Innovation is often associated with a paradigm shift in technology. Sometimes, also thought of as a ‘game changer’ or as being ‘disruptive.’ Innovation goes beyond what we make. It comprises of how we think and how we do things. In the recent years, healthcare ‘innovation’ often translates into big statements such as ‘AI’ ‘Machine Learning’ ‘Blockchain’ and ‘Interoperability.’ However, it is much more than that. Evolution in the type of work we do and how we do it is just as groundbreaking as building some new technology.
The greatest challenges in healthcare are centered at the human level. After all, it is a domain centered on humans and how to heal humans. Sometimes technology complicates human-to-human relationships instead of improving it. This begs the question: Why? Simply because administrative tasks, data management, claims management, billing & insurance, and bottom line take greater priority over patients and clinicians. For larger healthcare systems, complexity is inherent to the system. To keep the ship floating, all of the crew must perform their tasks, but in doing so, they forget about the passengers.
To solve the above-mentioned problem, a new trend is emerging in the healthcare sector. The new way is by listening to people – what Clinicians and Patients have to say and to work with everyone involved. The current movement is ‘patient engagement’ ‘participatory care’ and ‘human-centered design’. In this article, our focus is on human-centered design (HCD), partly because it is much more encompassing than the other terms (including being a stand-alone discipline) and partly because there is a recent surge in the interest and implementation of human-centered design. Before we dive into discussing how HCD works in healthcare, we should backtrack to understand how HCD came to be.
Human-centered design originated in the 1980s and continued to evolve through the 1990s. It began as human-computer interaction (HCI) to help product developers. Specifically, to help computer and software development companies in designing interfaces. And also understand the interaction between the user, the software, and the hardware. User experience (UX) and usability fall in the same category. The focus was to ensure that the users (presumably non-technical individuals) could understand how to use the computer and access and operate its various programs. Enabling that would require researchers understand what the users want, what the users need, and the workload on the users to complete a task. Through the 1990s and the 2000s, HCD evolved beyond focusing on computing to other domains such as; product design, user-centered product design, and gradually to a more holistic approach for interface, system, product, or process design.
Thus, human-centered design is a broad discipline that enables practitioners to focus on developing solutions that are built around user needs and outcomes. Almost anything we do and build is for humans, directly or indirectly.
Human-Centered Design Methodologies
Human-centered design is defined by International Standards Organization (ISO) as: ‘Human-centered design is an approach to interactive systems development that aims to make systems usable and useful by focusing on the users, their needs and requirements, and by applying human factors/ergonomics, usability knowledge, and techniques. This approach enhances effectiveness and efficiency, improves human well-being, user satisfaction, accessibility and sustainability; and counteracts possible adverse effects of use on human health, safety and performance.’ NASA’s Commercial Human Systems Integration Process (CHSIP) document states that HCD has four main principles:
- Active involvement of users and a clear understanding of user and task requirements
- Function allocation between users and technology
- Design iteration
- Multi-disciplinary design
The CHSIP is a framework developed by NASA to allow their commercial partners, such as SpaceX, to effectively use HCD principles for designing systems that apply to end-user. Additionally, NASA’s standard titled ‘NASA Space Flight Human System Standard Volume 2: Human Factors, Habitability, and Environmental Health’ details human-centered design requirements as follows:
Each human space flight program shall establish and execute a human-centered design process that includes the following at a minimum:
- Concepts of operation and scenario development
- Task analyses
- Function allocation between humans and systems
- Allocation of roles and responsibilities among humans
- Iterative conceptual design and prototyping
- Empirical testing, e.g., human-in-the-loop, testing with representative population, or model-based assessment of human-system performance
- In-situ monitoring of human-system performance during flight.
Within the process, there are:
- Methodologies for defining the user
- Techniques for assessing user needs
- Developing user work scenarios
- Defining tasks
- Discovering & designing tools (techniques, processes, and software) for the task(s)
- Building a prototype (Can be tangible such as hardware or software or process is driven)
- Test the prototype with potential users
- Refine the prototype based on user inputs until it’s ready for deployment
The above process is simplified by IDEO; a human-centered design consultancy company that developed their HCD process termed ‘design thinking’. Design thinking, as shown in the figure below, is more generalized approach that is widely used in multiple industries – including healthcare. Design thinking can be thought of as both independent standalone process and falling within the human-centered design discipline. The six steps of design thinking are briefly described as follows:
- Empathize – understand who your users are and what their needs are. Conduct in-depth research to gain deep insights regarding users and their concerns.
- Define – in this phase, formalize your user study outcomes and organize into meaningful information. At this stage, organize your results from the Empathize stage and determine what the user needs and wants are.
- Ideate – this is the concept formulation stage where a multi-disciplinary team comes up with wide-array of ideas for creating solutions for the user needs. The crux here is the breadth of ideas.
- Prototype – Now, build a prototype with your team that represents a possible solution, or range of solutions. The prototype can be high-fidelity (a nearly complete solution or a minimum-viable product), a low-fidelity (basic mockup, loosely defined operations), or mixed-fidelity (high and low).
- Test – test your prototype with users, incorporate their feedback to improve the prototype, and retest until the prototype is as perfect as it can get.
- Implement – deploy the solution in an operational setting with the users.
Technology industries, large enterprises, and even NASA use human-centered design. With the push for new paradigm and innovation within healthcare, what does human-centered design translate into for healthcare? I’m sure many of us have noticed recent events and news releases within the healthcare space about human-centered design. So what does that translate to?
