“Changing the culture of Healthcare” a case for clinically informed user experience (UX) research, in eHealth.
A call for culture change that invites a strong UX research and design strategy to lead the way.
Recognition that most eHealth apps fail to attract or sustain a user base is a daunting prospect for any innovator, whilst failing to reassure investors seeking a healthy ROI. I have my own experience of introducing award-winning health technology that doesn’t attract its intended user base.
In this scenario, it’s time for all parties to reflect.
But, let’s start with a brief review of how the issue is being framed…
There are calls to action to “change the culture of healthcare” across the health landscape, from Matt Hancock down. The meaning of this statement is seemingly diverse, with some calling for more innovation funding support, others blaming health services for not buying existing innovations fast enough and others blaming patients themselves for not being ready for technology and being hung up on old models of care.
I have discussed the emotional and tradition based barriers of the existing medical model in my TEDx talk and so won’t repeat here.
The problem with this call to action is that it negates the nature of culture. Cultures are self-maintaining through tradition and custom. A 70-year-old model of healthcare (the NHS) and an even longer understanding of the role of medical professionals, in our lives, is not going to be easy to shake off. From birth, most of us have been taught to ignore our health status until we are ill, then to seek a medical professional to cure us. It’s a model that medics are trained to serve and the NHS has been paid to support — with very little spent on creating systems that aid us in being fit, healthy and educated around managing our own health. This is our healthcare culture and it has remained relatively unchanged since the birth of the medical model some 200+ years ago.
The working practice of the NHS itself is near impossible to change faster than snail pace. Many healthcare innovations occur at a regional level, with NHS Trusts often unaware of other regional innovations in similar spaces — and newly developing infrastructure to identify and scale up good ideas to a national level. Good ideas are usually promoted to commissioners, who make regional purchasing decisions — a process that is expensive for innovators and slow for NHS Trusts to activate. Beyond this, the consumers of the NHS (patients) are not screaming out for tech innovation. The public are not complaining about what the NHS does, rather how fast it does it — usually.
Innovators beware, this is a hard nut to crack!
Changing our culture, of healthcare provision and consumption, requires us to reform our collective expectation of health to a new model that includes independent and proactive healthy living alongside self-managed treatment. There isn’t just cultural resistance, it is an alien idea to everyone involved. I will repeat, medics are trained to cure, patients are trained to seek medics for a cure and the NHS houses it all.
When ideas are alien, it is important not to force a conceptual leap or to demand a “cultural change” — no matter how appealing the predicted outcome may be. Change has to be digestible, appealing and seamless with existing behaviour. Humans are creatures of habit and familiarity, we prefer both and will choose both in any context of uncertainty or anxiety. Uncertainty and anxiety are perhaps the two emotions most associated with ill health and with suggestions that we should move outside of patterns of behaviour we trust.
Change, in this scenario, is a threat to a situation that is already experienced as a threat.
Patients don’t want to be left in the cold with no safety net and clinicians don’t want to send people away with a care model they don’t trust.
It is not impossible to change care and to innovate in this space, the NHS has thrived on R&D since its inception — however, innovators need to take extra care to realise that their consumers are driven by emotions unique to the health sector.
So, rather than pushing for culture change in a change-adverse setting, I propose that we work out what’s needed and desired. I also propose how we might go about discovering this.
What do patients & services need and want?
User experience (UX) research is king in the commercial, business and entertainment sectors. The boom in UX and usability research posts available, in the commercial sector, is at a constant peak. Investors and innovation leads have recognised that optimal ROI is linked to design psychology, building solutions that are wanted and desired, providing the right balance between interactive effort and user return.
UX and usability are also chanted like a mantra, by those who evaluate eHealth technologies. However, I am not convinced that the stakeholders in eHealth have grasped the scale of need in this respect and the specific requirements of UX for health change innovation.
There is one question that is rarely asked well if at all,
“what do clinicians, teams and patients want?”
This is paramount and is critical before any effort is taken to explore what works — but knowing what a collective of people and systems ‘wants’ is not as simple as asking a question.
