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Blog | Alto Pharmacy

A healthy pregnancy begins well in advance of trying to conceive. Preconception health planning sets you up to feel your best while growing a baby, allowing you to work towards health goals and manage preexisting conditions that could potentially result in complications.

How to Have the Healthiest Pregnancy Possible

It can also help you make any necessary changes to your treatment plan — for example, if you take a medication that is considered unsafe during pregnancy, your doctor can help you safely transition to an alternative.

Below, we break down some of the most important steps to take as you focus on your health and wellness while building or growing your family.

1. Consult your doctor about your health history

As you begin to plan for a baby, schedule a doctor’s appointment to identify any health issues that can impact pregnancy — whether it’s your first, second, third, or fourth.

While chronic health conditions like diabetes, hypertension, thyroid disease, and asthma are sometimes linked to pregnancy complications, you can prevent health challenges during pregnancy by staying proactive about treatment. For those with diabetes, this means working with your provider to maintain healthy blood sugar levels before trying to conceive. The same goes for hypertension and blood pressure levels.

Read Navigating Pregnancy With Type 1 or Type 2 Diabetes

Be sure to discuss any past pregnancy complications, if relevant. Experiencing certain complications in a first pregnancy can increase your risk of having them again in a later pregnancy. These complications include:

This does not mean that a recurrence is inevitable. Proactively managing your risk before and during pregnancy is the most important thing you can do to prevent these complications.

You should also share any health issues that you experienced during postpartum, including mental health challenges.

Changing a medication regimen or treatment plan

A pre-pregnancy care checkup is also an opportunity to discuss potential changes to your treatment plan. Bring all medications you are currently taking with you to this appointment, including vitamins and herbal remedies.

Never stop taking a prescribed medication without first consulting your doctor. Many medications cannot be abruptly discontinued and require you to slowly titrate, or taper off, over a period of time

It is recommended to focus on preconception health at least three months prior to pregnancy. However, everyone has unique health needs, and you may need more time to prepare for a healthy pregnancy. Try, as much as possible, to be patient and give your body the time and space it needs.

2. Get all recommended vaccines and screenings

At the beginning of your family building journey, ask your doctor which vaccines are recommended for your age. Certain infections or illnesses can cause birth defects or pregnancy complications. Many of these can be prevented with vaccines. And since illness-fighting antibodies can pass through the placenta, vaccinated individuals can pass along immunity to their growing baby in the womb.

It’s important to stay up to date since the recommended timing of vaccines varies. Not all can be given during pregnancy while others can. Your doctor can clarify which vaccines are recommended before pregnancy, during pregnancy, and after delivery. (Two of the most important vaccines for pregnant women, the flu vaccine and the Tdap vaccine (tetanus, diphtheria, pertussis), can be safely administered during pregnancy.)

Additionally, sexually transmitted infections (STIs) including HIV, HPV, and viral hepatitis can cause pregnancy complications and harm a developing fetus. Fortunately, treatment can prevent transmission to a baby. Screening for these infections is a critical step in planning for a healthy pregnancy.

3. Take steps to live your healthiest life

In the months before trying to conceive, revisit your health habits and make any changes to your routine or lifestyle that can support the healthiest pregnancy possible. There are several key areas to focus on.

Several nutrients are especially important to consume in the months before pregnancy. 

The American College of Obstetricians and Gynecologists recommends taking a prenatal vitamin with at least 400 micrograms of folic acid every day for at least a month before pregnancy through the first trimester. This important nutrient supports a baby’s growth and development and can prevent certain birth defects.

Depending on your health history and previous pregnancies, your provider may advise you to increase your intake of folic acid with an additional supplement.

(You can add prenatal vitamins to your next Alto delivery!)

Calcium helps build a developing fetus’s bones and teeth. Dairy products including milk, cheese, and yogurt are the primary sources of calcium, but you can also get this nutrient from other sources including:

If you are concerned about your calcium intake, ask your doctor about calcium supplements.

