissatisfied with the status quo,  but medication non-adherence—when people don’t take the medication they’re prescribed—has hovered at 50%. In addition to $300 billion in avoidable medical costs, non-adherence is estimated to cause approximately 125,000 preventable deaths per year in the United States. 

With these problematic statistics in mind, Alto set out to do more than just dispense and deliver medications. Our mission is to fulfill medicine’s true purpose: to improve the quality of life for everyone who needs it. We aim to make our better pharmacy experience available to 100 million people by 2025 and we’ve raised over $350 million—including more than $250 million at the beginning of the year—in pursuit of this goal. 

To reach more people and expand into new markets, we are building a strong, mission-driven sales team to help forge the way. For an inside perspective on sales at Alto, we sat down with Craig Thompson, our Vice President of Sales, to learn about his experience at Alto and his advice for qualified sales professionals looking to join the team.

Can you tell us about your own career path and why you joined Alto?

Prior to joining Alto, I spent about 20 years in the medical device space. Early on, I worked for a few different companies before landing at Abbott Vascular where I started as a sales representative, led trainings across the U.S. as the Director of Medical Education, then pivoted back to become VP of Sales. I always envisioned that my next role would be a bigger version of that position; one where I could swing big and settle in for the long haul. 

What intrigued me about Alto was the size of the market. We spend more than $330 billion on prescription drugs a year in the U.S., but it didn’t seem like anyone was nailing the pharmacy experience, especially from the patient’s perspective. When I met Matt, Alto’s CEO, I was impressed by his patient-centered mission and his humble approach. The opportunity to build something from the ground up really appealed to me. I also loved the idea of working alongside a team of high caliber people with diverse professional backgrounds.

Alto represents a true convergence of healthcare and technology. Moving from medical devices or pharmaceuticals and coming here, you learn new ways to communicate and have access to new technology and resources.  We have our eyes on the future and a vision for how we want to scale. By keeping a strong focus, we’ve more than doubled our revenue each year for the past few years. As we continue to expand into major markets across the U.S., we’re looking to bring in highly talented people with existing relationships to build out our sales team. 

While we've delivered fantastic growth over the last few years, we're still in a phase of evolution where a new member of the team can have a meaningful impact on our organization. This is an ideal opportunity to take part in building something new and to know that as you help build a better business, you’re also helping to improve people’s and healthcare professionals’ lives. Not only have we leveled up the patient experience with our app, but we’re also making the pharmacy experience easier for healthcare professionals. Alto is uniquely suited for those who care about benefiting the stakeholders we work with. It’s genuinely all about the mission.

What makes a successful partnership manager at Alto? 

We’re looking for builders—creative people who can operate in ambiguity and thrive in a startup environment. Working at Alto is an opportunity to build new territories and make a real difference for people. It’s for those who want to create novel solutions rather than work with rails around them. We need innovative people with existing relationships who are motivated by Alto’s mission to improve lives. 

What exciting challenges await a potential team member? 

We're really at the tip of the iceberg as far as the products that we are bringing forward. There's a ton of work to be done as we consider how we can continue to meet the needs of both people and health care professionals. We’re always working to develop services and technology that can help impact adherence rates, improve the overall quality of life for people, and make physicians' lives easier by reducing the burden that exists on their teams from insurance companies. 

There will be a ton of opportunities for people to come in, demonstrate success, and find fulfilling professional paths. One of my visions for the coming year is to develop additional resources dedicated to professional and personal growth and implement programs with specific learning tracks. 

We work cross-functionally and are always open to learning new ways of operating and finding success. If you’re excited by the opportunity to create something new rather than inherit an existing territory, we’d love to hear from you. 

This is an exciting time to join the team at Alto. As we continue to forge new territory, expand into new markets, and develop our specialty areas, we’re already on track to achieve $1 billion in annual recurring revenue by 2021. To maintain this trajectory, we’re looking to grow our team with highly skilled individuals who align with our values and are motivated to create change. There is abundant opportunity to not only achieve success but find fulfillment by working toward a mission that positively impacts people’s lives.  

If you've found yourself considering embarking on a new adventure, we’d be thrilled to have you consider Alto as your next career milestone. Visit our careers page to see if we're actively hiring in your city. If you're not quite ready to make a move, join our talent community and follow us on LinkedIn to stay apprised of upcoming opportunities. 

Mike McClay has spent the better part of two decades working in Silicon Valley. Here, he chats with software engineer Akash Gupta about the road from Software Engineer to VP, what it’s like to work in digital health, and his best advice to both independent contributors (ICs) and managers. 

Get to Know Alto’s VP of Engineering, Mike McClay

I'd love to first understand a bit about you personally. What do you like to do in your off time? What’s something most people don't know about you?

I grew up in Orange County, which is pretty suburban, so that afforded us a lot of time outdoors as a family. A life goal of mine is to do a solo hike of the John Muir Trail. The route starts in Yosemite Valley and heads south to Mt. Whitney. It’s about 225 miles and typically takes a few weeks to complete.

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Diversity At Alto: Building an Inclusive Healthcare Company and Culture

An Inside Look at a Sales Career with Alto

Get to Know Alto’s VP of Engineering, Mike McClay

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