The Real Key to Better Health Care Isn’t Technology
It all starts with communication, the central aspect of a great patient experience
It’s 10 p.m. on a Saturday evening when Cindy arrives at the hospital via ambulance with symptoms of chest pain and nausea. Doctors begin immediately working up her analysis and ordering the tests they’ll need to diagnose her disorder. After the standard “work up,” doctors determine that Cindy has a blockage requiring a cardiac stent. She undergoes surgery and spends nearly a week in the hospital making a full recovery. Her prognosis is excellent and she returns to a normal life in the weeks following her release. It’s a happy ending in a world where similar stories do not always end so happily.
This scenario is nothing new for a hospital and it’s a routine occurrence in an emergency department on a Saturday night. But it was all new for the patient. For Cindy, this was a life-altering experience she’ll remember forever.
A few months following Cindy’s recovery, the hospital’s director of patient experience, Roger, receives a scathing letter from Cindy outlining a number of grievances involving her treatment. Despite the positive outcome of her health condition, Cindy clearly holds a very low opinion of the care she received during her stay.
In a follow-up conversation, Roger discovers that few of Cindy’s complaints focus on her medical treatment; rather, they are related to how she was treated socially. She complains that her procedures and test results were not explained. There was a nurse who made what Cindy believes to be a rude comment concerning her weight and lifestyle choices. Cindy also mentions a physician who never once looked her in the eye and referred to her as a “41-year-old, white female with no history of heart problems” as he spoke to his residents — residents whom he would parade into her room for instruction on a daily basis.
Roger asks probing questions concerning the actual medical treatment Cindy received. She has nothing but positive comments to say about the quality of her treatment, her outcome, and the EMT service members who brought her to the emergency room. But the compliments end there. Cindy soon returns to her chief complaint — poor communication and treatment from the staff — which seems to bleed into and spawn other, more minor complaints about excessive wait times, the mishandling of her insurance claim, and even the quality of the food.
Once he gets off the phone with Cindy, Roger sighs. He encounters this far too often in his work with hospitals that get the job done. They give patients quality medical care and meet all of the metrics related to medical guidelines and procedures, but somehow they fail on another level.
Unfortunately, this is not a fictitious scenario. Lisa Suennen laments many of the same issues in her article, “My patient experience: at times comforted and other moments abandoned.” Lisa is not just an average patient, either. At the time when she wrote that article, Lisa was the senior managing director at GE Ventures, leading the firm’s health care venture fund. She knows health care.
In relation to her own experience of a hospital submission, she states:
One of my areas of greatest interest in health care is how patients engage with and are treated by the health care system. Too often the patient is the last person to be thought of in these situations, despite the situation’s inability to occur without their presence.
That last line is particularly intriguing. Health care would not exist without the patient and yet Lisa is right: The patient and their experience are often an afterthought.
When we consider the importance of patient experience and try to formulate methods to improve it, we quickly discover just how momentous a task this can be. Where do we start? How can we get our arms around an experience that encompasses everything from a patient’s first contact with a health care provider and ancillary services, to aftercare and the financial aspects of their treatment?
Health care would not exist without the patient, and yet their experience is often an afterthought.
One method is to use a systematic means of analyzing what patients are dissatisfied with. A 2014 article from the British Medical Journal did just that. The authors attempted to develop a taxonomy for coding patient complaints. In the process, they evaluated 59 studies (from across the world) encompassing 88,069 patient complaints. This amounted to a total of 113,551 issues, which were then coded and categorized into subcategories for analysis. The study concluded that patient complaints fall into three overarching categories:
- Quality of clinical treatment: This category refers to the safety issues patients report or complain about, such as medication errors and errors in diagnosis, and the quality of treatment the patient feels they’ve received. For example, patients may complain that their examination was inadequate or that there were problems in the coordination of their care.
- Management of the health care organization: This is a mostly administrative category which includes issues with delays (or waiting), access to services, bureaucracy, service design, and issues with finance and billing.
- Staff-patient relationships: This is the heart of the three categories, as I will explain below. This category includes rude behavior; absent, delayed, or inadequate communication; insensitive behavior; and perhaps most important, not listening.
When you examine these issues closely, almost all of the categories and subcategories, even billing and financing, can be traced back to communication issues. As with most aspects in life, communication is a key factor in health care. We are social creatures and though we like to believe we are rational, a good percentage of our views on life are shaped by emotions and feelings. Communication and our social contact with others play a large role in shaping our feelings.
In fact, how we feel about the care we receive may actually be more important than the quality of the care itself. Studies have shown a strong correlation between malpractice claims and the quality of communication between patients and physicians. One study describes the specific complaints of patients who pursue litigation:
Physicians would not listen, would not talk openly, attempted to mislead them, or did not warn them of long-term neurodevelopmental problems (in the case of newborn injury). Other communication problems cited included perceptions that doctors deserted patients or were otherwise unavailable, devalued patient or family views, delivered information poorly, or failed to understand the patient’s perspective.
The authors follow up with this observation:
Patients are not likely to sue physicians with whom they have developed a trusting and mutually respectful relationship. Simply put, patients do not sue doctors they like and trust. This observation tends to hold true even when patients have experienced considerable injury as a result of a “medical mistake” or misjudgment.
Let’s consider this from another perspective and industry. Suppose you are out to dinner and have been waiting more than 30 minutes for your order to arrive. The server whooshes by your table routinely and avoids eye contact with you. By the time your food comes, you are intent on seeking out a manager to complain, and you’re unlikely to return to that restaurant again.
In the same scenario, how would your attitude change if the server stopped at your table to explain that the restaurant screwed up your order but they are working as fast as they can to get it out to your table? Soon after they stop by, the manager arrives with a free appetizer and apologizes profusely for the error. These are two similar scenarios with very different outcomes. In the latter scenario, communication effectively managed an abnormally long wait.
