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design

StopThoughts: how to improve healthcare through reverse culture shock (or why CBPR matters)

note. introducing a new category on this blog: < /stop> thoughts. < /stop> thoughts are those ideas you hear that make you stop, cock your head, blink a few times and then feel goosebumps while your brain goes in a different than you had thought about before. In < /stop> thoughts, I’ll share concepts, often loosely defined, which I think have massive potential to disrupt, improve or otherwise positively effect healthcare.

NIH

Yesterday, I had a phone call with someone who I’ve gotten to know as a big thinker around socioeconomic determinants of health. That’s a mouthful of a phrase which I love. During our conversation, she introduced me to the concept of Community-Based Participatory Research, or CBPR.

From Wikipedia:

Community-based participatory research (CBPR) is a partnership approach to research that equitably involves, for example, community members, organizational representatives, and researchers in all aspects of the research process and in which all partners contribute expertise and share decision making and ownership.

From the National Institutes of Health:

Community-based participatory research (CBPR) is an applied collaborative approach that enables community residents to more actively participate in the full spectrum of research (from conception – design – conduct – analysis – interpretation – conclusions – communication of results) with a goal of influencing change in community health, systems, programs or policies.

And, from AHRQ:

In CBPR, community-based organizations (CBOs) or groups (such as churches, church members, neighborhood organizations, community residents, and other social organizations) help researchers to recruit subjects. But they do more than that. Community-based organizations play a direct role in the design and conduct of the research study by:

  • Bringing community members into the study as partners, not just subjects.
  • Using the knowledge of the community to understand health problems and to design activities to improve health care (interventions).
  • Connecting community members directly with how the research is done and what comes out of it.
  • Providing immediate benefits from the results of the research to the community that participated in the study.

Why isn’t very hospital service conceived of, planned and executed according to CBPR?

I know, some of you rival my cynicism (and mine pegs the meter). You’ll say but Nick, these organizations are more interested in the almighty dollar… And, perhaps they are. But, wouldn’t they stand to make even more dough by building and providing services which communities actually want and need?

Fundamental to the idea of CBPR is moving past assumptions. Designers call this co-design. I’m proud to serve on the board of the Society for Participatory Medicine —an organization which, among other things, promotes the mantra let patients help! So, this idea isn’t entirely new.

Here’s the < /stop> thought:

What’s exciting, indeed the < / stop > thought here, is how simple doing CBPR is, and how doing it would inherently cause a culture shift in healthcare.

Imagine hospital executives, planners and clinical leaders spending as little as 10% of their time visiting the communities they serve, and asking “what needs do you have, and how can we, as your local hospital, fill them?”

Wow!

Take it as given that we’d see new, community and people-centered services. Maybe we’d see hospitals move to all organic, plant-based menus. Maybe we’d see them open medically supervised fitness centers. Maybe we’d see them move health services out of the hospital and into schools and churches. We might also see programs for mental health grow. Who knows‽

But we’d also see how the community would affect the hospital leadership and its culture. Do communities speak about health and wellbeing using the same terms hospitals use? Do most people in a community look, dress, act and present like hospital leaders?

Can you imagine the reverse culture shock?

And here’s the best part, I suspect, for those willing to embrace CBPR, it would feel good. Revenues will probably follow, but even better, I bet there’d be more joy for everyone involved and almost certainly better outcomes.

I’m reminded of how my friend Jason Albrecht closed his recent talk at Medicine X:

“Once you start this, you don’t want to stop. It feels good. It feels good because if feels right… it leads to a much greater sense of joy for everyone involved in the care process.”

—Jason Albrecht, MHA at Stanford’s 2013 Medicine X program

Patient Designed Care or Doctors 2.0 & You redux

NOTE: This post is intended as a companion post to the session recap from Doctors 2.0 & You here. Untitled

I recently published a recap of Doctors 2.0 2013. I’m no Bob Woodward, but I tried to take a neutral observer role in relating the content of the panel. When I asked for feedback, my friend Liza suggested my personal passion around the topic was missing.

challenge accepted

In early 2013 I wrote to conference organizer Denise Silber and suggested a panel discussion around patient-designed care. It was a nascent idea then, largely still is.

