I rarely ever dig into the detriments of working in healthcare design. Those critiques are usually buried in some article touting the benefits of working in this industry. But after many years as a healthcare designer, it’s easy to spot the negative aspects of the job.
On a long enough timeline, familiarity accentuates the imperfections.
It’s like my first house. The showing went well and I remember thinking how perfect it would be for my daughter, our new dog and myself. It had been freshly painted and carpeted. It was clean and empty with a huge backyard that was freshly trimmed. I couldn’t find a single flaw with it and could almost immediately envision myself living there.
Things changed after I moved in and lived there for a while. I began to notice the cracks in the ceiling. I noticed the flawed edge on the cheap linoleum and how the backdoor didn’t quite shut right. I noticed the leak in the roof the inspector didn’t find and the shared driveway that was a pain in the ass to pull in and out of. I didn’t have to live there long before I realized it wasn’t as perfect as I thought it was. Life wasn’t as grand as I envisioned it would be.
There are a lot of things in life like that. That new job you thought was going to catapult your career. The new car or the new computer. That new “smart” TV that doesn’t seem to be so smart. My first marriage.
Familiarity accentuates the imperfections.
My venture into healthcare UX was like this. I saw the field of healthcare as ripe for the picking — a grand place for a designer to both sharpen and utilize their skills. I even predicted a massive upsurge of designers in healthcare — a prediction that has yet to materialize.
Slowly, I began to notice the cracks in the ceiling, the leaky roof and the linoleum that didn’t quite fit the floor right. That huge backyard? It was great to roam around in, get lost in. But it was albatross around my neck when the mowing season arrived. Healthcare UX was like much else in my life. Fifteen years of working in the industry allowed me to see opportunities. But it also allowed me to see all that was wrong and all of the hurdles I would need to surmount.
Familiarity accentuates the imperfections.
I wake up most mornings ready to get back at it. But every once in a while, I look up to see a dark cloud over my head. There are some aspects of the profession that keep me up at night or, at the very least, weigh heavily on my mind. Other times, there are just the hard, cold facts about working in healthcare design that I never realized until I was well into my career.
The Impact of Your Work
I once worked at the “corner of happy and healthy” for Walgreens. When I would interview candidates, they would often ask me what the big challenges were for the UX team. My answer was always the same: Most people use a pharmacy because it is convenient — a right turn on the way home, for example. How can a UX team make an impact given that scenario?
I was about halfway through my tenure at Walgreens, working on a project to replace the electronic health record (EHR) in the pharmacy, when I realized how insignificant much of my work would be from a brand loyalty perspective. No matter how much of a bang-up job we did in creating that new EHR, it was unlikely to result in a surge of new customers.
The problem most people have with pharmacies isn’t the technology per se, but how convenient the service is. Walgreens gets far more mileage out of their drive-through service (a patented service), their overpopulation of stores (location convenience) and the speed at which you can get in and out (something they struggle with).
According to our research, the greatest pain point of a Walgreens customer was waiting in line. Could a more efficient EHR interface address that pain point? Of course it could. However, the AI and increased efficiency of the new system we worked on would undoubtedly allow Walgreens to also cut labor, which could put them right back at square one.
The most beautiful and functional EHR in the world wouldn’t have meant much at the end of the day. People would still only choose Walgreens because it was a right turn on the way home, had a drive-through and allowed them to pick up a few miscellaneous groceries or healthcare needs in the process.
It was an important lesson for me. Clinicians and patients are not necessarily loyal to a brand and when they are, it is only because of what the brand can do for them. A doctor has to choose the service or brand I am working on before any of the work I do can have an impact. It often does not work the other way where the work I do is what compels a doctor to choose the brand.
But that is where the real misconception comes is. Once you have been in the industry for a little while, you’ll realize doctors or nurses rarely pick a product. Hospital networks and systems do. That means an administrator, a CEO, CFO or a CTO is making the decision. Their decisions are usually based less on the product itself and more on financial or technical benefits.
In healthcare, the true customer is the patient and they are often one step away from anything a designer touches. It becomes difficult to make an impact or to influence the customer to choose whatever service or technology you’re working on. Most of us choose a healthcare provider for trivial reasons. They are close to the house, a friend recommended them or we just Googled it. We rarely have a definitive reason in choosing a provider and healthcare networks generally have “vanilla” branding.
It sometimes becomes difficult to determine what impact you have as a designer in this type of environment. This is especially true in situations where you have limited access to your primary users, clinicians. But when you have multiple layers of users, the impact of your work can easily get lost in the crowd.
Playing Technology Catchup
Until the late 20th century, healthcare was not an industry known for technology. Oddly enough, it was and is an industry where there is ample technology present. This, of course, depends on how you define technology. The stethoscope, a microscope or an otoscope are all technologies.