Iron also helps support a healthy pregnancy. Some prenatal vitamins include iron. It can also be found in the following iron-rich foods:

In addition, be sure to eat foods that support your body’s absorption of iron, including the following fruits and veggies, which are rich in vitamin A and beta-carotene:

If you have anemia, your doctor may recommend additional iron supplements.

An omega-3 fatty acid called DHA, or docosahexaenoic acid, is important for fetal growth and development. It can be found in some foods such as fatty fish. Depending on your diet, your doctor may recommend taking supplemental DHA before and during pregnancy and in the postpartum period. Some prenatal vitamins contain DHA, but not all, so be sure to check the ingredient list.

Since heavy caffeine consumption can affect fertility, it is recommended to reduce your intake to 200-300 mg per day.

Aim for about 150 minutes of moderate physical activity per week, incorporating some muscle-strengthening exercises.

Being underweight or overweight can cause health issues during pregnancy. Try to reach and maintain a healthy weight in the months before trying to conceive. Your provider is an important resource and can advise you on whether your weight may impact your pregnancy.

Smoking, drinking alcohol, and using certain drugs — including misusing prescription medication — can cause serious health issues during pregnancy like preterm birth and birth defects. When planning for a future pregnancy, do not be afraid to ask for any support needed to give up harmful behaviors. Your provider can offer resources. 

It’s also important to avoid secondhand smoke during pregnancy.

Genetics are a factor in your baby’s health and the progression of your pregnancy. Prior to pregnancy, discuss your family’s health history as well as your partner’s with your provider. This allows them to identify any genetic risk factors.

Some couples and individuals may be referred to a genetic specialist for reasons such as the following:

A family history of a genetic condition, birth defect, chromosomal disorder, or cancer

Two or more pregnancy losses or a stillbirth

Having given birth to a child with a genetic condition, birth defect, or intellectual disability

These risk factors do not guarantee that your baby will develop a health condition or that you will have a complicated pregnancy. Genetic testing can determine the likelihood of passing on a genetic issue to a child. A genetic specialist can help you understand your options for testing.

5. Prioritize your partner’s health as well

Preconception health concerns both parents. Male partners should also take steps to become as healthy as possible, which will improve their own reproductive health and fertility. This includes limiting their alcohol intake, quitting smoking or using harmful substances, and eating a healthy diet. (These lifestyle factors have been linked to issues with sperm production.)

Other important steps for male partners to take before trying to conceive include getting screened for STIs and consulting with a provider about family health history and medication use.

Alto Pharmacy can support you in preparing for a healthy pregnancy, however that looks for you. From delivering prenatal vitamins straight to your doorstep, supporting you in managing a chronic condition, or helping you navigate fertility treatment, we make it as simple as possible to focus on your health.

We offer free, same-day delivery and in-app medication management tools like reminders and auto refills. Additionally, our pharmacists are available to answer any questions you may have about medications or side effects.

To learn more, reach out any time through secure in-app messaging or by phone at 1-800-874-5881.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition.

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.

What motivated you to pursue a career in pharmacy?

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.

What challenges have you encountered as a pharmacist?

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.

Alto’s board of advisors was formed in 2020 to deliver strategic guidance as we work toward a better healthcare system for all. With diverse leadership experience in the industry, our board of advisor members ensure that our efforts are both impactful and efficient, with services grounded in the highest standards of operational excellence.

Meet the Newest Members of our Advisory Board | Alto Pharmacy

Today we’re thrilled to welcome three new members to the board of advisors: Adam J. Fein, Harry Leider, and Brad Fluegel. Their passion and expertise will no doubt be an asset as we focus on reaching even more patients — and delivering even more comprehensive care — in service of our mission.

Read on to learn more about their backgrounds in the industry and join us in giving them a warm welcome!

Adam J. Fein, PhD, is the CEO of Drug Channels Institute, a leading source of industry research about pharmaceutical economics and the drug distribution system. Widely published in academic and industry publications, he also heads the Drug Channels website, praised by readers for its comprehensive and witty coverage of pharmacy benefit managers (PBMs), medication pricing, and other industry topics.