I keep telling this running joke (and it keeps flopping. Note to self…): there’s probably a German word for that concept of once you understand an idea, its hard to imagine a time when you didn’t think that way, and it probably has 7 syllables.

Yeah, not that funny, is it? But the point is still true. The term patient-designed care came out of the first Medicine X IDEO Patient Design Challenge. Through Stanford’s Medicine X program, about 40 conference goers spent a day collaborating with ePatients and IDEO designers. I was lucky enough to observe. As the group was wrapping for the day, one of the designers remarked:

"I think this is the first time we’ve had the people we design for participate in a design challenge. 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”.

The idea has grown, and is still pretty simple. Involve patients in designing anything affecting them. It might be a process, or tool, or space, or service offering, or strategy. Whatever it is, make sure there are patients on the committee.

How could it be any other way?

Regrettably this is still a pretty novel idea to the healthcare industry. I’m as guilty as anyone. I can think of dozens of projects during my time working in hospitals where we set out to do patient-centered things. We had the best intentions. Let’s make this bill more patient friendly… or Let’s add patient-centered training to our new employee orientation.

That kind of work, despite noblest intentions, is inherently based on assumptions. We made assumptions about what patients would want. They’ll love this furniture… and If I got this bill, I’d want it to say….. Don’t get me wrong, that’s not a bad start. It’s still an empathic approach. But why didn’t we involve patients, asking them about their experiences and to share their suggestions?

It’s time to start.

I’ve been using the phrase patient-designed care for almost a year now. I’ve also been trying to put it into practice. For example, In 2012 I was still in an operations administration role in a hospital. When it was time to schedule an off-site team meeting, I invited a former patient to come speak to our group and participate in the meeting. I met the patient when she came to my office to voice a complaint one day. She went on to become a strong proponent of our department.

In my role helping lead a start-up focused on staff and patient experience, we’ve included ePatients in all of our project proposals. We sneak them in as experts consultants, or sometimes directly identified as ePatient experts.

On a personal level, I count many ePatients among my personal board of advisors. (How fun is that term? You should have a personal board of advisors too, if you don’t already.) When I’m stumped and need to bounce ideas around, I call on my friends. When I’m excited and need someone to share with, or poke holes in an idea, I call on my friends.

Here’s the bottom line: I cannot, anymore, imagine doing anything in healthcare which affects patients without involving patients. And that’s the idea I wanted to explore at Doctors 2.0 this year.

My hope for the panel was an honest conversation involving ePatients. I knew some of my Medicine X friends would understand the term. And others, despite doing participatory design work, may not know it yet. I wanted us to get representatives from those groups together.

Largely, I think we pulled that off. The discussion was made richer and more well rounded by our moderator, Michael Seres. Michael is an ePatient - sometimes he prefers iPatient - who takes an active role in designing his care plan. Liza Bernstein, a student of product design, understands the concept inherently. She sees how patients can play an active role in the design of processes and things affecting patients. Kathy Apostilidis is using her patient-acquired expertise to participate in designing European policies.

What’s next?

Maybe we need to find that german word I jokingly alluded to earlier. It’s hard to convey in a talk or panel discussion something so profound (and yet so simple). From my perspective, the next big hurdle is getting healthcare provider organizations (hospital, health systems, clinics, etc) to really embrace this concept. I’m unsure if we need to increase awareness, or reduce fears, or facilitate the formation of formal ePatient hospital advisors.

Hospitals have focus groups and patient advisory boards today. Those are admirable starts. But doesn’t it seem silly to have a meeting about improving the experience of a department or facility without including the people who have been through as patients? It’d be like going to a restaurant where the chef assumes what you want to eat without asking.

Panels like ours help start the conversation. And they broaden it. While I’m focused on integrating patients in hospital process and service design (strategy), others are focused on policy, or research or treatment plans. We need to have these conversations and I’m really glad Doctors 2.0 & You and Medicine X are among the first programs to host these dialogues.

