506: A Breath of Fresh Air: Wendy Lawson's Mission for Accessible Lung Care

Wendy Lawson is the Founder and CEO of Exhale Lung Rehabilitation, a company offering online lung rehabilitation and remote therapeutic monitoring services. Wendy's extensive background in chronic disease epidemiology, respiratory therapy, and her role with the American Lung Association have been pivotal in her mission to address the gaps in lung rehabilitation accessibility. She discusses the challenges faced in making lung rehabilitation widely available, especially in rural areas, and the exacerbated need for such services during the COVID-19 pandemic. Exhale leverages technology to offer personalized rehabilitation programs, making them accessible to a wider audience regardless of their geographic location. This approach has significantly impacted the quality of life for individuals with lung diseases, especially in a time when remote services have become more crucial than ever. The conversation also touches upon the technical and business aspects of running Exhale where Wendy candidly shares the challenges and pivots in the early stages of the company, from developing proprietary algorithms to realizing the need for a scalable and efficient technological platform. This journey of continuous improvement and adaptation is a testament to her commitment to her mission. The episode concludes with a discussion on the future of lung rehabilitation, the potential changes in healthcare policies, and Wendy's unwavering commitment to improving the lives of those with lung diseases. Exhale Lung Rehabilitation Follow Exhale Lung Rehabilitation on Facebook, Instagram, or X. Follow Wendy Lawson on LinkedIn. Follow thoughtbot on X or LinkedIn. Become a Sponsor of Giant Robots! Transcript: VICTORIA: This is the Giant Robots Smashing into Other Giant Robots podcast, where we explore the design, development, and business of great products. I'm your host, Victoria Guido. And with me today is Wendy Lawson, Founder and CEO of Exhale Lung Rehabilitation, which provides online lung rehabilitation and remote therapeutic monitoring services. Wendy, thank you for joining us. WENDY: Thank you so much for having me. VICTORIA: Wonderful. And we like to start the show with a little warm-up introduction about ourselves. Is there anything exciting happening in your life recently that you'd like to share with our audience? WENDY: You know, I think the biggest event that has happened for my husband and I and our son and daughter is the marriage of our daughter a couple of weekends ago. So, we're really coming down off of all of the events that surrounded that wedding, and we're so excited for them to start their new life. VICTORIA: That sounds like a big activity, lots of family life all happening at a time when you are also founder and CEO. So, within that time for your wedding, did you make time or have to learn any new skills for putting on these events? WENDY: You know, it was really interesting. I did have to do a couple of skills. First of all, planning a wedding is just madness. I knew that it was going to be a big task, but after really having hands on and doing it, it was a lot. It was really fun to learn some new things. And one of the new things that I learned is really flower arrangements. I did some flower arrangements for some of the tables in a couple of the events that surrounded the wedding. And so, that was really fun, new skill. I love to learn new things. That was enlightening and fun. And I'm glad I don't have to do that as a job. [laughter] VICTORIA: Yeah, so I'm curious, how did you approach learning this new skill? What was your method? WENDY: My entire life I've loved to learn new things. And I probably approach each of those the same way, and that is get a vision for what I want, or what I want to learn, or what I want it to look like, and then do some research, find people who have done it themselves. Ask advice. Of course, YouTube is fantastic now for things like DIY. So, I definitely went to YouTube and found some experts and watched what they did and tried to mimic it, and so, I'm not sure that I got it as well as they did. But it was certainly enlightening and a lot of fun to learn. VICTORIA: I appreciate that being a lifelong learner, being excited and loving to learn new things. How has that value of loving to learn new things and being a lifelong learner served you as founder and CEO at Exhale? WENDY: Being a lifelong learner is something that, I think, started early for me, not just in my career but in my life. I've loved to learn new things. Being a founder comes with lots of unexpected pivots and turns. And I think being open and available to learn new things really furthers your business as a founder and ensures that your business is placed in a position where if you need to pivot, you can learn something new, pivot in that direction, and move on. So, I think learning not just as a founder but in any profession that you do is really a key to success for a long and successful career. VICTORIA: That makes a lot of sense to me. And I'm going to ask you about your pivots. But first, tell me just how did it all get started? So, what led you to decide to start Exhale? WENDY: Yeah, well, I have a background...my graduate degree is in chronic disease epidemiology. I'm a registered respiratory therapist. I'm also a board member for the National Board of the American Lung Association. And I have really dedicated my life to dealing with those with lung disease. It is interesting in the clinical realm that you cross things that, scientifically, we know