Why I Design in Healthcare UX
This article was originally published on Medium.
Healthcare was something of accident for me. As I was working my way through graduate school, I never had any intentions of working in this profession — nor had I considered healthcare much of an option. Healthcare, to me, was messy, technical, scientific and full of terms and concepts I didn’t understand. But, I also believed I wasn’t cut out for it. There’s a story behind that.
Long before graduate school, I had toyed with the idea of a career in healthcare. After finishing my enlistment in the Marine Corps, I thought firefighting might be a good fit. It was the closest profession to my six year enlistment with the Marines that would allow me to help people in a different way. In the Marines, I mostly learned how to help some people through hurting other people. I saw law enforcement (a logical choice upon leaving the military) as a similar endeavor and was seeking a different direction via firefighting.
Now I know what most readers might be thinking: Firefighting isn’t healthcare. Right and wrong. It does involve helping people, but most who are not familiar with the profession (or spend too much time watching bad television shows) don’t associate firefighting with healthcare. However in many precincts, firefighters also serve as paramedics or emergency medical technicians (EMTs). So before I could attend fire school, I had to go through EMT school. That’s where healthcare comes in.
As I remember it, I wasn’t too hot on the idea of being an EMT. But as I worked through the program, my heart began to soften to the profession and the professionals who made this a career. I was exposed to the sick, the aging and the poor. I watched phenomenal professionals work what seemed, to me, like miracles. It was a whole new way of helping people.
Training as an EMT, beyond classes, involved spending a lot of time on call, riding in ambulances and hanging out in hospital emergency rooms. I mostly observed in those situations. And there was always something to observe.
One day, I watched a young woman undergo a c-section — she, speaking Spanish to her husband, while the physicians counted out the blood-laden towels they had used, throwing them on the floor in front of my partner and I. Another day, I watched the catheterization of a young man whose kidneys were in acute failure due to repeated drug use — the calloused nurses roughly handling him, speaking terse words as my observing partner explained the concept of a “frequent flyer” to me. On ambulance runs, I would encounter the elderly, the impoverished, accident victims and dangerous situations where there were weapons on the scene.
I was 26-years-old. I found the sadness and tragedy of the human condition was more than I wanted to bear. These were real people with lives and loved ones. And here I was — this stranger on the scene, an actor suddenly sucked in to the stage play. Except it wasn’t a play. It was real life.
I didn’t feel I was cut out for this work. I did want to help people and remained attached to that concept. But, I didn’t think my personality or psyche was a good fit for all I knew I would have to see and encounter. Another opportunity came along that year and I never finished fire school. I steered as far away from healthcare as I could — only to return a decade later while an intern in graduate school. But this time, my participation was significantly more anesthetic…and accidental.
In the spring of 2005, I read “Information Architecture for the World Wide Web.” That book, along with the classes I was taking at the time, changed my life and career direction. By the summer of that year, I had taken a position as an intern for Eli Lilly — working the entire summer on their intranet portal. I was to evaluate the search capabilities of their portal — conducting search log analysis, analyzing their taxonomic structure and writing up reports with recommendations.
Shortly thereafter, I took another internship evaluating a public health statistical engine at Indiana University, Indianapolis. I was essentially doing the same thing — building a standardized taxonomy to support the search engine. I was back in healthcare and finding the administrative and technical aspects of it quite fascinating.
If you would have asked me then what my dream job was, I would have told you Google. I was studying library and information science at the time and terribly interested in search engines, controlled vocabularies, data bases and the underlying structure of the web as a system. I wanted to be a taxonomist — the kind that worked with words, not biological structures or dead animals.
Around that same time period, an opportunity came along to work for a rural community hospital in Columbus, Indiana as their medical librarian and continuing medical education (CME) coordinator. I wasn’t much of a librarian in the traditional sense. My first agenda was too move from print materials to online materials — essentially converting the library to a digital entity. This was based on conversations, interviews, surveys and shadowing I conducted with the physicians and nurses to gain an understanding of their needs. I built a portal, figured out how to IP authenticate resources and created a system where healthcare professionals could access information at the point of need rather than having to walk to a physical library if and when they could. I began rounding with physicians and nurses to capture their research needs and would later scour medical resources to answer their questions. This precluded my second master’s degree in informatics and served as the roots to my experience in UX.
I eventually transitioned to the Indiana University School of Medicine working through Regenstrief as a technical project coordinator. I worked in telemedicine, developed electronic health records and created prototypes for studies. A large portion of my work at IU was in human factors where we would redesign clinics to shape behavior. For example, one large study I worked on involved mapping clinics to understand workflow and increase hand washing — a novel concept in even today’s medical world.
Through all of this experience, I gained an education (both formal and informal) in healthcare. I learned a lot about human psychology and the philosophy of medicine. I learned even more about UX and the craft of design. And, I realized I had, once again, returned to the concept of helping people — just in a different way.
