Building a pragmatic definition for sensemaking.

The one-year course at the Austin Center for Design is aimed at helping students build a framework for approaching interaction design in a way that builds autonomy for the designer while helping them address problems worth solving.  For me personally, some of the sharpest spikes in learning and independence have occurred when I am able to see how the practice that we are learning is also embodied in the design of ac4d itself.  Typically, we have already been applying a technique for a while in the program before the theoretical underpinning really makes sense.

Most recently, we have been exploring the role of perception and abductive reasoning in the sensemaking process.  After already going through sensemaking in a variety of different ways in the last seven months, I’m starting to develop my own ethic and practice as an interaction designer.  And so while the theoretical readings around perception were very dense, abstract, and seemingly unrelated… my tacit knowledge of the sense-making process made it possible to delve into them a derive my own meanings.

I think one question central to the question of design practice (of which sensemaking is at the core) is why it has largely eluded definition or refinement in the past.

So our understanding of design is in many way inhibited by our lack of understanding of the mechanisms of the creative process.  Because we see a linear causal chain, we are fooled into thinking that the decisions made along the way were the result of deductive reasoning or else just a spark of randomness that can’t be defined.  What we lose in this sort of retrospective is the context of each decision and how a pragmatic consideration of context results in a kind exploratory reasoning called abduction.  What we think of as creativity may in fact only be the result of practicality in the right context.

If it is possible to highlight some of the mechanisms that push us toward new insights, then of course it’s also possible to build a methodology that refines and enriches those mechanisms.  I tend to think of abduction not just as a lateral thinking process, but actually as a sort of filter that helps us select from all of the ideas in our subconscious from moment to moment.

And so the sorts of problems that are the most difficult to navigate–ones with complex external dependencies and incomplete information–are also the problems where a rigorous sensemaking methodology will differentiate itself as most useful because it’s the sort of sensemaking that puts the highest premium on a pragmatic, integrative approach to exploring new ideas.

Pragmatism is, of course, highly dependent on intuition.  And in order to be pragmatic in a way that is mostly likely to be relevant to a problem, designers must make their intuitive understanding of a problem space rich with of the context that is most likely to make their ideas relevant.  Perhaps most importantly, context can’t be abstractly understood, it is inherently informed by activity in the problem space with the affected people.

And while ethnographic techniques are widely used in design research today, I think there is a lack of definition around the sensemaking process that follows research.  Just as a perceptual layer exists between the interactions that users have with systems, there is also a perceptual layer that exists between the designer and the system they are designing.  In order to create an effective dialog with a design, the designer must externalize their ideas as often as possible in the form of iconic artifacts that allow for new projections and subjective reactions.  During our course on rapid ideation and creative problem solving, our class had a shared experience around the need for this sort of dialog as we rapidly prototyped and iterated on designs of thermostat systems.

Externalizations create a kind of relationship with a system and the system itself starts to impose its own constraints and shapes the designer’s understanding even as the design shapes it.  Resilient traits survive this dialog and a solution eventually emerges.

This articulation from the designer isn’t the solution it’s a solution: it’s an argument through a rigorous and methodical creative process.

Thoughts?

-Scott

Designing Meaningful Models for Interaction

Recently our class has been exploring modern design history and its intertwined relationship with computing technology and approaches to human and computer interactions.  Technology is both active and contextual in our lives and as a result any discussion of how humans and technology is characterized by both granular detail and broad societal trends.

Designers are rightfully wary of the effects of amplification that are possible through modern technology.  Industrialization showed us the immense power and terrifying unintended consequences of amplifying design ideas.  And in the computer age we have seen many of the same naive, shortsighted views that characterized industrialization repeated in new mediums.

In one of the articles we recently read, Steve Mann advocates for the use of a video capture device that will record every moment of our lives and act as a filter for our perspective of the world.

Having an on-demand photographic memory can help all of us by offloading, to a wearable computer, the task of memorizing now-mundane details that might only later become important.

I couldn’t help but think of the idealized representations of home life in mid-century advertisements for appliances and how they would free women from the arduous everyday tasks.  And while Mann’s perspective may have seemed extreme not long ago the introduction of google glass clearly demonstrates our willingness to continue to hand off tasks to automation.

In another article, Paul Dourish explores (among other things) how our everyday activities shape our view of the world.  Out of this view we begin to see technology that simply attempts to model and replace human activity more realistically: in severing out connection with the environment around us through our activity, we lose our ability to make meaning of the world.

Practice is first and foremost a process by which we can experience the world and our engagement with it as meaningful. As technologists, then, our concern is not simply to support particular forms of practice, but to support the evolution of practice—the ‘‘conversation with materials’’ out of which emerges new forms of action and meaning.

Dourish’s wider point is about how the people that we interact with and the social norms that we establish inform, shape, and ultimately collaborate with us to establish the context from which we make meaning of the world.

In another article that Dourish collaborated on this idea manifests into an important implication for designers who wish to affect people rather than divorcing them from meaningful experiences.

This requires a shift from designing systems to model and transmit emotion to designing systems that support humans in producing, experiencing and interpreting emotions.

As designers we design for people to able to understand and use our systems efficiently.  The computing mediums that interaction designers often bring ideas to life in are biased toward an information based approach to the world that relies on representational models.  And so designing for people by creating computational models that match the observational models we see in the world becomes a natural extension of modern mediums.  But over time this disconnects people for the everyday world and leads to hollow, filtered interactions with the world around us.

Liz Sanders explorations in co-design offer a relevant counterpoint to consider.

People are naturally creative. As designers of scaffolds, we need to give them participatory tools to promote generativity in their thinking.

Sanders describes the designer’s role primarily as a facilitator: a conduit for other’s creativity.  I think Sanders overreaches in pushing all of the active creativity out of the realm of the designer and so I think her model is flawed as a model for methodology in the design process.  But they may offer a powerful model for how to think about the systems that interaction designers put into the world.

As with so many themes in design, the ethic for a designer emerges as a tension between competing needs.  Our medium requires us to think about how to leverage information models and our subject requires to consider how to create interactions that lead to meaningful understandings of the world.  So our task becomes to explore interaction scaffolds that give people the opportunity to create their own meaning and then create models of these scaffolds that are appropriate for the medium.  In this way we design systems that embrace the new interactions that are only possible in new mediums rather than simply creating a virtual shadow of meaningful interactions.

