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Blog | Alto Pharmacy

No industry is immune to burnout, including pharmacy. At many traditional retail pharmacies, individual pharmacists are often asked to do more than is possible on any given workday. Not only does this deprive talented and extensively trained health professionals of a manageable working environment, it deprives patients of the exceptional care they deserve.

pharmacists-spotlight-roni-hein

The better pharmacy model we’ve created at Alto makes life easier for everyone involved in the prescription process: patients, physicians, and pharmacists. And in restructuring how pharmacists work, we haven’t just separated fulfillment and patient care responsibilities into different roles — we’ve ensured that there’s ample support for each specialization, as there should be in any profession.

To wrap up our series of pharmacist profiles in celebration of American Pharmacist Month, we spoke to Roni Hein, a patient care pharmacist lead who takes care of her team so that they can in turn care for patients.

What motivated you to pursue a career in pharmacy?

It all began with my high school and college job at Target. I interacted a lot with the pharmacy team while working in the health and beauty section and eventually moved into that department.

I never expected it to be more than a college job, but it turned into the beginning of my professional path. As I worked there, I was able to see the impact pharmacists made in customers’ lives each day. It really struck me that in many communities, including mine, pharmacists were the most accessible healthcare providers. That accessibility is so impactful on a person’s well-being.

What challenges have you encountered as a pharmacist?

Limited time and isolation behind the counter, without question. In retail pharmacy, more and more responsibilities were added to my job description, with fewer resources to accomplish them.

All pharmacists value the personal connections we make with patients. I think many of us would say that making an impact through patient counseling is the best part of our day, but that is often what gets lost when pharmacists are asked to do more. Our primary driver for entering the profession is the first thing to go. I found a very refreshing change at Alto.

Everyone at Alto, no matter their department or role, has the same shared goal of improving patient lives by transforming the pharmacy model. As a patient care pharmacist lead, I do that by supporting my people. I create the space for our pharmacists to do their best work. They are able to have better interactions with patients because they are taken care of.

The pandemic has been a trying time for many companies and teams, including mine. I am constantly looking for new ways to ward off burnout and maintain a sense of camaraderie, not only for the pharmacists I manage, but for the benefit of our customers as well.

The individual locations of many retail pharmacies can feel very separate from each other. Each one often serves a single population.

The centralization of Alto’s patient care team is a contrast to that model. We have a cohesive, unified team serving all patients. That means there’s a depth of resources available to each pharmacist, which is also really important for retaining great talent.

Our pharmacists have a great support system in their colleagues. There’s other smart, driven pharmacists to bounce ideas off of. Unfortunately, you don’t always get that in our profession.

It also means that you don’t have to worry about anything falling through the cracks if something comes up outside of work. It's a game changer to be able to take time to grieve a loved one or to care for your child if they’re sick while knowing that your patients are still in expert hands. I never had that in retail pharmacy.

Finally, what is one thing people would be surprised to know about life as a pharmacist?

At a tech-oriented pharmacy like Alto where there’s so much innovation, you’re constantly thinking of new and creative ways to problem solve. It’s challenging in the best possible way. There isn’t a day when I don’t have to put my critical thinking skills to use.

This is part of a series of pharmacist profiles to recognize American Pharmacist Month 2022. Meet the other pharmacists featured in this series: patient care pharmacist Travis Allison, specialty patient care pharmacist Gabrielle Kaplan, and medication therapy management pharmacist Wei-Lin Chang.

National Pharmacists Month Spotlight: Roni Hein

Pharmacists are one of the most accessible healthcare professionals, seeing people 5 to 8 times more frequently per year than primary care providers. Their role has become more expansive than ever, and many people don’t realize just how integral they are to a patient’s health and well-being.

National Pharmacists Month Spotlight: Travis Allison

At Alto, fulfillment pharmacists focus on dispensing medication — ensuring that the entire process is carefully monitored every step of the way — while patient advocacy pharmacists tackle anything related to a patient’s wellness, from provider communication and insurance coordination to guidance on managing chronic health conditions.

These specializations have opened up entirely new possibilities for the patient-pharmacist relationship at Alto. And this October, as we celebrate American Pharmacist Month, we’re spotlighting a few of the extraordinary Alto pharmacists who focus on patient advocacy.

To kick things off, we’re pleased to introduce Travis Allison, a patient care pharmacist based in Dallas, Texas.

I took the long and winding road here. I didn’t always know this was what I wanted to do. In college, I started off as an English major but had a change of heart after a semester or two. I went on to study agriculture, and those experiences made me believe that I could pursue a path grounded in science.

My childhood memories of visiting the pharmacist were always in the back of my mind. As a kid, I hated going to the doctor. When those dreaded appointments were over and done with, I knew I’d get to see a guy in a white coat who would give me something to feel better. I always saw pharmacists as a comfort in the often scary world of healthcare.