are beneficial to individuals with certain diseases. However, getting that thing out to the general population is challenging, and lung rehabilitation is one of those things. We've known for a very long time that lung rehabilitation helps people with lung disease live a more successful life and a more enjoyable life and with less symptoms. But the availability of lung rehabilitation to people that really need it is few and far between. If you live in a big city, you usually can find an in-person rehabilitation program, but due to constraints with insurance not approving people until late stages or the inability of a program to get people in because they have long waiting lists, it really has been a struggle for physicians, for clinicians, for individuals with lung disease to actually find a program and do it. And so, I really wanted to solve that problem, solve the problem of the accessibility, availability, affordability of lung rehabilitation because it's so important to people with lung disease. So, really how I started is identifying the problem of here's a big problem. We can't seem to get people effectively into lung rehabilitation. So, why don't we take use of technology and create a program that is all online and available to a person in their home, on their timeline, no matter where they live? If they live in a rural community and don't have access to a big city hospital, that it's available to them. VICTORIA: Wow, that's a really fascinating story about your background and how you discovered this problem. And, of course, you know, looking at the timeline, to me, you know, September 2020 is when you're founded. Certainly, something was happening in the world that created an even larger need for lung rehabilitation than before, right? WENDY: Yeah, I had identified the problem probably...a couple of years before that; I thought, there's got to be a way, you know, there's got to be a way that we can solve this issue of people not having access. Really, the perfect storm of people being cooped up inside—they were quarantined; people couldn't get out. All of the sudden, technology was really our means to be doing a lot of things, and seeing our physicians was one of those things. Individuals who did not have faith in online technology, or seeing physicians virtually, or going to programs virtually, all of a sudden, those fears were gone because that was really the way that you had to do things in 2020. It was the majority of the way that we talked with our loved ones. It was how we interacted with individuals, whether it was work or medical, lots of different things. And so, I really felt like the timing was right to go ahead and pull the trigger on this. And let's see if we can find a way...now that people are using technology in a very different way than they were two years prior to that, let's see if we can make this work and get this out to people who need it. And at the same time, there was a major pandemic with a viral illness that affected the lungs specifically. And so, we were going to have that many more patients that were going to need pulmonary rehabilitation on the flip side of being ill and coming out of this pandemic. So, I think it was, like I said, a perfect storm of individuals in the community receiving technology in a positive manner and then also having a pandemic that affected people with lung disease. VICTORIA: Wow, that's incredible. So, you already had identified a problem about lack of access to rehabilitation, especially in rural areas. And if people don't know that, you know, hospitals are really, even more, and so as time goes by, getting around major metropolitan areas, so people don't have access to hospitals or doctors in rural areas. And those are also probably the people who maybe need more lung rehabilitation. And then the perfect storm happened, and the pandemic and everything. It became not only the way of doing business and care–a very acceptable way of doing medical care, and also very critical in terms of, like, our national health infrastructure. WENDY: Yes, absolutely. And, you know, one other component that really propelled me into going ahead and founding this company and then figuring out a way for technology to aid us was that individual programs, even if you did live close to a program, the pandemic shut those programs down completely. Things like cardiac rehab, pulmonary rehab, were all stopped because you could not put a large amount of people in a small space together, working out, breathing hard, learning in classroom environments when they were also immunocompromised. So, the risk to the patient was very high. And so, those programs, even if you did live close to a program, in 2020, they were completely shut down. And due to individual struggles of hospitals as hospitals opened back up, financial struggles, clinical struggles on having enough staffing is still a really big problem in the medical community. And so, a lot of pulmonary rehabs did not come back, even if you lived in a large city. So, there are some rehabs that are opening back up now, but there's still that initial problem that we had, even before the pandemic, of there were not enough programs. Only about 2% of the population that can use pulmonary rehab ever got to a pulmonary rehab. And then we shut some down, and it became even worse. So, we estimate now that it's less than 2% that actually get to a pulmonary rehab if they have lung disease, and certainly, because so many more people have lung disease now on this side of the pandemic. VICTORIA: Wow, yeah. That's a really incredible story, so thank