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Design Thinking

What if … there was a scale for patient-identified outcomes?

pain scale

After every knee surgery I’ve had, there’s this strange period where you float in and out of awareness. Those moments where my eyes are open rearrange themselves in time, like one of those puzzles where you have to slide a tile out of the way to make room for another one. But one of the constants is the first question: “How’s your pain level? On a scale of one to ten, how do you feel?”

The patient pain scale is has been called the fifth vital sign. Today, we often see the scale as a range of faces — from grimace to smily —on the walls of inpatient rooms. Asking about pain, on a scale of one to ten, is a pretty good assessment of how someone is feeling in that moment.

Unlike pain, we don’t have a great way to indicate our true goals, the outcomes we want. In fact, the term outcome has different meanings depending on our frame. To a provider, a successful, safe, infection-free surgery could reasonably constitute a great outcome. Oncologists may see the completion of radiation therapy, particularly when a patient is in remission, as a successful outcome.

But what about skiing?

For me, being cleared to ski has always been the canonical milestone after knee surgery. Six months, that’s the minimum amount of time which must pass, regardless of surgical site healing or amount of physical therapy, before someone can ski after an ACL repair. Making those first turns, hopefully on hollywood snow on a blue bird day, is what I call a successful outcome.

When my dad and I stood at the top of Vail Mountain, in February 2012, we hugged and cried. That was the end of being a cancer patient for him. That milestone, skiing again, was his goal during treatment.

Goals vs Outcomes

Are goals and outcomes different? I suppose, on some technical level, yes they are. If you believe in dictionaries and particulars and whatnot. Still, fundamentally there’s an important connection.

Rehab therapies have been practicing goal attainment for a long time. When you start PT, a therapist is likely to ask: “so, what activities do you want to be able to do again?”

That’s an important question for two reasons. First, it’s part of motivational interviewing. The patient is establishing their own goal, rather than being told what to do by the provider. It’s like deciding I’m going to eat better vs being told by your doctor you need to diet and lose 20 lbs. We’re more likely to work towards choices we make ourselves.

Secondly, it builds an important bond between the provider and the patient. If I tell you I want to ski again, you know skiing is important to me. You know a little about me now too. I probably like adventure sports and travel. (Actually, I just like the aprés ski part). Now we’re working towards something together.

why scales matter

The nice thing about a scale is it allows for a range. Our idea of ideal goals for outcomes change depending on our circumstances. If you arrive at the hospital via ambulance, during an emergency, your goal may simply be to receive the best clinical care possible - to have your life saved.

After a week-long inpatient stay, your goals may be to return home. It may be to attend your child’s wedding, or to hold your grandchildren. It may be to have your own children.

The circumstances around a visit might also effect our answer - type of visit, type of doctor, check up vs chronic vs acute.

Having a scale allows us to reframe our goals based on our health circumstances.

The patient goal scale

What if there was a patient goal scale? On a scale of save my life to climb Mount Everest, what are your goals? What moment or activity are you most looking forward to after treatment or discharge? And what would happen if that scale were as visible as the pain scale to both you and your doctor? Would it help build a deeper connection between you both? How might your treatment plan be affected, based on your goal, your definition of a successful outcome?

I polled twitter and Facebook about the idea of goals and what matters:

I’m no graphic designer, but it might look something like this…

goal scale

What if…

  • it was in every waiting room, and you could ponder your goals and identify them before each visit?
  • it was on the bedside of every inpatient room, and you could write out your goal, so everyone entering your room knew what you were working towards?
  • there was an app with examples from others and simple questions to help you identify goals?
  • and you could share your outcome goals with your doctors, friends and family?

How else might this work?

Orthopedic Surgeon and healthcare social media expert, Howard Luks, MD, wrote a blog post pondering a similar theme. Its well worth a read to understand the physician’s perspective.

What would you list as your outcome goal?