At any chain pharmacy — which is where I spent my career before Alto — pharmacists are inundated with so many tasks. It isn’t that these tasks are unrelated to pharmacy, but they interfere with our ability to deliver patient care.

On a typical day, I would give 100 Covid shots and fill 200 prescriptions by myself while also coordinating billing and calling doctors’ offices. We also had to think about corporate metrics. I was frequently asked to get more people signed up for text message alerts and hit specific quotas.

Patient care is always the priority, for any pharmacist, but the reality of my job made it extremely difficult, and often impossible, to give patients the time they deserved.

The first thing I noticed when I started at Alto were the specializations. We have many different team members to handle all the responsibilities that fall on a single person’s shoulders at a traditional retail pharmacy.

I’m a patient care pharmacist, which is distinct from fulfillment pharmacists who process prescriptions.

I review prescriptions for accuracy and initiate medication transfers, and I interact with both patients and doctors. I’m here to answer any questions a patient has about their medication.

In a way, I feel like I’m on the frontlines the same way that I was when I worked in a pharmacy chain. It’s all of what I liked about retail pharmacy without the distractions of retail. We’re able to practice our most important functions as pharmacists without the noise.

We’re utilizing technology in a way no other pharmacy does, which allows us to communicate with patients and providers in so many different ways — without having to rush through interactions.

And the wheels of change turn much more quickly at a tech-oriented company than they do at a massive corporation. At my previous job, you could have conversations all day about what improvements were needed, but nothing ever happened. Alto was founded by software engineers, and we’re able to easily make changes in real time.

As a digital pharmacy, we serve so many patients that only we can serve. I talk to many who are homebound without a caretaker. Because of Alto’s model, I’m able to communicate with them, and we’re often their only point of contact within the healthcare system. I don’t know of another way these patients could get pharmacy care.

The digital model also allows us to get a broader view of healthcare, and to make an impact on a larger scale. Alto was one of few places where New Yorkers could get the Covid medication Paxlovid when it was first introduced.

It was incredible to be sitting here in Texas, getting prescriptions out in New York City just as a new variant came out that was really devastating to the city. At no other pharmacy would I have been able to help out my neighbors in New York.

Those moments where you can tell in a patient’s voice that you seriously helped them. To me, that’s an indication of how well I’m doing my job, much more so than the number of prescriptions processed or dollars generated.

Redux is great for managing client state: it allows data to be synchronized across the whole app, reduces prop drilling, and makes it easier to understand when state changes occur.

Server state is a different story. Sure, it’s nice to have data available everywhere in our app, which is why we tend to fetch data from the server and dump it into our Redux store. But because our client application doesn't own that server data, it’s hard to know when it has become stale. And what if multiple components trigger calls to fetch the same data? How do you dedupe requests? How do you decide when to refetch?

Why We Switched to React Query for Managing Server State

Redux is great for managing client state: it allows data to be synchronized across the whole app, reduces prop drilling, and makes it easier to understand when state changes occur.

Server state is a different story. Sure, it’s nice to have data available everywhere in our app, which is why we tend to fetch data from the server and dump it into our Redux store. But because our client application doesn't own that server data, it’s hard to know when it has become stale. And what if multiple components trigger calls to fetch the same data? How do you dedupe requests? How do you decide when to refetch?

Below, we’ll dive into how we’re using React Query at Alto to solve these problems and achieve separation of client and server state.

The Old Way: Fetch Server Data and Store It in State

Historically, we would fetch data and set the response in our React component state.

fetchUser(params) {
 this.setState({ isLoading: true });
 
 return getUser(params)
   .then(({ data }) => {
     this.setState({
       isLoading: false,
       user: data.user,
     });
   })
   .catch(() => {
     toaster.toast({ title: 'Something went wrong...' });
     this.setState({ isLoading: false });
   });
}

To make that data accessible from other components, we’d set that data in the global Redux store. This works fine, except that you have to manage your own loading state, the logic for when and when not to make the request, updating the store when mutating data on the server, and knowing when data is stale.

The React Query Way: Fetch and Cache Server Data

With React Query, fetching data and using that data is more declarative.

const { data, error, isLoading } = useQuery(
 // This is our Query Key, which is unique per query so that React
 // Query can manage the cache for us.
 ['user', { userId }],
 
 // This is our Query Function that actually does the data fetching.
 // We can use anything we want: built-in fetch, axios, etc.
 fetchUser({ userId }),
 
 // This query will not execute until the userId exists.
 { enabled: !!userId },
);

Here, we define our query for a user with a Query Key and a Query Function. The Query Key is unique per query, so React Query can manage our cache for us, and if any part of the Query Key changes, the query will automatically fetch new data. In this example, if the user ID changes, the query will fetch new data for that specific user and store that data in the cache.

Naming is hard, but caching is harder. React Query gives us caching of server data out of the box with cache invalidation and request deduping. If we use this same query with the same Query Key in another component, it'll check the cache: if the data is already there, React Query will simply return it, avoiding extra network requests!