Delivering medications to our patients at the lowest price possible is central to our mission. Dr. Fein’s deep expertise in pharmacy economics supports our ongoing commitment to improve adherence rates by way of more affordable medication options and total price transparency.

“The pharmacy industry has entered a period of structural change. There’s a tremendous need for the cost transparency, efficiency, and commitment to patient well-being that Alto delivers. I’m thrilled to support Alto in building innovative solutions to foundational issues within the industry,” Dr. Fein said.

Dr. Fein holds a doctoral degree in managerial science and applied economics from the University of Pennsylvania’s Wharton School of Business.

Harry L. Leider, MD, MBA brings more than 25 years of experience as a senior healthcare executive to our board of advisors. Since 2018, he’s served as Chief Medical Officer and Executive Vice President of Gelesis, an innovative biopharmaceutical company.

In addition to his current leadership in the biotherapeutic space, Dr. Leider has broad experience in telemedicine, retail healthcare, laboratory medicine, and payor strategies, as former Chief Medical Officer of Walgreens Boots Alliance, Ameritox, and Care Improvement Plus.

Dr. Leider shares Alto’s commitment to driving lasting change within the healthcare system for better patient health. With both clinical expertise and executive experience, he’s spent his career designing programs, services, and intellectual property that improve health outcomes.

“Alto’s pharmacy model brings us closer to a future where everyone can receive the highest standard of care and is equipped to manage their health. I’m personally inspired by Alto’s bold vision for healthcare and look forward to what we can accomplish together,” Dr. Leider said.

Dr. Leider has served on the faculty of Harvard Medical School and the Johns Hopkins Carey School of Business and holds five patents in laboratory medicine.

Drawing on more than three decades of healthcare experience, Brad Fluegel is a strategic advisor to organizations, entrepreneurs, and other industry participants. Most recently he served as Senior Vice President and Chief Healthcare Commercial Market Development Officer for Walgreen Co, where he managed all commercial healthcare activities, from sales and contracting to biopharma relationships and market planning.

Previously, Brad oversaw Walgreens’ corporate strategy and business development as Chief Strategy and Business Development Officer. He also led Elevance (then Wellpoint)’s strategic planning and corporate communications as Executive Vice President and Chief Strategy and External Affairs Officer.

His expertise in strategic planning and operations will allow us to deliver an exceptional patient experience as we continue to grow.

“Since 2015, Alto has proven itself to be a leader in the rapidly evolving digital pharmacy space. It’s a privilege to support their efforts to redefine what’s possible in healthcare, and together we can deliver industry-leading care to more patients,” he said.

Brad earned a master’s degree in public policy from Harvard University’s Kennedy School of Government and a bachelor of arts in business administration from the University of Washington. He also serves as a lecturer at the Wharton School of Business.

Dr. Fein, Dr. Leider, and Brad join three other advisory board members: Dr. James Hildreth, the President and Chief Executive Officer of Meharry Medical College; Jennifer Kent, previously the Director for the California Department of Health Care Services; and Ajay Khatri, previously Alto’s Chief Strategy Officer. 

Dr. Hildreth, Jennifer, and Ajay have offered invaluable guidance as we’ve grown throughout the past two years, and we couldn’t be more grateful for their partnership and support.

Learn more about Dr. Hildreth and Jennifer’s healthcare experience.

Visit alto.com/careers to learn more about our open roles and join us in delivering industry-leading pharmacy care.

Meet the Newest Members of Our Advisory Board

Many of us are familiar with the disappointment of a failed New Year’s resolution. Only 35% of Americans who made one in 2020 kept at it until the end of the year, and a study from 2015 found that 80% of New Year’s resolutions fail by mid-February.

The Science of Habit-Forming

Since healthy lifestyle choices are a key part of preventing or managing many chronic conditions, it’s important to continue working toward your health and wellness goals, no matter how frustrating it may feel. And while giving up old habits or cultivating new ones is never easy, you have more control over this process than it may seem.