How we feel about the care we receive may actually be more important than the quality of the care.
The power of communication in health care cannot be understated. Poor communication enables medical errors and negates the patient’s existence. Health care is often all about waiting, but how different does a long wait feel when an office manager comes to your room, looks you in the eye, and apologizes, telling you the doctor experienced an unexpected patient emergency?
Similarly, when someone cannot understand their medical bill or their coverage for a medical procedure, or when an insurance company or hospital makes it difficult to submit a claim, that’s simply poor communication, too.
I would estimate a very high percentage of poor patient experiences revolve around communication. It is everything, and the health care system could gain a lot of mileage from addressing just this one issue.
How do we fix it? In UX design, our knee-jerk reaction to problems usually involves the introduction of technology. And while I do believe technology can play an important role as a conduit for communication, I don’t believe it can adequately substitute for genuine and sincere human contact and interaction. In fact, I believe technology often exacerbates the problem of poor communication in health care.
We expect technology to “push” and “pull” communication for and to us. It often does not work as intended. We also wade through a sea of information on a daily basis. Adding more electronic communication often complicates that problem. Additionally, most online health care systems do not often make it easy for us receive the information we need, or else the information is buried. Finally, there is no technology I know of that compensates for rudeness or insensitive treatment, or that can replace the humanistic aspects of our interactions.
In Mark VanderKlipp’s article “Only You Can Prevent PX Wildfires,” he writes about a husband who had just lost his wife. As he was passing by a nurse station in abject grief, he overheard the nurses laughing and talking about non-work-related stuff. The husband mentioned this in a later interview with the hospital staff.
After apologizing profusely, they [the hospital staff] resolved that this situation not happen again on this or any other unit. They looked at the entire journey that the husband had experienced, and designed a simple solution: a light on each end of the unit hallway that represented an end of life issue on the unit. Inexpensively purchased from Hobby Lobby, staff were notified that when it appears and is lit, they need to be aware and respectful.
A lamp purchased at Hobby Lobby. It wasn’t an expensive software system years in the making. It wasn’t a mobile app. It was a simple lamp used to communicate something sacred.
As I began to study patient experience design, I found a few places where I thought technology could provide an apt solution to certain problems (billing and finance, remote communication, and telemedicine or telehealth, for example). But more often than not, I found technology to be the problem and not the solution. Adding more technology is often the equivalent of placing a Band-Aid over a Band-Aid.
Improving communication in health care largely involves culture change which is difficult, but possible. To do this, the focus must shift. Health care is not currently designed around the patient. It is, as I have noted before, designed around the business of health care.
If we want to improve communication between health care professionals and patients, we must give professionals more time with patients and less time in front of computers — less time spent wrestling with technology. Clinicians tirelessly document care, procedures, and protocols, creating an endless stream of data with generally low discoverability (but of high value to the business of medicine). Changing this obsession with regulating via technology is a large part of moving toward a culture where the patient is the focus.
We can begin to apply cultural change in the most critical aspects of the health care system: the emergency room, the ICUs and CVUs of hospitals, hospice care, and pediatrics. When our children’s lives or our lives are threatened, we badly need good communication from those who hold the keys to our health.
Health care is not currently designed around the patient. It is designed around the business of health care.
When we encounter a situation where we have a less-than-stellar experience, we often begin to filter every touchpoint through that singular experience. It is something of a halo effect, where we begin to find every fault we can with an entire product or service. In contrast, an exceptionally good experience can have the opposite effect, where we overlook problems within a service or product because the good outshines the bad. Good communication can create this halo or cascade effect and I believe many of the minor complaints in health care — finance and billing, excessive waits, and poor quality food — can be alleviated through good communication and quality care. Caring communication can induce that halo effect. But that isn’t the only reason we should focus on the patient and good communication.
In the summer of 2006, I was a fresh face at Columbus Regional Hospital (now Columbus Regional Health). It was a special hospital that still brings back warm memories. The architecture was modeled in the Prairie School style of Frank Lloyd Wright with inviting lobbies, carpets (not common in hospitals during that time), and luxurious furniture for comfortable lounging. You could tell this was a different sort of hospital just by walking into any lobby.
In my first few weeks of orientation, I attended a group session with the CEO. He read to us a letter from a patient who detailed a poor experience they had during their stay. The patient’s grievances were not focused on her medical care but rather on how she was treated socially — how we communicated and did not communicate with her.
The CEO read the letter and then proceeded to give us a speech I will never forget. He stressed that we could have no way of knowing what sort of day a person has had. We don’t know what sort of news related to their health they may have received that day or the day before. He called them “guests,” not patients, and said they often come to our hospital and receive terrible news. We don’t know if a guest may have just been given a terminal diagnosis. This, he said, is why it is so important for us to always treat our guests with care. They are, after all, why we come to work each day and receive a paycheck each week.
The patient experience must become central to health care design efforts and yet the majority of our efforts lie in the pursuit of new technologies. I know this has been true for my own career. If and when we make the patient central to our design and redesign efforts, we will likely win more than half the battle in improving our health care system. And it all starts with communication, the central aspect of a great patient experience.
On her final show, Oprah Winfrey said:
I’ve talked to nearly 30,000 people on this show, and all 30,000 had one thing in common: They all wanted validation. If I could reach through this television and sit on your sofa or sit on a stool in your kitchen right now, I would tell you that every single person you will ever meet shares that common desire. They want to know: “Do you see me? Do you hear me? Does what I say mean anything to you?”
This is what patients want: to be seen, to be heard, and to be understood.