A few months ago, I sat in on an interesting meeting with our design team and people from a medical device company. The company had recently completed a study with more than 100 patients to understand the effectiveness of a new product they were developing. Having spent months on the investigation, their presentation was full of data, charts and statistical results. The study was unquestionably thorough, well executed and analyzed, however we noticed what we considered to be a fault in their approach: they couldn’t name a single person who had participated in the study.
Instead, they presented distilled information about their average patient. Having been in the business of design and usability for quite some time, we pointed out something that seemed to be a revelation to them. That designing a product or service for the average person is much different than designing a product or service that works for 100 individuals.
Companies have an opportunity to help patients comply with health regimens by realizing that design affects behavior.
People are complex—and therein lies the problem. Many companies, in an apparent attempt to streamline conference room presentations, veer toward oversimplification. Human issues surrounding complicated topics such as personal health care are reduced to bullet points, perhaps under the assumption that the audience wouldn’t otherwise comprehend it. Yet true innovation and ultimate success often lies in the ability to understand—and design for—the details that are often left out or overlooked.
In contrast, our design team receives great feedback when we incorporate the personal stories of individual patients in our presentations. We include photos and videos. Sometimes we even bring the patients to join in the discussion. The point is, individual real-world examples mean a lot.
Successful home health care depends on the patient and it’s difficult to measure by numbers alone. It relies on the knowledge and information available to the patient or caregiver, and the subsequent action he or she takes to help prevent, maintain, monitor or improve his or her health or condition. Quite often, technology—whether a drug or a device—is not the weak link. It’s our ability to uncover and accommodate the drivers for patients’ actions and behaviors—their desires, motivations, pain-points, mechanisms of avoidance, habits and willingness to adhere to proper in-home practices. These human elements are crucial to effective at-home health management.
So while technology is important, it doesn’t assure victory. In fact, our design group takes the view that unless it’s easily usable and used as intended, technology is not really technology at all.
Health care is not about products
Health care is not about the products we create. It’s about the ultimate effect the product or service will have on someone’s life. Although this may sound obvious, we are constantly surprised by the number of medical companies that seem to know so much more about their products than they know about people. But it’s not because they don’t care. It’s because most medical researchers and engineers aren’t trained in even the basic elements of human perception, physical ability and behavior.
When our design group approaches product and service development for the health care field, we begin by understanding two people-centered topics. First, the impact of design on behavior, and second, the ways people behave under stress.
We have seen instances where design has been the determining factor in adherence to a regimen and improvement in health. For example, we worked on the design of a new syringe for use with Cimzia, a biologic drug for rheumatoid arthritis (RA) patients. RA patients have limited strength and dexterity, making self-injection at home an arduous task. In designing the Cimzia syringe and its associated packaging, we set our goals not on the syringe and package, but on “compliance.” In other words, what can we add in the design of Cimzia’s delivery system that will help patients take their medication successfully?
With this approach, the questions we asked and the design solutions we conceived were quite different. The packaging, for instance, wasn’t simply a box to house the medication. It was an opportunity to walk patients through the steps required to take the medication, almost like a storybook.
The power of design to communicate and to affect behavior is a business opportunity. It’s too bad that we usually need to point this out to companies that come to us. Our design group is rarely approached by medical companies that aspire to use design to influence patient behavior to improve the efficacy of their medications or treatments.
Also rare is a discussion of usability and behavior under varying levels of user patient stress. If you think about it, the very simple act of taking a blood pressure reading can induce anxiety in some people. And under stress, the mind and body work differently. So for all the logic that may have been put into a task flow for a medical device, the development of medical devices (and many other types of products for that matter) often takes place without any real-world context. This means a designer or engineer’s logical explanation of how a product works and is “supposed to be used” can make perfect sense in the lab—but not once the product is at home in a kitchen or bathroom. Unfortunately for the patient, it’s extremely unlikely that a medical company will send out designers and engineers to patients’ homes to explain the reasoning behind it all.
We all know from numerous pleasant or annoying examples in our daily lives that people’s behaviors are heavily influenced—for better or worse—by the products, services and environments that surround us. Home health care products are no different. A patient’s actions will determine to what extent a product or service will work. It also means that a patient’s ability and willingness to operate the device or perform a task will ultimately determine the reputation of that product, service or brand.