Habits don’t start from nothing. They are a three-part psychological process of triggers, actions, and rewards, often referred to as the habit loop. This process can unfold passively, as if you’re on autopilot when engaging in many familiar behaviors. But fortunately for those with new habit goals, the habit loop can also be a more intentional rewiring of your brain to turn aspirations into lasting change. Here’s how.

As humans, we’re wired to search for feel-good experiences (and quick hits of dopamine, the brain’s feel-good chemical). Habits are born when the brain recognizes a connection between action and reward. It stores this information in a region of the brain called the basal ganglia. Unlike the prefrontal cortex, the area of your brain that makes conscious decisions, what happens in the basal ganglia is largely beyond your conscious control. That’s why it can be so challenging to break an old habit: sometimes you don’t even realize you’re doing it.

Cue — a stimulus, like a certain location, smell, person, or emotional state, sends the brain into autopilot and motivates you to act.

Action — you then perform a repeated behavior associated with the cue.

Reward — you experience a sense of pleasure or relief as a result of the action, reinforcing the link between cue and action (and perpetuating the habit loop).

It’s easy to see how unhealthy behaviors might emerge from this cycle, but with some effort, the habit loop can result in healthy changes, too. You can replace a bad habit with something more positive, like reading a book, going for a walk, or meditating instead of smoking or overdoing screen time. Or you can use this knowledge of how the brain works to develop a new habit without giving anything up. Either way, you’re more likely to find success if you connect a positive habit with an immediate reward, like linking physical activity with your favorite song or podcast.

In addition to considering the connection between your default behaviors and rewards, the following tactics can set you up for success as you commit to your physical and mental well-being. 

Start small and aim for incremental progress

It’s admirable to have big ambitions for your fitness routine, but it often takes time to build up your strength. Sometimes the disappointment of not arriving at a goal quickly enough is what causes people to set down their goals and resolutions altogether. Many health experts suggest starting with a small and specific action rather than the end state. Rather than focusing on running a half marathon, try to run a little more than you did the day before. The same principle applies to other habits like meditating or reading instead of social media scrolling.

At the same time, taking it slow doesn’t mean being inconsistent. Studies show that it can take anywhere from 18 to 254 days to form a new habit, and the best way to establish a routine is to actually do it. If your goal is to be more physically active, try doing a small, gentle exercise every day — a certain number of jumping jacks or push-ups, or a quick walk — and building up from there once you’ve got a foundation in place.

Since we’re all creatures of habit, there are probably many patterns in your day that can help you cultivate your new routine. For instance, try meditating after your morning cup of coffee, or going for a walk after your lunch break.

This approach is referred to as habit stacking, and it uses our tendency towards autopilot — and the habit loop fundamentals — to our advantage. Your new habit will quickly become linked to what the brain already knows, increasing your chances of success.

While change is never easy, you can make it easier by removing the obstacles that stand between you and your health goals. So rather than trying to muster up more will power, add a visual cue to your new routine, or remove a preparation step. This could mean packing your bag for your morning workout and leaving it by the door before going to bed, choosing an exercise you can easily do from home, or putting heart-healthy snacks in a visible spot on your kitchen counter. Whatever you’re trying to achieve, there’s probably a way to minimize the time and effort it requires.

Let Alto support your health and wellness

At Alto, we believe that staying on top of your health should be as simple as possible, and we’re here to support you with exceptional pharmacy care all year long. We offer free, same-day delivery and medication management tools like reminders and auto refills in our mobile app.

Reach out any time through in-app messaging or by phone at 1-800-874-5881.

Vaccines — which were first developed in 1796 for smallpox and continue to evolve with new research and technology — build on your immune system’s natural function to protect you from serious diseases. Just like white blood cells and the other components of your immune system, vaccines help you develop immunity, but without the initial illness and risk of health complications. Here’s a look at how vaccines work.