Additionally, useQuery runs wherever you use it — no more fetching data when a component mounts. You just use the query and display the data when it’s ready. The cherry on top? The query returns status updates by default, so we don’t need to store isLoading in component state all the time.

Three Optimizations We Get With React Query

When we rebuilt Alto Connect, our web app for healthcare providers, we found impactful benefits in using React Query to help us manage server state instead of using Redux. Alto Connect provides instant access to patient and prescription information and enables messaging with the pharmacy. Because healthcare providers need to quickly switch between patients and clinics, caching data is important to provide a delightfully fast experience. Apart from the cache, what other optimizations do we get by using React Query? Below are a few that helped us.

Once we’ve queried for some data, it gets entered into our cache, so we can utilize that cached data when using the same query in a different component or when fetching new data for a stale query in the background.

React Query is configured with aggressive but sane defaults and considers cached data as stale. Stale queries will always query for new data when the following criteria are met:

The query is optionally configured with a refetch interval

The fetching for new data when the browser window or tab is refocused is especially useful because the healthcare providers using Alto Connect often switch between multiple browser tabs. If there’s an update to a task, status, or message while they’re checking a patient’s medical chart, it will be immediately reflected in the UI when they come back to Alto Connect.

We also set a refetch interval for our queries involving messages. In the old app, we used WebSockets to enable real-time messaging. Although it’s possible to integrate WebSockets with React Query, we opted for a polling solution instead. Because our app isn’t a real-time messaging application, and we don’t need messages to show up immediately, we set a refetch interval on our messages query to poll for new messages every 30 seconds.

const { data, error, isLoading } = useQuery(
 ['user', { userId }, 'messages'],
 fetchMessages({ userId }),
 {
   // This query is disabled from automatically running if we don’t have a userId
   enabled: !!userId,
 
   // Refetch every 30 seconds
   refetchInterval: 30000,
 
   // Continue to refetch while the tab/window is in the background
   refetchIntervalInBackground: true,
 },
);

This is where the enabled option, which disables a query when it evaluates to false, is particularly powerful. We can pause polling for messages if we route to another page and we know that we won’t make any unnecessary requests if there isn’t a valid userId. We don’t have to worry about closing any socket connections or manually clearing an interval.

Most web apps have some sort of navigation menu, and if you already measure or understand your user behavior, you can prefetch data before users even navigate to a different page. Custom hooks makes it easy to expose a function to prefetch data:

export const usePrefetchUsers = () => {
 const queryClient = useQueryClient();
 const prefetchUsers = async () => {
   await queryClient.prefetchQuery(
     ['users'],
     fetchUsers,
   );
 };
 
 return { prefetchUsers };
};

We prefetch queries when users mouseover or hover over a navigation item so that when they navigate to the next page, the data is either actively being fetched or is already in the cache waiting.

We’ve been talking a lot about queries, but what about mutating data? Mutations, in contrast to queries, are imperative. While queries run automatically when we use them, we need to fire a mutation method in order to run mutations. And in order for our user experience to feel snappy, we can optimistically update the cache and then invalidate it after successfully executing the mutation. useMutation gives us some nice side-effect handlers to deal with every stage of the mutation lifecycle. Now when the user sends a message, that new message is immediately reflected in the UI and we keep the data in sync by invalidating the cache and refetching the messages.

With Redux, we needed to build out solutions to each challenge of managing server state. React Query, on the other hand, gives us those tools right out of the box. We no longer need to worry about when to invalidate or fetch new data, making the user experience more predictable — and the developer experience more enjoyable.

Last year, we set out to tackle this technical debt by splitting the User model into separate concerns and refactoring the entire system into this new paradigm.

Tackling Technical Debt and Improving Security: How Alto Untangled an Overloaded User Model

At Alto, we have three types of users: customers, healthcare providers (nurses, doctors, etc), and operations users who run the pharmacy. For each type of user, we maintain a separate application (though they share a monolithic backend for now): our customer app; our Alto Connect app for providers; and our internal pharmacy management tool called Wunderbar, which powers the pharmacy experience from prescription intake to fulfillment.

Early on, we made the pragmatic choice to represent both customers and operations users with a single User model, distinguishing them with a “roles” attribute. This required repetitive checks that, over time, slowed down our engineering teams, presented substantial privacy risk, and posed difficult scaling challenges as we evolved our monolith into different microservices. 

The challenges of relying on a single User model for different types of users

The notion of a User is core to our concept of identity from which authentication and authorization proceeds. From a security perspective, it’s difficult to build an extensible and clean authentication and authorization system when you’re overloading one model for two very different populations of users. From a privacy perspective, this muddied customer records (which are subject to more restrictions because they’re healthcare records) with workforce records, hamstringing many analytics efforts.

Authentication: Alto employees who were also Alto customers were required to use their work emails for their customer accounts. Not only was this restriction frustrating for Alto employees, but it also posed a security risk: employees should only be able to access Wunderbar via corporate SSO, not their personal account passwords. 