you so much for sharing that. I'm curious now to get into, like, you made the decision. You found the problem. You started the company. What were some early pivots you had to make, and what surprised you about it early in the process? WENDY: I put together a team of...I have a couple of physicians that are intensivists and focused on lung disease, a pharmacist, a couple of respiratory therapists, physical therapists, Yoga expert, nurse practitioner. So, my whole team really got together, and we decided, okay, we have to make this as close to in-person rehab as humanly possible. And the problem initially in getting pulmonary rehab out to people, is that anyone that has attempted it before did not have that initial assessment in the program that was really based on algorithms that gave them a personalized experience so that the yoga classes or the strength training classes, or the breathing classes were specific to, one, their lung disease, because there are 26, 7 different lung diseases, and, two, that was very specific to their exercise tolerance of themselves and their lung disease. Some people are on oxygen 24/7 and can't make it from the bathroom to the kitchen without sitting down in between and catching their breath. And then, other people with lung disease they can walk a mile. So, how do you make sure that the program is based on you and you're really gaining those strides based on your exercise tolerance? So, that was probably the biggest hurdle that we had to make or really decisions surrounding that, like, how do we do this? And so, creating proprietary algorithms that were then going to help us was a daunting task. It began as a bunch of sticky notes on my office wall and me staring at it going, okay, how do we figure this out? I know we can figure this out. And just having iterations of that algorithm until I got it right. The next hurdle for me was really how technology could be used to create this experience that was beneficial to the users and the clients and also that we could be proud of as clinicians because we knew that it was providing solid advice and goals, care plans for those individuals that needed it. I came from a clinical background. And so, I was not privy to all of what technology could do. And so, I had to really go out and research, how do we incorporate these things? And how do I envision, you know, the program working and maneuvering around? I initially hired a company that I thought I was communicating well what I wanted. And they were developers, so they did what I asked, but it was not scalable. And so, me I think that combination of maybe I didn't hire the right company. And then, the second thing was me not really being able to speak the technology terms and understand everything that was available so that I could outline it a little bit better. Created a product that I wasn't proud of and I knew was not scalable. And so, we had to really pivot and start again, hire a new company, and really sit down with them and say, "Okay, I want you to understand my sticky notes on my office wall. And let's really get this down before we begin to build." So, I would say probably that was my first big pivot moment. And the ups and downs of being a founder are endless. And that was definitely one of those, like, really high points where we're, okay, you know, we're at a point where I believe we can launch and then the low of realizing it is not what I wanted it to be. So, I think that was the first one. VICTORIA: I appreciate you sharing that. And I think that if the first product you build is something you're not proud of, then you're at least doing it right. You got something out there [laughs]. And you probably learned so much from that process, and it sounds like you applied those learnings to your next phase of the project. And now you've built something that you are proud of. WENDY: Yeah. I think a founder will continue no matter...and technology certainly is this. But I think this applies to really any business, whether it's a brick-and-mortar or anything online business. I believe that you are constantly improving. You're constantly thinking of, you know, what's version 2 going to look like? What's version 3 going to look like? What's version 25 going to look like? It's definitely a work in progress. And, you know, having something that you're very proud of, that you worked hard on, and collaborated, and really researched a lot I think that's where we are right now. We're very proud of...I am very proud of this program. And we're seeing some fantastic results. And people who have very severe lung disease and, all of a sudden, they can sit in the floor and play with their grandchildren, or they can go out and get the mail. Just to walk to the end of the block was a big deal for them but now they can do that. I hear stories all the time. Our clients love to talk to us about, "Hey, guess what I did?" And I love to hear those stories because it means what we created did the job that we created it for. And so, that's very satisfying. It doesn't mean that we won't do pivoting in the future. We certainly will. But as we see those roadblocks, or as we see the hurdles that we have to cross to make sure that this program stays true to what we want it to be, we certainly will find a way over, around, or through those roadblocks to make that happen. VICTORIA: You can hear your commitment to your mission and your drive to solve this problem in the way that you talk about it and the iterations that you're willing to keep solving it. And you mentioned that, you know, one of the issues you saw in the first