Edited to include this absolutely brilliant idea:

From Elsewhere: The Best Medicine For Fixing The Modern Hospital | Fast Company

Hospitals were designed for the wants and needs of doctors and hospital administrators. Patients werent ignored--but they werent top priority, either.

via The Best Medicine For Fixing The Modern Hospital | Fast Company.

Today's Fast Company post nails an essential problem with healthcare. The article focuses on architecture, although the quote above is really applicable to almost every part of how we deliver care.

Other industries, particularly dot com startups, know the term user centered design. It's a simple concept. What does the end user want?  Think about the best hotel you've stayed in, or something as simple as the famous Oxo vegetable peeler. What they have in common are roots in user centered design. They were created by thinking how will guests move through this lobby? Where will they sit? Is it comfortable? Quiet? Is there free wifi?  And, in the case of the peeler, how does it feel in your hand, could someone with limited grip strength hold it?

The Fast Company article makes a very compelling point. It's not that healthcare has ignored user centered design entirely. It's just that our definition of the end user has ignored several key constituents: patients and staff.

Ok, I added staff, but I believe it to be true. Just ask a nurse. Nonetheless, the point is clear, we've got to involve patients and staff, along with doctors and us admin types, in the design of the processes, spaces and things in healthcare.

Patient Designed Care - The Story of Medicine X 2012

Prologue: I've been digesting all the intellectual and emotional morsels from Medicine X for about a week now. I've written, discarded and re-written this post several times. There are several well thought recaps online. It doesn't make sense for me to try and create one of my own. There are also videos of the entire program on the Medicine X site, so I don't need to summarize all of the talks. And, thankfully, there tweets galore which tell the behind-the-scenes stories and offer colorful commentary. No, for me this post is about one theme which I cannot (nor do I want to) shake: Patient Designed Care. I'm pretty sure that term was newly minted at Medicine X and I'm tingling with the promise it is a trend just on the verge of taking off. There is so much potential energy in the idea of patient designed care and this year's Medicine X was the kinetic kick to inspired many to fan the flame.

I'm looking forward to the next few weeks and months. This is going to be big!



“I think are just made to work this way…” The smile crept up on M.A. Malone. “…this is how people are supposed to be.” She wasn’t referring to being surround by post-it notes. M.A. was feeling the vibe of Medicine X. Untitled

Healthcare is inherently about humans. It is, at its raw core, people talking care of people. And that should feel good. As M.A. would say, it’s how people are supposed to be. And yet, we find ourselves in a world where healthcare is often about everything other than the people on the giving and receiving end. KERN-120929-144_MA_Malone_11


Speakers like Michael Graves do not see an impervious membrane between a patient-friendly world and the current state of healthcare. In fact, he sees opportunity. During his talk he set a tone for the next two days —one of human-centered design in healthcare.

Wonder [Triplet] powers, activate!

#MedX IDEO design thinking is a balancing act. Starts with understanding people

On Saturday evening, IDEO’s Dennis Boyle, Massive Health’s Aza Raskin and ExperiaHealth’s Kim Petty each took the stage to discuss design thinking. When Dennis Boyle talks about design, he says we have to consider what is viable, feasible, and most importantly, desirable. Desirability is the human component —what do people want an experience to be like?

Big-thinker, particle physicist and designer Aza Raskin echoed similar themes when we spoke about designing support systems for those with chronic conditions.

Kim Petty made no qualms about it, healthcare is about people first. How caregivers feel, how patients feel, how the spaces, terms and tools make us feel…that’s what matters. Design for experience, and the rest will follow.

The importance of design

Before the conference officially started, select attendees were given the opportunity of a lifetime. They were embedded in renowned design firm IDEO to experience a design challenge. The group of fifty or so conference goers was divided into teams. Each team centered around one of the Medicine X ePatient scholars. Through the day, the IDEO team introduced participants to their process, starting with their philosophy.

“We’re not experts in anything,” they extoll, “we just have a process and it always works.”

