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On Norman doors, sign design, and why you need to think like a designer!


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My talk for the Michigan Center for Integrative Research in Critical Care (MCIRCC) Reimagining Critical Care Seminar Series

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On Norman doors, sign design, and why you need to think like a designer!

  1. 1. On Norman doors, sign design, and why you need to think like a designer! Joyce Lee, MD, MPH Robert Kelch Professor of Pediatrics Twitter: @joyclee
  2. 2. Professor of Pediatrics Clinical/Health Services Research Learning Health Systems Quality Improvement Director Epic Physician Builder Participatory Design / Maker Movement Patient online communities Background @joyclee
  3. 3. T1D Exchange No ties to Pharmaceutical Companies Disclosures @joyclee
  4. 4. I don’t know anything about innovation in critical care; you guys are the experts Disclosures @joyclee
  5. 5. YOU are a designer. (Welcome to the club.) @joyclee
  6. 6. @joyclee
  7. 7. Design is a Process Design is a Mindset Design is a System @joyclee
  8. 8. What is Design? @joyclee
  9. 9. @joyclee
  10. 10. Design is a Process Design is a Mindset Design is a System @joyclee
  11. 11. Can the user accomplish their goal? @joyclee
  12. 12. It’s a Wednesday at 4:30 PM and you have a 30 min meeting. Can you interpret this sign? @joyclee
  13. 13. Can I park here? How long can I park? @joyclee
  14. 14. The Problem A $95 parking ticket @joyclee
  15. 15. “But I read the sign, and I thought I could park there! Did I misunderstand something??” “I wondered why the signs had to be so complicated.” “My mind felt like it was doing intense math whenever I tried translating the signs.” -Nikki Sylianteng @joyclee
  16. 16. Understanding the Problem
  17. 17. Ideating Solutions
  18. 18. @joyclee Prototyping Solutions
  19. 19. @joyclee Testing
  20. 20. Testing and More Prototyping @joyclee
  21. 21. Testing and More Prototyping
  22. 22. @joyclee
  23. 23. Finally, A Parking Sign That's Easy To Read @joyclee
  24. 24. Design Success! “Up to 60% improved compliance” @joyclee
  25. 25. Graduate School Applicant Who is qualified to be a designer? @joyclee
  26. 26. @joyclee Anyone can and should be a designer!
  27. 27. Parallels between Parking Signs and Healthcare @joyclee
  28. 28. What medicine do I take? What time and day do I take it? @joyclee
  29. 29. Design is a form of problem solving. @joyclee
  30. 30. “An approach that puts human needs, capabilities, and behavior first, then designs to accommodate those needs, capabilities and ways of behaving.” -Don Norman Human-Centered Design/ Design Thinking @joyclee
  31. 31. Patients and caregivers. NOT doctors, nurses, clinic managers, administrators, or insurers. Focus on the end-users in healthcare. @joyclee
  32. 32. Use the Design Process. Empathy. Define. Ideate. Prototype. Test. @joyclee
  33. 33. Talk to patients about the pain points; don’t make assumptions Empathy. @joyclee
  34. 34. Encourage patients to define the problem. Define. @joyclee
  35. 35. Collaborate & think of lots of wild and crazy ideas. Ideate. @joyclee
  36. 36. Sketch, draw, glue, code. Prototype. @joyclee
  37. 37. Show your prototype to users and get their feedback. Test. @joyclee
  38. 38. Prototype. Test. Prototype. Test. Prototype. Test. @joyclee
  39. 39. Design helps you ask the right questions, to ensure that you are solving the right problem. @joyclee
  40. 40. @joyclee
  41. 41. @joyclee
  42. 42. If you do not engage with your users, you will be doomed to solving all the wrong problems. @joyclee
  43. 43. “If the most fundamental definition of design is to solve problems, why are so many people devoting so much energy to solving problems that don’t really exist? How can we get more people to look beyond their own lived experience?”
  44. 44. A “smart” button and zipper that alerts you if your fly is down. A service that will film anything you desire with a drone. A service that delivers your beer right to your door. An app that analyzes the quality of your French kissing. An app with speaker that plays music from within a mother’s vaginal walls to her unborn baby.
  45. 45. Problem: Replace my missing limb with an artificial limb Reality: “universal high-tech artificial limbs were a dead weight”
  46. 46. Problem: Augment me, by helping me become a rock climber”
  47. 47.
  48. 48. Cindy calls it her “Darth Vader hand,” and finds it is hot, heavy, and too robotic-looking; she finds the inhumanly long fingers awkward to use.
