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innovation

What if there was an EMR built on Wikipedia?

WikiEMRI’ve been thinking about EMRs, electronic medical records, lately. It’s a subject, despite some professional experience, I don’t feel particularly close to. In fact, if anything, they are a source of consternation. As an industry insider, I see them as an expensive albatross around our collective neck. As a human centered design advisor, I see them as an encumbrance for both providers and patients. And, as a patient I see them largely as an opaque blob of data about me with a placating window in the form of a portal.

Which makes me wonder, am I obsessed with EMRs lately?

One of the reasons is certainly my personal interest in technology. And, while I don’t work in health IT, it’s natural to draw some connections. For instance, Wikipedia is consistently in among the top 10 most visited internet sites ( it is currently number 6 ). And, say what you will about citing Wikipedia, but a 2010 study found it as accurate as Britanica. Google trusts Wikipedia enough to use it as the primary source for its knowledge graph cards; and we’ve all settled a bar bet by finding some fact where a Wikipedia article is the canonical answer.

The secret sauce for Wikipedia is in it’s roots. Literally, the root of its name, wiki, describes the underlying structure. Wikis were the internet’a solution to knowledge bases – large repositories of information about a process or thing. Companies had been using knowledge base software for years. Traditionally, a central maintainer, often a sort of corporate librarian, curated information, such as common answers to customer questions, so customer service reps could find it quickly.

Wikis democratize the knowledge base by allowing anyone to edit an entry. If you work for a company which sells widgets and you discover a new way to service the widget, you simply amend or append to the record in the corporate wiki. But what about the corporate librarian, they all cried. Except, no body cried.

It turns out, the network effect and the wisdom of crowds produce richer, more accurate databases of knowledge when the literal barrier to entity is removed. Make it easy for anyone to input knowledge, and the database and its accuracy grow. And so it came to be, since anyone can edit almost any entry in the largest encyclopedia the world has ever known, Wikipedia is remarkably current and accurate.

So I wonder…what if medical records worked like Wikipedia?

What if, my record lived on some commonly accessible platform; not open to anyone, but accessible by my providers and I? Maybe we have to do some kind of online handshake to mutually access it.

What if we could both edit the record, at the same time? My doctors could put in their notes and I could add my own. Or I could edit theirs. And they could edit mine.

Some readers may have concerns about the records’ integrity but as patient advocacy expert Trisha Torrey points out reviewing our own medical records can help spot and fix errors. And, as we know from Wikipedia, more eyes and contributors on a record increase its accuracy and reliability.

Another important lesson from Wikipedia is the idea of revision log, which Wikipedia calls page history. Any registered user can make edits to almost any record in Wikipedia’s vast online encyclopedia. Every time an edit is made the changes are logged, including the name of the user who made them. Anyone can review the changes and roll back some or all of them, or make additional changes of their own.

Imagine a medical record platform where patients can review the entries made by a doctor, and if appropriate make additions at it or even changes. For instance, after reviewing notes from my last physical, I discovered a small unimportant inaccuracy in my record. I take Vitamin D supplements, and in the record, it was noted that I take Vitamin E. Big deal? Probably not, but what if it was related to a prescription medicine? Providers are human and, as we know, to err is human, but by allowing patients to review and edit their own records, they would be able to fix errors.

A Wikipedia-style EMR would also better allow for patient-contributed data. There are often symptoms, observations or measurements which patients observe outside of the timeframe of a visit with their doctor: a week of poor sleep, a month of improving blood pressure measurements, an off-again, on-again skin rash. These kinds of things may not even warrant a phone call, but wouldn’t it be nice to log them directly?

Finally, and this may perhaps be my strongest argument for a Wikipedia-style EMR, we’ve got to do something about data exchange. Color me cynical, but I’m not convinced the health information exchanges (HIEs), offered by the major EMR vendors as well as technology giants such as Oracle, are the answer. Each EMR vendor has a financial incentive to keep their data in a proprietary format. Further, their customers are, by definition, the providers, not patients.