Authorization: Engineering new authorization capabilities required intricate knowledge of the idiosyncrasies of our user structure. This both slowed down development and created tremendous risk that any mistake could easily escalate user permissions.

Privacy: Because they existed in the same table, both customer records and Alto operations user records were classified as Protected Health Information, or PHI, which severely limited what we were able to do with them.

Attribution: Our robust audit logs were significantly less useful when a user ID in the transaction log might refer to either an ops user or a customer.

State management: Some updates pertaining to admin identity lived on the customer model, some lived on the employee model, and others lived in other various models.

Architecture: Tight coupling would have prevented us from decoupling our monolithic system into smaller services.

Our backend is primarily a monorepo Rails application that shares a tremendous amount of functionality between our customer, provider, and ops user-specific domains. Generally we use JWTs to secure customer and ops user sessions. These JWTs are issued only once valid credentials have been present.

Ops users are required to log in via Okta SSO, enforcing both valid username/password as well as a two-factor authentication (2FA) prompt. We use Devise and Omniauth to wire up the OIDC flow with our upstream identity provider, and we use CanCan to expand a set of roles per-user into a set of capabilities that restrict what resources they can access/modify.

Ops users primarily work in our internal pharmacy management app. However, the state of these users was shared between several different tables: Users, which otherwise refer to customers, and Employees, which share some ops user-specific state tied to Users.

Large change sets of code being deployed at once are harder to code review, harder to unwind if something goes wrong, and are more likely to be more disruptive. For this project, we knew that such a large architectural change had to be broken up into many more-digestible pieces if we were to be successful. The plan:

1. Create a new dedicated model for our ops users

# == Schema Information
#
# Table name: wunderbar_users
#
#  id                        :bigint(8)        not null, primary key
#  user_id                   :bigint(8)        indexed
#  email                     :string           not null, indexed
#  first_name                :string           not null
#  last_name                 :string           not null
#  token_last_invalidated_at :datetime
#  roles_mask                :integer          default(0), not null
#  title                     :string           not null
#  team                      :string           not null, indexed
#  is_active                 :boolean          default(TRUE), not null
#  slack_user_id             :string
#  pod                       :string

This was the easy part: create the database structure for a properly isolated admin user type, which we called a WunderbarUser.

We now had our admin user state split between Employees and Users, with a new table that engineers and analysts wanted to use that was not yet populated, and we had to make progress while allowing new hires and new customers alike to onboard to our platform.

2. Synchronize state between the old tables and new table

Next, we created a WunderbarUser for any User who was, or ever had been, a Wunderbar user. This required some historical digging —we had a lot of people who were onboarded, and even some offboarded, before we even had the intermediate Employee record!

Two major choices at this stage really helped the project succeed. First, we ensured that the WunderbarUser records all had IDs matching the corresponding User records. This is because a lot of our legacy audit records (that we’re required to preserve and keep useful as a Covered Entity under HIPAA) referenced an `admin_user_id` column populated with the ID of the User. If we just created all new entries for WunderbarUsers, these old logs would require at least one level of indirection (e.g. querying back to User) to make useful.

     # Create with the same ID as the user that we're creating this from.
     wunderbar_user_attributes = {
       id: user.id,
       user_id: user.id,
       email: user.email,
       roles_mask: user.roles_mask,
       date_of_birth: user.date_of_birth,
       token_last_invalidated_at: user.token_last_invalidated_at,
       first_name: user.first_name,
       last_name: user.last_name,
       preferred_first_name: user.preferred_first_name,
       is_active: false,
     }

Second, we created a new WunderbarUser any time we created a new Employee record (e.g. when we onboarded a new employee) and synchronized any changes between Users, Employees, and WunderbarUsers tables. As a side note: we knew we’d have to protect this syncing logic to ensure that we only copied each change once — otherwise, our callbacks would fire forever!

3. Migrate functionality slowly to use the new ops user model

We migrated logic to reference WunderbarUsers where previously we’d referenced Users and/or Employees. Authentication, authorization, audit logs, and pharmacist licenses were all updated here — albeit painstakingly!

We then migrated all of the foreign keys our various Postgres database tables held to either the Users or Employees tables to instead reference the WunderbarUsers. This ended up being around a hundred foreign keys, but a constraint-only migration that fortunately didn’t involve any data changes.

In short: our goal was to do this change slowly and steadily enough that nobody would notice until, one day, we could announce to the team, “Hey, we did a big security-pertinent project, and now you can change your customer email to be anything.”

Authentication: While we use the same JWT format for each, our customer and operations user authentication systems are now totally separated.

Authorization: With separate user types, we have separate capabilities and domain-specific authorization checks for each area, enforced in code.

Experience: Onboarding as a new Altoid (somebody who works here; come join us!) is totally separate from the customer experience, and you no longer need to link your accounts together.