Thoughts?

-Scott

Design in Healthcare: Improving Support During Recovery

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Over the last four months, as students at the Austin Center for Design, Jacob Rader, Bhavini Patel, and Scott Gerlach have been designing around healthcare.  As a result, we are now in the process of developing Recovery Text: a text messaging service to support patients as they recover.   It’s a simple, direct idea but one that we are confident can make an impact based on the understandings we have developed through research and testing.

At ac4d we apply a rigorous, human centered design process and we focus it on wicked social problems. And so as we are developing our craft as creative problem solvers, we are also learning how to address worthwhile subject matter.

 

Our Research

In research, we put ourselves into context and attempt to quickly build rich mental models in different aspects of a problem space.  By connecting with people and engaging in activities that facilitate empathy and understanding with their behavior, we inform our intuitions much more richly than we would through statistical models, abstract principles, or academic exercises.  Design research is meant to provoke new ideas and creative problem solving.  And it’s in the complex, interwoven, and often self contradictory nature of specific human interactions that we are most likely to provoke ourselves toward innovative understandings.  So the drive to relate to people isn’t just an empathetic exercise, it’s a practical primer for building new mental connections.

Our research into Healthcare focused on how documents, artifacts, and medical records affect at-risk patients as they interact with the Healthcare system.  We sought out perspectives from patients as well as medical professionals.Final Q3 Presentation 01-5-all.014.png

Patients

One of the things that stood out in talking to patients was the contrast in perceptions.  We spoke to a number of homeless veterans who were happy about the care they have access to.  And we tried to unravel what the factors are that lead to that positive relationship.  Final Q3 Presentation 01-5-all.015.png

Over and over we saw that when healthcare felt most successful for patients was when it was reaching out to them and meeting them on their level.  The VA does things like help patients schedule appointments and arrange transportation.  When people didn’t have access to healthcare that reached out to them, they felt much less stable and supported.

We came to understand that a patient’s perception of care has a significant impact on how engaged they are and consequently on their outcomes from healthcare.  And these perceptions are often tied most strongly to the extent that their healthcare is able to meet them on their level and communicate with them.

 

Professionals

In professionals we saw a group of people who are constantly working near the limits of what time will allow them.  They have to interact with a high volume of patients.  And for each patient, professionals must perform rapid problem solving and significant documentation. Final Q3 Presentation 01-5-all.016.png

So it’s in parallel with this high frequency application of their technical know how that medical professionals must also attempt to convey as much pertinent information to patients in the brief time that they have with them.

In high volume hospitals that serve at-risk populations the gap between patients and professionals is the most challenging to bridge.  When the demands on professionals and greater needs of the patients are layered over one another, it becomes almost impossible to prioritize a patient’s understanding of their situation and facilitate a stronger  perception of their own care.

 

Hospital Discharge and Readmission

We had the opportunity to spend time with the medical records department at a large volume hospital. Seeing the processes that support the flow of documentation was like gazing into the circulatory system of a vast, incomprehensible beast.  And although it’s impossible to align all of the complexity in a large team of individual motivations such as a hospital, we came to understand that the hospital has been adapted to–above all–create legal, billable records of the care it provides.

From the moment a patient arrives at the hospital, the hospital is preparing for their departure; it has to be.  But as the volume and complexity of the care provided by hospital has rapidly dilated, the confluence of information, instructions, and paperwork directed at patients in the discharge process has become overwhelming.Final Q3 Presentation 01-5-all.009.png

The way that hospitals attempt to convey information as patients are leaving care and the lack of support during the recovery process create an obvious opportunity for design to make an impact.  We believe that many of the complications that patients experience and the resulting hospital readmissions are preventable.Final Q3 Presentation 01-5-all.013.png

Underpinning the idea of a text message service is a frank understanding of the constraints on patients and professionals during the discharge process.

Professionals are conveying too much in too little time to each patient.  And patients are in a compromised state during the interaction that is supposed to inform much of their recovery process.

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Recovery Text is an opportunity for mutual benefit for both patients and professionals by changing the flow and timing of this information.

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Small, digestible pieces of information delivered to patients at the times when they have the most relevance will improve the chances of patients avoiding preventable complications as well as creating more opportunities for understanding and reflection during the recovery process.  This will help patients avoid reaching back for access to professionals in order to get redundant information during their recovery.  And professionals will be able to concentrate on only the most immediately relevant information during their interaction with patients.

 

Testing

Good design is tested and iterated early and often during the prototyping process.  Recently our design team has been testing and validating the idea of a recovery text messaging service with patients, professionals, and healthcare decision makers.

 

Patients

From patients we have learned a good deal about the tone and content of text messages.Final Q3 Presentation 01-5-all.027.png

We’re developing heuristics for the text messages in order to give them the best chance to resonate with patients over the course of their recoveries.

 

Professionals

With professionals we wanted to ensure that the concept of a recovery text messaging service made sense and seemed like something they could see as part of their workflow.

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We tested wire-frames with hospital nurses and social workers and found that not only did the idea feel useful to them, but they had specific advice about how it could fit into the hospital workflow and be the most useful.

 

Decision Makers

Finally, we’ve had the opportunity to put Recovery Text in front of decision makers at large medical providers.  Our goal was to gain an understanding of how this service might fit into the current trends of healthcare landscape that large healthcare providers operate in.

We found that many large healthcare providers are rethinking the way they provide care.Final Q3 Presentation 01-5-all.030.png

While many minds in healthcare have recognized that the fee-for-service model is at odds with the some of the underlying principles of medicine, the Affordable Care Act has helped hasten an impetus for change.Final Q3 Presentation 01-5-all.031.png

In our conversations with large healthcare providers here in Austin, it’s apparent that many of them are looking to interaction design as a means to help them find innovative ideas.  They are actively seeking new approaches to improving hospital readmission and expanding outpatient support.  Recovery Text has a good opportunity to fit into this overall initiative by addressing preventable readmissions and establishing a new foundation for communicating with patients during recovery.