Here I will briefly describe two themes to consider when trying to address this question to inform the foundations of a UX design strategy. In later writing, I will expand on the methods I allude to in this introductory piece:
Problem Identification
It is imperative to identify a problem that needs to be solved, a problem that is visible and recognised as a need by all stakeholders. There are numerous methods for accessing and articulating a health problem — tailored to the problem type — a system, process, monitoring need, educational gap, treatment etc. I won’t summarise all approaches here, as they are legion and project specific. The key is finding the uniform language that describes the problem across all stakeholders, alongside the barriers and opportunities for change.
Some may call these barriers and opportunities the ‘cultural issues’, which I wouldn’t necessarily argue with, except that I would recognise cultures of health delivery as being at the micro level (regional and clinic setting) to a macro level (organisational, national and policy). In both cases, we need to identify the beliefs about the respective health condition, models of care and what is considered best outcomes for those involved.
Innovation has to be described in a way that builds on this information and has to address themes such as change management, logistics, implementation practice, impact, engagement and economics.
Without this clear problem, all construction is on a foundation of sand. From persuading commissioning through to identifying the user, the case for health interventions is multi-system wide and must be drawn out of recognised need. More immediately tangible, system design has little to draw on beyond the approaches of competitors or models that appear successful in other areas. Both of these lead to a cul-de-sac in respect to design.
Problem identification can be very difficult without the relevant experience of health research, psychological theoretical knowledge and access to the right expertise (patient, clinical, NHS and theories). Seeking development partners early is a recognised tenant of success.
For those considering working with inexperienced or isolated development teams, beware. Health innovation is context dependent and will rely on being accepted into the largest village in the world, the NHS. Most of my calls to support are from projects that should have sought expertise earlier, needing to invest in redevelopment or failing to understand their own USP in the complex world of healthcare.
Users have health conditions
Health beliefs are central to user experience research and specific to each medical condition. Health consumers are not engaging as if they are downloading a new album or to buying new clothes online, they are resigning to using technology as their primary wish (to be healthy) has not been met.
Standard methods of UX research hold at their core ideas around motivation and reward-seeking behaviour that are less applicable in health service/intervention design. There is a strong case for ditching the constricted user persona and a need for a design team to know their target health construct.
Illness does not discriminate, there are rarely demographic characteristics that group users, except their relationships with their health condition and their healthcare provision. Note that I refer to the relationship and not the condition itself. Interactions are imperative to understand as the UI within eHealth solutions needs to resonate with how patients already interact with their health condition — and not just with their health providers.
Interaction styles are taught to patients as they are incorporated into a new, and usually unwelcome, health identity. A newly diagnosed patient interacts and expects different experiences and outcomes to the long-term patient, your design has to know where patients are in their health journey and pick up engagement at the right point, or in tailored ways at different points.
All users who want to download Pink Floyd are at the same point in their journey — wanting to consume Pink Floyd. A person with ‘diabetes’ can be at one of many points in their health journey, usually with an array of complex needs and conflicting emotions — some that drive engagement and others that deny the condition/need.
A range of qualitative approaches that tap social constructs in the real world (social media, charity publications, TV representation etc) alongside personal constructs (health condition experiences, clinic experiences, family experiences etc) can provide a valuable route into the social representation of wellness, education, treatment and management of health conditions.
To avoid a leap of faith, designers need to blend design standards with health constructs — often compromising what may be considered standard design in other sectors. This is a huge challenge to experienced designers, where ideas about how best to interact with UI can cloud the need to think totally out of the box. The perfect balance is the effort needed (usability and engagement) against the reward gained. Reward in eHealth is rarely immediate and often long-term, so creative thinking is required to offset this ‘savings’ account approach to engagement.
The closer this creative thinking fits with an informed ‘health construct’, the more likely you can achieve engagement.
Summary
eHealth should not wait for the entire nation to wake up tomorrow and have forgotten our 200+ year relationship with healthcare. Rather, UX research needs to draw on health service change models to identify what patients, clinicians and systems want and can accommodate.
Engagement is the holy grail in healthcare delivery, without it — even the best theoretical model will fail.