Empathy: a designer’s best trait

The clip above comes from a british series called Blue Peter. Blue Peter is show airing in the UK for school-aged children; its focus is hands-on projects. Imagine Mr. Rogers meets Mr. Wizard.

The rest of the video is worth watching for another reason. Great designers are highly empathetic. It’s a chicken and egg thing. Watch Ive’s expressions as he reviews the designs children sent in to the show. The things he applauds and latches onto give him an emotional reaction. He’s touched by the art in one girl’s drawing and unique shape of a boy’s backpack design.

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 thing...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!

-N

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“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?

 

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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!

Untitled

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.

Untitled

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.

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

For some healthcare players, innovation is already a priority

Lately, I’ve been writing about innovation and design thinking in healthcare. I often make general observations about the industry like innovation is rare in the delivery of care or we need to learn how to use design thinking. While they may be present as buzz words, largely I stand by the assertion that they are rarely deeply integrated into the culture of most health systems. But there are some standout exceptions and I’d be remiss if I didn’t highlight the places where innovation is part of the culture.

  • Kaiser’s Garfield Center for Innovation - Kaiser’s center was among the first of its kind in healthcare. The Garfield center was established out of work the health system did in collaboration with IDEO. A team of clinicians was tasked with redesigning nursing units and the processes around them. On the heels of a successful redesign, the team formed the center to become a source of new ideas for the system as well as internal consultants. Kaiser’s innovation center is profiled in Tim Brown’s Harvard Business Review case study on Design Thinking.
  • Mayo Clinic Center of Innovation - Mayo’s center builds on the Mayo brother’s early idea of patient-centered care. The Center occupies a large glass workspace in the lobby of Mayo’s Rochester location, giving it both prominence and literal transparency.
  • United Healthcare’s Innovation Team - United is a large commercial payor with roots in the provider world. United has a VP of Innovation who, along with his team, is responsible for promoting design thinking across the organization. United has also started offering innovation consulting to providers through its process improvement program.

This is by no means an exhaustive list. You can probably name some other health systems or industry players with innovation and design teams. We have a ways to go before empathetic design becomes widely adopted in the industry. But it is important recognize that innovation is already a priority in some organizations.

Designing for happiness

I have the privledge of conduting new employee orentation for my health system. There is an excersize I ask the new hires to go through which I’ll share with you here.

Take a few moments and think about something in your life you cannot imagine being without….something where you think I don’t remember how I got along without XYZ… It can be a thing, or a place, or even a person.

What did you think of?

9 out of 10 new hires usually shout out “my iPhone”.

Sure, some folks reply with non-consumer answers such as my family, my children, or my last vacation. But for the ones who say it is their phone, what makes it such a compelling device, why could they not live without it? What they often tell me is it’s just magic, it just works. Apple’s marketing department would be happy with that response. I believe its just magical is a proxy for it was designed well.

Over the weekend I had the chance to re-watch one of my favorite documentaries, Objectified. Objectified is director Gary Hustwit’s homage to industral design and designers. The film moves from vignettes of iconic design to narritaves of personal insight from famous designers. It is a wonderful film and part of a trillogy where Hustwit focuses on asthetics and design.

In healthcare, we often think about design in a few very narrow contexts. We think about the archatecture of new buildings. Sometimes we think about the shape and styling of medical devices. Yet, that’s not how designers see the world. As Jony Ive, head of design for Apple, puts it: “it’s part of the curse of what we do… think about how everything we encounter is designed.”

In Objectified, Erwan Bouroullec, of the designers says the goal of design about creating an enviroment where people feel good.

Isn’t that sort of also the goal of a hospital or doctor’s clinic? Don’t doctors start practing medicine because it feels good to take care of people? Don’t we go to the doctor because we want to feel good?

Regrettably, so many of our processess for delivering care were designed by consensus, rather than with a goal of creating an eivnroment where people feel good.