No, what we need instead is a common, centrally accessible platform where patients and providers have parity, equal footing. No one party’s observations, notes, measurements, or data trumps the other. A common platform would make it easier for different providers to openly collaborate, in front of the patient, virtually, in a common record. Your specialist could be literally updating the same records which you, the patient, are adding to while your primary care doctor is also reviewing and making edits. Dogs and cats, living together. Mass hysteria!

GB

And there’s an extra credit reason we need a Wikipedia-style EMR. It doesn’t just promote or enable patient empowerment, it demands it. Owning our own data requires responsibility. It becomes the patient’s garden to tend. And its our right to tend those gardens.  Stephen Ross and Chen-Tan Lin, writing in JAMIA, concur:

Overall, studies suggest the potential for modest benefits (for instance, in enhancing doctor-patient communication). Risks (for instance, increasing patient worry or confusion) appear to be minimal in medical patients.

This doesn’t have to be a pie-in-the-sky dream either. Someone could build a WikiEMR today. The platform which runs Wikipedia is called Wikimedia. In fact, it would likely meet all of the Meaingful Use Stage 1 requirements…except one, and could be regarded as HITECH-compliant:

  • Anyone can download it, or install it on a hosted server. It can use the same strong SSL encryption which protects Epic, Allscripts, Athena and McKesson platforms.
  • It is free (a substantial discount off the price tags stuck to the EMR giants).
  • It provides user access audits and record edit history.
  • It is accessible via mobile and desktop
  • It can use multi-factor authentication
  • Wikimarkup, the simple language used on Wikimedia sites, supports mathmatical calculations so a WikiEMR could do unit conversions, Boolean checks, and data aggregation and reporting (including graphing).
  • It can generate reports for the MU core measures including abstracting 14 core objectives, 5 out of 10 of the menu objectives, etc.

What one, small, requirement is missing? As far as I know, Wikimedia is not a certified EMR. Anyone want to start a fund drive?

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.

Milk's Oink - a model for rapid development in healthcare

Last week, tech startup Milk, inc shuttered its first and only app, Oink. Stop laughing. Those are the real names. Ok, only in the tech world, right? Jokes aside, deciding to pull the plug on a major project is not easy. Kevin Rose, Milk's founder, and the team have stated they are committed to rapid, agile development. It's an idea we could learn from in healthcare.

The company’s explanation was: “We started Milk Inc. (the company behind Oink) to rapidly build and test out new ideas. Oink was our first test and, in preparing to move onto the next project, we’ve decided to shut it down to help focus our efforts.” - via All Things D

Easy to say, hard to do

The trend of rapid development is gaining traction in tech startups. The basic idea is to continually innovate on products and services - they may never reach a finished state. In some instances, like Milk's, the products may yeild some success, but fail to fully meet expectations. In that case, developers look at lessons learned from the project and move the successful parts into new projects, leaving the failed peices on the cutting room floor. Continue what works, abandon what doesnt.

If the idea of abandoning projects mid-stream sounds challenging, it is. Teams have to ask themselves many questions such as when is the right time to pull the plug? How do we define success vs failure? What are the parts to keep and what should we leave behind? Perhaps that's why tech pundants have lauded Rose and team for their decision to stop Oinc.

Hey, clearly it worked out for them:

Google today confirmed the news we brought you yesterday: Kevin Rose and some of the team from his mobile app incubator Milk will be joining the company. - Via All Things D

Like most established industries, healthcare is steeped in tradition. One of the challenges of our tradition is a cautious approach to change. Largely, and justifibly, that's because rapid change in the practice of medicine has high risks, and we don't want to take risks with peoples lives. But there are some places within healthcare where rapid develipment and risk taking makes sense.

