(This article was published in the November/December 2010 issue of interactions magazine.)
It seems likely that we find ourselves at an inflection point in the evolution of healthcare. While the situation has certainly been brought to a boil by recent American political events, the opportunities for change fit into a much larger context; they have the potential to truly transform the delivery of healthcare globally.
Unlike some, I don’t believe our current healthcare system is totally broken. I’ve conducted design research in quite a number of clinical settings and have consulted for businesses representing many different aspects of the healthcare industry, including provider networks, medical-device manufacturers, and even health insurance companies. I’ve seen magic worked on regular basis, and from a historical (and global) perspective, the standard of care in the developed world is astoundingly high. I am in awe of the abilities of doctors, nurses, techs, and other clinicians to consistently function at a very high level despite the fact they’re forced to work with archaic infrastructure in less than ideal environments. (As for the insurance companies, perhaps the best thing to say is that they function to make money but could be dramatically more successful as businesses if they changed their approach to things.)
It is at this level—the level of infrastructure—where these big opportunities for transformation exist. It isn’t that we don’t know what kinds of patient and clinician behaviors and medical interventions result in healthy outcomes; it’s that at a systemic level, we’re not doing a good job facilitating these behaviors and driving appropriate interventions. The right changes here will provide a conduit for evolutionary change to cascade throughout the system to achieve dramatic improvements in the quality and cost of healthcare. Which isn’t to say that it also isn’t incredibly important for medical knowledge to continue to evolve; it’s just that we already know enough to dramatically drive up quality and drive down costs.
Many of the opportunities to improve our healthcare system can fit into three big categories: proactively engaging individuals to take better care of themselves; providing better interventional care beyond the walls of the hospital; and improving care delivery inside hospitals through standardization and better collaboration between clinicians, patients, and families. All three of these strategies require new infrastructure and perhaps a shift in the definition, role, and activities that characterize the hospital.
The first two ideas are mostly about what happens outside the hospital. These are things that architects wouldn’t traditionally worry about when designing hospitals. But that kind of thinking has gotten us into our current predicament, where the current built “environment” for providing healthcare is sometimes an impediment to necessary change. If we step back and define a hospital as the nexus for healthcare in a community, we have a platform on which we can imagine the ideal infrastructure for keeping people healthy as possible in a cost-effective way.
In the May+June 2010 issue of interactions, Hugh Dubberly suggested designers ought to help reframe what healthcare is and how it is delivered, as well as to reframe what it means for design to help. I couldn’t agree more, and in this spirit, propose reconsidering what healthcare infrastructure is necessary to better care for people, how design should address this new notion of infrastructure, and what this all means for the institution of the hospital.
Proactive Engagement of Individuals
The first huge opportunity for healthcare transformation is around proactively engaging individuals with their own health. In case anyone has missed this striking fact, many of the most common chronic diseases, like diabetes, heart disease, and cancer, are not only a substantial cause of death (70 percent in 2006, according to the U.S. Agency for Healthcare Research and Quality), and a substantial source of healthcare costs ($500 billion in the U.S.in 2006), but they are largely preventable or controllable by lifestyle choices such as diet and exercise.
So not only is a person with diabetes who is able to proactively keep their blood sugar under control with diet and exercise more likely to have a “positive outcome” (i.e., live a long life, avoid the nasty complications of poorly controlled diabetes like loss of vision or amputation), but they are also likely to cost their health insurance payer a lot less than someone with poorly controlled diabetes. Put another way, you can buy an awful lot of proactive engagement with the cost of one ambulance trip to the hospital followed by even a short hospital stay.
But people without the symptoms of disease rarely encounter the healthcare system, and by the time someone faces Type 2 Diabetes or a first heart attack he or she has probably developed some habits that are pretty tough to break. So as obvious as this opportunity is, it’s a tricky challenge—how can we educate and motivate pretty much everyone to live in a healthy way as early as possible, and then how do we help people make radical adjustments to their behavior if either the first round of engagement didn’t work, or they’re genetically or otherwise predisposed to a chronic disease and they’ve fallen ill?