It has been a long journey. But 12 years later, I am still in healthcare working as a UX professional. I occasionally get an itch to work in another industry — maybe something simpler where I can just build a landing page or frilly website with nice images. I rarely get very far in contemplating an idea like this before rejecting it. Recently, a former colleague of mine mentioned a UX position they knew of with McDonald’s. My immediate reply: “I’m not really interested in selling more hamburgers or Happy Meals to the world. There just isn’t much meaning in it.”
Still, it would be nice to work on an application or website where aesthetics took a priority — where creating something beautiful is a primary goal. Healthcare interfaces are rife with data tables, excess controls and information-packed screens with little to no imagery. Iconography is challenging in respect to ensuring the icon matches the function (or what it represents). Information architecture is deep for these applications and the cross-functional nature of the workflow makes it difficult to develop strict navigational paths. Chunking out features and functions into different screens is not always an option as efficiency is a primary concern and chunking can slow the user down in reaching their goal. This often results in bloated interfaces and applications.
So why have I stayed in healthcare UX for 12 years?
Making an Impact
The opportunity to make an impact has largely been the reason I have stayed. I could work in e-commerce, the financial industry or for various startups. But the bottom line in those industries just doesn’t have the same impact for me. I’m not knocking any other industry. Healthcare is just as financially driven as e-commerce or banking. But at the end of the day, I know there is a patient on the other side of what I am doing.
I have, on occasion, had direct contact with these patients. I’ve worked in hospitals where contact with the patients was routine. I’ve seen the ugly side of Alzheimer’s and aging while working to integrate systems for better care in clinics. I’ve walked ICU and CVU units hearing the quiet sobs of family members as I implemented hygienic systems to prevent hospital acquired infections. I have crawled around the floors of some sick and elderly, networking their homes for telemedicine studies. I have worked with the hearing impaired to develop better systems and tools in managing their hearing devices.
It has all been rewarding and meaningful work. But over the years, my contact with actual patients has decreased. It’s rare that I see or talk to a patient today. I find I need that contact less than I did in the early stages of my career because I know they (the patients) are there — somewhere on the other side of my work.
A Clear Need Exists
Good interface design (and sometimes good design, period) is not pervasive in the healthcare industry. Neither is UX. Many hospital systems do not even employ a UX staff, opting instead for out-of-the-box products to manage patients’ electronic records. It is still somewhat rare today to find a large staff of UX professionals working for a single health entity. Oddly enough, as the rest of the country has jumped on the UX Bandwagon, the healthcare industry still generally suffers from a dearth of UX professionals.
Whether it’s the interface and controls for an IV pump or some complicated piece of software like an electronic health record, healthcare is plagued with a lack of design-thinking. This isn’t necessarily true everywhere you go. But you generally have to scour the depths and far corners of healthcare to find good design. That was one of my early motivators and something that still keeps me in healthcare today — there is a clear need for good design. There is a niche to fill.
The first time I saw an electronic health record, I was horrified at how primitive the interface was — both in functionality and aesthetics. My ethnographic observations in hospitals and healthcare centers revealed a plethora of usability issues and systems that were not designed with the end-user’s goals in mind. Systems in healthcare are often driven by various agendas. Many are financially driven to ensure compliance (which maximizes compensation). Security plays a large role where your average doctor or nurse has to memorize a dozen passwords or more for logging in to a fragmented set of systems. Whatever the goal or agenda, good design usually falls at the bottom of the list.
Working in a place where there is a clear need for your services is something I have always found appealing. But there is also something deeper here. Healthcare is one of the few industries where the user is essentially forced to use your application. Other software applications such as e-commerce apps, social networking apps, gaming etc. have user bases who generally want to use your application. Doctors, pharmacists, nurses and other healthcare professionals, however, did not enter their profession with the yearning to sit in front of a computer for a large part of their day. To them, it is simply a tool and sometimes a barrier in completing their work with patients — working with patients and helping people being a primary driver in their career choice.
Healthcare professionals are not unique in that they are forced to use various software platforms to complete their everyday work. Enterprise software users also share this characteristic (think of your average intranet or your company’s software to manage your time card and/or benefits). But, healthcare UX has a much greater risk profile than Enterprise UX. There is a large difference between making a mistake on your time card versus making a mistake on a patient’s medication order. In comparing efficiency, poor usability on an enterprise platform does not hold the same consequence as it does in healthcare where every second spent with a computer is one more second not spent with a patient. It isn’t that enterprise UX is not important. It is. But the consequences are not the same and this makes it that much more important to develop solid interfaces, good user experiences and efficient means of completing tasks in healthcare.
