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Healthcare Design Is About More Than Aesthetics
Working in healthcare was something of accident for me. I never had any intentions of working in this profession — nor had I considered healthcare much of an option. Healthcare, to me, was messy, technical, scientific and full of terms and concepts I didn’t understand. I also believed I wasn’t cut out for it.
After finishing my enlistment in the Marine Corps, I wanted to continue helping people and thought firefighting might be a good fit — until I began my training. In many precincts, firefighters also serve as paramedics or emergency medical technicians (EMTs). So before I could attend fire school, I had to go through EMT school. That’s where healthcare came in. I wasn’t too hot on the idea of being an EMT, but as I worked through the program, my heart began to soften to the profession and to the people who made this their career. I was exposed to patients who were sick, aging, and poor. I watched phenomenal professionals perform what seemed like miracles to help them.
One day, I watched a young woman undergo a C-section. She spoke in Spanish to her husband while the physicians counted out the blood-laden towels they had used, throwing them on the floor. Another day, I watched the catheterization of a young man whose kidneys were in acute failure due to repeated drug use. The nurses handled him roughly, speaking terse words as my partner explained the concept of a “frequent flyer” to me. On ambulance runs, I encountered accident victims and dangerous situations where weapons were on the scene.
I was 26 years old. The sadness and tragedy of the human condition I witnessed was more than I wanted to bear. I didn’t feel I was cut out for this work. I still wanted to help people, but I didn’t think my personality or psyche was a good fit for a first-responder profession.
Another opportunity came along, and I steered as far away from healthcare as I could, not knowing that I’d return to it a decade later.
In the spring of 2005, I read Information Architecture for the World Wide Web. That book, along with the classes I was taking at the time, changed my life and career direction. By that summer, I’d taken a position as an intern for Eli Lilly working on their intranet portal. I evaluated search capabilities, conducting search log analysis, analyzing taxonomic structure, and reporting recommendations.
Good interface design is not pervasive in the healthcare industry. Neither is UX.
Shortly thereafter, I took another internship evaluating a public health statistical engine at Indiana University, Indianapolis. I was essentially doing the same thing: building a standardized taxonomy to support the search engine. I was back in healthcare and found the administrative and technical aspects of it fascinating.
Around that same time, an opportunity came along to work for a rural community hospital in Columbus, Indiana, as their medical librarian and continuing medical education (CME) coordinator. I wasn’t much of a librarian in the traditional sense. My first agenda was to move from print materials to online materials, essentially converting the library to a digital entity. I shadowed, interviewed, and surveyed the physicians and nurses to gain an understanding of their needs. I built a portal, figured out how to IP authenticate resources, and created a system where healthcare professionals could access information at the point of need rather than walking to a physical library. I went on rounds with physicians and nurses to capture their research needs and later scoured medical resources to answer their questions. This precluded my second master’s degree in informatics and served as the roots to my experience in the field of user experience, or UX.
I eventually transitioned to the Indiana University School of Medicine while working as a technical project coordinator. I worked in telemedicine, developed electronic health records, and created prototypes for studies. A large portion of my work at IU was in human factors to redesign clinics and shape behavior. For example, one large study I worked on involved mapping clinics to understand workflow and increase hand-washing, a novel concept even in today’s medical world.
Through all this experience, I gained an education (both formal and informal) in healthcare. I learned a lot about human psychology and the philosophy of medicine. I learned even more about UX and the craft of design. And I realized I had once again returned to the concept of helping people — just in a different way.
Beyond just making something beautiful, aesthetics serves a higher function in design.
It was a long journey, but 12 years later, I’m still working in healthcare as a UX professional. I occasionally get an itch to work in another industry — maybe something simpler where I can just build a landing page or frilly website with nice images. I rarely get very far in contemplating an idea like this before rejecting it. Still, it would be nice to work on an application or website where aesthetics took a priority, where creating something beautiful was a primary goal. That just isn’t the case with healthcare interfaces, which are rife with data tables, excess controls, and information-packed screens with little to no imagery.