While this all sounds good in theory, people’s habits are notoriously difficult to change, and psychologists’ and economists’ substantial understanding of human motivations can seem meager in the face of rampant unhealthy behavior in our society. However, there are instances in which these strategies have been clearly shown to be highly effective.
Like many large companies, Safeway’s health insurance program is self-funded, meaning the employer pays all health insurance benefits (and therefore incurs most of the risk and benefits from all cost savings). Starting in 2005, Safeway has offered significantly discounted premiums for people with healthy behavior related to tobacco usage, weight, blood pressure, and cholesterol levels. During the first four years of the program, Safeway kept per capita healthcare costs flat, while most American companies’ costs increased 38 percent over the same period.
Safeway CEO Steven Burd recently described the thinking behind the Healthy Measures program: “Safeway’s plan capitalizes on two key insights... The first is that 70 percent of all healthcare costs are the direct result of behavior. The second insight, which is well understood by the providers of healthcare, is that 74 percent of all costs are confined to four chronic conditions (cardiovascular disease, cancer, diabetes and obesity). Furthermore, 80 percent of cardiovascular disease and diabetes is preventable, 60 percent of cancers are preventable, and more than 90 percent of obesity is preventable”. (For more about the Safeway Healthy Measures program, see this piece by Burd in the Wall Street Journal.
So it seems that with even the most basic motivators (money), it’s possible to both reduce costs and improve health for a relatively large and diverse population. The next obvious question is what infrastructure is required to proactively engage individuals to behave in healthier ways on a broader basis.
Research by behavioral economists has found that people tend to make good decisions where action and result are closely tied together (either through feedback or when consequences are obvious), when doing the right thing isn’t too difficult, and when a decision is made repeatedly (i.e., the individual is able to practice). People also tend to be highly motivated by making progress toward achieving goals, and by group social dynamics—fitting in with and impressing (or not disappointing) their friends, family, colleagues and neighbors. (For a good primer in behavioral economics, see Nudge by Richard Thaler and Cass Sunstein.)
It seems then that the starting point for behavior change is good information, and the starting point for the supporting infrastructure must be a robust health record that includes a wide range of information, including data from clinical systems (e.g., hospital electronic medical records), as well as more personal information about things like diet, exercise, and health data collected at home (weight, blood sugar, blood pressure). Of course this data must be accessible and easily maintainable for patients, their families, and the clinicians (or institutions) whom they choose to allow to create or consume data from the personal health record.
While there is strong evidence that just tracking personal data can have a significant impact on health-related behavior, what is done with and in response to the data is critically important. The most basic motivator is a good understanding of the potential consequences of individuals’ actions, so interfaces into this personal health record must help people understand what diseases and conditions they are at risk for based upon the clinical and personally tracked information. From here various levers are used to help people reduce the likelihood of these unhappy consequences with capabilities for goal setting and progress tracking, rewards for healthy behavior, and education about the potential ramifications of unhealthy behaviors tied in to various social media to provide community and support.
There are also huge opportunities to present data in such a way as to help people understand correlations between their actions, environmental factors, and their health. This can help individuals fine-tune treatment of a disease or condition or better understand an undiagnosed problem. While my assumption is that mobile- and Web-based software interfaces will be invaluable in delivering these experiences, we shouldn’t at all discount the role of clinicians—nurses in particular—in educating patients about their diseases and helping them establish and track goals to improve their health.
Sadly, for any of this to be effective, there is considerable work to be done both in translating medical (and legal) information for general consumption, and in educating the public on how to comprehend even basic medical facts. According to the 2003 National Assessment of Adult Literacy, fewer than half of American adults were judged to be proficient in health-literacy skills to the extent that they could accomplish tasks like finding the correct age range during which children should receive a particular vaccine, or using a chart that shows all childhood vaccinations and the ages at which children should receive them . While interactive experiences can provide useful assistance to people struggling to understand their medical and health situations, our overall healthcare infrastructure must better account for the education of almost everyone, probably through integration into secondary-school curriculum. (Perhaps this would be an aspect of usefully reimagined “home economics” or “civics” classes.)