 

Next Steps

Over the next eight weeks our team will look to pilot the most important aspects of this service.  We recognize that at the heart of Recovery Text are recovery timelines composed of meaningful messages.  We’d like to develop a deeper understanding of these timelines by embedding in a professional environment.  We’re going to closely study the discharge process to understand how Recovery Text could best integrate into workflows.  Our team also would like to run a pilot program with a handful of patients so that we can better understand how specific text messages affect their recovery process and perception of support from their healthcare provider.

 

Contact Us

If you’re interested in more details about our project or discussing opportunities for meaningful design in healthcare, please contact us: HealthRecords@ac4d.com

Healthcare: A Proposal for Supporting Recovery

Over the last few months Jacob Rader, Bhavini Patel and Scott Gerlach have been studying healthcare.  Our research focused on the documents and records that patients interact with and how these artifacts affect their relationship with the medical industry as well as their understanding of their own health.  Through contextual, qualitative research we had the opportunity to learn from a wide variety of people and identify many opportunities for design to make an impact in the healthcare system.

 

 

Patients

In talking to patients in at-risk communities we encountered a disconnect between the quality of care that people have access to and their perception of that care.  Put simply, most people’s perception of healthcare is largely linked to the extent that their healthcare reaches out and meets them on their level.

Insight
Patients will not be proactive in their own care, they need the system to guide them and help them establish accountability.

Through our research we found that when healthcare was at its best was when patients were being proactively engaged by their healthcare provider; the provider would meet the patient on their level and would facilitate care for them.  Even in situations where the technical care was good, if the system didn’t reach out to them, patients didn’t feel as stable.  Whereas, people who have access to healthcare that addresses simple things like helping them schedule appointments and arrange transportation feel much more supported and cared for by their providers.

 

Professionals

On the other side of this we saw that healthcare professionals are stretched very thin, pulled by both the volume of patients they care for and the bureaucratic demands of their work.  Much of the time and energy that professionals have to expend is not directly perceived by patients.

Insight
Due to the technical nature of modern healthcare doctors have lost a common language for communicating with patients.

As modern medicine has developed it’s become increasingly complex and specialized forcing doctors and medical providers to develop a vernacular and understanding of the care their providing which is increasingly disconnected from their patients.  Additionally, most professionals’ technical workflows don’t lend themselves to an understanding of the patient’s experience of healthcare: so problem areas like confusing or conflicting documentation don’t get addressed and become an additional obstacle that patients must negotiate.

 

Good Communication

When the two previous insights are layered together, we start to understand why miscommunication and misunderstanding so often develop in medical care.  If we understand some of the factors driving poor communication between health actors, it becomes crucial to define what good health communication looks like.

Good health communication happens through interactions that meet the patient on their level.  It gives patients small, understandable pieces of information as well as the time needed to process them.  It gives patients actionable information and prompts when they need it.  Ultimately good health communication helps a patient build understanding while encouraging self reflection.

 

Supporting Patient Recovery

Our goal is to leverage interaction design to help extend more support and clarity to patients without demanding more time and energy from professionals that are already stretched to their limit.  In our research the most pronounced need for this sort of good health communication is in the transition from inpatient hospital care to outpatient recovery.

From the moment a patient enters the hospital, the hospital staff must be preparing for that patient’s departure.  The high-volume nature of the hospital along with the reality that so many individuals in the hospital have a part to play in the care of each patient means that there must be very clear goals that create some alignment between all the professionals.  Near the top of that list is ensuring that the patient can leave the hospital as soon as they are well enough to do so.  The consequence: as they are leaving a hospital’s care, patients receive a condensed burst of information about their recovery.

Many of the doctors and nurses who participated in our research reported that the majority of patients who call during recovery are asking redundant questions that had been addressed with the patient through written or verbal instructions prior to them leaving care.

Clearly, patients are not processing the information they are being given in a way that is relevant to their recovery.  This doesn’t just lead to confusion and redundant phone calls, it also leads to complications in recovery.  Patients don’t understand or adhere to the treatment plans that doctors have in mind for them.  They don’t heal properly, aggravating weakened areas which often forces them to be readmitted to the hospital.  This causes extra strain on an overloaded system.  Readmittance is a problem area that many hospitals are actively trying to problem solve, in part because of new guidelines in the Affordable Care Act.

 

Our Proposal

The current system overloads the patient with a deluge of technical information at a single moment.

We propose taking all the information and sending it to the patient in manageable pieces over time via text messages.

We see a system that reinforces the education that patients receive while in care with timely reminders after they return home. What might this look like:

Patient is informed about the text messaging program as they’re preparing to leave care.

The patient starts receiving texts while still in care and the messages continue after care at targeted times that corresponds to the patient’s recovery.

Weeks out of care and the patient is still receiving helpful recovery information and appointment reminders.

 

Impact

We believe that a system like this will help on a number of levels.  Firstly, it will connect patients with information at appropriate times in a formats they are more likely to digest and act on.  Secondly, it will reduce preventable complications and readmissions.  Finally, systems like this will encourage patients to think about their health on a more continuous basis and will help them feel more connected to their own health and the healthcare system.

Health Records: Reflections and Opportunities

As graduate level students at the Austin Center for Design, we are leveraging interaction design methodologies with the purpose of creating social change through double bottom line business endeavors.  Our design process is characterized by three distinct, interdependent phases: research, synthesis, and prototyping.  Over the course of the one year program at ac4d, students aim this process toward wicked social problems.

For the last eight weeks, our design team (consisting of Bhavini Patel, Jacob Rader, and Scott Gerlach) has been researching and making sense of the complexity in the health record system.  We conducted three weeks of qualitative research focused on how patients and medical professionals interact with each other and in which ways the documentation and artifacts created in that process affect the care given and received, respectively.  We had a specific interest in studying this topic through the lens of patients who are at risk due to insufficient insurance and access to care as well as people who face challenges like chronic or concurrent health issues.

Through our research process we had the opportunity to inform our intuitions by putting ourselves in context with people and orchestrating opportunities for them to share their latent knowledge and informed understandings of themselves and how they relate to the healthcare system.  As a result, we were able to develop rich mental models of the people we met and the challenges they face.

