It was late in the evening on St. Patrick’s Day 2017 when the nurse entered the room for the second time to administer my medication. This was also the second time I noted he had not washed his hands or sanitized prior to conducting what is referred to in health care as an “invasive procedure.” (The administration of my medication necessitated a needle piercing my skin.)
He was rushed, I could tell. I kindly asked if he would mind sanitizing his hands before he “stuck me.” I couldn’t help it. I had been in health care for 12 years and this was my third night in the intensive care unit (ICU). I knew this was a place where hospital-acquired infections are more common due to the nature of illnesses and invasive procedures conducted. But, I also understood he was working against the clock. He complied, but it was obvious he was perturbed. It wasn’t necessarily his fault. He was rushed because of the decisions someone in hospital administration had made influencing the design of his workflow.
There was a computer in the corner of the room networked to the electronic health record (EHR). The nurse would have to scan the medication label and then scan my wristband to ensure I was, indeed, the right person to get this medication. He would then have to log the administration of the medication into the EHR, which would provide a time and date stamp as to when the medication was given. If he was late in doing this, he would be held accountable. And that was only one metric affecting my care. There were many others: If the doctor did not document my diagnosis correctly along with the need for the medication, the hospital might not get paid. If, upon discharge, I returned to the emergency room with complications, there could be a black mark against the hospital’s ratings.
At that point, I had spent a considerable amount of my life designing EHRs and other health care technologies. I had attended meetings with administrators who would direct my team to design these systems for compliance, regulation, and efficiency — not realizing the unintended consequences such direction would have on the overall design or user workflow. They often were not able to see the larger picture, how their decisions influenced a larger system.
A day later, I would be discharged by a physician I had never met during my stay. She was on call that day and filling in. Later that same day, I would arrive at my local pharmacy to discover the medication I had been prescribed upon discharge, which I desperately needed, was not covered by my insurance and bore a whopping price tag in comparison to another similar medication that was covered by my insurance. There was no way this could have been known when I was discharged, because the hospital, pharmacy, and insurance systems do not have a three-way conversation concerning such matters. This meant I had to get the physician who discharged me to change my medication. It was a Sunday. I knew it wouldn’t happen until the next morning when her office was open.
I was sick, tired, and weak. I’d suffer through the night in my condition until I could get a medication I could afford. I would, later, navigate further through the labyrinth of health care on my way back to full health. I was, I found, in the midst of a user experience ecosystem — an ecosystem I played a part in designing, but had never thought of in such a light.
Touch points and ecosystems
In user experience design, we may spend weeks or months conducting user research, conceptualizing and fine-tuning a design for a feature or system. We’ll establish the problem and seek solutions. We will deliberate over the use of controls and components in the design. We’ll discuss color palettes and branding. And this will often only address one small part of a system or a single feature. But ecosystems are larger than your feature. They are larger than your organization. And your journey map will often not span the entire ecosystem of the user experience.
At IA Summit 2018, Jared Spool gave a presentation on UX ecosystems. He used the U.S. government and the Hawaii false missile alert of 2018 as a backdrop for his presentation exploring an ecosystem viewed from different perspectives. In his presentation, Spool stated, “ecosystem-wide design issues are our next tough challenges.” He illustrated this as he walked through local and federal government bureaucracies — complex portions of the greater government ecosystem.
Health care is also a complex ecosystem and has, of late, perpetually been in the public eye as a controversial aspect of government. Patients journey through a myriad of systems and agencies to receive their care. A patient with diabetes, for example, will have a minimum of three different physicians on their care team. These physicians may or may not share the same EHR and, thus, may not coordinate care. If that patient is hospitalized, the hospital may have a different care team and use a different EHR as well. This patient will undoubtedly need medication from a local pharmacy. The pharmacy has a system for managing the medication therapy of a patient. This system usually only communicates with the previously mentioned systems to receive orders for prescriptions. Additionally, the patient will use different apps and devices for managing their dietary intake and monitoring their blood glucose levels. The insurance industry may also play a role in the patient’s care, as well as local and federal regulations. The average diabetes patient could easily find themselves navigating a half-dozen different systems to manage their care.