Privacy: Our ops users who choose to be customers enjoy the full privacy afforded to our customers without tying their account to their work identity in any way.

Attribution: Legacy audit logs are still index-able and query-able with the same IDs, just in a slightly different table.

State management: Customer state lives on the User table, and ops user state lives on the new WunderbarUsers table. Our callbacks on each have been dramatically pared down, and our intermediary Employee table is entirely gone, along with a number of other now-ancillary tables.

Architecture: We have a clear path to federate RBAC checks without shipping our entire customer database between services.

Bonus: Performance and code readability generally improved by removing complex joins and join tables and isolating concerns between the customer and ops user domains.

Another Bonus: Significant refactorings and increased test coverage along the way while we cleaned up some very old, very stale code.

Large architectural changes of legacy systems with heavy use are rarely 100% smooth. Here are a few learnings to keep in mind the next time you tackle a hefty piece of technical debt. 

1. Always validate your assumptions (e.g. the data your constraints are against) when foreign keys are concerned. Multiple times we assumed, “Hey, we’ve migrated a bunch of really big tables that are really old (insurance claims, prescriptions, and more), so there’s no way we could have another admin user that we haven’t created a commensurate WunderbarUser for, right?” Wrong! Your data can always have inconsistencies, but a simple SQL query (e.g. validate that all values of the column you’re migrating the foreign key to have a matching WunderbarUser) can save a lot of time and headaches.

2. When migrating foreign key constraints on tables with active reads in Postgres, ensure you break it into two steps. Migrate your foreign key with `{ validate: false }`

 def up
   remove_foreign_key :inventory_orders, to_table: :users, column: :created_by_id
   add_foreign_key :inventory_orders, :wunderbar_users, column: :created_by_id, validate: false
 
   validate_constraint
 end

Validate the named constraint of your foreign key separately

 def validate_constraint
   validate_constraint_statement = 'ALTER TABLE "inventory_orders" VALIDATE CONSTRAINT "fk_rails_abcd1234";'
   ActiveRecord::Base.connection.execute(validate_constraint_statement)
 end

3. When working with legacy tables, be mindful of legacy systems. Our Billing service used a very outdated golang ORM that panicked if a column specified by the `struct` in source no longer existed; this caused a late-night outage that made auto billing requests back up the next day.

4. Scoping projects is hard! This was a larger project than our team had ever scoped and delivered before. Once all the dust settled, this project took several months longer than our initial scoping estimates.This project was worth doing, but better estimates allow us to prioritize better. If we’d had a great scope of this immense project upfront, would we have chosen to do it first? Also, this was a tremendously difficult project to separate into material stages; all the benefit was really backloaded.

In the end, this was a very satisfying and important project to complete. We wouldn’t have been able to accomplish it without a lot of help from our colleagues on the Platform team, the Security team, and across many other functions atAlto. Very large projects that involve a lot of moving pieces and impact other teams are always scary — but we can’t let that fear prevent us from making the changes we know we need to do in order to be successful long-term.

The Engineering Team is hiring! Learn more about open positions here.

In our previous post, we discussed how we designed our biometric authentication system with both privacy and a better user experience in mind. In this post, we'll show you exactly how we did it.

Considerations and Approaches for Implementing Biometric Login: Part 2

In Part 1, we discussed how we designed our biometric authentication system with both privacy and a better user experience in mind. In this post, we'll show you exactly how we did it.

To build a new authentication mechanism, we opted to use the react-native-biometrics library. This library interfaces with the device's biometrics, generates a keypair, and stores the private key within the device's keystore. When logging in with biometrics, the library creates a signature using the stored private key, and the signature is then sent to the server for validation. (Note: this library is now unmaintained. At the time of writing, this implementation can instead be accomplished with the following maintained libraries: expo-local-authentication to access device biometrics, keypair to generate a keypair, react-native-keychain to access the device keystore.)

Check if biometrics are supported and configured by the user for this device.

const { available } = await ReactNativeBiometrics.isSensorAvailable();

If yes, prompt the user for a biometric scan.

const { success } = await ReactNativeBiometrics.simplePrompt({ promptMessage: 'Confirm ID' });

If the scan succeeds, generate a keypair. The react-native-biometrics library's createKeys method will automatically save the private key to the device's keystore, and return the public key counterpart. Send the public key to your server.

const { publicKey } = ReactNativeBiometrics.createKeys('Confirm biometrics');

// Save the public key to your database
post('/save_biometric_key', { key: publicKey, device_id: 'xyz' })

When the user tries to login with biometrics, scan their biometrics. This time, if the scan succeeds, create a signature using the stored private key. The react-native-biometrics library's createSignature method handles all of this.

// Prompts for scan
// On scan success, accesses private key and uses it to generate a signature, which is then returned
const signatureResponse = ReactNativeBiometrics.createSignature({
  promptMessage: 'Face or fingerprint ID for Alto Pharmacy',
  payload: BIOMETRIC_SIGNATURE_PAYLOAD,
});

Send the signature to the server to validate against the public key. If validation succeeds, the user has successfully authenticated with biometrics and can proceed into the app.