In synthesis we took this research, externalized it and started making sense of it.

Once put into malleable, moveable forms we created groupings of data that seemed related.  Our research area was so large that we found it necessary to arrange these groupings into broad categories.  Subsequently, we took these broad categorical groupings and went back into the details of the data to see if we could see a meaningful narrative forming across each broad category of the research.  This is inherently a deeply biased and subjective process meant to provoke new ideas and identify meaningful opportunities for impact through interaction design.

What follows are articulations of our design team’s shared understandings which were synthesized through this rigorous process.

 

Bureaucracy

The healthcare system is multifaceted and very complex.  As hospitals and clinics have consolidated and formed into larger heath entities, the systems and tools that they’ve created to manage that complexity have also grown.  As these systems of organization have rapidly dilated, they’ve outgrown their supportive role and now occupy an authoritative one that is creating it’s own layers of complexity.  Sadly, it’s primarily this bureaucratic structure that sets the tone for how, when, and why care is delivered to patients.

We were able to engage with these systems contextually: touring medical facilities, spending time in records departments, and interviewing nurses.  When you spend time in this world it’s hard to not recall the opening sequences of the movie Brazil, where our harried technocrat tries to navigate a convoluted and confused world of files and procedures.  We met some of those technocrats.  Probably more than anyone else in a hospital, they see the hospital’s behavior on the whole because they have to interact with every part of it. They’re smart, talented problem solvers who are constrained by both a system that is overbuilt and a dearth of qualified people who want to do the work.

A majority of the time spent by a doctor is not visiting with patients, it’s filling out paperwork and documenting their procedures; in many cases they have to retell the same story in multiple formats in order to appease the requirements of the system: the records department, the billing department, and the legal department all of which draws their attention and energy away from patient interactions.

As daunting as this systematic problem is, we are compelled and convinced that it is ripe for design solutions.  A co-created medical document, where the doctor and the patient create the record together would allow the doctor to spend more time with the patient and help build understanding and consent while still obliging the hospital’s bureaucratic requirements.  There is also the possibility that if we put more power into the hands of the people that know this space, those heroic technocrats, they could build a more robust, agile system to better serve everyone’s needs.  Finally we feel that the biggest potential comes from the patient side. If patients have a way to become more engaged and invested in the record system the balance of that system would shift from a focus on legal and billing toward patient understanding and stories.

 

Patient Stories

One of the most stark disconnects we observed in the medical care system was between two parties we would expect to have the strongest relationship: the doctor and the patient.  The disconnect is created on both sides.

Doctors expect a patient to have an understanding of their own health and to articulate it quickly. Of course this isn’t the case in practice and as a result doctors treat patients articulations anecdotally and have relied more on tests and metrics to determine a patient’s health.  This in combination with faster appointment times and less contact with patients in the context of their day to day means that doctors don’t develop a deep, intuitive understanding of their patients.  

Patients don’t have a good way to manage or tell their health story.  The way the modern health system is built, we often see multiple new doctors and the prospect of starting over with a new doctor can be exhausting for a patient.  Many people have a binary view of their own health: sick or healthy.  Since they don’t feel heard or well understood in interactions with doctors, they are less likely to have a meaningful dialog about their own view of their health or develop a more nuanced and autonomous approach to their health care.

Additionally, patients don’t have authority over their own health story.  Healthcare providers own and manage patient records.  As a result the most tangible versions of our health history are spread out, fractured, and obscured from us making it almost impossible for patients to see or understand an authoritative narrative of their health.

At present medical records exist as part of the billing cycle, but we see the opportunity to craft a two part medical record, one part that exists similarly to the current system, with metrics and test results, and a second part that is a narrative around the patient’s health.  These records could be built cooperatively between patients and doctors and would be a living document that would travel with a patient no matter where they went or who their doctor was.

Patients need to tell their stories, and doctors need to understand a patient’s history.  This dual record system would lead to more patient ownership and engagement in their own health and a more productive contribution in the patient-doctor dynamic.  In turn, doctors would gain more respect for and reliance on a patient’s perspective on their own health which would help restore the trust and intuitive understanding that are crucial to patient and doctor interactions.

 

Healthcare as a Bully

When we have health issues and emergencies, in many ways we become victims of our own health.  When we enter into the healthcare system it’s usually when something is wrong.  Once in that system, our choice and control is stripped away from us and reduced into a the form of a yes or no question; will you accept care?  And, of course, that question is loaded with huge and often obscured implications.  If we choose to reject care we’re denying ourselves, in some cases, life saving procedures.  But by accepting care we’re agreeing to accept it at poorly communicated outcomes and ambiguous costs.  And the price ends up being entirely disproportionate to what we normally expect things to cost.  One of our participants, who had insurance, incurred $30,000 worth of debt from her accident, that’s on scale with other large ticket purchases we make in our lives, like a car or a house, but without the planning that’s associated with those items.

As we are making some of the most impactful decisions in our lives, we’re turned into consumers and denied the tools to apply critical analysis by the lack of information and emotional context.  Furthermore, during our recovery, we are hounded by hospitals and collection agencies, bullying us for payment. It’s not surprising that the lasting impression for patients is that the very system that should be caring for us ends up victimizing us.

Everyone is constantly calling you and sending bills and all this stuff about how much you owe and why you owe it… I remember talking to someone about it and being in a hit-and-run and how it would be better if the person would have stayed.  And I remember being so frustrated because, of course I know it would be better if the person who hit me would’ve stayed and given their insurance information, but the fact that they didn’t… it’s not helpful to me as a victim of a hit-and-run.

– Participant B

[Is there any any item or, or place that makes you feel anxious in your house?] I guess the mailbox, but it’s not in my house.  But I guess the mailbox is where I have the most sense of dread. I hate getting the mail … ‘cause there’s bills in there and I hate them bills.

– Participant K

We think healthcare providers will benefit greatly by being exposed to and embracing a view of themselves as patient centered services.  They must give weight to supporting the healthcare needs and all the surrounding service touchpoints with patients.  This would leave patients with better perceptions about the care they receive and make them more likely to engage in outpatient care and adhere to treatment and payment plans.