  49. 49. The standard tools provided to her…didn’t facilitate some of the most important things she wanted to recover—how to write a thank you note, feed herself, put on makeup and jewelry, turn the pages in a picture book as she reads to her grandchildren. So Cindy started to design and build what she needed. @joyclee
  50. 50. Design is a Process Design is a Mindset Design is a System @joyclee
  51. 51. There is a lot of bad design in healthcare. @joyclee
  52. 52. @joyclee
  53. 53. Don’t fix the problem, make the user do more work “Do you carry multiple pagers and our phones on your belt? If so, it can result in pages being missed for jumbled. This is a documented issue and can have a serious impact on patient care. If you carry multiple devices on your belt, please be sure to keep each device approximately 1 hands width apart.” @joyclee
  54. 54. Hide Admin Docs “The EHR made ”Hide Admin Docs” the default which hides lots of documents. If you are unable to find something that was imaged, first look to see if the “Hide Admin Docs” box is checked and uncheck the box if it is” Don’t fix the problem, make the user do more work @joyclee
  55. 55. “Learning to design is learning to see.” - Oliver Reichenstein @joyclee
  56. 56. @joyclee Design Flaw #1: The Needle is Opposite to the Cap
  57. 57. 15,000 Unintentional injections from Epi-Pens in the US between 1994-2007 @joyclee
  58. 58. “Despite instructions rendered on the package insert, a large number of health care professionals including nurses, paramedics, and physicians inadvertently self-inject while attempting to administer the EpiPen to patients. One recent report chronicles a 6-year experience at a single US poison center that fielded 365 epinephrine injections to the hand.” - Greenberg, 2010 @joyclee
  59. 59. @joyclee Design Flaw #2: Life or death is stressful! Don’t make me think!
  60. 60. @joyclee Design Flaw #3: It’s an awkward size, & doesn’t fit in your pockets
  61. 61. You don’t know what bad design is, until…
  62. 62. Redesign #1 The cap and needle are at the same end!
  63. 63. It talks to you! Redesign #2
  64. 64. It’s thinner and shorter and fits in you pocket/purse. Redesign #3
  65. 65. Auvi-Q serves the exact same medical purpose as the Epipen, but the experience and the outcomes are very different. “Emotions change the way the human mind solves problems-the emotional system changes how the cognitive system operates” –Don Norman
  66. 66. The culture of healthcare blames patients. @joyclee
  67. 67. @joyclee Design Flaw #1: The Needle is Opposite to the Cap “Patients frequently do not understand how and when to use [the epi-pen].” -Sicherer, 2011
  68. 68. “Children had only used their EpiPen device in 29% of recurrent anaphylaxis reactions. This is perhaps unsurprising because a fear of needles / injections is common.” @joyclee Design Flaw #2: Life or death is stressful! Don’t make me think! -Sicherer, 2011
  69. 69. “…patients often forget [the device], allow it to expire.” @joyclee Design Flaw #3: It’s an awkward size, & doesn’t fit in your pockets -Sicherer, 2011
  70. 70. Patient problems are really healthcare design problems. @joyclee
  71. 71. Fix the design, and it’s no longer the patient’s problem. @joyclee
  72. 72. A designer would never say, “It’s the user’s fault” @joyclee
  73. 73. “When I overheard a physician describe me as ‘trying to die on us’, I was horrified. I was not trying to die on anyone. The description angered me.” “‘Guys! She’s circling the drain here!’ You know I can hear you, I thought.” “We’re going to have to find you a new liver, unless you want to live here forever.”
  74. 74. “Small things would gut me. Receiving a bill for the attempted resuscitation of the baby, for example. My husband took on the task of reconciling the bill with the lack of a baby. The billing department explained that the bill was generated when we had failed to enroll her in our insurance plan. No one could explain, of course, at what exact juncture we should have called our insurance company, seeing as how she’d never technically been alive. It took four phone calls to settle the charges.”