The good news is that while the development of a new technology or medication could take many millions of dollars and years to develop, the opportunity for companies to increase the effectiveness of a product or service through design is often much closer at hand. That same attention to design will simultaneously enhance their brand equity.
It starts with self-awareness and diagnosis
State-of-the-art health care design demands a holistic approach. It needs to consider all of the touchpoints a person will have with a medical product, service or brand throughout time. This is not unique to medical products—we see this happening in many different types of products and services—but it is especially important in home health care, where the needs can be urgent and the consequences serious.
For the patient, the very first step to managing health is simply awareness that he or she may, in fact, have a medical concern. The first diagnosis may not come from a medical professional, and maybe not the second, third or fourth either. Friends and relatives are often the first to be consulted, along with whatever information can be called up on the Internet. This online search can be an individual or a group effort, performed not just by the person with the problem, but include others who are trying to help.
Although the reliability of Internet-sourced medical advice may be questionable, some can be credible. In the U.S., a Google search for a number of illnesses will take you quickly to PubMed, an information service published by the U.S. National Library of Medicine. And a simple search inquiry—such as diabetes, obesity, arthritis, depression or any other specific problem—brings up sites that may not include any medical device or pharmaceutical companies at all. The first pages link to sites run by organizations or government agencies—sites bearing more impartial or objective information.
Even when doctors personally consult with patients, their authority is not what it used to be. Patients look to many sources for information and guidance. So while a company’s website or product offerings may not be the very first point of contact for understanding a problem, they can be significantly influential in establishing early impressions not just of the products or services that company is offering, but of the patient’s illness itself. If it’s too medical looking or difficult to understand or navigate, the site will scare patients who are new to the illness, as well as scare away interest in that company’s line of products.
Medical devices that blatantly look like medical devices can be intimidating. The patient may be the only person to use the device, but he or she may not be the only person to see it. The same is true of packaging. Visual impact can’t be ignored. A badly designed package or device can make a person feel even sicker than he or she actually is. Or it can give that impression to others around them. It can also affect a patient’s decision to “hide” the device in a closet, as opposed to keeping it in a place more easily accessible, which can encourage use. Visual appearance can also affect the willingness of the patient to take the device along when he or she travels.
Therefore even first impressions, printed materials or web sites can predispose the patient to behavior patterns that may not be in the best interest of that patient’s future health.
Of course many medical conditions are serious, and the visual communication of a product or service needs to reflect that—but these products and services also need to integrate neatly into peoples’ homes and lives. An illness does not define a person. He or she is very much the same person as they were before the illness. This is one of the reasons we like to meet and know patients personally. Without that we could also fall into the trap of “imagining” a patient, and grouping him or her into an “average” that can unnecessary conjure stereotypical and misleading images.
Ramping up to cruise control: the first six months
After first awareness of the illness comes awareness of the products, services or brands that are available. And as a patient’s need arises, the willingness to use them does as well. Health care companies are in a unique position to initiate emotional connections with patients during the first six months. More than many other types of products, the relationship can be long-term and truly meaningful.
The “out-of-box experience,” literally the first 20 minutes or so of use, are critical to establishing a relationship between the patient and the product, service or brand. Failing to get started within this time window can lead to product returns. For example, products developed for sleep apnea can be difficult to use. We know of one case where the number of unused, returned products accounted for approximately one-third of sales. The product worked as designed, but the design was just too difficult and patients too confused about how to use it.
A patient’s experience using the product in the days immediately following first-time use is also critically important to shaping behaviors and attitudes. Establishing proper behavior in the first weeks or months of use is a project unto itself, and it should be managed as such.
Patients will be most interested, curious and apprehensive after first discovering a medical condition or starting a new routine. That start-up period, up to the point where the patient is on “cruise control,” requires special attention. That is, special care should be taken up to the point where the patient has successfully mastered use of the product or service. Not simply by knowing how to use it, but by integrating the product or service into his or her daily, weekly or monthly routine as required. If you can keep a patient on track for the first six months, they may be loyal for life.
The start-up period prior to “cruise control” provides an opportunity to create a bond with a patient, but can also be a time where the relationship can go bad. For any number of reasons the patient can fail to get up to speed on the routine, use it infrequently, or refrain from using it altogether. Surprisingly, a fear of increasing health problems in itself may not provide enough motivation to a patient to continue with a prescribed regimen. Better motivators include convenience, ease of use and instant, positive feedback. Good feedback is important, but so is “forgiveness” when a person stumbles. Other sources of motivation can come from the community. Friends and family can assist, and so can other patients. These could take the form of personal contacts or online “virtual” communities of people with similar conditions.