The above scenario does not, of course, factor in every single touch point a patient could interact with. Peter Morville outlined a “touchpoint taxonomy” in his IA Summit 2012 presentation, “Designing for Cross-Channel Experiences.” His taxonomy illustrates both how complex a user’s journey can become and how holistic an experience truly is.
In health care, there are touch points beyond a patient’s direct contact with the health care system. Patients consult the internet for information and are lead through a series of different websites and information repositories. They have friends and families, a community of people who support or influence their care. They have professional lives they must manage when adapting to a new disease or medical disorder. There are government agencies that may affect their care, such as the FDA as it approves new medications, federal, state, and local regulations, and Medicare or Medicaid for those who are eligible. The UX ecosystem for a diabetic is shown below.
All of the above makeup a user experience ecosystem. And, in designing for such a system, one must consider touch points beyond the organization. We can journey-map a patient’s experience through a pharmacy, for example, quite easily, and design teams have become adept at this. However, what happens before and after a patient encounters your product or service? What ancillary services and products are they receiving or using?
In order to adequately design for an ecosystem, we must evaluate touch points across a continuum. When we move across the continuum in this way, we are better able to identify the gaps in care patients receive, their pain points, and where the ecosystem breaks for them. This allows us to discover the failures in consistent care and explore solutions.
Consider a patient who receives a new prescription for blood pressure medication. She is noncompliant, only taking her medicine two or three times per week instead of daily as prescribed. The pharmacy knows this because she is not refilling the prescription every 30 days. After a few months, she returns to her doctor and her blood pressure is still high. So, the doctor increases her dosage, not realizing she is noncompliant. She returns to the pharmacy to fill the new prescription. If she becomes compliant and begins taking that medication every day, there is the chance her blood pressure could become too low — a dangerous situation.
When we look at the above scenario and design at the level of an ecosystem, we begin to understand the pharmacy has a larger problem than just filling a medication and getting it dispensed to a patient. There is now a problem concerning patient safety and a gap in the ecosystem. A bridge between touch points could be created: A pharmacy could conceivably coordinate care and communicate with the doctor about the patient’s noncompliance. In turn, this would also address a larger problem concerning patient safety. Additionally, the pharmacy would now address not only the patient’s health and well-being, but also the well-being of the health care system, because noncompliant patients contribute to higher insurance costs and poorer outcomes of care. This can only happen when we address ecosystem-wide design issues.
The challenge herein is that touch points often represent a different system (i.e., a different technology or channel) or domain with a different set of agents and designers. For example, an average hospital will have staff functioning within different areas of care administration. Some of the staff are responsible for direct care. Some are responsible for quality control. And others are responsible for the administration. Additionally, an EHR largely manages the care a patient receives — everything from lab and medication orders to ensuring the caregiver complies with state and federal regulations (and regulations ensuring compensation is received). The EHR is most likely a product designed by an external team that the hospital purchased and had modified to suit their needs. And it may or may not communicate with other hospital systems such as the laboratory information system (LIS) or the billing system or the on-call and scheduling system. A hospital is just one organization — almost its own ecosystem.
Gaps between touch points
What happens when the patient leaves that ecosystem? What happens when they return home and do not understand their complete regimen of therapy? What happens when they return to their primary care physician or travel to their local pharmacy (different systems designed by different teams)? Care coordination breaks down across the boundaries of the ecosystem when the design is compartmentalized and only addresses single organizations.
As I note above and in a previous article, I spend a lot of time with my design team discussing things like colors, controls, and the functionality between screens in a system designed to quickly and safely dispense medication to a patient in a pharmacy. Those efforts do not completely ignore the ecosystem that is a larger part of what I work on. But the ecosystem is a very small part of what I touch in design efforts.
If you are admitted to a hospital today, you stand a chance of being harmed due to medical errors. Medical errors are, according to a 2016 article in the British Medical Journal, the third leading cause of death in the United States — just behind heart disease and cancer (respectively). A leading cause of medical errors is technology. But a less obvious place where medical errors are likely to occur is during what is referred to as patient handoff.
Patient handoff occurs any time a patient moves from one care team (or unit) to another. For example, moving from the emergency room to an intensive care unit is a handoff. The patient will encounter a whole new care team who must quickly apprise themselves of the patient’s status, history, and the therapeutic regimen prescribed. Error rates are higher between handoff teams due to the communication gap between the care teams. An analogy would be if, in UX, you were to hand off your designs for a feature to a new design team. They would have to quickly develop all of the knowledge you have around the design and research in order to proceed.