The Science Behind Vaccines

Your immune system has a natural way of defending you from the viruses and bacteria that cause illness. As these germs multiply rapidly and infect your body, an army of white blood cells fights back, producing antibodies that attack the invaders.

The first time you are infected by a specific virus or bacteria, your immune system often cannot destroy the germ quickly enough to prevent you from becoming sick. After you’ve recovered, certain immune cells hold onto the memory of the infection. This allows them to mobilize quickly if they encounter the same germ again, preventing illness in the future. Immunity, your body’s resistance to certain types of infection, is the outcome of this process.

To understand how vaccines work, it’s helpful to know how your immune system naturally fights an infection. B-lymphocyte white blood cells produce blood proteins called antibodies, which attack antigens — the part of the invading germ that triggers an immune response. T-lymphocyte white blood cells attack already infected cells in the body. After the infection has ended, a few T-lymphocytes, or memory cells, remain to ensure a fast immune response should the same germ reappear.

Vaccines imitate infections, triggering the process of building immunity to a specific disease without causing illness. Your immune system responds to these imitation infections the same way it would to an actual infection. Detecting antigens from the vaccine, your immune system produces antibodies and T-lymphocyte cells. The imitation infection leaves your body with T-lymphocyte memory cells and B-lymphocytes, which will know how to quickly fight that antigen in the future. This prevents you from becoming sick if you are exposed to the virus or bacteria that cause the disease.

It typically takes several weeks for your body to produce T-lymphocyte and B-lymphocyte cells in response to a vaccine, which is why in most cases you will not immediately develop immunity. This means that you could become infected with a disease and develop symptoms shortly after vaccination, so it’s important to take necessary precautions until you become fully immune to the virus or bacteria. The healthcare professional administering your vaccine will inform you of the anticipated timeline for immunity.

Sometimes the imitation infection created by a vaccine causes mild symptoms such as a fever. These side effects are normal and indicate that your body is building immunity.

While all vaccines arrive at the end result of immunity, there are several paths for getting there. When deciding which type of vaccine to create for a disease, researchers consider a variety of factors, including the immune system’s response to the germ that causes the disease, the population likely to receive the vaccine, and the regions of the world where it will be used. These are the seven types of vaccines commonly used in the U.S.

Live vaccines use a weakened version of the living virus or bacteria that causes a disease. They are most similar to the natural infection and produce long-lasting immunity. The weakened form of the germ does not lead to serious disease, like that caused by the wild form of the germ, for most individuals with strong immune systems. However, live vaccines aren’t safe for those who are immunocompromised, including children undergoing cancer treatment. Examples of live vaccines include the measles, mumps, and rubella (MMR) vaccine and the chickenpox vaccine.

Inactivated vaccines are produced by inactivating, or killing, the germ that causes a disease. Examples include the polio, hepatitis A, and flu vaccines. They don’t provide as strong of immunity as live vaccines, so additional doses, also referred to as booster shots, are often needed for ongoing protection.

Toxoid vaccines target a toxin, a harmful substance produced by a germ, rather than the entire germ itself. They contain a weakened version of the toxin to be targeted called a toxoid, which teaches your immune system how to fight off the natural toxin. Similar to the germs used in live vaccines, toxoids are weakened to a point where they do not cause illness. These vaccines are used to prevent diseases caused by toxin-producing bacteria such as diphtheria and tetanus.

Subunit vaccines use portions of a virus or bacteria called subunits rather than the entire germ. Vaccines for diphtheria, tetanus, and pertussis, or whooping cough, are combined into the DTaP vaccine. The pertussis component is a subunit vaccine.

Conjugate vaccines fight a specific type of bacteria whose antigens are more difficult for a child’s immune system to detect due to their outer coating. The vaccines link the coating to stronger antigens that the immune system can more easily respond to. Like subunit vaccines, these vaccines are more targeted and only use part of the germ. Examples of conjugate vaccines include the haemophilus influenzae type B (Hib) vaccine.