// Call your server API to validate the signature against the public key that you've stored in the database
const validationSuccess = await post(
  `/validate_biometric_signature`,
  {
    signature: signatureResponse.signature,
    payload: BIOMETRIC_SIGNATURE_PAYLOAD,
		device_id: 'xyz',
  },
);

if (validationSuccess) {
  // Login Success
} else {
  // Login failure
}

import ReactNativeBiometrics from 'react-native-biometrics';

const setUpBiometricLogin = async () => {
  // Check if biometrics are supported and configured on this device
  const { available } = await ReactNativeBiometrics.isSensorAvailable();

  if (available) {
    // Prompt user to scan biometrics
    const { success } = await ReactNativeBiometrics.simplePrompt({ promptMessage: 'Confirm ID' });
      
    if (success) {
      // If scan is successful, generate a keypair, then save the public key to the server
      const { publicKey } = await ReactNativeBiometrics.createKeys('Confirm biometrics');

      post('/save_biometric_key', { key: publicKey, device_id: 'xyz' })
    }
  }
}

const loginWithBiometrics = async () => {
  // Scan user's biometrics. On scan success, generate a signature
  const signatureResponse = await ReactNativeBiometrics.createSignature({
    promptMessage: 'Face or fingerprint ID for Alto Pharmacy',
    payload: BIOMETRIC_SIGNATURE_PAYLOAD,
  });

  // Validate the signature against the public key saved on the server
  const validationSuccess = await post(
    `/validate_biometric_signature`, 
    {
      signature: signatureResponse.signature,
      payload: BIOMETRIC_SIGNATURE_PAYLOAD,
      device_id: 'xyz',
    },
  );

  if (validationSuccess) {
    // Login Success
  } else {
    // Login failure
  }
}

1. build a way to store a public key associated with a device

2. write a method to validate a signature against a public key

3. expose endpoints to save a public key, and validate a signature

Once biometric authentication is built, there are additional decisions to make. The right decisions for your app will depend on your goals; the approach we took here at Alto may not align with what is best for your app.

How should biometric sessions interact with our existing email and password sessions?

We opted to treat email and password sessions as longer-lived primary sessions, with biometrics as a shorter-lived secondary session on top of that primary session. This means that a user must first login with email and password in order to use biometrics on subsequent app opens. If the user logs out for any reason, they will need to log in again with email and password before they can use biometrics again.

How often should we prompt the user for biometrics vs. email and password?

We opted to prompt the user for biometrics far more frequently than email and password, but made this configurable in case we want to adjust.

We use tokens and cookies for session management.

There are plenty of edge cases to consider as you're developing biometric capabilities for your app, including: what should happen when the biometric scan fails, or when the signature validation fails? What should happen if a user disables biometric permissions from their device? What should happen when two users share a device? What should happen if 'risky' activity is flagged for this account? How can we disable biometric login if needed?

Face and fingerprint ID login has clear benefits for both the end-user and the application itself, but it comes with a host of implementation decisions. If you're considering building biometric login for your app, I hope this article gives you clarity on what biometrics is, the different ways you can integrate it into your app, and the tradeoffs and edge cases to consider.

At Alto, the Patients Engineering team worked closely with our Security Engineering and Product teams to align on our goals and build the best solution for our needs. Our Security team offered deep expertise on the authentication strategies to adopt and avoid, and our Product team kept us tethered to building the best experience for our users.

Working as a team is one of the best parts about developing at Alto. If you want to meet the awesome team I'm talking about, come join us - we're hiring!

Alto Connect is the industry’s first mobile app for clinical teams to track prescriptions and message with the pharmacy on-the-go.

Introducing Alto Connect

Big news from the team here at Alto: today we launched Alto Connect, the industry’s first mobile app for clinical teams to track prescriptions and message with the pharmacy on-the-go! You’ll also see the new Alto Connect brand on our desktop portal, formerly known as AltoMD: new name, same great pharmacy services.

The Alto Connect mobile app is the next evolution of Alto’s custom-built provider communications center, formerly known as AltoMD. Alto was the first pharmacy in the United States to offer a prescriber-focused pharmacy communication platform when the original desktop-based AltoMD product launched in March 2016. Since then, more than 500 doctors offices have integrated Alto Connect into their daily workflows and prescription management. 

Doctors offices who work with Alto Pharmacy can now access Alto Connect across all of their devices, providing greater flexibility and convenience for monitoring prescriptions on busy days spent juggling patient consultations and other business needs. Instead of spending hours on the phone or fighting with the fax machine, Alto Connect provides instant access to prescription information and pharmacy messaging, and Alto Connect users can move seamlessly between the two platforms throughout their workday.