Cardiac monitoring devices, the echocardiogram, imaging technology and a host of diagnostic devices have been present in healthcare for a half-century or longer. But computers were not as prevalent. Human-computer interaction in the form of humans using computers was not common in healthcare until the 20th century was nearing its end.
This has resulted in an industry where software development and the adoption of software has been slow. With the advent of software and connected technologies, healthcare has struggled to catch up and to keep pace with other industries. According to a report from the Nuffield Trust healthcare is at least a decade behind in the use of information technology.
Consider Walgreens. This is a company with a former tagline or motto of “Trusted since 1901.” Walgreens cannot be characterized as a company lacking innovation. But, it has mostly been business innovation, not technology. That is, the focus for Walgreens has been dispensing medications and not software development. The first computerized pharmacy dispensing system (an EHR for the pharmacy) at Walgreens, Intercom Plus, was developed and released around 1993. In 2015, that same system experienced an outage effectively forcing 8,200 stores to manually fill prescriptions. That dated system is still in use today.
The hearing instrument industry is another example. Until the late ’80s or early ’90s, software was not employed to adjust the algorithms on hearing instrument microchips. Hearing instruments, prior to the advent of software, were adjusted with a small screwdriver-like device. Software development has not been a priority for the hearing instrument industry and one could make the case that it still isn’t.
The majority of hospitals did not employ the widespread use of computers until the EHR became a common tool. What this has resulted in is an industry that has a lot of experience with caring for patients (though it is debatable as to how well we do that in the United States) and very little experience with computer technology and software. Walgreens, for example, existed for nearly 100 years until they began the widespread use of computers in their stores. The same can be said of the hearing instrument industry. Hospitals, as a whole, did not begin adopting the EHR until the Affordable Care Act provided incentives (roughly 2010 is where the uptick started).
As I began my career in healthcare design, I saw a lot of opportunity in this industry. As I progressed in my career, I realized I was working within an industry that had, in a general sense, remedial technology skills and generally a very poor understanding of software development. The result has been a lot of time spent arguing for designs and technologies that would have been no-brainers in other industries. It resulted in a lot of projects where I designed products that were never to see a full development cycle. It has also resulted in a number of band-aids and patchwork designs to connect systems that should have been connected long ago.
Even I can admit technology is not necessarily a top priority in healthcare. There are bigger problems to address in our healthcare system. But I believe technology can play a large role in solving some of those problems with telehealth, better EHRs and technologies to monitor patients beyond the hospital or doctor’s office. It might take a crisis like COVID-19 to help push this agenda along.
The EHR: Lock Me In
The electronic health record is, arguably, the heartbeat and lifeblood of healthcare today — at least, from a technological viewpoint. Twenty years ago, it was the Holy Grail of many health systems and just as unobtainable. But all of that changed with the ACA and Hi-Tech legislation that provided incentives and financial assistance for hospitals to implement EHRs.
It seemed like we were finally making progress. Hospital systems began implementing the EHR in droves. The market readily met the need with several large corporations offering solutions. Companies like Epic, Cerner and McKesson peddled their EHRs across the country becoming the largest providers in the industry. This, of course, was quite lucrative for each of these corporations (leaving one to wonder just how active their roles and lobbying efforts were in the ACA and Hi-Tech legislation).
For a short period of time — very short — healthcare looked as though it were on the rise and was ready to meet the new millennium despite being more than a decade late. But the EHR has not been the boon we all thought it would be for a number of different reasons.
The largest reasons relate to the unintended consequences of the widespread implementation of EHRs. In some instances, the EHR increases the error rate in medicine or creates new errors. Because technology multiplies the speed of almost everything, the EHR has, in some implementations, multiplied the number of errors (and subsequent deaths) made in healthcare.
Another unintended consequence is the amount of clinician time spent managing this new technology. Atul Gawande wrote an in-depth article covering physician burnout as a result of the EHR a few years ago. His points are still relevant to the industry today. And over the past decade, I have often realized I am designing products and features that actually create more work for healthcare professionals. I am, sometimes, part of the problem — a contradiction to my true professional purpose of improving the lives of healthcare professionals and patients. If you can’t keep your healthcare professionals in their positions because of burnout, you will have trouble realizing that larger vision.
But the element of the EHR that truly becomes that dark cloud over my head is vendor lock-in.
There was a time not that long ago where your entire music collection was kept on physical media — LPs, CDs, cassette tapes. MP3s and iPods changed all of that. Today, you walk around with thousands of songs or albums in your pocket (or mostly in the cloud). The downside to this is you are often married to your platform of choice. Apple, for example, is real good about ensuring you continue to buy their phones, iPods, Apple TVs and subscribe to their services. Once you have hundreds or thousands of dollars purchased in movies or music, are you really going to switch platforms? You might. But you’ll think twice about it and likely calculate the expenses before doing so.