The professional side of healthcare - administration, business development, IT, marketing, management, etc - has historically taken clues from the medical tradition: slow, calculated decisions based on evidence, research, detailed financial plans, etc.

In adopting a rapid development model, professional teams could reduce some of the ramp up time for projects by getting comfortable with failure and change. Not every idea is a home run, sometimes it's just about getting on base. If the idea has some merit, take the positives and apply them to the next iteration.

Practicing rapid development

In the last few weeks, I've had an opportunity to explore rapid development. A team approached me with a clever idea. (It really doesn't matter what team or what their was. Names have been changed to protect the innocent, you get it.) As the innovation guy, it's my job to help them incubate and pilot the idea. So we tried it.

A few days in to the pilot, we hit snags. Part of the process stalled, dependant on another team and other processess. Pretty soon we had a massive reply-all thread going on email and enough differing opinions to make Congress jealous. (I'm here all night, tip your waitress, try the veal).

We were at a crossroads - stall the project, build a larger team and try and compermise on the orignal idea, or rapidly develop the idea into something else. We chose the later.

We did a quick assessment of the orignal idea and looked at the parts we felt worked well. We then discontinued the pilot in its current form. We let the other participants know and told them why and what our next steps were. Right away, we started a new pilot, plan b. Since we had building blocks from the successful parts of the first pilot, we were able to drop those processess and tools into place right away. We again communicated with the larger team.

To pharaphrase: "Hey, were't not perfect, but with your help and support we'll continue to refine this process. Thanks for your patience. Instead of A B and C, would you please start using X Y and Z?"

So far, the team has gone along with us. We understand they will eventually reach a point of change fatigue. To mitigate that risk, we know we cannot be in a state of rapid development forever. However, if we can use the tactic to keep the important parts of the orignal idea moving while we develop a stable process, then it will be a success overall.

What about you - have you practiced some sort of rapid development in healthcare? What are your tips and lessons learned? How have you learned to accept partial success along with partial failure? Does rapid development differ from basic project management skills?

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

Ask Paxton | Medicine X Stanford

A few weeks ago Dr. Larry Chu asked me to write a blog post for Stanford's Medicine X. Medicine X is an exciting conference focused on healthcare design, innovation, patients and technology. I'm honored to be a part of their advisory board and ePatient committee along with a bunch of other folks way smarter and more qualified than I am.

I'd been kicking the story of Joseph Paxton around in my had for a while. Here's a guy, totally unschooled in classical architecture, who designed and built a structure they said couldn't be built.

According to Bill Bryson: “The finished building was precisely 1,851 feet long… 408 feet across, and almost 110 feet high along its central spine-spacious enough to enclose a much admired avenue of elms that would otherwise have had to be felled. Because of its size, the structure required a lot of inputs-293,655 panes of glass, 33,000 iron trusses, and tens of thousands of feet of wooden flooring…"

He did it in 1851.

So, what does Joseph Paxton have to do with Medicine X and the future of healthcare? Everything!

Click here for the full post. 

Paxton, without any formal training, changed the face of London and, in many ways, global architecture. He gained so much acclaim as an innovative problem solver “ask Paxton” became a comment retort when people asked challenging questions.

...

Joseph Paxton was a passionate self-advocate. Rather than relying on the committee, he showed his design right to the people of London. Does that sound like ePatients to you too? This year, Medicine X will make 35 scholarships available for ePatients to attend the conference. ePatients are engaged, informed, empowered and most of all, connected. Just like Paxton, ePatients know the power of self publishing, sharing expertise and involving others. Having ePatient scholars at Medicine X means the event will be patient-focused, all the way.

The Crystal Palace pushed the bounds of what people thought was possible. Medicine X is all about healthcare transformers – those boundary busters who think beyond what is possible today, and create the future they envision. This year’s Medicine X will feature presenters who don’t settle for the status quo. Instead, they are fueled by a passion to design patient care experiences in a whole new way.

via Ask Paxton | Medicine X Stanford.

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.