Iconography is challenging in respect to ensuring the icon matches the function (or what it represents). Information architecture is deep for these applications and the cross-functional nature of the workflow makes it difficult to develop strict navigational paths. Chunking out features and functions into different screens is not always an option because efficiency is paramount (and chunking can slow the user down in reaching their goal). This often results in bloated interfaces and applications.
So why have I stayed in healthcare UX for 12 years? For several reasons.
Making an Impact
The opportunity to make an impact is the main reason I’ve stayed. I could work in e-commerce, the financial industry, or for various startups. But the bottom line in those industries just doesn’t have the same impact for me. Healthcare is just as financially driven as e-commerce or banking, but I know there is a patient on the other side of what I am doing.
I have, on occasion, had direct contact with patients. I’ve worked in hospitals where patient contact was routine. I’ve seen the devastating side of Alzheimer’s while working to integrate systems for better care in clinics. I’ve walked ICU and CVU units, hearing the quiet sobs of family members as I implemented hygienic systems to prevent hospital-acquired infections. I have crawled around on floors, networking homes for telemedicine studies for sick and elderly people. I have worked with hearing- impaired people to develop better systems and tools in managing their hearing devices.
Over the years, my contact with actual patients has decreased. I find I need that contact less than I did in the early stages of my career because I can more easily anticipate their needs, and I know the patients are there, somewhere on the other side of my work.
A Clear Need Exists
Good interface design (and sometimes good design, period) is not pervasive in the healthcare industry. Neither is UX. Many hospital systems do not even employ a UX staff, opting instead for out-of-the-box products to manage patients’ electronic records. It is still somewhat rare today to find a large staff of UX professionals working for a single health entity. Oddly enough, as the rest of the country has jumped on the user experience bandwagon, the healthcare industry still generally suffers from a dearth of UX professionals.
Whether it’s the interface and controls for an IV pump or a complicated piece of software like an electronic health record, healthcare is plagued with a lack of sound design. That was one of my early motivators and something that still keeps me in healthcare today. There is a niche to fill.
The first time I saw an electronic health record, I was horrified at how primitive the interface was, both in functionality and aesthetics. My ethnographic observations in hospitals and healthcare centers revealed a plethora of usability issues and systems that were not designed with the end-user’s goals in mind. Systems in healthcare are often driven by various agendas. Many are financially driven to ensure compliance (which maximizes compensation). Security plays a large role where an average doctor or nurse has to memorize a dozen passwords or more to log into a fragmented set of systems. Whatever the goal or agenda, good design usually falls to the bottom of the list.
Working in an industry where there is a clear need is something I have always found appealing, but there is also something deeper here. Healthcare is one of the few industries where the user is essentially forced to use your application. Other software applications, such as e-commerce apps, social networking apps, gaming, etc., have user bases who generally want to use the application. Doctors, pharmacists, nurses, and other healthcare professionals, however, did not enter their profession with the yearning to sit in front of a computer for a large part of their day. To them, it is simply a tool, and sometimes a barrier, in completing their work. Healthcare professionals are not unique in that they are required to use various software platforms to complete their everyday tasks. Enterprise software users also share this characteristic (think of your average intranet or your company’s software to manage your time card and/or benefits). But, healthcare UX has a much greater risk profile than enterprise UX. The difference between making a mistake on a time card versus making a mistake on a patient’s medication order is enormous. Poor usability on an enterprise platform does not hold the same consequence as it does in healthcare, where every second spent with a computer is one more second not spent with a patient. The need to develop solid interfaces, good user experiences, and efficient means of completing tasks in healthcare is essential.
Give Me the 411
I had a routine checkup with my primary care physician recently. We always somehow get on the topic of electronic health records, and this time she turned the screen toward me so we could discuss the interface and how it works (or doesn’t) for her. The hospital network I belong to uses Epic,perhaps one of the largest out-of-the-box electronic healthcare record system in healthcare.