Viral vector vaccines produce immunity to a virus by using a modified version of a different virus to deliver instructions to your immune cells. The modified version of the other virus is referred to as a vector virus. Recent Ebola vaccines have used this technology, and the Johnson & Johnson COVID-19 vaccine is also a viral vector vaccine.

mRNA vaccines help your body produce a protein that triggers an immune response and the development of antibodies. This technology was used to create the Pfizer-BioNTech and Moderna COVID-19 vaccines.

Read ‘What the COVID-19 Vaccine Means for Those With HIV’

All vaccines in the United States require approval by the Food and Drug Administration (FDA) and are held to rigorous safety and effectiveness standards. The vaccine approval process starts with lab tests, which may take years in some cases. The FDA analyzes the results to determine if the vaccine should be tested with people. If the vaccine moves forward, the next step is clinical trials where the vaccine is tested on volunteers.

Clinical trials typically begin with a smaller group of 20 to 100 volunteers before including thousands more. The trials gather information about vaccine safety, the typical immune response, and dosing. If any safety concerns emerge during this stage, the FDA must address them before it can authorize the vaccine.

Vaccine manufacturers are required to continuously monitor vaccine safety after approval and test every batch produced to ensure effectiveness, quality, and purity. These test results are reviewed by the FDA, which also conducts an inspection of the factory where the vaccine was produced. If you experience severe side effects after vaccination, contact your healthcare provider so that they can report potential concerns to the Centers for Disease Control and Prevention (CDC)’s vaccine monitoring database.

COVID-19 mRNA vaccines were developed and approved more quickly than a typical vaccine given the urgent nature of the pandemic. This expedited timeline was made possible by significant investment from governments and companies in the vaccine development process and decades of research on mRNA vaccine technology. These vaccines were as thoroughly vetted for quality and safety as any other vaccine.

Many vaccines are received during childhood, like the polio, chickenpox, and MMR vaccines, but there are others you may need as an adult. The CDC recommends the zoster vaccine, which prevents shingles, for adults ages 50 and older and the pneumonia vaccine for those over 65. Other vaccines may be recommended based on additional factors including job or school requirements, travel, and health conditions. Check in with your doctor about which vaccines you need.

The CDC also recommends an annual flu vaccine for everyone 6 months and older. New versions of flu vaccines are developed annually in anticipation of circulating flu virus strains, so health experts recommend getting one every year to prepare for cold and flu season. It’s especially important to be proactive about flu vaccination if you are over the age of 65 or have a chronic condition such as COPD or diabetes.

For detailed vaccine recommendations by age group, reference the CDC’s recommended immunization schedules for children and adolescents and adults.

At Alto, a pharmacist is your partner in health. If you take medication, we will work with your doctor, your insurance (if applicable), and any third party savings programs that you may qualify for to make your medications as affordable as possible. And our team of pharmacists is available to chat whenever questions come up. 

Reach out any time through in-app secure messaging or by phone at 1-800-874-5881.

To automate a manual, error-prone pharmacy workflow, we turned to event streaming. Here’s what we learned from one of the first Kafka use cases at Alto.

How We Used Kafka to Build an Event-Driven Automation Pipeline and Scale Our Pharmacy

Imagine this: You're at the doctor’s office, and your doctor just wrote you a new prescription. Minutes later, before you even check out with the receptionist, you already have a notification from Alto Pharmacy on your phone that your prescription is ready. All you have to do is pick the date and time that works best for your free courier delivery.

This is the future we’re building at Alto: a future where a prescription can be transcribed, billed, and verified by a pharmacist in five minutes, flat. To get there without dramatically increasing Alto’s head count, we need to automate much of the process, starting with the first step: transcribing, or intaking, a prescription.

As a pharmacy, we receive prescriptions in many different forms. Some are sent electronically, in a structured format, but others are handwritten, phoned in, or even faxed. To represent all of these forms in a single table, we previously required every incoming prescription to be transcribed by an Alto team member, who would answer questions like:

Whom is this prescription for? Is this customer already in our system?

