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5/25/2015
12:06 PM
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Why We Need Design Thinking In Healthcare

Designers begin by understanding how people work in the real world, and then create the best IT system that's technically feasible.

The one given across all sectors of healthcare today is that change is coming, and not the gradual kind. This is multi-billion-dollar, build-up while tearing down kind of change. If that change is to lead to dramatic improvements in the effective and efficient care of patients, our systems must be redesigned, not re-engineered. Here's why: It's a matter of life and death.

On Sept. 25, 2014, Eric Duncan reported to the emergency department of the Texas Health Presbyterian Hospital Dallas with a low-grade fever, abdominal pain, dizziness, and headaches. When he returned to the hospital on Sept. 30 and was diagnosed with Ebola, the question asked by nearly everyone paying attention (and we all were) was, "How could the doctors and nurses have missed the telltale signs of Ebola presenting in a man just returned from west Africa?"

The hospital's first response was to blame a design flaw in its electronic health record (EHR) system that prevented travel history data entered by nurses from presenting itself to doctors. It later retracted that claim, stating, "There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event." The system behaved exactly as it was intended to.

So was there a flaw? Absolutely. The system was built with the assumption that the people using it should conform the way they work to the way the EHR was built, rather than the other way around. In other words, like most healthcare systems, their EHR was engineered.

Design, on the other hand, begins by gaining an understanding of how a system is likely to be used within a given environment and creating that system accordingly.

For those on the delivery side of healthcare, it is not news that very few of our systems are created with consideration of how they'll actually be used.

First, learn how they work, then figure out what they need.

(Image: Darko Stojanovic  via Pixabay)

First, learn how they work, then figure out what they need.

(Image: Darko Stojanovic via Pixabay)

Our methods of "handing off" patients from one clinician to another create deadly information black holes and miscommunications. The devices in our incredibly sophisticated Intensive Care Units emit a cacophony of competing sounds, causing nurses and doctors to ignore the occasional deadly warning. Clinicians cut and paste pages of text into the notes sections of electronic medical records, ensuring adequate documentation for billing, but burying potentially critical details. In fact, health services researchers have filled medical libraries with details of poorly designed systems that contribute to the accidental deaths of hundreds of thousands of patients globally each year.  

[ See how Hoag Memorial delivers better care through data sharing. ]

So why the urgent need for design in healthcare now? There are three macro-level developments that are combining to create a perfect storm of change in healthcare.  

  1. Payment reform. The shift from "fee for service" toward a "fee for value" reimbursement will affect nearly every aspect of care, from who pays, to where and how care is provided.
  2. Healthcare goes digital. Significant government investments, including up to $44,000 per adopting clinician, have driven electronic medical record adoption from 11% in 2007 to 78% in 2014. In turn, healthcare is increasingly awash in data that has yet to be widely employed to improve care.
  3. Affordable high throughput sequencing. The dropping cost of reading a human's DNA is leading to a fundamental rethinking of disease and biology, and  to new classes of drugs and diagnostics. The implications of what is sometimes called "personalized medicine" will affect everything from how clinicians will make sense of mountains of new data, to how IT departments will store it, and how payers will reimburse for it.

Each of these impending changes represents fundamental change to existing processes, systems, and structures. Success in transforming these systems will be dictated by good or bad design -- regardless of whether designers are involved (they are usually not) or even if it's recognized that "design" is actually what is taking place (it usually isn't).

What Exactly Is "Design?"

Most of the healthcare industry views designers as a luxury afforded to consumer product companies. They are the more-stylish-than-thou gurus who use words like "metaphor" and "user experience." Sure, one or two wander into healthcare now and then, adding a bit of contrast to our drab lab coats and beige walls.  

But the need for design is popping up in more industries these days. The notion of involving designers in improving healthcare pinged twice for me in a couple weeks -- once at a meeting and once during lunch with a colleague. That's enough of a sign that I had some homework to do in order to figure out what exactly they were talking about. I had heard one or two interesting talks from designers about their work in re-orienting the architecture of hospitals to "promote" health, and of wheelchairs designed to climb stairs. But what design had to do with the type of health-system-improvement work we do at Ariadne Labs wasn't obvious to me.

So, I started knocking on the doors of designers. I met with the founders of the design firm Invivia, the co-founder of the strategy firm Jump Associates, and spoke with the lead designer at the HELIX Center. I watched videos, read the books they suggested, and asked questions.

In short, I learned just enough to be dangerous, so let me offer a disclaimer. There is an enormous difference between the abilities and approaches of those that have mastered their fields and those of people just learning them. Unlike the novice musician or chef, the masters are so proficient with the tools of their trade that they are no longer restricted to sheet music or recipes. My intent isn't to make master designers out of clinicians or health IT professionals (nor of me) but to show just how important and accessible the basics of design truly are. While I'll surely misrepresent aspects of this field, I am convinced that

 Page 2: Get a handle on design.