Give Me the 411
I had a routine checkup with my primary care physician earlier this month. We always somehow get to the topic of electronic health records and this time she turned the screen towards me so we could discuss the interface and how it works (or doesn’t) for her. The hospital network I belong to uses Epic — perhaps one of the largest out-of-the-box electronic healthcare record system in healthcare.
Aside from updated chrome and minor differences, the screen she showed me looked pretty close to what you see below.
Once again, this comes from one of the largest healthcare record vendors in the United States. And in 2017, I was astonished this is the best a major vendor like Epic can do. There was entirely too much information on the screen my physician showed me, the scannability was near zero and the functionality was overly complicated for the submission and maintenance of orders.
Healthcare is a field where information is of the utmost importance. As a result, the systems and interfaces are information-heavy. It’s a lot like Enterprise UX in this respect where there is a plethora of information (and functions) to pack into a given screen. Adding to the complexity, healthcare is a highly interruptive environment where professionals are often conversing with patients while they attempt to complete a complex task (such as ordering a lab test or medication). The ability to quickly digest information and accurately complete tasks in a highly interruptive environment becomes a major priority.
This becomes an exercise in information design and information architecture. What information truly needs to be on the screen? What information can we hide or leave out without posing a risk to patient safety? How should the information be prioritized on the screen or how do we give it a hierarchy? Can it be summarized in brief allowing the user to dig deeper should they so need to?
Healthcare is not the only industry that has to mitigate information overload in interfaces. But it represents one of the worst case scenarios and largest challenges. In other industries (news, enterprise etc.), you might be able to hazard an educated guess and get it right. But in healthcare, there is so much information delivered via our applications that you are statistically bound to get it wrong via guessing. There is little room for error.
All of this makes it challenging for me — much like a puzzle I have to find all of the pieces to and fit together. It is a constant process of discovery and one where I am always learning. And, the complexity of the information design challenges means I am never bored.
Aesthetics — Cultivating Beauty
Healthcare interfaces and associated technologies are not exactly noted for their beauty or aesthetic qualities. They often, in fact, are terribly clunky, years behind current design trends and comic in their antiquity. I have always seen this as an opportunity to bring beautiful design to an industry where there is a dearth of it.
I admit there is personal satisfaction in taking an antiquated design and modernizing it. In fact, it is deeply satisfying for me to move from something that looks like this:
To something that looks like this:
It isn’t just the aesthetics, but also looking back and seeing the progress and iteration of a design that is rewarding. To me, this whole process is similar to watching a restoration — sort of like those car shows where they restore an old vehicle to new beauty. When I was in high school, I wanted to be a “body man”- working in auto shops, repairing, restoring and painting vehicles. I was fascinated with the idea of taking something old and making it new again. Instead of working with cars, I obviously ended up working with screens and interfaces. Same concept, different restoration.
But beyond personal satisfaction, why is something as superficial as aesthetics even important?
There is a wealth of research to support the idea that aesthetics have an impact on the user experience. One study with a sample size of 257, showed a significant increase in enhanced performance where poor usability was persistent in the design. Completion times and error rates were used as measurements. High visual aesthetics even improved task completion times, speeding up users. Another study with a sample size of 60, also showed increased task completion with an appealing design versus an unappealing design. However, this study also showed higher perceived ratings of usability with the highly aesthetic design (even when the interface was not more usable).
I think aesthetics will only get you so far in a design. It (the designed product) obviously has to function well. But UX to me is quite synergistic where the sum of the combined parts is greater than the sum of their separate effects. Aesthetics coupled with solid functionality equates to a greater user experience. But no design is ever perfect. They all have their flaws. This is where aesthetics plays a prominent role. Users are much more likely to overlook minor usability issues in designs with a high aesthetic quality.
Beyond just making something beautiful being a principle I find personal satisfaction in, aesthetics serves a higher function in design. And it is an element that, up until recently, has been largely ignored in healthcare where function and task completion trump all else.
Healthcare can be a very serious environment with sick people, dying people and extreme pressure on professionals each day. Healthcare professionals today spend as much time (or more) with the software we design as they do with the ailing patients they care for. Striving for aesthetic quality in a software platform gives us the opportunity to elevate the mood of a given healthcare worker — even if only slightly. In my exposure to UX, nowhere is this more important than in the healthcare industry.
Lack of Good Design Principles — Consistency, Structure, Clarity and Simplicity
I often refer to healthcare systems as “Frankenstein Systems” — not only because they are usually built at various points along a timeline by different designers and developers (a trend in other industries as well), but mostly because they are inherently fragmented. On this latter point for example, your lab work is likely handled through an entirely different system (an LIS or Laboratory Information System) than your patient record, which is an entirely different system than the system used to bill and handle your insurance coverage. A typical hospital admission could easily have touch points with six or more different systems. This leads to a fragmented system and often a designer’s nightmare.