iteration was about scaling. So, I was wondering if you could share more about that. Like, what did you see that made you think, oh, this isn't going to scale? Was it a technical issue? Was it the algorithm the way it was working? Or was there something else that made you think, oh, we got to redo this whole thing? [laughs] WENDY: Yeah, you know, the algorithm was working great, fantastic. It places individuals in classes that they need to be. It's very beneficial. The beta tests on our clients were actually coming out with individuals that were at least doubling their strength in a 12-week period of time, which is really unheard of. Usually, you shoot for 20 to 25% increase in their strength and ability to do things. And so, early on, we were so excited because we thought this is working. And coming out of the gates, out of our beta tests, we thought it is doing clinically what we want it to do. Now, what we saw was that the process was time-consuming on our side, on the business side, so ensuring that those clients that we looked at what they were doing, that we made sure and contacted them, and did those things. Our system was very labor-intensive. So, to get into the system and actually see what an individual person was doing, was difficult. We didn't have auto alerts that alerted our team, "Hey, this person is struggling today and probably needs a call." So, those types of things were what we really decided this is not going to be scalable. And they were not easy fixes in the system that we had created. And so, that's really why we chose to pivot and go a different direction because there was just no way to scale it because each individual client was taking so much time that it really was not feasible to be able to gain a lot of clientele without putting more resources in place than we were actually being paid. VICTORIA: That makes a lot of sense. Like, we are providers. You need to be able to make it less work for them [chuckles] and still be able to provide that quality of care to the individuals. So, it's really interesting you were able to solve for that in your next iteration. Mid-Roll Ad: When starting a new project, we understand that you want to make the right choices in technology, features, and investment but that you don’t have all year to do extended research. In just a few weeks, thoughtbot’s Discovery Sprints deliver a user-centered product journey, a clickable prototype or Proof of Concept, and key market insights from focused user research. We’ll help you to identify the primary user flow, decide which framework should be used to bring it to life, and set a firm estimate on future development efforts. Maximize impact and minimize risk with a validated roadmap for your new product. Get started at: tbot.io/sprint VICTORIA: As a company providing health and medical services, how have you navigated the industry? Clearly, you have a big background in health. But how did you get to make your business viable, considering all the bureaucratic nature of the American healthcare system? WENDY: [chuckles] Really, a part of our mission at Exhale is making pulmonary rehab accessible and affordable, and those two things are difficult in our healthcare system right now. Affordability for pulmonary rehab...just a background in what happens if you go to an in-person program, in-person programs, if you are lucky enough to have one available, and get through the waiting list, and your insurance approves you, then each time you go in, which is usually 2 to 3 times a week over an 8 to 12 week period of time, insurance will pay a portion of that, but you will have a copay each time. And a lot of times, the copays range between $15 and $30 time period. So, individuals who are on a fixed income, because we're dealing with a lot of people who are older and on Medicare, probably have a very fixed income, they cannot afford that. And often, the attrition in those programs is a big problem because, one, getting a lung patient who is carting oxygen and can't walk very far, can't walk to the end of the block, but you're asking them to park in a parking lot, walk all the way into a hospital, up the stairs, and get into the program. They're exhausted by the time or can't do that. And then they have to pay a copay each time they go in. And so, we wanted our program to be affordable and accessible. So, we created it where we did not accept insurance at first at all. Insurance does not cover online programs right now. And so we priced ours at the price of a copay per month. So, for the cost of an individual to go one week at an in-person program, they can do our 12-week program and get all the way through. So, that was really important to us to ensure that accessibility, and availability, affordability were all a part of our program and our mission. VICTORIA: Yeah, it's interesting that insurance doesn't cover online services in a time when a lot of things are [laughs] online. WENDY: It is really confounding that a service like this is not covered by insurance. Now, we did recently...there is a remote therapeutic monitoring that was available through CMS, added it to their care in 2022, to their fee schedule. We have just implemented our remote therapeutic monitoring side of our lung program. And it is specifically for those with lung disease. We help their offices, the patient's physician's office, to monitor these patients on a daily basis and then give them feedback on whether or not the patients are taking their medication, and how well they slept, and whether or not they're feeling well that day. And that way, the physician's office