Figure. Design Thinking Methodology. Image Source
Human-Centered Design in Healthcare
One issue that has plagued healthcare is the approach to solving problems. From a human-centered design perspective, we go from purpose to means. A good example where HCD would be useful is about electronic health records (EHR). EHR are sometim
es poorly designed from the user and operational point of view. They unintentionally serve as a data repository for clinical, administrative, and financial information.
One study published in the Annals of Family Medicine measured the time and workload related to EHR’s with 142 family medicine physicians. Astonishingly, physicians spent nearly 6 hours out of an 11.4-hour workday at the EHR. Furthermore, physicians spent additional 86 minutes after-hours on the EHR as well.
For Health IT developers, optimizing and understanding how and why users (i.e., Clinicians, Operations, and Administration) use their EHR is important. A study published in 2015 in the Journal of Informatics in Health and Biomedical sponsored by the Office of National Coordinator assessed the user-centered design (UCD) of top EHR vendors to determine the usability and user-oriented focus of their EHR. Of the 11 vendors interviewed, four were categorized as having ‘Well-Developed UCD,’ four were categorized under ‘Basic UCD,’ and three were categorized under ‘Misconception of UCD.’ Only 36% of the vendors were determined to be proficient with UCD. Considering the complex needs of an EHR, it is imperative to simplify it. EHR operations are user dependent. Thus it is important to ensure ease of usability.
Before getting into complex requirements of a health IT system, let’s step back and try to understand whom, how, and why the system will be used. The process below illustrates an HCD approach that can be taken by health IT companies for a better-designed system.
- Begin by understanding the value and the purpose of the system
- Who will use the system?
- What is the purpose of the system?
- Speak with potential users of the system
- What hurdles do they face with current processes and systems?
- What would the potential users want the system to do?
- What goals must the system fulfill for users and the organization?
- Conceptual framework
- Build concepts of system capabilities and functions
- Multi-disciplinary approach incorporating input from users, system designers, technical team, and managers
- Build basic prototypes beginning with low-fidelity mockups and conduct initial user tests
- Transition to higher-fidelity prototypes with interactive features as concepts are refined
- ‘Mixed-fidelity’ can be used
- Incorporate usability principles throughout the prototyping phase and conduct early usability testing
- Testing and Iterative design
- Test and retest prototype with users
- Keep improving the design over time
- Once prototyping has evolved into a mature system and has the blessings of users and end-customer, deploy the system.
- Keep improving the system over time
For the health IT community, a major leap is required to reimagine and redesign to help healthcare organizations and clinicians to better achieve their goals.
Healthcare organizations are often customers of health IT and have a different set of duties, goals, and stakeholders they must satisfy. Internal stakeholders include clinicians and operations staff that ensures everyday functions. External stakeholders are patients followed by payers, etc. Hospitals and Practices exist to provide care and improve the health of people. Healthcare is very complex (Not even considering the insurance and billing!), and often we forget why people come to see their physician. Most people do not enjoy going to see a doctor; many even have ‘white-coat syndrome’ leading to an unpleasant visit to the doctor’s office.
Many patients lack the means to improve their health – problems affording medication, no means to improve lifestyle, and stress due to various issues.
So how can healthcare organizations use human-centered design to improve how clinicians and patients feel?
Understanding your stakeholders is important if you want to improve the quality of care. Problems and pain points exist in all organizations, and the best place to start is by understanding the problems faced by clinicians and the operations staff as well as the patients.
For example, I had attended the IHI Summit 2017: Improving Patient Care in the Office Practice and the Community in Orlando, FL where clinicians and administrators where being provided workshops on implementing HCD at their organization. The workshop focused on exercises where teams of healthcare professionals would build a prototype of processes to improve patient care. The quick takeaway of implementing HCD within your healthcare organization is as follows:
- Understanding problems faced by patients that impede improvement of their health
- Speak with patients, ask them questions
- Provide a questionnaire to the patient before their visit or when they arrive at the office. Ask them questions about what are the top concerns they have regarding their health. Their concerns may be completely unrelated to the purpose of the visit.
- When a large number of patients provide their feedback, a bigger picture starts emerging.
- Build a data map of what are the common and persistent concerns of the patients
- Stratify data into meaningful information
- Bring all of the stakeholders to the table as a workshop
- Bring patients, clinicians, administrators, and patient families all together
- Have them discuss their problems openly and write down the issues
- Brainstorming – idea generation
- Now that the problems have been identified start by discussing and brainstorming for possible solutions
- The focus is to generate as many ideas as possible
- Once the ideas are generated, group them based on their similarities
- Conceptual framework
- Start turning the ideas into a means for solving the problem
- Build a prototype based on the concepts and ideas generated
- The prototype can be paper-based solution (low-fidelity) that can evolve into a more sophisticated form later on
- A prototype doesn’t necessarily need to be a system. It can be a process, protocols, etc.
- Test and Reiterate
- As the prototype evolves, test it with your stakeholders and refine it until it is ready to be deployed.
Children’s Medical Center in Houston, TX used HCD process to improve the wellness and health of the local community by addressing problems upstream to ensure children are less likely to suffer from juvenile chronic health problems.
This process isn’t restricted to patients; the same process can be used when addressing dilemmas experienced by clinicians, operational staff, etc.
What human-centered design offers are a means to solve problems by recognizing the cause of a problem and understanding the ‘why?’ Before addressing anything else. When we focus on answering the right questions and speaking to the right people, we can implement lasting effects for all involved parties.
As healthcare becomes more adept at understanding and implementing human-centered design for all, we are getting closer to achieving healthcare that is better for everyone, especially the patients.