Personal-data acquisition is also a huge field of need and opportunity. Current solutions for tracking personal health data tend to be extremely siloed. While mobile devices provide a great new way of delivering sensing and monitoring capabilities, and while there are some nicely designed health-info trackers, exercise logs, and food diaries in the iPhone App store, almost all require a user to actively launch the application or interact with a reminder in order capture data. These all tend to be plagued with the same problem as paper trackers—the people who remember to use them regularly tend to be people who are already in good control of their health.
The real opportunity lies in figuring out how to integrate data tracking and education with experiences that people already find engaging—whether it’s social networking, television, games, or reading news. The tricky part is figuring out how to present these capabilities so that they provide enough friction to capture people’s attention, but not so much friction that they detract from the overall experience. And of course, they should be as lightweight to interact with as possible. I could even imagine insurers paying to advertise in media and software—behavior placements instead of product placements and even setting up incentive programs where media providers are rewarded for driving healthcare engagement (like paying for clicks in online advertising). This would seem to be a small expense in the face of the cost savings shown by Safeway.
Changing the Boundaries of the Hospital
Clearly, as healthcare institutions continue to reach out into the community to concern themselves with proactively motivating healthy behaviors, the boundary of the hospital will increasingly no longer be defined by physical walls. This trend also extends to interventional and nursing care.
Home healthcare is nothing new, and millions of people in the U.S. alone receive some form of home care (according to the February 2004 "National Home and Hospice Study", by the National Center for Health Statistics), but it is very expensive for patients and payers alike to get an in-person visit for basic healthcare monitoring for patients with chronic conditions like congestive heart failure. A number of products exist that walk patients through the process of collecting vital signs (in the case of congestive heart failure: blood pressure and weight), reminding them about their care regimen and uploading the vitals to a central nursing station where software tools can help nurses spot trends that may require in-person intervention.
A recent study by Kaiser Permanente and the American Heart Association has shown that patients with high blood pressure using home healthcare monitoring were 50 percent more likely to have their blood pressure under control. This alone represents a dramatic opportunity—hypertension is a leading predictor for heart attacks and strokes, both of which are highly deadly and expensive to our healthcare system as a whole (and therefore expensive to every one of us). Another recent study conducted by Kauffman Foundation and Brookings Institution economist Robert E. Litan predicts that the U.S. could save $197 million from implementing telehealth systems to help treat chronic ailments like diabetes, congestive heart failure, chronic obstructive pulmonary disease, and chronic skin ulcers.
Current home health monitoring products are mostly dismally designed. For example, the Health Buddy, a popular telehealth device, communicates to its (mostly elderly, sight-impaired, arthritic) users entirely with small, center-aligned text, which is clearly not as readable, let alone as engaging, as it could be. These products also suffer from the same issues that plague many existing solutions around proactive engagement: They aren’t already integrated into a person’s daily routine. For example, given the prevalence of television watching among the chronically ill, it seems that the cable-TV box would be a much more useful platform than a standalone “medical device,” which is as easy to ignore as the blood pressure pump itself.
The Mayo Center for Innovation (CFI) has been working on a program to design a “patient-centered medical home” that provides a better connection between patients and their healthcare providers beyond the in-person visit. According to the CFI, it is “exploring ways to implement unobtrusive systems into a patient’s daily routine—perhaps a coffeemaker or refrigerator that records blood pressure or glucose levels—without disrupting their busy lives”. While this certainly points in the right direction, it is the tip of the iceberg. Whether it’s in a coffeemaker, the television, or PC-based social media, there is a huge opportunity for designers to imagine how home healthcare monitoring and telehealth can more seamlessly fit into people’s daily lives.
Using technology to provide better care beyond the walls of hospitals and doctors’ offices need not be limited to monitoring chronic-disease patients. Many routine trips to a doctor’s office might easily be replaced by a videoconference or even an email exchange. This, of course, would be especially beneficial to patients in rural settings.