Similar to a hospital, an ecosystem has handoffs. Each time a user moves to a new section or domain of the ecosystem, there is a gap to fill. These can be gaps in communication, the level of service, technology, etc. For example, when a patient is discharged from a hospital and subsequently visits their primary care physician or local pharmacy, they enter (or are handed off to) a new system where the events in the previous system must be communicated (or aligned) within the new system. It is during these “handoffs” that the ecosystem is more likely to break, resulting in a poor experience, errors, or a pain point for the user.
Designing for the ecosystem
But how do we design for something as intricate as an ecosystem — especially an ecosystem as complex as health care? It may seem an impossible challenge. After all, Hospitals are independent entities, as are pharmacy chains, physicians’ offices, medical device manufacturers, and the communities in which patients live. As organizational technologies such as computers, systems, and applications become more ubiquitous, the future of designing for ecosystems may be closer than we think. As such, there are some elements designers can take under consideration.
- Map the ecosystem. A user’s journey will not necessarily begin and end with your product or service. Users live in communities. They have social networks and use products and services ancillary the one you design for. What happens when they leave your system and enter a new part of the ecosystem? In health care, the coordination of care across the continuum is crucial to patient outcomes. Something as simple as a follow-up phone call from the hospital after discharge to answer questions or just check on a patient can markedly improve patient care and aid in coordination among different parts of the ecosystem the patient will journey through. Mapping the ecosystem will enable us to design across a continuum, understanding the pain points and gaps.
- Evaluate all touch points. The user journey and touch points along their journey do not start and end with the experience you design. For example, a user’s journey does not begin when they walk through the doors of a hospital and end upon discharge. There are touch points along the journey long before they encounter your product or service, and far beyond.
- Agency partnership. In an ecosystem as complicated as health care, there will have to be stronger partnerships across disciplines and agencies. For example, hospitals will have to work toward a model where they share information and form partnerships to provide a better continuum of service to patients. This is no small challenge in health care and many other industries. But designing at the ecosystem level will require industries to work together in order to fill the gaps among services and products.
- Improved standards and mandates. Just as there are ISO standards for everything from quality management to information security, we also need new or improved standards to enable design at the ecosystem level. In the case of health care, there is meaningful use for EHRs (part of the American Reinvestment and Recovery Act of 2009). Meaningful use provides incentives for the use of EHRs to improve the quality of care for patients. Primarily, this revolves around the exchange of information. Similar efforts could encourage tighter collaboration among the different agencies in an ecosystem to enable better handoffs and design at the ecosystem level.
- Design influencers. As organizations, we cannot forget who we serve, that our business is not to serve ourselves or our organizations but to serve the user. Nearly everyone who sits in any sort of meeting to plan a product or service becomes, in some way, a designer. If we make decisions at the business level to increase profit, we cannot do this at the expense of the user. Systems that are built for efficiency, with metrics to measure efficiency, will drive efficiency regardless of what organizational values are listed in the vision statement. The nurse who did not wash his hands prior to administering my medication sacrificed quality because he was working in a system that prodded him toward efficiency. No one would likely know whether he had washed his hands prior to the procedure since there was no metric in place to measure that. But there was a metric in place to measure the timeliness of his medication administration. At some point, there was a meeting in which the unintended consequence of that business decision was not considered. The designers on a UX team are not the only people influencing design.
To be fair, we aren’t there yet. That is, we are moving toward the ability to design for the ecosystem in UX. But we are not yet able to bridge the gaps among different domains within the entire ecosystem. There is every indication that the ubiquitous nature of technology and the connectedness of our lives will push industries toward an ecosystem design model.
The UX profession has moved from designing singular interfaces to designing large systems at organizational levels and, recently, to cross-channel design where we consider design across different devices or channels. The next level of design for our profession, as Spool states, will be bridging the gaps among elements and domains in a larger ecosystem. To do this, we will have to shift our thinking and paradigms to a larger set of experiences our users encounter. We will have to design for the ecosystem.
Originally published at uxpamagazine.org