A few months ago I wrote a post about designing for experience where I suggested many processess are designed by consensus, or created through committees which often involve compromise for political agreement or to avoid conflict.

Try my new hire exercise again only this time think about an object or process which makes you feel frustrated or challenged when you interact with it.

My guess is whatever that thing is, it was probably not well-designed. It may be the result of design through consensus or it may simply not have been designed with attention to user experience or detail.

Now, more than ever healthcare needs to begin to apply design thinking to its processes and services. Design thinking has two major benefits: first it builds things which are in empathetic towards the user. Secondly, as Bouroullec says, it makes people feel good.

Davin Stowell, a principal designer at SmartDesign discussess working with OXO, the kitchenwares company on their vegitable peeler. Stowell says it’s not as important to understand how the average person who use the vegetable peeler. What matters is the extreme usecase - the person with arthirtis in his example. “When you design for extremes, the middle takes care of itself…” says Dan Formosa, also of SmartDesign.

Healthcare has an opportunity to embrace its extreme users too.

Examples most certinally include those who identify as ePatients. ePatients want to participate in the development and implementation of their treatment plans. They often lament a lack of access to their clinical data, or even access to their physicans using modern things like text messaging or skype.

We might also look at other extemes for inspiration. What can a “frequent flier” in the ER tell us about processess in the emergency room? What can the single, working mother with three kids tell us about process in the familiy medicine clinic?

These users are all around us, yet for some reason, we fail to consider them when designing care delivery processess and services. Instead, we design for the middle, creating average offerings rather than standout offerings.

There are competitive advantages to good design. It gets more people in the door. There are also imporant humanistic aspects. If good design really does create an enviroment that makes us happy, doesn’t healthcare have an obligation to design things well?

It is not my intent to judge our entire industry unfavorably. Good design can be as ambigious as the term itself. If it were easy, every phone manufactureer would have invented the iPhone years ago, right?

Still, there are ways to learn and practice design thinking:

  • Watch Objectified - pretty good place to start. It’s on Netflix for streaming. Listen to the designers talk about the objects they’ve designed and apply their terms and language to processess and experiences in healthcare.
  • Be empathatic - Empathy might be the single most important skill for anyone working in healthcare. Practice by thinking "Today, I’m not a provider or administrator. Today, I’m the patient walking in these doors for the first time. What do I see? Riff on the idea, always challenging yourself to put yourself in the patient’s shoes. How would a patient use this service? What would a patient think of this cafeteria food?
  • Embrace extreme usecases - Identify the extreme users of your services and observe their behaviour and listen to their communications. What can you learn from them? Are your waiting room seats uncomfortable for the elderly? Do ePatients with smartphones portend the future for the entire next generation of patients? What processess would you develop or change based on the answers?
  • Engage designers - OXO didn’t re-invent the vegitable peeler on their own. They worked with SmartDesign. Healthcare providers can find local or nationally renound tallent. Sure, it comes at a cost, but think of a well designed offering as a compeitive advange. You’d pay a reasonable price for a consultant who could help you grow marketshare, right?

By the way, healthcare device manufacturers and supply vendors are no strangers to working with designers. IDEO and SmartDesign have both worked with vendors on items such as:

  • Cardinal Health Endura Scrubs

    Many hospital workers complain about the baggy, pajama-like, and unprofessional look of traditional ‘scrubs’. Furthermore, over 70% of hospital employees are women, yet they are forced to adapt to clothing that was designed for an XL-sized man. The Endura Performance Apparel Scrubs is a line of cost-effective high performance scrubs that we designed as true unisex wear with benefits for women and men alike. They are a vast improvement on their predecessors because of design innovations such as collars that don’t blouse open to over-expose females…

  • Ethicon Endo-Surgery Generator

    Equipment in the operating room environment can be complex and intimidating, prompting the need for intuitive technology solutions that help OR nurses focus more on patient care. The new EES Generator combines advanced technology, multifunctionality, and intuitive touch screen simplicity into one compact, easy-to-operate unit.