can intervene faster, and it keeps those individuals out of the hospital. A bonus of the Exhale program is that our lung rehab comes free to those who are enrolled in remote therapeutic monitoring. So, if you are a part of our program, then you will receive that service and the benefits of having a rehab program to you. And that's just one more way that we're making it accessible, available, and affordable to people. VICTORIA: That's really interesting and leads me to my next question, which is, what are some of the biggest hurdles that you see ahead of you in the next six months? WENDY: The biggest hurdle probably is, where is insurance going? Will it begin to cover it in the future? Because that is super important to getting people the care that they need. And then, how will Medicare and other insurance providers decide to change things? Usually, January 1st of every single year, they put out their new fee schedules. In some years, they just completely cut off services altogether. And so, what I would like to see is expansion of online services becoming reimbursable through insurance companies, and certainly that they see the value of having a service like this that is incredibly affordable, that is getting fantastic outcomes for people with severe lung disease, and giving them a better life, and keeping them out of the hospital, that they see the value in reimbursing programs like ours so that we are sustainable in the future. VICTORIA: Yeah. It seems like a win-win for everyone because it keeps your healthcare costs down when you're not going to the hospital and probably helps with all other kinds of health...like you mentioned before, how if your lungs are healthy and you're able to move, it makes your overall body much more healthier. So, what is the wind in your sails? What keeps you going with the program? WENDY: As a founder, there are always times whenever you're like, okay, what are we doing here? Like, this is so hard. It's [laughs], you know, the ups and downs. And what are we doing? Maybe I just stop this and go back to the clinic. But ultimately, I think what keeps me going is hearing the stories of our clients and how much this program has affected their day-to-day life, and how appreciative they are that we have created something that they can do from home and when they did not have this service available to them previously. I spoke to someone just on Monday, and he was talking about how he had been in a difficult position. And he said, "I just channeled those lessons that you taught us, and I did my breathing techniques. And I got through it. And I just am so thankful that you guys had taught me how to do that because I don't know if I would have gotten through that situation." And those are the stories that we love to hear. We love hearing, "Hey, I was able to play with my grandchildren on Thanksgiving because of your program," or "I was able to cook for myself, and that's the first time that I have cooked for myself in three years because I can't stand there that long without being too short of breath." Those stories and talking to our clients it's why I keep doing this. It's why I get up every day and go, okay, whatever problem that we find, we're going to solve it and make this company viable long term because of those outcomes that we're seeing. VICTORIA: And what a great way to know that it does matter when you're hearing those stories. And for those individual people, that's a huge life-changing difference. WENDY: Yeah, it certainly is. And it, really, you know, in the grand scheme of things, you don't think about how important it is to just be able to walk from one room to another or be able to clean your bathtub or go get groceries. I mean, those little tasks you don't think about until you are so sick or debilitated that you can't do those things. And it means the difference in having a life that they love to live and having, you know, the resources that they need to be able to live that life. Those stories definitely keep us going and will keep us going as long as we possibly can. Because we really truly, for those that are utilizing our service, believe that we're helping them reach their goals and beyond and live the best life that they can possibly live with lung disease. VICTORIA: Oh, that's really awesome. I really appreciate you coming on and sharing that with us today. Do you have any questions for me or for thoughtbot about anything? WENDY: You know, I think the big question for us is, do you have any users out there? Do you have anyone that is listening to this program right now that needs lung rehabilitation? Or are you a clinician, or do you know a clinician that deals with people with lung disease? We would absolutely love to talk to them and provide our services, and tell you how our outcomes are looking with the patients that we've served so far. So, I guess the big question is, do you know anyone with lung disease, and would you be willing to send them our way? VICTORIA: Oh, that's incredible. I certainly have some people in my mind who I'm like, oh, you should really introduce to this group of folks over here. I love that that's what you're working on. And is there anything else that you'd like to promote today? WENDY: Just in general, pulmonary rehabilitation is so important. And if you have an in-person program that's near you, I want to promote them, too. I want you to know that pulmonary rehab is an incredible service. And the outcomes, we have so much research that says if you do an 8 to 12-week program, that you will gain benefits from going through the program. So, whether