Centralization of specialized resources seems to generally be a good thing in the organization of a healthcare system. It’s more cost-effective and easier to standardize care (and thereby improve quality) to deliver cardiac care in a single large facility in a metropolitan area than in a number of small facilities spread around. However, a huge downside to this approach is the increase of travel time—and decrease in access—for patients. Telehealth provides great opportunities to mitigate these problems by allowing patients to access the expertise at specialized facilities from far away. And not only ought our new healthcare infrastructure better support remote clinician-patient interactions, but because of this trend to centralize specialization, healthcare providers will also increasingly need information systems to support non-collocated collaboration between clinicians.
A common concern about an increased reliance on telehealth is that the lack of face time will result in a reduction in quality of care. This thinking goes that it will be even easier for doctors to be less thorough, and they won’t benefit from their well-developed senses of observation. The counter-argument to this is that by reducing the amount of time spent on very routine visits, doctors will actually free up time to spend with patients whose conditions require their full attention.
Current payer policies are perhaps the biggest infrastructure challenge when it comes to telehealth. As often is the case with many kinds of preventive care, currently telemedicine and remote consultation and treatment are not well-covered by Medicare or private health insurance plans. Remote consultations between doctor and patient are reimbursable only if conducted over video, and preventative examination of remote monitoring data is not reimbursable. It’s clear that both public and private payers could reap significant cost savings (and care improvements) by better compensating physicians and hospitals for using telemedicine effectively, but are too bogged down in bureaucracy to make the necessary policy changes.
While telehealth is largely about extending the impact of the healthcare system into people’s homes, when we talk about redefining the boundaries of the hospital it is also important to consider how healthcare institutions can have a bigger impact in communities, perhaps even by bringing these communities into the hospital. While it may be common sense to many of us, a 2009 paper in the Archives of Internal Medicine showed a 38 percent lower incidence of Type 2 Diabetes among people who lived in neighborhoods with better resources for food and exercise .
Determining exactly what should be done as a result of this data is certainly a ripe opportunity for design thinking, and some would reasonably argue that access to healthy food and exercise is a civic good that is best handled at the municipal level. That said, if we truly want to orient our healthcare infrastructure in such as way as to result in better health at a lower cost, perhaps there is an opportunity for healthcare institutions to have a hand in providing these essentials to a community. It’s clearly outside their core expertise now, but as these institutions move in the direction of encouraging healthy behavior, is it really too much of a stretch to imagine that hospitals could have a hand in providing exercise facilities and farmers markets full of fresh veggies (one of the biggest drivers of diabetes reduction on the food side of the above-mentioned study)?
Changing Care Delivery
Even if we are successfully and proactively engaging people to live more healthily and we are better able to use telemedicine to avoid expensive trips to the hospital, a significant portion of medical care will still be delivered in hospitals and doctor’s offices. One of the most significant recent changes in healthcare is a move to standardize treatment upon what has been scientifically shown to produce the best outcomes. It turns out that this incredibly reasonable (and surprisingly new) approach does in fact tend to improve patient outcomes while reducing cost of care.
For example, at Intermountain Healthcare, a Salt Lake City-based system of hospitals and clinics, clinicians adopted practices to more tightly control of the glucose level of patients in intensive care units (ICUs), which “led to a statistically significant reduction in the rates of mortality in this patient group.” And by standardizing care for patients on ventilators, they ended up reducing the average time each patient was on a ventilator by more than a day. These adjustments reduced the rate of ventilator-associated pneumonia by 10 percent over two years, shortened the overall length of stay in the ICU, and reduced costs by more than $3,000 per ICU patient. (For more about IHC, see this article in the NY Times Magazine. Also, in the name of full disclosure, I should say Cooper has worked with IHC for the past couple years.)
As obvious as it might sound, on a practical level, actually practicing evidence-based medicine is harder than it might appear. The rate of new findings in medical science continues to increase, and for all but the sub-sub-specialists it is nearly impossible for a physician to read and retain all the research relevant to the patients that they see. For evidence-based medicine to be a reality, it requires that medical decisions be made in light of appropriate patient data, which is viewed in the context of up-to-date medical research (it also requires that substantial data be captured about the treatment and progress of each patient to feed back into research). Further, while all this data is absolutely critical to the endeavor, information systems must also be smart and help make people smart.