IDEO starts with interviewing end users of a thing or process. Groups listened intently to the stories of the ePatient scholars in their group. What challenges do they face with healthcare? What is their biggest burden? What workarounds have they created?



Next comes the problem statement. How might we…. * make accessing your records easier? * avoid preventable harm? * make it easier to get in and out of a chair? * educate children on a parent’s medical needs * feel better about an industry which purports healing and human life

For hours, each group immersed themselves in ideas, or ideating as IDEO calls it. It was a blizzard of post-it notes.

IDEO designers continued by taking participants through the brainstorming phase. Just like improve, the number one rule of brainstorming is never say no. There are no bad ideas, in fact, you should encourage the zany ones. Just keep ’em coming.

#medX IDEO - ideo's rules of brainstorming:

An important part of any innovation process is rapid iteration. Groups prototyped the designs which resulted from their brainstorming. Let’s practice this interaction with a doctor. How would this device look and feel? What should this website look like?

Quick, grab the hot glue gun and let’s make this thing!


IDEO experts taught the groups about the importance of storytelling. This is your design and innovation, you have to sell it to others. How is the world better with this new thing? What problem does it solve? Groups presented their design in the form of skits, mockups and storyboards.


And that’s when the magic happened

As the day at IDEO, itself a precursor to the main event at Medicine X, came to a close, designers, participants and patient scholars reflected. Unlike other group events, these MedX’ers were emboldened by a day of creative energy; of working how people are supposed to work. One after another, the emotions came pouring out.

Thank you for showing me what the future can be like

Thank you for giving us this day

Thank you for creating a day when no one said no

The impact of the day was not lost on IDEO’s team. Designers, each and every one, had that kind of infectious smile which comes from deep within the soul. It was the kind of smile which suggests we did something special today, magic happened here…

“We hear a lot about patient-centered care…” one designer started, “but that’s kind of a hollow phrase. What we discovered today was something new. Patient designed care

If that new term was born that day, it could have just as well been celebrating an elder birthday among it’s close friends. It was as at home in that space, among patients and newly-minted designers as ones own pulse. And so too it took root as a theme, a heartbeat itself, through Medicine X 2012. Nothing about me without me. Let’s talk about what can be. How might we incorporate patients to create …. patient designed care.


Medicine X 2012 Reading List (missing yours? Leave it in the comments and I'll update this list)

The Vanity of Designing [Healthcare] for Pleasure: The Eames Model

It makes me feel guilty that anybody should have such a good time doing what they are supposed to do. - Charles Eames

Designer is a tricky term. To some it means the someone who makes clothing. For others it is synonymous with architecture, or the person who picks out the furnishings inside of a building. It might also be a person who does graphics for the web.

Charles Eames made his name by designing a chair. He, and his wife Ray, went on to usher in post modern architecture with their iconic Eames House. They created films for international diplomacy efforts, for IBM trade shows and, when captivated by spinning toy tops, for their own amusement.

When they hosted dinner parties, Ray’s table settings were meticulously whimsical. They featured hodgepodge of vases, plates, candles and utensils as thought out as a surgeons tools and as visually rich as an impressionists painting.

Above all else, they wanted people to feel good about viewing, using and interacting with the things they created. And why shouldn’t they? The Eames had too much fun creating them in the first place.

That’s design.

Their story, and certainly their talents, should be inspiring to anyone who do work which affects people. And, really, isn’t what healthcare is?

Eventually everything connects - people, ideas, objects. - Charles Eames

Eventually, we will all be a patient. Eventually, someone will take our pulse, or prick our finger. If we are lucky, that’s the limit of our experience…for a while. But the reality is, most of us, at some point, will interact with healthcare spaces, services, objects, and workers in much more detail. Eventually, we will find ourselves in a hospital bed, with frequent office visits and that proverbial brown bag of perscription bottles with unpronouncable names.