Where did this prescription come from? Who wrote it?

What is the relevant prescription information (medication to dispense, quantity, days supply, directions, etc.)?

This manual process is both time-consuming and prone to human error, which, if uncaught, could impact our ability to process the prescription downstream. Furthermore, at our busiest times, it could take up to two hours for a team member to get through the pending intake queue — unacceptable if we hope to have prescriptions ready to schedule before people even leave their doctor’s office. 

Automating intake required close collaboration between three teams:

Data Science, who built the decision-making algorithms 

Data Engineering, who served up the results of those algorithms

Product Engineering, who used those results to automatically intake prescriptions 

To allow the teams to operate in parallel without toe-stepping — and in the language most suitable for each (the Data Science and Data teams prefer Python, while product engineers work mainly in Ruby) — we separated the code into two environments: 

1. Data Prod Interface (DPI), where the code for generating automation results lives

2. Wunderbar (our proprietary pharmacy operations platform), where the code for requesting and using those automation results lives

The key question: to establish robust communication between these two environments, should we use an API-based approach, or an event-driven one? Each has its pros and cons. 

Legacy approach everyone at Alto is familiar with

Existing enforcement of strong types and data

Difficult to scale with increased data & requests

Requires ongoing authorization / authentication

Infrastructure relevant to other business areas

Automatic retries, reprocessing, and queueing

Our existing infrastructure currently utilizes a hefty API-based structure, so there was a natural tendency to go down this path, but we knew that beginning to migrate services towards an event-based architecture with Kafka at its heart would help us in the long term.

Kafka is a framework implementation developed by LinkedIn, now open-source with the Apache Software Foundation. It aims to provide a unified, high-throughput, and low-latency platform for handling real-time data feeds. 

Alto uses Amazon Web Services as our cloud provider, and luckily, they offer an out-of-the-box managed solution for Kafka, MSK. To configure Kafka with our system, our infrastructure team worked with AWS to set up managed instances to comply with our business requirements. Our Infrastructure team will share more details about this work in an upcoming blog post. 

Kafka offers many benefits. The asynchronous nature of the message system allows for retries, reprocessing, and queueing as well as easy recovery from outages. In addition, the infrastructure work done for setting up the managed cluster would be a one-off workstream. When complete, we’d be able to re-use the same setup and configurations across various business needs to streamline other projects that leverage Kafka. 

Setting up for success: defining a strict contract

One element we had to get right from the start was the data contract. As we send messages between DPI and Wunderbar, we need to ensure messages are produced with the correct schema, so that downstream consumers know what to expect.

Protocol Buffers, or Protos, is an open-source, cross-platform data format used to serialize structured data. Developed by Google, Protos allow you to define how you structure your data once and then use generated code to easily write and read the structured data in a variety of different languages. 

At Alto, we’ve been using Protos for the past few years to speed up development with auto-generated code and ensure data continuity between our Ruby on Rails backend and JavaScript / React / React Native frontend. Protos may seem antithetical to JavaScript and Ruby since they’re both dynamically typed languages, but in practice, they have saved us countless hours of debugging and back-and-forth Slack messages. 

For this project, we turned again to Protos to define the schema for messages produced by DPI and Wunderbar. We defined IntakeAutomationRequest and IntakeAutomationResult messages in Go and generated the types (Sorbet, Flow, etc.), which both DPI and Wunderbar now refer to when producing or consuming messages.

Because Wunderbar is already configured to run on AWS and houses our existing intake logic, it was easy enough to send a prescription to DPI for automation. Where we would normally create a task for an operations team member to manually transcribe the prescription, we instead produce a message to our “request automation” Kafka topic using the ruby-kafka library.

Our consumer, instantiated in an executable that runs on a dedicated worker, consumes messages from a “receive automation” Kafka topic. First, the consumer verifies that a given message corresponds to a prescription we previously sent to DPI. Then, it persists any automation results included in that message. If the automation results are sufficient, we skip intake altogether. Otherwise, we create an intake task to be handled by an operations team member.

