Three Ways Designers are Taming Complexity in Health Care
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Health care has been dubbed the most complex industry. There is ample evidence that this complexity is growing. At The Penn Medicine Center for Health Care Innovation, designers are taming complexity using simple, but powerful approaches.
A Growing Concern
You might reasonably assume that once a patient is treated, it’s all smooth sailing from there. However, the complexity of health care isn’t limited to treating patients.
Consider the tenth edition of the International Classification of Diseases (ICD-10), the near-universal library of diagnosis codes that rolled out this month. The new library contains 68,000 diagnosis codes, far exceeding ICD-9, which contained a paltry 14,000.
After a patient encounter, providers search the ICD 10 library, select the appropriate diagnosis codes, and enter them into a process in which they are matched with insurance companies’ ever-changing plans and algorithms for billing. If all goes well, the patient and the insurance company are presented with bills, and the provider and the health system receive checks. None of the parties know precisely what the resulting sum will be until after the billing process is complete, making for an extremely opaque and convoluted experience.
Though it’s only a small piece of the puzzle, the transition to ICD-10 is a good barometer for how complexity in health care is evolving.
It is important to note, however, that complexity is not necessarily a bad thing. A system or process that is ‘complex’ consists of many different and connected parts. In health care, new communication technologies like electronic medical records (EMRs) have made it possible for physicians to refer their patients to an ever-expanding network of practices and health systems, dramatically increasing patient access to care.
Understanding that complexity will always be a part of health care, the question is not how to eliminate it, but rather how to optimize its benefits while mitigating its costs. In other words, how can complexity be tamed?
Taming Complexity in Health Care through Design
At The Penn Medicine Center for Health Care Innovation, my fellow designers and I are working to tame complexity in order to improve health care delivery and patient outcomes. Using examples from our Improving Access to Specialists project, I will outline three design approaches and explain how they produce value.
1. Designers Draw to Learn
How Designers are Different
Drawings are often used as a way of imparting information from experts to novices. Designers, on the other hand, use drawing as a tool for learning and building a shared understanding among stakeholders.
Why it’s Effective
Individuals seeking to understand and improve complex processes tend to avoid using visualization until after they are confident in their understanding. This is slow, and it’s a mistake.
Designers aren’t afraid to visualize the current state of their understanding, no matter how incomplete, as a way to learn from stakeholders. Creating a visual representation of a process allows stakeholders to easily point out flaws and identify areas for improvement.
Drawing to learn not only accelerates learning, it also builds a shared understanding. In health care, processes are divided among many stakeholders, each responsible for their own part. Most stakeholders only have the bandwidth to manage their own responsibilities, so the larger process remains largely unmapped. When designers bring people together to discuss and visualize their roles, complex processes begin to take on a tangible form, getting everyone on the same page.
It’s not rocket science — a simple whiteboard drawing will do.
In practice
Our team was asked to find ways of improving patient referral process from regional health systems to Penn Medicine. We began our project in part by learning how referrals currently happen at Penn Medicine. We quickly saw that the current referral process is divided into many steps and channels.
In order to better understand referral intake, I went to the Penn Medicine Access Center to observe and listen in on schedulers as they fielded calls and made appointments. Using my notes, I began to map out the schedulers’ process as I understood it. Similarly, Carolina Garzon Mrad, the project’s lead designer, observed and mapped other pieces of the process.
Our team invited stakeholders from each part of the referral process to a design session. As a group, we laid out the rough process maps, quickly made changes, and began to complete the larger picture. By converting the otherwise nebulous referral process into something tangible, we were able to get everyone on the same page and more effectively identify areas of the process that could be improved.
2. Designers Do to Learn
How Designers are Different
In health care, designers often find themselves working under the umbrella of research. Though there are many similarities between the human-centered design and traditional research approaches, they differ in their attitudes towards intervention. While researchers employ a highly formalized approach towards interventions, designers leverage quick-and-dirty interventions to accelerate learning.
Why it’s Effective
To state the obvious, the traditional approach to research is responsible for profound advances in medical knowledge. For instance, the highly methodical process of randomized control trials (RCTs) results in unbiased, authoritative findings. The downside, however, is that RCTs are expensive and slow. Depending on the study, RCTs can cost millions of dollars and take several years to complete. Sometimes, the findings are no longer relevant by the time the study has concluded.