How do we want people to feelabout their healthcare experiences? The Eames were very clear about the intent of their work. It should make people feel good, and, in doing so, they felt good about doing it.

I’ve written about this concept several times when writing about design. It’s important. Maybe the most important thing about designing in healthcare. Healing, or helping elevate pain, is solely about improving how someone feels. And, that, as a healthcare worker, that should feel good to do.

The Vanity of designing for pleasure… - Charles Eames

Designing for pleasure. What a wonderful phrase. It implies a higher order. Something more lofty than function alone. It’s one thing to create a chair which is ergonomic, or a video which shows off IBM’s latest mainframe. It’s another thing entirely to produce furniture so wonderful to look at, touch and sit in, it is still a top seller nearly 60 years later. In their many IBM films, their goal wasn’t to shill for Big Blue. It was to create something as interesting to watch as an oscar winning movie. Eames was so particularly about the viewer’s experience, he hired his own greeters for theaters and immersed himself in the layout of the seats and screens. Experience was that important.

Don’t we have the same obligation in Healthcare? Shouldn’t people feel good about being in our spaces, talking with our staff and providers and interacting with our equipment?

That’s what thinking like a designer is all about. We don’t have to label ourselves, or wear rimless glasses and pinstripe suits. We just need to think like Charles and Ray Eames. How would I want to experience this space? Is the checkin window inviting, or off putting? Do I feel comfortable in this treatment room, comfortable enough to disrobe and let someone examine me?

It’s a skill each of us has, although we rarely allow ourselves the vanity of designing for pleasure. Give it a try. Sit in your hospital’s lobby or ER. Observe for an hour, or day, or more. What details do you see? How do people move in the space? What does that loud TV do to conversations? What little details does your eye see which seem out of place? Chances are, patients and visitors see them too.

When we get more practiced at design thinking, we don’t have to limit ourselves to visual elements. Consider processes. Is your billing process designed to make life easier for you, insurance companies or patients? What about referrals? What would you prefer - to be given a name, or for someone to make a phone call on your behalf and offer to follow up with you directly?

Design thinking, the Eames way, is about creating things which make people feel good. That kind of design may mean rethinking entire services. Should people even come into a hospital for this, or should we even have a doctor doing that? Asking those kinds of questions and lookin at every little detail isn’t easy. But when you get it right….wow, does that feel good!

To get inspired, check out Eames: The Architect and the Painter. It’s an entertaining look at the couple, their work, influences and challenges. It is available on Netflix iTunes, or DVD purchase on Amazon

On bridges - connecting the real world and technology through emotional bridges

20120604-125607.jpg I saw a picture online the other day. “I love my computer because all my friends live in it.” It’s funny because it’s true. I’m also pretty sure there are magic, nearly microscopic elves who live in my iPhone. Think about it, how else can you explain how an iPhone works? Don’t give me that hokum about nanotechnology. It’s elves. Now get back inside my computer, friend.

Regrettably, sites like iFixIt and Wikipedia tell attest there are not, in fact, elves in my phone. As it turns out, you don’t live inside my computer either, though I’m still suspect. The bitter truth, is these things are just metal and silicone. It turns out, according to “experts”, Facebook isn’t really a place either. For that matter, the entire Internet doesn’t really exist anywhere. There go my plans to move there one day. Come to think of it, we’re spending more and more time with things that are really pretty cold and austere; void of any emotional connection.

The real world and what we see on a screen aren’t as connected as we might think. Sure, Facebook has changed how we keep in touch. But, there’s no way to reach out and touch something on someone’s wall. We can have an emotional experience via these sites and technologies, although it’s not the result of an interaction with something real. That’s exactly what an emerging big trend is all about.

Last week I came across two examples of things which connect the real world and the physical world with a particularly enormaring emotional appeal.

DearPhotograph is a site from the same team who did Post Secret. The premise is pretty simple, take a photo of yourself holding an older photo superimposed over the scene where it was originally taken. Then write a little note to that photo.