  75. 75. The Norman Door
  76. 76. “If it needs a Sign, it’s probably Bad Design” @lenagroeger @joyclee
  77. 77. Signs signify a lack of respect for the user @joyclee
  78. 78. “If it needs a Sign, it’s probably Bad Design” @joyclee
  79. 79. Design is a Process Design is a Mindset Design is a System @joyclee
  80. 80. The Current Health System @joyclee
  81. 81. “We envision a transformation from the current state to one in which research, improvement, management, and patient care are intentionally integrated. In such a health system, “learning while doing” is the default, thus ensuring that the right care is provided to the right child at the right time, every time.” The Learning Health System @joyclee
  82. 82. The Singularity! @joyclee
  83. 83. The Singularity! The Artificial Pancreas @joyclee
  84. 84. Goodbye Pediatric Endocrinologist! You have been eliminated! The Singularity! The Artificial Pancreas @joyclee
  85. 85. The Singularity! …not really @joyclee Suboptimal glycemic outcomes <10% adoption of Artificial Pancreas Systems
  86. 86. Diabetes tools are very expensive and insurance companies don’t like to pay for them $1411 Starter Kit $596 Transmitter (every 3 months) $349/month for Sensors $70-80 Starter Kit $120-150/month for Sensors @joyclee
  87. 87. Patients can’t afford their insulin let alone the technology @joyclee
  88. 88. Patients don’t trust a black box “I don’t know what it’s doing so how can I trust it?” “I wouldn’t give up my DIY AP” @joyclee
  89. 89. Clinicians fail to embrace technology at all levels @joyclee ”It was unacceptable to me in 2002 when my son was diagnosed to be given needles, an insulin vial, and a piece of paper” -Jeff Brewer, Bigfoot CEO
  90. 90. Clinics are tired of the Sisyphean Process of Prior Authorization 20,028 calls in 2017 DME Insurance Family Conflict School Forms Pharmacy Child Protection Services
  91. 91. The Design of the Technology Sucks “Consider a Suspend: It literally takes 10 clicks (including opening the screen and scrolling)…ten goddamned clicks I think it’s safe to assume that I actually do want to do this, don’t you?” “My sensor needs to be recalibrated in the middle of the night when I'm sleeping. So the alert sounds on my pump…Every hour, on the hour…” @joyclee
  92. 92. Quality Improvement Implementation, Sustainability, Outcomes @joyclee Learning Health Systems
  93. 93. Aim: To decrease the % of the population with HbA1c ≥ 9% and increase the % of the population with ≥ 0.5% HbA1c interval improvement Preference driven treatment and effective self- management Enhanced registry population management & Pre-visit planning Peer/community support Education/training to support technology use and patient viewing and problem solving with blood glucose data between visits Interventions/toolkits for addressing barriers to adherence Efficient use of technology and data to support care Access to care and regular follow-up Screening for depressionPsychosocial Support Shared decision making Partnership between engaged patients and the care team Effective use of EHR by diabetes team for population management • % of pts. testing ≥4 times/day or using CGM (6/7 days/week) • % of pts. giving 3 or more short-acting boluses/day • % of pts reviewing data between visits • % pts setting, documenting, and reviewing goals • % completed pre-visit planning • % with ≥ 4 visits per year • % of pts with annual CDE/RD/SW visit • % of pts on case mgmt. pathway • % pts screened for depression Developing a Clear Measurable Aim and a Theory of Change Care Process Measures @joyclee
  94. 94. Quality Improvement Implementation, Sustainability, Outcomes Health IT @joyclee Learning Health Systems Big Data, Reducing Garbage Data
  95. 95. The EHR is a combination of Microsoft Word and Pinterest Clinicians are inputting data in unstructured format in the notes Patient paper questionnaires and diabetes data are scanned to PDF @joyclee
  96. 96. @joyclee Clinical Interface Redesign Flowsheets/Smartforms Portal Questionnaires Population Reporting
  97. 97. @joyclee
  98. 98. “No one is going to use that tool if you can’t BOLD the text!” Rogue commas Tool for Data Input Insulin sensitivity 12AM 90 2:30 AM 110 4 AM 230* 10 AM 160 Patient Instructions Insulin sensitivity 12AM 12AM 90 2:30 AM 110 4 AM 23, 0* 10 AM 160 @joyclee
  99. 99. Collaboration and Co-Design Quality Improvement Implementation, Sustainability, Outcomes Human-centered Design Health IT @joyclee Learning Health Systems Big Data, Reducing Garbage Data
  100. 100. Data Literacy Interventions and E-health Models of Care
  101. 101. Examples of Bad Healthcare Design @joyclee
  102. 102. Prior Authorization Rejections
  103. 103. Examples of Good Healthcare Design @joyclee
  104. 104. “Hostage bargaining syndrome” (HBS) In the presence of clinicians, patients and their families may behave like hostages negotiating, from a position of fear and confusion, for their health.
  105. 105. Health Designers, Which users will you engage in design thinking? What will your Parking Sign Project be? @joyclee
  106. 106. Joyce Lee, MD, MPH Twitter:@joyclee Jacob Dwyer, Ashley Garrity, Valeria Gavrila, Emily Hirschfeld Dorene Markel, Ram Menon, Amy Ohmer, Lilia Verchichina, Michelle Wichorek, Pediatric Diabetes Team, The Nightscout Foundation, T1D Exchange Acknowledgements