  • Lifeport Kidney Transport System

    The LifePort Kidney Transporter provides a new high-tech alternative to the conventional method of organ storage and transportation—a cooler filled with ice.

  • Finally, here’s IDEO’s Tim Brown at the 2009 TEDmed event on Designing Healthcare

Designing for Experience

The 4AM Wake Up Call. My friend was in the hospital a few weeks ago, nothing serious, a precautionary measure more than anything. I went to visit her and we sat and chatted. I always ask people about their experience. "What's going well, what would you change?" At first, you hear a lot of kudos. "Everyone has been really nice." I don't doubt it. But, you can't improve on compliments. I've found you have to ask people at least three times to get the juicy stuff.

"Well, I don't understand why they keep waking me up at 4 AM to take blood. Is my blood only good at 4 AM," she joked.

I know why they do it.

In The Accidental Mind, David Linden talks about the evolution of the human brain in Gladwell-like simplicity. He says evolution didn't just pop out this perfectly coordinated mass of nerves and synapses. The brain, in fact, is the result of years of renovations, additions and remodels. One part developed to respond to the needs or deficiencies of another. The process of healthcare, unsurprisingly, isn't much different.

Doctors usually want to round on patients first thing in the morning, around 7am. It frees them up for surgical cases or office visits early. When they round, they want to see the latest lab results. Lab tests take a few hours to coordinate and run. Thus the 4 AM blood draw.

It would be easy to point the finger at the doctor and say the patient is being inconvenienced to fit the doctor's schedule. But, much like the human brain, it's not that simple. Could the lab speed things up? How do we even get specimens to the lab, is that an efficient process? Well, that depends on who's eyes you are viewing the process through.

Designing for experience

Designing for experience is about true customer focus. It is deeper than what we traditionally think of as customer service, which describes the way people interact with each other. Designing for experience requires an almost painfully high degree of empathy for the person using your product of service. You have to not only be willing to see it through their eyes, but also feel it the way they might. Getting to that level requires a holistic attention to detail. After all, how much of what we feel is defined solely by our verbal interactions with someone? How much comes from environment, ambiance, touch, visual details, perceptions, waiting times?

In 2001 Susan and I were living in Paris. No, there are no buts, it was that cool. One weekend in July started like so many others. We descended into the local metro station, Odeon, out of the sun and into the belly of Paris. After an hour of riding, including a transfer to a regional train, we began the ascent back towards the surface. The first thing we saw was a giant, antiqued sign proclaiming our location to be Main Street U.S.A. It was utterly surreal. On one corner was a 1950s themed ice-cream parlor. Across the street was a video arcade. There was even a mini Statue of Liberty. Somewhere in the distance Its a Small World After All was floating through the air.

At that moment, we weren't in a field outside of Paris, we weren't even in France. We were in Disney's world. We were 12 years old, wide eyed and ready to run through the park at 100 miles per hour. They had gotten every detail right. The writing on the street signs, the food vendors, even the rides. It was a classic Disney experience.

Disney is a master of designing for experience at its resorts. That's not a young French girl playing Snow White. It is Snow White. That's not a facade in front of a concrete building, it is an honest old-time ice-cream pallor. It has to be, because if we saw behind the curtain, if the magic were revealed, then our brains would instantly unplug from the illusion and we'd feel like we were, in fact, in a field outside Paris, or marsh outside Orlando.

The challenge with designing for experience in healthcare, and probably most businesses, is the historical precedent of designing by censuses and compromise. Politics have become part of our corporate culture. If we do X, does it upset the person in charge of Y? If so, what is the compromise? And there's the rub. When we compromise to satisfy internal politics or business pressures, more often than not, we are making an even bigger compromise for the patient. It's how we get the 4 AM blood draw.

The PocketPC and importance of the foot fetish

In 2002, I had a PocketPC device. Its marketeers clearly took liberties with the size of the average pocket, but nonetheless it was a fairly compact thing for the time. It had a stylus-based touch screen, miserable handwriting recognition and very limited Windows PocketPC software. But, I like to live on the cutting edge with gadgets, so I picked one up.