 

Care vs. Perceived Care

Fundamentally healthcare is a service. There isn’t a tangible product that we get from the healthcare system. We go to the doctor to get care; they’re called healthcare providers.  As we went around talking to individuals and hearing their stories it’s clear that, as patients, we have built a mental model and understanding of healthcare as a service.

The breakdown comes around the fact that healthcare providers don’t view what they view as a complete service.  Their focus is on the life and death decisions and care that they provide, and rightfully so.  But by ignoring all the other aspects of their service, health organizations are fundamentally driving people away from engaging in their system in a more proactive way.

Even if you save someone’s life, if you treat them poorly throughout the rest of the process and bully them, you drive people away from the very system that they need.  When people have a negative experience with a service they are less likely to engage in that system again.  The healthcare system is unique in that, for the most part, people can’t avoid it completely, they have to engage in care when their sick.  This creates a mental model for patients that healthcare is only for when you’re sick, and in turn individuals ignore preventive care that in the long run would improve their overall health and reduce costs.

A significant disconnect is that healthcare providers don’t seem to see what they do as a service. This is reflected in even something as simple as the word patient; it implies that we need to be “patient”. The negligence of many of the service touchpoints leads patients to have worse outcomes because it encourages systemic procrastination which turns health problem into health emergencies.  If healthcare providers looked at what they do as a complete service, not just one focused on saving lives, they would create better outcomes, both in an individual’s health and experience, and would encourage better engagement overall.

 

Informed Consent

Interactions between doctors and patients are layered with complexity and mismatched expectations on both sides.  Patients expect doctors to offer packaged explanations and solutions.  Doctors expect patients to be able to absorb information rapidly and adhere to treatment plans outside of care.  Increasingly, doctors have less time, less context, and less familiarity for each patient and naturally there is less comfort, honesty, and trust reflected from patients toward doctors.  Meanwhile, the decisions that both doctors and patients are asked to navigate through these stressed interactions grow more and more difficult because of increased bureaucracy, cost, and latent social factors.  Overlaying these themes together, it’s no surprise that Informed Consent–a clear appreciation and understanding of the facts, implications, and future consequences of an action–is often not really achieved in these interactions.

It seems unlikely that doctors will magically have more time for each patient or that healthcare options will suddenly become less complex or expensive.  There seems to be a clear opportunity for interaction design, in particular, to significantly impact both patients and doctors through the creation of mutually beneficial, agile activities that help doctors foster better rapport of their patients and help patients build a more relevant understanding of their options.

One example of this, observed in our research, was a surgeon who hand-draws the basics of a surgical procedure in front of patients and uses the process to facilitate an open, questioning dialog.  

The creative process serves as a series of queues for her to ensure that she is covering all of the pertinent information with a patient as well as naturally pacing the interaction to give space for her to address questions and assess comprehension.  The activity also builds trust between her and the patient as a result of her ability to distill a complex procedure into a simple sketch that shows them important details like where incisions will be made, how surrounding anatomy will be affected, and what to expect in terms of outcomes.

An area we are interested in pursuing is in piloting a series of creative articulation activities with a healthcare provider as a means of facilitating more consistent and robust versions of informed consent and less erosion of doctor and patient trust.

 

Behavior Change

Long-term, self destructive, habitual, behavior is pushing itself to the center of the healthcare crisis.  Like many of the issues related to this problem space, there is an imminent rising tide without any clear plans of action.  The most serious health issues that people are being treated for are largely the result of the lifestyle they lead.  Diabetes, obesity, heart disease, liver damage, renal conditions and arguably even cancer and HIV result in part from negligent or destructive lifestyles and require persistent care plans that overwhelm the system on a logistical and financial basis.

Surprisingly, the medical professionals we interacted with don’t seem well equipped to help patients change their behaviors.  The general approach to many chronic conditions like diabetes involves regular, knowledge-based educational meetings with a medical professional.  And while these meetings are a good first step, they are inherently discrete. After consulting experts in behavior and habit modification like nutritionists and dieticians, we think a continuous approach with an emphasis on the patient’s development of tactics is more appropriate. One registered dietician we spoke to relayed a compelling story about her “non-compliant client”:

I would tell her what to do, but she never would do it. She still would keep coming back.  She still paid me, you know?  Every time … every time we talked, she paid me, um, and then suddenly, she shifted. And I was like, well what, what happened?  She went on a trip and it was like a … a mission, like a helping the children trip, right?  And she saw a picture of herself that wasn’t her.  Like the … the photo was of like 2 kids or whatever, but like her belly somehow made it into the photo and she was like, whoa, you know?  She kind of finally saw herself, but she had to like be in this other situation. And she was just like I’ve got to get it together.  I’m helping these kids in Africa like for wealth in their orphanage and you know?  I’m over here and not dealing with my own … my own stuff.  Um and it clicked and then she used all of the stuff that we had talked about for the last 2 years and like immediately dropped like 80 pounds.

-Participant PB

In many ways, behavior change can be hard to pin down because the moment that a patient changes their motivation is inherently serendipitous and the triggers for their behavior may not be easily identified.  This can feed into a false perception that behavior change is out of the hands of healthcare professionals.  But we believe just the opposite is true, no one is in a better position to give patients a reflection of their own behavior and create opportunities for motivation changes and awareness of triggers.

It’s obvious that if new tools and technologies are not developed and aimed at the issue of behaviors that are destructive to health, the system will not be able to address the volume and persistence of chronic health problems in the future.  The first steps are to help medical professionals make more meaningful probes into client behavior in their initial assessment process and leverage that to create greater trust and dialog in treatment plans.  Since interaction designers are already utilizing ethnographic techniques and cultural probes to reveal human behaviors and motivations, there are many opportunities for meaningful adaptations of existing practices.

 

Healthcare Encourages Misuse

Among the themes we observed in the healthcare system, one of the hardest to unwrap was the self abusive cycles that are gridlocking many healthcare facilities.  Consider an uninsured person who suffers from chronic renal conditions.  In Austin, they don’t have access to dialysis outside of emergency care.  The consequence: they wait until they are so ill that they qualify for hospitalization, they are admitted through the emergency department (which cannot deny them care), they receive life saving dialysis, and then they leave the hospital and repeat the same process over the next three-four weeks.  The hospital absorbs the loss (and ultimately has to compensate for it by charging more for care or cutting costs elsewhere) even though the patient could receive regular, less costly care that results in better patient outcomes.