Leonard D'Avolio, PhD, is the Director of Informatics at Ariadne Labs, a joint venture of Brigham and Women's Hospital and the Harvard School of Public Health. He is co-creator of the healthcare prediction platform Cyft, an assistant professor at Harvard Medical School, and a ... View Full Bio
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PeterF028
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PeterF028,
User Rank: Moderator
6/15/2015 | 10:35:12 AM
People need to appreciate the offering
Great article. Even the best innovations are meaningless if no one uses them. This is why its so important for organizations to involve a diverse mix of people when coming up with and pursuing new ideas.  It's really about having the culture in place capable of providing perspective. Peter Fretty, IDG blogger working on behalf of CSC. 
asksqn
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asksqn,
User Rank: Ninja
5/30/2015 | 2:58:52 PM
Beam Me Up, Scotty: there is no intelligent life down here
Designing software around end user habits is one thing, but if the end user is a techno-moron -as most particularly in Healthcare are- well, there is no patch for human stupidity.  I expect even more patients to die from healthcare personnel errors the more tech is leaned on than the current bodycount from not being able to read a physician's handwriting.
GarrettG406
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GarrettG406,
User Rank: Apprentice
5/28/2015 | 2:56:13 PM
Re: I live it first hand
     Cognitive Ergonomics is important here in designing informatin solutions that match well with the users' and their environment. For example, the bottlenecks in certain decision processes due to something like too many decisions at once or informatin overload can be relieved some by designing the information system to level out the mental workload. However this takes managerial understanding and a commitment to quality over some short-term cost. An information system that requires noted documentation to be entered before opening the next client case that occurs at the same time the provider should be interacting and counseling with the client is not a good solution from a cognitive ergonomics perspective. However, recognizing this bottleneck, using assistive technology in the documentatin process at this point would reduce the bandwidth and increase the effectiveness of the provider, to the benefit of the client and long-term cost and quality deliverables. In my projects I am committed to design technolgoy for the users and stakeholders not just the engineering viewpoint of accomplishing the list of functions to be included and completed.
PedroGonzales
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PedroGonzales,
User Rank: Ninja
5/26/2015 | 9:42:09 PM
Re: I live it first hand
I think we often times forget that software is meant to improve users' process.  That the design of any product is the main way how users interact with our product.  If developers do not understand this then the faulty software will always be the norm. 
ldavolio
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ldavolio,
User Rank: Apprentice
5/26/2015 | 7:09:20 PM
Re: great points
Thanks all commenters on your thoughtful feedback and follow on points.   Dr. Tsega, I read your blog post and i think you summarize nicely the ridiculousness of EMR design.  It's a really interesting topic that's lighting up the medical listservs and message boards these days.  Often overlooked is the government-funded oligarchy that created the rapid adoption of the decades old EMR design.  The unanwered question (in my opinion) is, "was it worth it?"  
ChrisBarnes
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ChrisBarnes,
User Rank: Apprentice
5/26/2015 | 6:29:15 PM
Additional resources
For those who want to go beyond the resources mentioned, I also recommend the following:

GameStorming: A Playbook for Innovators, Rulebreakers, and Changemakers by Gray, Brown,and Macanufo -- An excellent receipe book for helping groups of people explore ideas, problems, and solutions.  

This is Service Design Thinking by Stickdorn and Schneider -- This textbook explains design thinking in the context of creating/innovating services, describes practical techniques, and includes case studies. It's also beautifully designed.

Chapter 7: "Getting Personal: Developing Yourself as a Design Thinker" in The Design of Business by Roger Martin -- Many kernals of useful wisdom here, though a bit more "thinky" than practical.
progman2000
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progman2000,
User Rank: Ninja
5/26/2015 | 3:27:48 PM
Re: I live it first hand
We've taken our developers onsite to hospitals and the result is always the same. After years of listening to developers explain how the user "should be" using the program, you can see that light come on and they finally "get it". There is no substitute for actually seeing and living what the users actually do.  
Stratustician
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Stratustician,
User Rank: Ninja
5/26/2015 | 3:23:30 PM
Re: I live it first hand
Sadly, you aren't alone in this.  I think what a lot of software/application companies forget is that while they might think their solution checks off the key functionality, if it isn't developed with users in mind, it might not be as successful as they hope.  In healthcare for example, hiring developers who have industry experience, not just because they worked at a company that created solutions for healthcare, but who actually worked in hospitals and other healthcare providers and understand how the tools are used, might provide better user acceptance and usage overall than those solutions designed for these industries but not created with users in mind.
drtsega
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drtsega,
User Rank: Apprentice
5/26/2015 | 12:51:02 PM
great points
Thanks for writing this and providing some helpful resources. I very much agreed with your point about the problem with bringing in designers at the end of a project (or thinking about design at the end, rather than the beginning).

I wrote something about this previously, and wouldn't mind getting your thoughts on it: https://medicalminimalist.wordpress.com/2015/03/18/diagnosis-clutter/
progman2000
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progman2000,
User Rank: Ninja
5/26/2015 | 7:00:03 AM
I live it first hand
I work fof a software company that sells a healthcare product and have seen us make this mistake for years. Our product was developed by programmers that thought they understood what it was the user wanted. The sad part is we either lose deals because of this gap or well sell and implement a solution that forces a user to change their workflow based on our flawed assumptions. It's amazing how ofter that happens in the world of big ticket software purchases.
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