With Alto Connect, clinical staff can view all current prescriptions at Alto Pharmacy, including delivery status, out-of-pocket costs and refills. You'll never have to wonder if a patient picked up their prescription or stayed on track with their refills between visits - our system tells you exactly where every prescription stands for every patient.

Have a question for our pharmacy team? Curious about insurance coverage, delivery times, or other aspects of our service? Our team is here to help! You can send us a general message or ask a question specific to one of your patient's prescriptions. 

Alto Connect's push and email notifications alert you when a prescription needs additional information to move forward — most commonly, a clinical clarification or additional data needed for a prior authorization. We'll only alert you when we're certain we need your team's input, so you can stay focused on your patients.

Using AltoMD on your computer today? Nothing changes other than the name! Ready to try Alto Connect mobile for yourself? Scan the QR code above to download the app - your AltoMD login works on the mobile app. 

Need help setting up an Alto Connect account or want training for your staff? Reach out to providersuccess@alto.com.

When engineering incidents happen, typical deployment pipelines are just too slow—especially if customers’ medications are on the line. Here’s the speedier rollback process we use at Alto Pharmacy to ship fixes in 3 minutes, flat.

How Alto Reduced Time to Resolution for Production Incidents

Production incidents caused by newly-merged code happen to us all. When they do, most engineering organizations discuss the root cause and how to prevent similar incidents in the future. At Alto, we evaluate two additional metrics:

Time to detection: How quickly did we know something was wrong?

Time to resolution: How quickly did we restore service?

Time to resolution is especially critical for us as a pharmacy, where a long-running incident could block a user from getting their medication on time.

Over 30 times a day, an engineer at Alto hits the merge button, deploying a new build to production. Our well-automated CI/CD pipeline, built by our Infrastructure team, handles the 3-step deployment process:

1. Build: install Ruby & JavaScript dependencies

The average runtime for our standard deployment pipeline is 30 minutes—reasonable for a CI/CD pipeline, but too long when shipping a fix for a production incident.

We introduced a “hotfix” workflow as a first pass at an expedited deployment pipeline for incident response. A hotfix is a commit that introduces new code to address the incident by either removing or reverting the buggy code that introduced the issue in the first place or by shipping new code that fixes the initial issue. 

The hotfix deployment pipeline reduces incident time to resolution by triggering a specific CI job that removes the test step from our standard pipeline, reducing the workflow to just the Build and Deploy steps.

Implementing a hotfix pipeline on top of our standard pipeline in CircleCI was relatively simple—in our `.circleci/config.yml`, any part of our CI workflow that should be skipped in case of a hotfix runs a job called “early_exit_if_hotfix” that will skip the current step if the last commit message of the code being built includes the keyword “[hotfix]”.

early_exit_if_hotfix:
    steps:
      - run:
          name: Early exit if hotfix
          command: |
            git_commit_message=$(git log --format=%B -n 1)
            if [[ $git_commit_message =~ "Merge pull request #" ]]; then
              echo "This is a merge commit. Checking if this is a hotfix deploy"
              git_commit_sha=$(git log --format=%H -n 1)
              git_commit_message=$(git log --format=%B $git_commit_sha^-)
            fi
            if [[ $git_commit_message =~ "[hotfix]" ]]; then
              echo "exiting early for hotfix deploy"
              circleci-agent step halt
            fi
            echo "not a hotfix deploy, continuing"

run_ruby_tests:
  steps:
early_exit_if_hotfix
run_tests

The hotfix workflow reduces time to ship a resolution, once we identify the fix, from 30 minutes to ~18 minutes. It’s faster than our standard pipeline but still requires considerable hands-on work from the engineer performing the hotfix.

To further speed up deployment and reduce manual work, we introduced a workflow that simply rolls back to a previously-built healthy deployment image. In this workflow, the entire pipeline is reduced to just the Deploy step.

To invoke a rollback, an engineer commits a message with the keyword “[rollback]”, followed by the SHA of the commit to rollback to. Similar to the hotfix approach, any build step that should be skipped during a rollback checks the commit message for the “[rollback]” keyword before running:

early_exit_if_rollback:
    steps:
      - run:
          name: Early exit if rollback
          command: |
            git_commit_message=$(git log --format=%B -n 1)
            if [[ $git_commit_message =~ "Merge pull request #" ]]; then
              echo "This is a merge commit. Checking for rollback sha..."
              git_commit_sha=$(git log --format=%H -n 1)
              git_commit_message=$(git log --format=%B $git_commit_sha^-)
            fi
            if [[ $git_commit_message =~ "[rollback]" ]]; then
              echo "exiting early for rollback deploy"
              circleci-agent step halt
            fi
            echo "not a rollback deploy, continuing"

run_ruby_tests:
  steps:
early_exit_if_hotfix
early_exit_if_rollback
run_tests

The rollback workflow looks for a build matching the specified SHA and posts a confirmation message for the engineer, then deploys that build to production. The rollback approach dropped our time to resolution even further, from 30 minutes to ~3 minutes.