What I really wanted was to watch movies and TV shows while at the gym. The problem was that it used some obscure file encoding. Not only that, the videos had to be perfectly formatted for the screen size. I found that if I ran a video through two different programs on my desktop PC, I could manipulate the file enough that it would usually play on the PocketPC.

I was the only one at the gym watching their own personal video screen.

I'll never forget the reaction of a friend who saw me on the elliptical one day: "you really are a huge nerd aren't you?" It was a friendly jab. At least I think it was. Fast forward to today, almost every runner on a treadmill has an iPod, iPhone or small personal device. This morning I saw one musclebound guy in a weight belt and tank top entering reps onto his iPad which he carried with as much pride as his protein shake. I dare you to call him a nerd.

What once was once a niche use case, is now the norm.

This summer, at Stanford's Medicine 2.0 conference, the precursor to the recently announced Medicine X series, Dennis Boyle from IDEO spoke about design thinking. He flashed up a slide of a stocking clad leg disappearing into a bright red high heel shoe. "If you want to make the best shoes, ask someone with a foot fetish to review them, they know more about shoes than you do," Boyle told the audience. What a line!

The past few years have given rise to a new term, e-Patients. These paradigm changers are empowered, engaged, informed, and most of all, desiring to participate in their care and planning as an equal peer. An e-Patient can be someone who googled symptoms before going to the doctor, or someone who studies their lab results with the veracity of a Rhodes Scholar.

The Pew Internet and American Life Project reports, "one in five Americans have gone online to find people with similar health concerns."

Still, not everyone one is convinced. One doctor privately quipped to me, "thats just what we need, more people using Dr. Google."

I understand his reaction. The perception is e-Patients come with inaccurate information, too many questions, or have unrealistic expectations of a doctor's availability. That misses the mark. The value of e-Patients, in addition to arugably reducing the burden on providers, is as the extreme use case. What if they are high-contact and high-need? Embrace it. They are the early PocketPC users who can tell you why using two programs to put videos on a device is seriously flawed. They are the ones with a foot fetish who can tell you why that color red isn't ideal.

They are the ones who can tell you why a 4 AM blood draw is not a good idea.

Facing the future

Designing for experience in healthcare requires a wholesale change to the way we plan for and implement services. Rather than design by committee, teams need to focus on putting themselves in the patient's perspective. If you want the ideal inpatient blood draw, sleep in a hospital room, and have someone wake you up at 4 AM two days in a row. By the third day, you'll have some creative ideas for solving the problem.

Boyle suggested being pushed around your hospital in a wheelchair, not once, but hundreds of times. See if from the eye level of someone sitting down. You'll notice how most nursing stations have counter tops higher than the eye level of someone in a chair. A hospital CEO once remarked to me, "you know it doesn't really matter what art we put on the walls, all of our patients are laying down and only see our drop tile celling, and man is it ugly."

Designing for experience also requires a high degree of empathy for the customer. It means you have to open yourself to feeling what they feel. Imagine being scared or confused or sedated. Empathy means thinking about what you would want in the same position. Have you sat waiting for 45 minutes in a doctor's waiting room? Do you like it? Then why do we think our patients will. There are solutions to these problems, but they require us to design for the patient experience, not the personal or political needs of the organization.

If you think designing for end user experience comes at a high cost or the sacrifice of revenues, just look at Apple's current market valuation. It can be done.

Designing for experience also means embracing the fringe use cases. Look towards our most frequent users, our e-Patients or our squeakiest wheels. What can they tell us about what works and what doesn't? What feels like fringe today will probably be the mainstream of tomorrow. Do we want to be ahead of it, or behind it?

Experience is a differentiator. In describing my experience at Thomas Keller's restaurants in this post, I said I expected the food to be amazing; it's was a given. What makes the meals memorable are the experiences. It is the same thing which sets Disney's parks apart from Six Flags. The Disney visit is a complete experience. It is the same thing which has made the Ritz-Carlton a world famous brand. We make choices based on emotion first, and reason second. Emotional connections are made with experiences. We expect excellent clinical care whenever we walk into a hospital. (If it's not excellent, we have bigger problems.) Experience makes the competitive difference.