Different systems and fragmentation aside, even when working within a single system or platform, style guides are often non-existent as are good design principles — leading to a lack of consistency and structure in many products. This is somewhat normal in the industry. It would be comical if it weren’t so sad and there weren’t thousands of users victimized by poor navigational structures, completely different interfaces and a generally fragmented experience (in the same application).
Consistency and structure allow end-users to develop a sense of familiarity with an interface. The less consistent and structured an interface is, the longer it will take to enable memorability and learnability. As memorability and learnability are primary usability components, an application lacking these components obviously falls lower on the usability scale.
Clarity in healthcare interfaces is common problem as well. Confusing controls and navigational cues along with linguistic variations (i.e. labeling problems) between systems and interfaces lead to confusion for the end-user. Errors often result in such situations and efficiency is compromised. It is no small challenge to understand the different types of end-users and their linguistics.
Clarity and simplicity go hand-in-hand and it could be argued they are similar (if not one in the same) principles. This involves the ability to determine where you are in an application, quickly determine the purpose of a given screen and promptly execute tasks. This is a challenge in healthcare applications which will often attempt to jam a dozen or more functions into a single screen. Equally challenging is explaining to stakeholders (who, remember, are often former users) why this should not be done.
I could probably write pages upon pages about the lack of good design principles in healthcare applications. It’s what keeps me employed and it is what keeps me challenged. It is both rewarding and challenging to flesh out new designs while serving as a gatekeeper for good design principles in an industry that has fallen short in this regard for so long.
People Can Die…Or They Can Be Saved
Back when UX designers were still using Visio to wireframe and Axure RP was in version 4, I had begun the initial writings for what would become a master’s thesis on the topic of health information technology-induced errors. That is, I conducted research in how technology causes errors — these errors often resulting in patient harm. This research was amassed via an integrative literature review where I sought articles in the medical literature documenting health information technology-induced errors.
[Note: This research was not beyond controversy with my thesis committee at the Indiana University School of Informatics — a program that was primary focused on educating students to work on Electronic Health Records in the health sector.]
The research results netted 18 articles containing a total of 228 errors. Of the 18 articles identified for inclusion, 89% involved poor interface design. Of the 228 errors, 51.38% involved poor UX — more than half.
The types of problems identified as a result of interface design were broad and represented issues such as juxtaposition errors in selecting from drop menus, inability to find items within a system, lack of cohesion in design and the presentation of data. When considering the UX (or the design) of health technology systems as a whole, problems such as cognitive overload, workarounds (due to poor design), the system not matching the workflow and rigidity in system design all posed problems and resulted in some type of identified error. But, “identified error” is something of an antiseptic term. In many of these instances, patients were hurt…or died.
In healthcare UX, the stakes are high. When we overload the cognition of healthcare professionals or give them the wrong information or give the right information in the wrong order, we pose a risk to the person receiving treatment. There are a number of design-related and human factors issues where the wrong design can cause errors. We can get the workflow wrong where there is a mismatch between the interface (or system) and how the end-user conducts their work or completes a task. We can choose the wrong device for the end-user (this recently happened to me). We can over-regulate or over-alert the user. And the list goes on and on.
Healthcare UX offers me an opportunity to fix these errors. Conversely, it also challenges me to avoid creating errors. This dichotomy keeps a designer walking a fine line with multiple points of focus between designing for functionality, error prevention, aesthetics and efficiency. There is rarely a dull day and as I mentioned above, there is a busy healthcare professional helping a sick patient on the other side of what I do. That, to me, is much more meaningful than designing a new social networking app or optimizing a customer shopping cart for check-out.
It may seem as though I am talking down to other industries in this article. But I am not. I use social networking apps, banking apps, enterprise apps and regularly purchase items online via e-commerce. I can appreciate other industries as a user — especially good UX in terms of functionality and aesthetics in those industries where I am a user. It is important to have good designers in those industries and I am glad they are there. I’m sure there are designers in other industries who derive great meaning and fulfillment from their work. But, it just so happens that it isn’t my cup of tea.
Healthcare UX is my cup of tea. It’s a niche requiring a great deal of domain knowledge along with a technical understanding of how healthcare in our country (and sometimes globally) works. It is a niche I have enjoyed thriving and sometimes floundering in over the past 12 years. Every industry requires domain knowledge. But healthcare runs deeper than most . As a result, I develop a greater mastery of my craft each year leading to increased contributions. This makes it immensely fulfilling for me.
It’s been 20 years since my failed start in healthcare as an EMT/firefighter. I didn’t have the backbone for it and have the greatest admiration for those who do. I also maintain a great deal of empathy for these professionals as they struggle to care for people with tools that often fall short in environments offering multiple barriers. But, I have found my way of helping people by helping the people who help people. And on days when the design isn’t working and I am in a proverbial pixel hell, this is what keeps me going. This is why I design in healthcare UX.