Because this project was among our early use cases for Kafka, we wanted to be prepared for the worst-case scenario: we produce a message requesting automation results, and for whatever reason—maybe DPI is down—we don’t hear back. For us, we defined a reasonable time frame as fifteen minutes, in order to avoid building up a large backlog of work that would have to be offloaded back onto our operations team.
To this end, we store metadata about the automation lifecycle in an intake_automation_results table, which includes timestamps representing when we sent a message to DPI and when we received a response back. A cron job runs every minute to check that table for rows where received_at is blank, and sent_at was more than fifteen minutes ago. If this occurs, we flag the prescription to be manually intaken by an operations team member.

The diagram below illustrates our intake automation architecture.

Intake automation is now live at Alto. We’re seeing prescriptions fly through in just a few minutes — during which time our automation creates a user profile if one doesn’t already exist, links the new prescription to that profile, and finds and bills the user’s insurance; a pharmacist reviews the prescription for clinical accuracy; and the user receives a text message to schedule their delivery. This single flow, prior to intake automation, once took up to four hours to complete!

Going from zero to one is quite a feat, and it wouldn’t have been possible without an event-based approach. Now that intake automation has laid the groundwork, we know that Kafka will only continue to provide exponential value to Alto as we grow and migrate more of our services to this event-based architecture. 

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

Reproductive endocrinologist Dr. Guy Ringler — a former faculty member at UCLA and an advisory board member at Men Having Babies — was one of the first doctors in the world to help gay men have children through assisted reprodutive technology.

Spotlight on Men Having Babies & Dr. Guy Ringler

There are many ways to start a family and raise a child. And as recent decades have brought forth milestones in marriage equality and the fight for LGBTQ+ rights, the options for LGBTQ+ family building have also expanded.

According to 2019 data from the Williams Institute, almost 29% of people who identify as members of the LGBTQ+ community are raising children, up from 16.2% between 2014 - 2016. That includes a growing number of gay men who’ve had children through surrogacy, a process in which a woman who is not related to the child — a gestational surrogate — carries a baby who is biologically related to one of the fathers and an egg donor.

Breaking down barriers to LGBTQ+ family building

Reproductive endocrinologist Dr. Guy Ringler — a former faculty member at UCLA and an advisory board member at Men Having Babies — was one of the first doctors in the world to help gay men have children through assisted reprodutive technology. Throughout the twenty-five years that he’s been in practice, he’s seen how scientific advances and cultural changes have broken down barriers for gay men interested in parenthood.

“Over two decades ago, when I began my career, people barely understood the concept of surrogacy for gay men,” he says. “It wasn’t as easy to find women who wanted to become surrogates for gay couples. There was still fear about HIV, and there were questions about the impact of surrogacy on a child’s development.”

The landscape looks a lot different today. Thanks to cultural shifts and greater understanding of the science behind surrogacy — and to awareness-raising organizations like Men Having Babies — there are now more options than ever to become a parent regardless of your sexual orientation or gender identity.

“Greater acceptance of the LGBTQ+ community and marriage equality has opened people’s minds and allowed them to see that gay families can thrive, just like any family,” Dr. Ringler says. “Gay men are now able to plan for a future that we once didn’t know was possible.”

Getting to meet prospective fathers at Men Having Babies’ annual conferences is one of Dr. Ringler’s favorite things about working with the organization. He’s observed a greater number of gay men pursuing parenthood at an earlier age.

“I’m so inspired by the next generation of gay men, who are planning their families in their twenties. That simply wasn’t an option when I was their age.”

Men Having Babies and financial assistance for IVF and surrogacy

There are many steps on the road to parenthood for LGBTQ+ individuals and couples: fertility treatments, legal consultation, and financial planning are all required to start a family.

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How We Used Kafka to Build an Event-Driven Automation Pipeline and Scale Our Pharmacy

Spotlight on Men Having Babies & Dr. Guy Ringler

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