On a broader scale, this sort of misuse of emergency care–as reactionary stop gap for challenges like chronic illnesses, mental health issues, and addiction management for populations without adequate healthcare access–reinforces poor mental models among at-risk populations.  Patients who finally get access to care via emergency room hospitalization are likely to return straight back to the emergency room in the future to attempt to gain access to any level of care.  One major healthcare network, here in Austin, calls these patients “frequent flyers” and has devoted staff and developed procedures for coping with the demands these patients put on the hospital.  In short, the hospital is forced to adapt and try to address gaps in other areas of the healthcare system because they are the last line of defense.  Paradoxically, the more the hospital adapts the more it attracts a disproportionate number of uninsured patients and the more difficult it becomes for the hospital to maintain a healthy revenue cycle.

Healthcare networks, particularly those in urban areas, have the opportunity to address the needs of the at-risk populations as well as reduce their own costs by taking a holistic approach with an emphasis on facilitating proactive efforts and maintenance care.  Put another way, they should emphasize outpatient care that reaches out into communities rather than inpatient care that is forced to catch everything that comes its way.

We see an opportunity to create pilot programs with local hospitals (in conjunction with city services like the Medical Assistance Program here in Austin) that develop mobile, durable medical records that are tied to proactive care, city transportation, and appointment services.

 

Holistic Care

Our research process gave us the opportunity to engage people who are facing many concurrent challenges in conjunction with managing their healthcare.  We talked to a homeless man who self identifies as alcoholic and bipolar.  He describes taking his bi-polar medication regularly as an attempt to do something healthy for himself and create some stability.

Well, yeah. Dealing with issues on the street, and I try to carry my medicine with me, like 24-7 a day, in my bag there. It goes there with me, but it’s not guaranteed that I’m going to take my medicine every day because it’s just … I have… not substance abuse, but I drink a lot. Sometime that will keep me … Well, anyways, there a lot of stuff that goes on with everything; literally, you live on the street being homeless and all, dealing with issues. Then the alcohol doesn’t help either when you … I like to say, that’s my best friend. I don’t know what I would do without it; but now, the doctor’s telling me that I might have to … well, I need to stop.  Basically, just dealing with bipolar and everything.

I am 53 years old, and it’s coming to a point where I just need to focus on my health. It’s kind of hard, but I think in my house it’s sitting at about 100, 170 on the housing list; so, maybe I can focus on me taking my medicine and be healthy. I think God is with me. That God is with me. I just want to be better. I want to feel better. If I move I can take my bipolar medicines and stuff, that I would feel better. Yeah, maybe I might not want to have that next drink; so, I think that have a lot to do with it, me not being all night. It puts me out there on edge.

-Participant L

We talked to many people like Participant L who were having a hard time finding any points of stability in their lives to build on.  Somewhat surprisingly, we found a counter-trend among many homeless veterans who have access to VA care.

Okay, here’s my situation. I was in prison for 26 years. I was just released last year. When I got out, I wasn’t able to get a job right away. In fact, I’m still unemployed, but I’m a student. Without the VA, man, I’d be in a bad, bad, bad position. I’m really thankful to them that they help me.

Yeah, because I’m being treated for hypertension. The main medical issue that I have right now is hypertension.

With the VA, they schedule for me. They schedule for an appointment. They try to do it every 90 days. If you have an appointment that should come up before that, then you can always go, and they’ll schedule you an appointment.

-Participant N

In talking to homeless veterans, this theme was repeated over and over: their perception was that they had a much more stable and manageable relationship with healthcare than those around them without access to the VA care.  They also expressed that they knew the VA had their medical history and relevant paperwork.  The doubt and uncertainty about where and how they would receive care was minimal and they knew they could rely on the VA to contact them and set up appointments on a regular basis.

It’s unclear how the VA compares with other healthcare facilities in Austin on the basis of actual treatment of medical issues.  What is clear is that as a service the VA performs much better and as a result, it’s clients are much more likely to engage in proactive care.  And actually, it’s a mistake to decouple the two forms of evaluation because they are linked together by the affect they have on patient stability and behavior.

Our conclusion is that healthcare providers need to be much more holistic in their approach: especially as it relates to the logistics of getting patients in a routine of regular appointments and helping them prioritize their medical care.  There are many design opportunities in this area: like responsive appointment systems that operate through text messages or repurposed atm machines (or kiosks, etc.) to help patients engage in care more regularly.  We think this would be especially successful if it also helped address transportation logistics and tied itself to existing care services for at-risk populations.

 

Going Forward

Our design team is currently developing ideas for businesses and then narrowing to one that we feel has to most opportunity for a sustainable model that creates the largest social impact.  Now that it’s exposed publicly, we are excited about questions and comments related to our work on this topic.  If you’d like to share you thoughts, experiences, and insights or just give us feedback we’d love to hear from you at HealthRecords@ac4d.com

Thoughts?

-Bhavini, Jacob, and Scott

Redesigning a Thermostat: Final Thoughts

In Rapid Ideation and Creative Problem Solving, we invested eight weeks of time into redesigning a Honeywell Thermostat’s Interface.  On a micro level this has been about tweaking the placement of a lot of pixels from week to week and spending entirely too much time thinking about temperature.  However, on a broader scale what we’ve been learning through practice is how to rapidly articulate ideas, produce meaningful representations of them, and coerce meaningful feedback from users.

And all of those skills mean that we can confront a problem space and apply our unique frame as designers in a creative, iterative process that leads to more meaningful interactions.  So although I don’t care much about thermostats, I thoroughly enjoyed the challenges we’ve overcome in the last quarter.  And I ended up with a design that I’m proud of:

You can also check out the Wireframes via User Flows

Although I’m happy about where the design ended up, I tend to struggle with premature judgement while I’m trying to get to that place.  So I’d like to talk a little more about the process that I’m coming to trust.