This is generally referred to as vendor lock-in. It is a situation in which it is too expensive or time-consuming to switch vendors. Once you’re on the platform, the burden of switching to some other product simply comes at too high of a cost.
This same situation exists in healthcare. But it’s much worse and it starts with the implementation of the EHR in a hospital system. Here is how Gawande describes his own hospital system’s implementation:
More than ninety per cent of American hospitals have been computerized during the past decade, and more than half of Americans have their health information in the Epic system. Seventy thousand employees of Partners HealthCare — spread across twelve hospitals and hundreds of clinics in New England — were going to have to adopt the new software. I was in the first wave of implementation, along with eighteen thousand other doctors, nurses, pharmacists, lab techs, administrators, and the like.
For another two weeks, my department doubled the time allocated for appointments and procedures in order to accommodate our learning curve. This, I discovered, was the real reason the upgrade cost $1.6 billion. The software costs were under a hundred million dollars. The bulk of the expenses came from lost patient revenues and all the tech-support personnel and other people needed during the implementation phase.
The sheer magnitude of this effort is mind-boggling both in terms of implementation costs and the number of labor hours devoted to the launch. Think of the implications here for just a moment. Once a hospital spends this much money and expends this amount of effort to transition to a health record system, is it likely they will ever want to switch record systems again? Something catastrophic would have to happen for a hospital or hospital system to train employees all over again, suffer downtime during the transition and risk implementation errors or risk safety issues as a result of implementation.
The other side of vendor lock-in is considering the company’s perspective. Companies often become like the big, fat cat that only moves off the couch for its daily can of Fancy Feast. They have little motivation to do anything else once their meal ticket is set for life.
If you’re a company like Epic, how likely are you to truly innovate when your market share is more than 50 percent? You are a giant in the industry, your customers are essentially locked in and just the maintenance of your existing software represents a huge percentage of your allocated labor. Pursuing some new innovation requires the assumption of risk. And while you are certainly a large enough company to absorb any loss a risky venture might impose, you have shareholders and investors to answer to.
The larger a company, the less likely it is to pursue risky ventures. Smaller companies (like startups) are often starting at less than zero with much less to lose. Unfortunately, companies like Epic, Cerner and McKesson are the big fish. They establish the rules and the smaller companies have to figure out a way to play nicely with their often poorly designed solutions.
The true question becomes one of change. How do you change an industry steeped in tradition as healthcare is? How do you make a change with technology when the predominant technologies are already established?
Like Sisyphus, I often feel as though I am rolling that rock up the hill — knowing full well it will push me back to the bottom. I’m Charlie Brown kicking the football. Just one more kick— maybe I’ll get it this time.
There is, however, hope. So even on those days when that dark cloud seems to be overhead, I can still spot a ray of sunlight.
In the summer of 1994, a tiny little online marketplace for books opened its virtual doors. The founder called the company Amazon and began to define a new way of buying books and, eventually, almost everything else. Four short years later, in the fall of 1998, a tiny little search engine called Google made its debut amidst giants like Yahoo!. These tiny companies changed the way we shop, search, socialize and live.
So while the big companies in healthcare technology trudge along like dinosaurs, smaller companies are finding their way. They are experimenting with new ways to use technology. Someday, one of those little companies will build the next EHR — the one that will far surpass the capabilities and technologies underlying the current giants. Someday perhaps, the healthcare industry will shed its technophobic persona and surpass other industries in deploying and exploiting new technologies.
If those two things can happen (and I believe they eventually will), the healthcare industry will have the time and the resources to begin focusing on who they are and how they are perceived — branding, if you will. This is already an effort in place with a huge movement around the patient experience — perhaps the best branding and differentiating strategy a healthcare system or network could pursue.
Providing an excellent patient experience is what will differentiate one healthcare system from another. This will also provide exposure to the technologies designers create. Whether you design for the clinician or the patient, the benefits will trickle down. Happier clinicians should conceivably create improved patient experiences and, thus, should beget a higher loyalty.
With the recent coronavirus outbreak, healthcare will have to embrace technology as it never has before. There is no longer as much room for the “old ways” in medicine. Businesses operating in the health technology sector, such as electronic healthcare record companies, will also have to raise the bar to meet new demands.
Healthcare design and healthcare as an industry isn’t too much different from that old house I lived in so many years ago. The ceiling is cracked and leaks a little. The huge lawn needs weeded and mowed. And the basement floods during a large storm. Healthcare is weathering its own storm right now.
But that old house I had? I eventually grew to love that house despite its need for perpetual maintenance. And in so many ways, I still love healthcare design…even on the darkest of days.
Familiarity accentuates the imperfections. But sometimes there are gems hidden within the imperfections just waiting to be discovered. Sometimes, the imperfections are what gives an entity endearing qualities. It’s what challenges us and keeps us showing up each day.