There are three edge cases that we’ve also baked into our rollback workflow: potentially stale images, database migrations, and blocking new merges and deployments.

Our script has a special block warning the engineer if a target image is older than an hour. The older the image, the riskier the rollback, as the delta between the image and the latest commit on main is larger.

time_rollback=$(git show -s --format=%ct ${rollback_revision})
time_now=$(date '+%s')
if [ $(($time_now - $time_rollback)) -gt 3600 ]; then
    message="${message}\n\n:warning:The rollback commit is more than an hour old."
    message="${message}\nThe [hotfix workflow](https://www.notion.so/alto/Deploying-a-Hotfix-Rolling-Forward-bb8e9cea05b44c67a64e23ae652653b6) might be a better candidate for this deployment."
fi

We also want to warn engineers if any database migrations have occurred between the current image and the target by checking the diff of the db/migrate directory. Rolling back application code without applying changes to the database can result in the database and application code becoming out of sync, resulting in further problems. Our script will warn engineers if a migration has been detected between the current and target image and provide instructions on how to rollback migrations if required.

Because a rollback deploys an image that’s older than our latest build, we also need to block continuous deployment until we’ve restored the main branch to a safe state — typically by deploying a hotfix as soon as we can identify an appropriate fix. We accomplish this using a Github issue with a specific tag that, when open, triggers a job causing any active CI job to fail. After the incident is resolved, the incident manager closes the issue, which will retrigger the blocked jobs and resume the normal build and deploy workflow.

The expedited rollback process has reduced our overall time to ship a resolution for incidents down to a speedy 3 minutes—a valuable improvement for our internal operations users, as well as for our customers and healthcare providers who rely on Alto’s service to get prescriptions filled. Branching these incident response workflows off of our existing standard deploy pipeline keeps the maintenance cost low for our infrastructure team, and robust automation reduces the risk of manual error for our product engineers when they need to invoke these workflows.

We’re excited to welcome Christopher Tidball to the Alto team as Director of Product Management, Supply Chain & Fulfillment. Learn more about his passions both in and outside of work and what drew him to Alto.

Introducing Christopher Tidball, Director of Product Management - Supply Chain & Fulfillment

We’re excited to welcome Christopher Tidball to the Alto team as Director of Product Management, Supply Chain & Fulfillment. Most recently, Christopher led a large team of product managers, engineers and program managers at Amazon to power the company’s most complex fulfillment operations. 

As Alto continues to expand our geographic footprint and customer base, Christopher’s nearly 20 years of industry experience will support us in scaling our systems, so that we can continue to deliver the same high standards of care and service to even more communities.

We recently sat down with Christopher to learn more about his passions both in and outside of work, what drew him to Alto, and the operational opportunities he’s most excited about. 

Welcome to Alto! What inspired you to join the team?

Before a recruiter ever reached out to me about a role at Alto, my wife and I were very satisfied customers. We had been on a long journey of trying to start a family, and that ultimately led us to a fertility clinic that recommended Alto. We had a great experience from day one: the app was easy to use, the same-day deliveries from couriers were always on time, and Alto’s pharmacists walked us through the various medications in our delivery and answered all of our questions. 

Alto’s focus on the customer experience was immediately clear, and I made a mental note that this was the type of company I’d like to work for. Fast forward a few months later, a recruiter reached out and introduced me to the leadership team whose passion and experience sold me on leaving Amazon to come here.

As the Director of Product Management - Supply Chain and Fulfillment, I'll focus on the technology investments that can help us continue to grow and offer exceptional service to our customers. “Supply chain” covers a lot of ground: procurement, inventory, pharmacy operations, delivery, and more. There are tons of opportunities to automate processes to make it easier for Altoids to run the business, especially as we grow and expand. 

What areas of the business are you most excited about?

The operations side has always been exciting to me—it's where the magic happens. At the end of the day, if we don't have sustainable, efficient ways to fulfill the promises we make to our customers, we won't survive. 

Alto has a great business model, and many happy customers to show for it, but there’s always room to continue to innovate and improve the delivery experience. It's one of the few in-person interactions we have with the customer and we want to make it exceptional.

Blog

National Pharmacists Month Spotlight: Roni Hein

National Pharmacists Month Spotlight: Travis Allison

Why We Switched to React Query for Managing Server State

Tackling Technical Debt and Improving Security: How Alto Untangled an Overloaded User Model

Considerations and Approaches for Implementing Biometric Login: Part 2

Introducing Alto Connect

How Alto Reduced Time to Resolution for Production Incidents

Introducing Christopher Tidball, Director of Product Management - Supply Chain & Fulfillment

The Next Evolution of Our Company Values

Get to Know the Team That Has Doctors Calling Alto “The Pharmacy of The Future”

Get to Know the Team That Builds Alto's Customer-Facing Apps

How to Make the Most of the Alto Pharmacy App

Switch to a better pharmacy.