Rapid Ideation in Isolation

In order to keep moving forward in design, I’ve learning it’s crucial to articulate your thoughts in a way that can provoke feedback.

More and more I’m finding that I work best when I have a chance to sketch out a few ideas (like above) and provoke myself before I consider those ideas with other people.

 

Theory Testing

It can be tempting to spend far too long designing and refining in isolation, insulated from critical feedback because your design “isn’t done”.  In order to meaningfully test a design idea, you need to approach the process with intention.

Early on, I built a crude prototype of the physical size and feel of the thermostat to be use in conjunction with paper prototypes.  Then I gave people goals to test out and and tried to put myself in their head-space as they were interacting with the design.

In this course we employed “think aloud testing” to prompt the testers to speak what they were thinking out loud in a stream of consciousness to help facilitate our own understanding of their actions (or inactions).  I took this process and had fun with it, probably due to my background in teaching and tutoring.

After a tester completes all the paper prototype scenarios, they fill our a questionarre that is scored and turned into a System Useability Score on a scale from 0-100.

I found the SUS scores to be far less useful than the think aloud testing, but I think they do represent a meaningful verification of the progression of a design project for people that are completely outside the process.  Over the course of my 4 weeks of testing, my design improved from an average SUS score in the low 80s to an average SUS score of 92 on my final paper prototypes.

Prototyping

If you’ve been following along with me throughout this process, you know that last time, I was looking forward to building a digital prototype of my ideas.

I’m happy to report you can check out my digital prototype online now.  Although there are still a few minor issues with how the animations are timed, I’m happy with how the digital prototype conveys a much more complete vision of how each interaction should look an feel.  It’s clear to me that in a collaborative environment, it would be extremely valuable to bring design ideas toward this fidelity before handing them off to ensure the ideas are well communicated.

Lasting Takeaways

I think this project was important for my progression toward an interaction designer who can work autonomously.  Matt Franks did a masterful job of offering feedback at each stage that pushed me forward but forced me to find my own way.  As a result, I feel very confident in the process because it’s one that I helped shape myself.  Now, as a class, we can stop thinking about thermostats and apply rapid ideation and creative problem solving to problems that are worth solving.

Thoughts?

-Scott

 

A Realignment with Gary Chou

I’ve spent the last ten years working in physics and mathematics tutoring. Part of what has been satisfying about that endeavor is that the intimacy of teaching one on one forces out articulations of abstract theory that are both palatable and personal. Through our work at ac4d, I’ve noticed that interaction design is laced with similar themes: theory grounded in practice and empathy. As I was listening to Gary Chou give a talk at the school last night, I was deeply encouraged by his ability to expose and align broad theory through a surprisingly open and personal articulation of his own experiences.

An idea that resonated strongly with me was the confidence and value inherent in embracing uncertainty. Gary shared insight about his time at Union Square Ventures and how–as a company–USV’s comfort with their own uncertainty had fostered a culture that wanted to learn from everyone they came into contact with and that ultimately led to them identifying opportunity and appreciating value that wasn’t already self evident.

More profoundly, Gary was acting out the theme as he was speaking to us: he’s putting much of his energy into an idea that he doesn’t yet understand how to bring to life. In conjunction with several other themes: Learning through Teaching, Structured Chaos, Activism through Creation, and the move to a Networked World; Gary built a compelling narrative about the potential for a Guilded Workplace. His vision is aimed at testing new theories through practice with small teams that are brought together by mutual interest in projects or ideas. The collaboration is inherently temporary and focused while encouraging learning through teaching, cross disciplinary roles, and shared tactics.

Gary’s talk was influential on many levels for me in no small part because his ideas are so strongly aligned with his practice.

Even the way that Gary delivered the talk embodied the themes he shared: Gary would stop mid sentence to welcome people who showed up late and introduce them to the group, or prompt someone from the audience to share something with the group.  Throughout the talk Gary’s depth of thought was evident but it was contrasted by his willingness to speak directly off the top of his head and let things topple out however they came: a sort of orchestrated entropy.

Perhaps closely related, Gary is actively trying to uncover a method for locating these pockets of people with mutual interest. So maybe Gary was intentionally trying to deliver his talk in a way that encouraged some level of chaos and interaction in it’s wake with the themes he built rippling out and shaping new thoughts. Maybe that’s Gary’s plan for identifying mutual interest and provoking himself into identifying opportunities for professional guilds. But my gut tells me that the orchestration of something so open ended is more likely the natural consequence of Gary’s willingness to take so much of what matters to him  and push it into practice. And as he articulated activism–the creative expression of belief–this is a powerful form of it.

Part of the reason that I came to ac4d was that I want to pursue a more unstructured professional path. I enjoy intense focus as well as space from ideas. I think there are many talented people that identify strongly with the notion of learning by collaborating with new people and working on projects that are inherently temporary. And so Gary Chou’s willingness to put theory into practice is both inspiring and horrifying. If he’s daring himself to make it happen, then it means that I’ll have to find a way as well.

A Point of Reflection

Jacob and I just completed our application to compete in the 2014 IxDA Student Challenge.  Applying is always an interesting mix of reflection and projection: articulating your past in the hopes of experiencing something new.  In preparing for the competition in Amsterdam, we were inspired and humbled by how much our perspectives have changed in such a brief amount of time.

The Austin Center for Design challenges its students to push past their own perceived limits: of how much they can accomplish, of how who they can affect, of what questions they can ask, and certainly of what they should demand of themselves.  I think I speak for every student at ac4d when I say I’ve never worked this hard at anything in my life.

Looking back at the work we have done in just a few short months put the value of this program into stark relief.   We’ve gone from grasping for well-defined design methods to having the confidence and autonomy to define our own methods to suit our purposes.   Jacob and I articulated the process that our design team has absorbed and come to value in this brief video for the application:

www.vimeo.com/81353861

We also summarized the design work we completed in the first quarter in these two design documents: Food & Identity and Firestarting

Looking back on that work made me extremely grateful to be working with Jacob and Bhavini and excited about the work we are currently doing with Medical Records and Health-Related Experiences.  We’re in the middle of making sense of an overload of data.