The semi-anonymous nature of Internet support groups can have its advantages. Online, patients can openly discuss problems and still be discreet. They may feel freer to discuss issues they would otherwise be shy about discussing in person. Sites such as patientslikeme.com put patients in touch with other patients who can offer unique support to those seeking to understand and get through their medical problem.
The first fight: resolving conflicts
The ease with which a product, service or company resolves a problem or conflict can affect subsequent behavior. It’s what we call the “first fight,” and like a problem in any relationship, the way it’s handled and resolved can have a big impact on that relationship’s future.
Within many companies, the department that manages this patient touchpoint can be different from the group that develops the product or service in the first place. Good customer service is imperative.
Some pre-planning in the event of a conflict can help speed its resolution. In past projects we have added design details such as readily identifiable shapes or colors specifically to help patients troubleshoot problems discussed over the phone with a customer service representative or a health care provider. Ideally, potential conflicts should be anticipated and not left as an afterthought.
During the design stages of medical devices, product development teams seldom incorporate “traps” into their usability studies. “Traps” are problems with the device that are intentionally presented to users. Understanding these situations can provide great insight into how a person can fail to carry out an intended task. From our design-and-behavior point of view, it is helpful to see how a patient would try to overcome a problem with a device. It gives us a sense of what solutions they may devise to work around the issue. It also helps us get a sense of when they may either make a phone call to a company’s help line, or give up completely.
The definition of product “failure” needs to include usability issues even in cases where there is nothing technically wrong with the product itself. In the United States, the FDA’s newly drafted guidelines on usability are offered to help reduce or prevent “failures” that are usability related.
But reducing failures is a minimum requirement. The FDA guidelines do not address “making it nice.” Our purpose as a design group involves more than simply eliminating errors. Our goals include encouraging use and making the experience as pleasant and painless as possible.
Behavior under stress: instincts and preconceptions
Stress can certainly occurs when a product fails to perform as expected. It can also occur at any point during a self-care procedure. Even mild stress or slight apprehension when using a medical product or service can make usability unpredictable. The mind will act differently, even when that stress is a result of self-imposed anxiety. Actions often revert to more primal impulses.
Philips points out in their product information that their HeartStart FRx Defibrillator’s on-screen guide, directed towards emergency response workers, is designed to “help the stressed user recall their training.” This was clearly a conscious effort of their design team, recognizing that even the minds of trained users may not be working as well as usual under actual emergency conditions.
Under stress people will first act on instinct, a force that can sometimes override even extended training. A simple example is the way humans are pre-wired to recognize red, the color of blood, as a common warning indicator. Using blue instead to indicate a warning, even with training, can be less effective.
People will next react according to individual preconceptions of how they think a product may work. These are very difficult to predict, since someone may base their thought process on something they have seen previously, perhaps a much different product they once owned. There is no immediate solution to overcome preconceptions other than to use design to make the proper use of the device so self-evident that its communication of use presides over those preconceptions.
After instincts and preconceptions, people will react to physical cues, making three-dimensional design a powerful tool. Communicating proper use through three-dimensional design is a stronger driver than even text. Common examples are door handles, a problem we have all experienced. We are likely to pull on a handle if it is shaped like a pull handle, even if it clearly says, “push,” especially when we are in a hurry. Simple graphics, simple text and other types of color-coding can also be effective in directing behavior and usability, but to a lesser extent.
Designing for extreme usability
There are many good reasons to move health care tasks from hospitals and clinics to the home. Cost and convenience are at the top of the list, and technology continues to make this possible. However, the move to the home will be most effective when those technologies are extremely usable.
The future of home health care, and the speed and extent to which it will develop in the next decade, will depend on the ability of patients to successfully use and understand the products we provide. Our ultimate goal is extreme usability, allowing untrained people to use the advanced-technology products that we make available, without problem.
Companies have an opportunity to help patients comply with health regimens by realizing that design affects behavior. And good design takes into account both the physical and psychological needs of the patient. The fact that design can heavily affect success or failure means that influencing the attitudes and behaviors of patients should be well within the definition of responsibilities of a product development team. While this approach can be applied whenever a new technology becomes available, the approach can also be used right now by leveraging existing resources.
Originally published in European Medical Device Technology Magazine