If we want a healthcare system which works, is high quality and patient focused, we have to start designing for experience.

Its not what you do, its why you do it

My new friend Ashleigh, a branding/experience/design guru, recently shared a concept with me. She told me about the golden circle theory from Simon Sinek. He says: "people don't buy what you do, they buy why you do it." Sinek cites Apple as a prime example of the golden circle way of thinking. I'm pretty fond of the little California design company as well. If you've run out of Ambian and read this blog as a substitute before, then you'll know I frequently draw on Apple as a source for inspiration in healthcare innovation.

This isn't a tech blog so I'm not really interested in how many thunderwire ports the new iWidget has and why google's robophone is superior because it has 1.21 gigawatts of magic dust inside. Sinek takes the same approach, focusing on the culture of Apple (and others like the Wright brothers and Martin Luther King, Jr). Sinek says most of us, and most companies, think from the outside in. We think about what we do, then how we do it and finally, maybe we get to why we do it. In the video, Sinek argues innovators like Apple reverse the process, they think about why they do what they do and move outward towards what it is that they do.

Sinek says Apple first says 'we exist to think different, to make things better, we are a design company who happens to make easy to use computers.' As consumers we identify first with their core beliefs and secondly with their products. We think 'I like to think outside of the box too!' Apple could innovate, design and produce running shoes and they would probably be equally regarded as innovators in that space. It is not what they do, but how they do it. (I'm practicing, Sinek repeats that line over and over, its and effective technique.) He counters with Dell's attempt at making an MP3 player to compete with the iPod. Consumers reacted by asking ' why would I buy an MP3 player from a computer company?'

An un-named Wall Street analyst quipped General Motors is a "hospital that makes cars on the side." While that quote is clearly drawing attention to the employee benefit structure GM has cited as a source of financial hardship, it is nonetheless poignant. Could anyone say the same thing about a hospital or other provider - that they are something else first and care givers on the side?

I optimistically think most hospitals and providers really are in the business of caring for patients. Find me a provider who doesn't list patient services as the largest source of revenue. A senior hospital executive once told me he liked working in healthcare because you can run a cafeteria one day, be an architect the next and work with doctors on the third day. While I think that kind of diversity excites a lot of people (myself included), those are all things we do, not reasons to do them. I believe most hospitals and providers really have the core beliefe they exist to care for people, to make them well and bring them comfort. So why are we so bad at expressing that as an industry?

I've written about "healthcare highway" before. A stretch of road which had billboards for every major provider in the area. Dan Dunlop regularly posts examples of hospital ads on his great blog. All of these, the print ads, healthcare highway, all talk about what the providers do. Some have the best cyberknife for brain tumor treatment. Others boast their rankings and awards. Others are the fastest. Almost none talk about why they do what they do. There is biology at work too; we can understand the sign that says "top 50 hospital", but we don't have an emotional reaction.

The message to consumers, Sinek says, is filtered through our biology. We are programed to understand the complex ideas and statistics these "what we do" ads throw at us. However, none of them go past our brain's basic stage of reading the words and understanding them. When companies and individuals talk about why they do something we register it differently. It is what we call a "gut reaction." We resonate with beliefs because, for many of us, we believe the same thing.

As always, I'm not sure what the solution is. There are plenty of ads for providers which talk about how much they care. I'm not sure that is the same thing in Sinek's world as talking about what they believe, what drives them to care. Sinek does give credence to the importance of the message in who you hire and how they ultimately help drive those beliefs. That resonates with me.

What do you think? Do you have any examples of healthcare providers who speak and work from the outside in? Are there hospitals who first say "we exist to change the patient experience, and we happen to heal people in the process?" Is the opposite happening? Are consumer's looking at ads featuring healthcare technology and asking 'why would I get care from a technology company?'