it's our program, whether it's an in-person program, or a program at a clinic that you go to, I would just encourage anybody to take part in pulmonary rehab if you have lung disease. And certainly, if you're new to lung disease, if you're a COVID recoverer that has some fibrotic changes in your lungs that you need help navigating, then reach out to those professionals that are in pulmonary rehabilitation because they can help you definitely. And Exhale would always love to serve those, whether post-COVID, or asthma, COPD, fibrosis, pulmonary hypertension, all of those lung diseases. We are here for you, as well as other clinicians that are in this arena. VICTORIA: One person I'm thinking of works with people who are vaping a lot, really high vaping community. And I'm sure [inaudible 30:48] [laughs], yeah, I hear that in your voice. WENDY: Yeah. [laughs] VICTORIA: So that's someone I was like, maybe that'd be a good program for her to share with the people she works with because yeah...and the other...this might be, you know, I know this is a disease issue, but in San Diego, we have a lot of freedivers and people who train holding their breath for a long time. And they've been trying to get me to do that. And so, I was like, well, maybe [chuckles] I could try it and just increase my lung capacity and overall be healthy, too. WENDY: Yeah, that's a great program, too. It is interesting, too, to see a person's lung function. We have pulmonary lung function diagnostic tests that can be done in a clinic. In the pre and post-diver training, yeah, lung function changes quite a bit in your ability to expand your lungs, hold your breath, and maneuver that oxygen across the membrane so that you are able to sustain longer. So yeah, that's really interesting. And your point of vape, certainly, we have smoking cessation programs that are involved in our lung rehabilitation. If you smoke, then you get some of those classes about how do I quit smoking? But vaping is becoming a really large issue. I have given several talks in high schools recently. And certainly, with my work with the American Lung Association, American Lung Association does a fantastic job of creating supplemental materials for individuals who, you know, are working with people in that arena. And so, they've really focused on the vape epidemic recently. And so, if you are dealing with anybody, and especially the youth population, there is a wonderful toolkit that the American Lung Association has available. You can download it. There are some videos or some, like, handouts and stuff like that. Those programs are helping, especially in our schools, because there is a true epidemic with vaping right now. And, unfortunately, when the vape industry created those items, they kind of took a key out of the book from the cigarette companies and promoted it as some, you know, health benefit. And what we're finding on the flip side in all of the diagnostic testing is it's just as bad as cigarettes. And it's creating a really big problem, especially if they're starting early, 14-15 years old, and their lungs are not developed all the way yet. It is not just water vapor, like they say. It is some very serious, toxic chemicals that they're inhaling, and it has some long-term effects that are going to create some fibrotic changes in the lungs long term. So, as you mentioned, you know, the vape industry, I'm definitely a proponent of preventing people from getting vape products and preventing youth from having access to that. VICTORIA: Yeah, absolutely. It's a big problem. And I'm excited to see how Exhale and other people are working together to kind of get that message out and solve those problems. So, I appreciate you coming on this show today and sharing all of that with me. WENDY: I would really love to say thank you so much for considering me and considering Exhale for your program. I always love an opportunity to talk about it. You can tell that I'm very passionate about Exhale and what we're providing, and so thanks so much for letting me come on today. I really appreciate it. It was wonderful to meet you. VICTORIA: Wonderful to meet you as well. And I really enjoyed hearing your story and hearing all about the great work you're doing. So, you can subscribe to the show and find notes along with a complete transcript for this episode at giantrobots.fm. If you have questions or comments, email us at [email protected]. And you can find me on Twitter @victori_ousg. This podcast is brought to you by thoughtbot and produced and edited by Mandy Moore. Thanks for listening. See you next time. AD: Did you know thoughtbot has a referral program? If you introduce us to someone looking for a design or development partner, we will compensate you if they decide to work with us. More info on our website at: tbot.io/referral. Or you can email us at [email protected] with any questions.Special Guest: Wendy Lawson.Sponsored By:thoughtbot: When starting a new project, we understand that you want to make the right choices in technology, features, and investment, but that you don’t have all year to do extended research. In just a few weeks, thoughtbot’s Discovery Sprints deliver a user-centered product journey, a clickable prototype or Proof of Concept, and key market insights from focused user research. We’ll help you to identify the primary user flow, decide which framework should be used to bring it to life, and set a firm estimate on future development efforts. Maximize impact and minimize risk with a validated roadmap for your new product. 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