Aside from updated Chrome and minor differences, the screen she showed me looked pretty close to what you see below.
Once again, this comes from one of the largest healthcare record vendors in the United States. And I was astonished this is the best a major vendor like Epic can do. There was entirely too much information on the screen, the scannability was near zero, and the functionality was overly complicated for the submission and maintenance of orders.
Healthcare is a field where information is of utmost importance, and as a result, the systems and interfaces are information-heavy. There is a plethora of information (and functions) to pack into a given screen. Adding to the complexity, healthcare is a highly interruptive environment where professionals are often conversing with patients while they attempt to complete a complex task (such as ordering a lab test or medication). The ability to quickly digest information and accurately complete tasks in a highly interruptive environment becomes a major priority.
This becomes an exercise in information design and information architecture. What information truly needs to be on the screen? What information can we hide or leave out without posing a risk to patient safety? How should the information be prioritized on the screen, or how do we give it a hierarchy? Can it be summarized in brief allowing the user to dig deeper should they so need to?
All of this makes it challenging for me, like a puzzle I have to find all the pieces to and fit them together. It is a constant process of discovery, where I am always learning.
Healthcare is not the only industry that has to mitigate information overload in interfaces, but it represents one of the worst-case scenarios. In other industries (news, enterprise, etc.), a user might be able to hazard an educated guess and get it right. But in healthcare, there is so much information delivered via applications that there is little room for error.
All of this makes it challenging for me, like a puzzle I have to find all the pieces to and fit them together. It is a constant process of discovery where I am always learning. And the complexity of the information design challenges means I am never bored.
Healthcare interfaces and associated technologies are not exactly noted for their beauty or aesthetic qualities. In fact, they’re often terribly clunky, years behind current design trends, and comical in their antiquity. I see this as an opportunity to bring beautiful design to an industry where there is a dearth of it.
I admit there is personal satisfaction in taking an antiquated design and modernizing it. It is deeply satisfying for me to move from something that looks like this:
To something that looks like this:
Beyond the aesthetics, looking back and seeing the progress and iteration of a design is rewarding. To me, the whole process is similar to a restoration, like restoring an old vehicle to new beauty. I have always been fascinated with the idea of taking something old and making it new again.But beyond personal satisfaction, why is something as superficial as aesthetics even important?
A wealth of research supports the idea that aesthetics have an impact on user experience. One study showed a significant increase in enhanced performance where poor usability was persistent in the design, using completion times and error rates as measurements. High visual aesthetics even improved task completion times, speeding up users. Another study showed increased task completion with an appealing design versus an unappealing design. This study also showed higher perceived ratings of usability with the highly aesthetic design (even when the interface was not more usable).
Aesthetics obviously doesn’t override functionality. But in UX, the sum of the combined parts is greater than the sum of their separate effects. Aesthetics coupled with solid functionality equates to a greater user experience. Aesthetics plays a prominent role when it comes to user perception, though. Users are more likely to overlook minor usability issues in designs with a high aesthetic quality.
Beyond just making something beautiful, aesthetics serves a higher function in design. Until recently, it’s an element that has been largely ignored in healthcare where function and task completion trump all else. Healthcare professionals today spend as much time (or more) with the software as they do with the patients they care for. Aesthetic quality in a software platform can elevate the mood of a given healthcare worker — even if only slightly. In my exposure to UX, nowhere is this more important than in the healthcare industry.
A Lack of Good Design Principles
I often refer to healthcare systems as “Frankenstein Systems” — not only because they are usually built at various points along a timeline by different designers and developers (a trend in other industries as well), but mostly because they are inherently fragmented. On this latter point, for example, lab work is likely handled through an entirely different system (an LIS or Laboratory Information System) than the patient record, which is entirely different from the system used to bill and handle insurance coverage. A typical hospital admission could easily have touch points with six or more different systems. This often leads to a designer’s nightmare.