Human bodies and diseases are incredibly complex, and research findings are rarely black and white (and are always changing). In top form, human judgment (for example, as portrayed in Gary Klein’s Sources of Power or Malcolm Gladwell’s Blink) is capable of things well beyond any AI or decision engine (or at least one that’s ready for prime time on a hospital floor). But the one thing that computers do have on even the smartest clinicians is consistency. This means that information systems must aid in filtering through the increasingly voluminous data captured about each patient; help clinicians understand relationships between data, observations and protocols, care guidelines, and other standardized approaches to care; and ultimately assist in making good judgments about patient care.
Rapidly increasing medical knowledge has resulted in an increase in specialization. This means that most patients with a chronic disease or comorbidities are treated by teams of clinicians rather than one or two individuals, and our healthcare infrastructure must also support communication, collaboration, and workflow coordination between clinicians. This means not only more team-oriented physical environments, but also better tools for remote collaboration: a way of conducting remote “rounds”—complete with videoconferencing, patient video feeds, shared viewing of imaging, and medical data, all with next-to-zero fussing with technology.
And as we consider how infrastructure should support communication and collaboration, we mustn’t forget patients and their families. Recently, there has been a drive to better involve patients and their families in care decisions. At the Mayo Clinic, the SPARC innovation group has been experimenting with consulting spaces that move the doctor out from behind the big desk, onto equal footing with the patient in an attempt to engage the patient as a participant in care rather than a passive invalid. (Read more about this work in this article by Businessweek.)
Similarly, at the St. Louis Children’s Hospital newborn intensive care unit, parents are encouraged to contribute observations during rounds, be involved in treatment decisions, and participate in routine care activities so they’re prepared before taking an infant home. Not only does this type of family involvement reduce emotional stress, and in fact help coordinate communication between clinicians, but the American Academy of Pediatrics has also found that pediatric care that actively involves parents generally results in shorter hospital stays, fewer readmissions, improved staff satisfaction, and fewer lawsuits. (Read more about St. Louis Children's in the Wall Street Journal.)
The infrastructure required here is actually quite similar to what we have already discussed with regard to changing care delivery. Hospital architecture and information systems must not only account for communication and collaboration between clinicians, but must also include patients and families. They should be able to monitor and enter data, to review and discuss care plans and specific orders, to ask questions and provide suggestions to clinicians, and to be reminded and encouraged about things like medications and physical therapy.
There is no way that healthcare transformation can be achieved solely by legislation. While the necessary changes absolutely do require new policies to be put in place that better align the interests of healthcare providers (doctors and hospitals) and payers (insurance companies and government) with the health of people, this alone will not achieve the cost reductions and quality improvements we seek. What must be changed is the way individuals interact with the healthcare system, and I believe this change must be driven by healthcare institutions.
The institution of the hospital is ripe for reinvention. By taking a step back and considering what infrastructure best supports a healthy community, we can reframe the idea of the hospital in a way that makes it more effective, both in terms of medicine and economics. What if instead of limiting our notion of a hospital to the building where clinicians physically act upon patients, we expanded that definition to include the physical and virtual environment that provides all kinds of interactions and experiences that result in healthier people.
Of course there is no shortage of challenges in achieving this vision. Medicine is very complex, and transitioning to the digital agehas been slow and not universally successful. As with everything built on a foundation of modern information technology, there is a huge potential for difficulty for the people involved—patients and clinicians alike. There are legacy systems, policies, and attitudes that threaten to unnecessarily slow the pace of progress. And at the end of it all, while digital infrastructure will be invaluable to the productive transformation of healthcare, the most important interactions will between people. As former Cleveland Clinic Chief Experience Officer, and patient-centered design pioneer Dr. Bridget Duffy put it, “I think there’s an understanding that as the higher tech we get, the more high touch we need to get”.