I feel lucky to be working with two people who have perspectives that complement my own.  I know that my team’s trust in method combined with our driven approach is going to lead to great ideas.

Final Iteration and User Testing

Testing an interface with people utilizing paper prototypes is a great way to encourage feedback and push your design in new directions.

Sometimes testing prompts you to make major overhauls to your interface because you are exposed to a critical flaw or limitation.  You draw, remake your paper prototypes and head back out to see if you’ve hit the mark.  A major benefit to paper prototypes is that they help you nail down the major paradigms for your interface before you get entrenched in a particular approach.

In Rapid Ideation and Creative Problem Solving we’ve been using this type of iterative process to design interfaces for a thermostat (concept map, version 1, version 2, version 3).  The major paradigms for my design were nailed down early: I wanted a device with a limited number of interactions that emphasized the most common uses of thermostat to be intuitive, quick, and easy.  I also wanted a design that wasn’t going to present as another screen in the home.  That meant avoiding rectangular designs.  There’s no doubt that I was heavily influenced by the Nest thermostat and I’ve tried to maintain Nest’s usability and compelling design as a bar for my design in this project.

You can check out some user flows as well.

Refining

In the last few rounds of testing my design has been more about refining details and creating cohesion across the device.  For instance, in the latest round of testing I realized that one trouble spot for people involved an inconsistency in how the interface was displaying information versus controls.  In order to exit sub-menus, users had to use the dial to select EXIT (below).

I had attempted to draw consistency between the controls in this submenu with font size, weight, and curvature.  But that relationship wasn’t immediately registering for some users and even though they were able to problem solve their way through it, I want the interface to be as intuitive as possible given the major paradigms I’m working under.  I think at least part of the confusion has to do with the way the top of the interface presents a unified circular set of controls and that makes the user feel like the top of the device is where they have control and the bottom is informational.  My previous version was actually reinforcing this impression because the interface offers prompts related to pressing the display in the same region where the EXIT appears (see below).

I have seen in previous testing that a few prompts like the one above helped users gain authority and confidence in the interface very quickly.  Rather than scrapping my approach to the bottom of the display, I decided to include a new hint to the user to indicate areas they can use the dial to select (see below).

It’s extremely satisfying when you can learn from testing incidents, identify an issue or limitation, and design a solution that unifies and strengthens your concept rather than forcing you to compromise some aspect of the interface.

Deciding When to Move Forward

There is no perfect interface that will be intuitive for every user.  Consequently, adjusting an interface through testing can be a never ending process.  How good is good enough?

One way of answering that question is to take that which is qualitative (the overall experience of using an interface) and attempt to quantify it.  In our testing each week, our users are filling our forms that rate their experience of the interface through a series of questions they can agree or disagree with.

Their responses are then scaled to an overall scale of 0-100 and this is broadly referred to as a System Usability Scale (SUS) score.  In my latest round of testing my interface scored an average SUS of 92 (compared with an average of 82 from a previous round).   But the SUS scores feel more like a backward justification than a rich indicator of progress.

Like most things in my brief experience as a designer, I’m finding that a significant portion of the answer of when to move forward is dependent on my own judgement and the constraints we are working under (certainly in a professional setting, constraint is a critical factor).  One of my personal goals with this project is to take this design into digital prototyping.  Given the amount of time left in the course and the strength and stability of my design at this phase, I’m comfortable leaving user testing behind (at least until the digital prototype is functional) and devoting my attention to the next phase.

I’m going to attempt to build my digital prototype using HTML, CSS, and custom Javascript. Beyond just the implementation, digital prototyping will involve new decisions and challenges.   What will animations look like?  What sort of transitions between states will present the most clearly?  How should a physical device’s controls be represented digitally?  Hopefully, I’ll have some new answers in the next few weeks.

Thoughts?

-Scott

Iteration and User Testing: Round 3

Taking a design idea from low fidelity to functional prototype requires a significant amount of attention to detail and each decision has implications for the user.  In our Rapid Ideation and Creative Problem Solving course we’re learning methods to help us address the inherent difficulty in this process by leveraging user testing and iterative redesign.  I’m quickly discovering that this makes the design process less arduous and most robust.  Major flaws are quickly revealed and the burden of addressing every detail in each pass is replaced by an attention to the most essential elements first.  What emerges for a designer that embraces this aggressive, fun approach is often more simple and elegant than what they would design in isolation.

Our class is specifically focused on redesigning a thermostat interface.  I’m currently straddling my second than third iterations of the design and hoping to move into an interactive prototyping phase soon.  You can view my initial concept models as well as my first design iteration and second design iteration for more detail on how I arrived at my current design.

In my last round of testing I discovered a significant hiccup in my design for some of the people who tried to use my prototype from last week (pictured below).

 

Several people really struggled with the use of the outer dial on the device as a means of navigation.  After problem solving with an experienced interaction designer, I tried to implement a new version of my interface that will hopefully avoid the same issues.

One issue that user’s had is that the outer dial didn’t translate as a way to control a linear band like the one shown above.

The other issue is that the notion that some users were perplexed and had differing interpretations of the navigation menu.  Some users though that turning the dial would control the triangular arrow while other though that the menu items themselves would rotate (like and oven dial).

I tried to change these interactions the map to a more consistent mental model and that involved a significant change in a lot of my design.

First, I created a circular band (to replace the linear one) at the top of the display (shown above).  I believe this will reference using the dial to adjust the temperature more directly.

This called for a new way of articulating a changing desired temperature.  I handled this by introducing an enlarged dialog that follows the selector as the user turns the dial (show above).

Once the user has confirmed their new desired temperature (by pressing the device or through inactivity) the dialog shrinks and the display indicated how long the according behavior will be in place (as shown above).

Meanwhile, I addressed the navigation issues by using a consistent model for how the dial controls things. If the user rotated the dial (above) to the right then they would see this:

Notice that the display is also dimmed to indicate that the user is still in navigation.  Once they press the device, the device will return to its normal brightness (see below) and they will be able to adjust the setting in COMFORT RANGE AT HOME display.

Off for a another round of testing.  If this round is more consistent, I’ll probably start trying to push my prototype into flash soon.

 

Thoughts?

-Scott