Fragmentation aside, even when working within a single system or platform, style guides are often nonexistent, as are good design principles, which can lead to a lack of consistency and structure in many products. This is somewhat normal in the industry. Thousands of users are victimized by poor navigational structures, completely different interfaces, and a generally fragmented experience (in the same application).
In healthcare UX, the stakes are high. When we overload healthcare professionals or give them the wrong information or the right information in the wrong order, we pose a risk to the person receiving treatment.
Consistency and structure allow end-users to develop a sense of familiarity with an interface. The less consistent and structured an interface is, the longer it will take to enable memorability and learnability. As memorability and learnability are primary usability components, an application lacking these components obviously falls lower on the usability scale.
Clarity in healthcare interfaces is a common problem as well. Confusing controls and navigational cues along with linguistic variations (i.e., labeling problems) between systems and interfaces leads to confusion for the end-user. Errors often result and efficiency is compromised. It is no small challenge to understand the different types of end-users and their linguistics.
Clarity and simplicity go hand-in-hand. Both involve the ability to determine where you are in an application, quickly determine the purpose of a given screen, and promptly execute tasks. This is a challenge in healthcare applications that often attempt to jam a dozen or more functions into a single screen. Equally challenging is explaining to stakeholders why this shouldn’t be done.
The lack of good design principles in healthcare applications is what keeps me employed and what keeps me challenged. It is rewarding to flesh out new designs while serving as a gatekeeper for good design principles in an industry that has fallen short in this regard for so long.
People Can Die…Or They Can Be Saved
Back when UX designers were still using Visio to wireframe and Axure RP was in version 4, I had begun writing what would become a master’s thesis on health information technology-induced errors. I conducted research in how technology causes errors, which often result in patient harm. This research included an integrative review of articles in the medical literature documenting health information technology-induced errors.
The research results netted 18 articles containing a total of 228 errors. Of the 18 articles identified for inclusion, 89% involved poor interface design. Of the 228 errors, more than half, 51.38%, involved poor UX .
The types of problems identified as a result of interface design were broad and represented issues, such as juxtaposition errors in selecting from drop menus, inability to find items within a system, lack of cohesion in design, and the presentation of data. When considering the UX (or the design) of health technology systems as a whole, problems such as cognitive overload, workarounds (due to poor design), the system not matching the workflow, and rigidity in system design all posed problems and resulted in some type of identified error. But “identified error” is something of an antiseptic term. In many of these instances, patients were hurt…or died.
In healthcare UX, the stakes are high. When we overload the cognition of healthcare professionals or give them the wrong information or give the right information in the wrong order, we pose a risk to the person receiving treatment. There are a number of design-related and human factors issues where the wrong design can cause errors. We can get the workflow wrong with a mismatch between the interface (or system) and how the end-user conducts their work or completes a task. We can choose the wrong device for the end-user. We can over-regulate or over-alert the user. The list goes on and on.
Healthcare UX offers me an opportunity to fix these errors. It also challenges me to avoid creating errors. This dichotomy keeps a designer walking a fine line with multiple points of focus between designing for functionality, error prevention, aesthetics, and efficiency. There is rarely a dull day, and more important, I know there is a busy healthcare professional helping a sick patient on the other side of what I do. That, to me, is meaningful and important work.
The opportunity to make an impact has largely been the main reason I’ve stayed.
Healthcare UX is a niche requiring a great deal of domain knowledge along with a technical understanding of how healthcare works. It is a field I have enjoyed thriving, and sometimes floundering, in over the past 12 years. Every industry requires domain knowledge, but healthcare runs deeper than most. As a result, I develop a greater mastery of my craft each year, leading to increased contributions, which I find immensely fulfilling.
It’s been 20 years since my failed start as an EMT/firefighter. I have the greatest admiration for those who do that work. I also maintain a great deal of empathy for these professionals as they struggle to care for people with tools that often fall short in environments offering multiple barriers. But I found my way of helping people by helping the people who help people. And on days when the design isn’t working and I am in a proverbial pixel hell, this is what keeps me going. This is why I design in healthcare UX.