Designers, on the other hand, use quick-and-dirty interventions to learn and inform next steps. Rather than succumb to analysis paralysis, a designer might put rough prototypes into the environment they’re studying to observe what happens. For each prototype the designer might ask: “Does it have the desired effect? How do I know? Which aspects of this prototype work? Which don’t?” Using insights gained from the intervention, the designer can then build a new, better prototype for testing and repeat the process.
This method has most famously been described in Eric Ries’ The Lean Startup as the build-measure-learn feedback loop. The beauty of the feedback loop is that it allows designers to learn quickly and inexpensively test assumptions — critical when taming complexity, lest you remain stuck in the weeds.
In Practice
Another central piece of our referrals project was understanding and improving the experience of the referred patient. In terms of transportation, we wanted to know what it was like for patients, many of whom come rural parts of the state, to travel to Philadelphia for their appointment. Rather than plan an extensive study, we began to look for opportunities to use intervention as a quick-and-dirty learning tool.
For several months, our small team of about five people offered patients free rides from the 30th Street train station to their appointment. I personally met patients at the train station and accompanied them all the way to the waiting room. Once their appointment was over, I accompanied them all the way back to the train station.
We learned that patients found immense comfort in knowing that someone was waiting at the train station to take care of them. We learned that helping new patients navigate Penn Medicine was a great way of preparing them for subsequent visits. We even learned that some patients made the decision to come to Penn Medicine because of the service.
In a few short months, our team put together a comprehensive set of transportation recommendations supported by quantitative data and illustrated by personal stories.
Did we conduct a thorough cost analysis before offering this service? No. Will it ultimately be a fiscally scalable solution? We may need to make adjustments. The important thing is that we tried something, and as a result, we learned quickly and cheaply.
3. Designers Embrace the Outsider Role
How Designers are Different
Designers are relatively new to health care. Many regularly interact with colleagues and stakeholders who are unfamiliar with design and who are skeptical of its value. Successful designers use the outsider role to their advantage.
Why it’s Effective
Given the chaotic nature of their environment, clinicians have adapted to manage complexity. In fact, experienced clinicians deftly navigate convoluted processes and tools without even noticing. When managing complexity becomes subconscious, it makes it very difficult to identify aspects of their work that could be streamlined.
When designers interact with clinicians, they use their outsider role as a tool. For instance, a designer might ask a clinician why they do something, then ask them why again, and again. While this may sound simplistic, this line of questioning helps designers cut through complexity to uncover the root cause of an issue or the reason for a behavior. This approach, sometimes called the 5 why’s, is increasingly being used in health care.
In Practice
Many patients looking for a referral call a central number which connects them with an intake hub called the Access Center. In order to better understand that process, I spent time observing schedulers’ interactions with patients seeking a referral.
At the Access Center, I was surprised by the number of calls schedulers received from patients and providers who were checking in about the status of a referral. Some patients, for instance, are required to send documents to Penn Medicine practices for review before they can schedule their appointment. These patients, eager to schedule an appointment, were calling the Access Center repeatedly to see if those documents had been received.
For schedulers, these calls, as well as the added complexity they produce, are a part of their normal workflow. As an outsider, however, I wondered why these calls were coming in at all. How do patients know when their documents have been received? How often to people check up on their status? By combining fresh eyes with simple questions, I learned that there was no existing system for keeping all the concerned parties up-to-date on the status of a patient referral.
With this insight, our team wondered if an online referral tracker, similar to those used to track packages by UPS and Amazon, could be used as a way of visualizing the referral process, and that push notifications could be sent automatically to concerned parties to keep them in the loop. We believe that such a tool would cut back on unnecessary phone calls, improve communication and patient satisfaction, and reduce delays.
An outsider who closely observes a process using fresh eyes and who isn’t afraid to ask simple questions is uniquely capable of identifying and addressing latent areas of complexity. For busy people who are deeply embedded in an existing workflow, this can be much more difficult.
Your Turn
While I associate these approaches with design, they can be used by anyone working within health care, regardless of background or role. Does that include you?
At The Penn Medicine Center for Healthcare Innovation, we are committed to building the capacity of the entire Penn Medicine community to use these and other approaches.
For information on upcoming presentations and trainings, take a look at our events page.