I know what you are thinking. Hey Nick, get on board the USS Clue, it set sail long ago and left you on the dock. Don’t you know Facebook just bought instagram for like a gagallion bucks? Why are you so amped over another photo site? The difference is in how Dear Photograph bridges the real world, with a real object (a photo) and creates and emotional tie. The site, and technology, are just a vehicle to share the emotional thing created. That’s a pretty cool.

Dear Photograph is more than instagram or flickr or faceboo. It requires you to go and actually do something. You have to find an old picture, one with an emotional draw. Then you have to go to the spot it was taken - does that place still exist? Can you get there? Now align the photo in 3D space over that real place and take another picture. Still sound like just s photo website? The result is an emotional connection with a time and place, and the technology which made it happen.

Now that we’re getting settled in our temporary apparent, I had the opportunity to play with a technology I’ve been eyeing for a long time. The Nest thermostat is…well…a thermostat. But it’s like the iPhone of thermostats. And that’s by design. The Nest was created by Tony Fadell who, during his time at Apple, launched the iPod. The nest is part of a growing class of devices which connects the real world to the digital. For starters, it’s a real thing. You mount this gizmo on your wall (and, as a excellent example of experience design, even the install is well designed).


Once hanging on your wall, the user experience melds between your physical interaction with the thermostat and it’s online features. You can check, set and monitor your temperature and energy usage from an app or the web. And if that sounds nerdy, it’s far from it. You really connect with this thing. It does something, it bridges the real, physical world of your home environment with the online world of data and numbers, and that creates a strange emotional bridge. It makes caring about energy use and savings a meaningful act.

I’m inspired by these two examples. They are bridges. They link our physical world with the intangible, elif-infested, silicone composed digital either. Think about a real bridge, it does more than get you from one side of a bank to another. It enables you to go someplace, to see someone, to touch something and to do something. That’s the next phase of technology - creating bridges.

In healthcare, we’ve known about technology bridges longer than many other industries. We’ve had medical wonder-gizmos for years. Considere the nearly ubiquitous heart rate monitor in every inpatient room. Beep, beep, beep… That rhythmic drone isn’t just a machine making nose, it is the heart beat of some we love. Each beep represents life, someone’s beating heart. Each beep also represents a data point inside the machine’s inner workings which will inform doctors and nurses. That’s a bridge.

We’ve also got a long way to go. While the inpatient room might be strewn with wires and beeps, funneling data into a black box, virtually none of those devices are designed with user experience or emotional consideration in mind. Neither are implantable medical devices. Just ask Hugo Campos who is crusading to get access to the data from a defribulator implanted in his chest.

The Internet is evolving to become an Internet of things, all connected to our real world, which is inherently tied to our feelings, hopes, needs, excitement, etc. Healthcare devices and services need to look towards sites like Dear Photograph and gadgets like Nest. What can we learn from things and services designed around creating emotional connections between the real world and the world of 1s and 0s. Now, more than ever, with health information growing by billions of dollars and health reform pushing much needed change on an already constrained system, we need user-centered design. We need bridges which connect us, real living things, with the beeps and wires, or our doctor’s avatar on a patient portal.

"to feel and be felt" Ze Frank on designing for happiness

I saw a post today on Swiss Miss the great design blog, which made my day. Ze Frank is coming back! And that bit of exciting news reminded me of this gem:

In his 2010 TED talk (warning, some adult language), Ze Frank talks about his experience running a popular blog and a video series. But that doesn’t begin to describe what Ze Frank’s world was. Fans will remember his posts and videos as so much more just than a blog.

Ze Frank’s gift is one of designing for happiness.

In the TED Talk, Frank says the most fundemental thing we can do is to “feel and be felt”. In essence, all of his work was about spinning things - existing works, people’s concerns, negitive emotions - into something positive. His daily video posts were ways to rapid prototype the outcomes of his ideas. If that’s not the essence of experience design, I don’t know what is.