On Norman doors, sign design, and why you need to think like a designer!

On Norman doors, sign
design, and why you need
to think like a designer!
Joyce Lee, MD, MPH
Robert Kelch Professor of Pediatrics
http://www.doctorasdesigner.com/
Twitter: @joyclee

Professor of Pediatrics
Clinical/Health Services Research
Learning Health Systems
Quality Improvement Director
Epic Physician Builder
Participatory Design / Maker Movement
Patient online communities
Background
@joyclee

T1D Exchange
No ties to Pharmaceutical Companies
Disclosures
@joyclee

I don’t know anything about
innovation in critical care;
you guys are the experts
Disclosures
@joyclee

YOU are a
designer.
(Welcome to the club.)
@joyclee

Design is a Process
Design is a Mindset
Design is a System
@joyclee

Can the user
accomplish their goal?
@joyclee

It’s a Wednesday
at 4:30 PM and
you have a 30 min
meeting.
Can you interpret
this sign?
@joyclee

Can I park here?
How long can I
park?
@joyclee

The Problem
A $95 parking ticket
@joyclee

“But I read the sign, and I
thought I could park there!
Did I misunderstand
something??”
“I wondered why the signs
had to be so complicated.”
“My mind felt like it was
doing intense math
whenever I tried translating
the signs.”
-Nikki Sylianteng
@joyclee

Understanding the Problem
@joycleetoparkornottopark.com

Ideating Solutions
@joycleetoparkornottopark.com

toparkornottopark.com @joyclee
Prototyping Solutions

Testing and More Prototyping
@joyclee

Finally, A Parking
Sign That's Easy To Read
@joyclee

Design Success!
“Up to 60% improved compliance”
@joyclee

Graduate School
Applicant
Who is qualified to be a designer?
@joyclee

@joyclee
Anyone can and should be a designer!

Parallels between Parking Signs
and Healthcare
@joyclee

What medicine
do I take?
What time and
day do I take
it?
@joyclee

Design is a form of
problem solving.
@joyclee

“An approach that puts
human needs,
capabilities, and
behavior first, then
designs to
accommodate those
needs, capabilities and
ways of behaving.”
-Don Norman
Human-Centered Design/
Design Thinking
@joyclee

Patients and caregivers.
NOT doctors, nurses, clinic
managers, administrators, or
insurers.
Focus on the end-users in
healthcare.
@joyclee

Use the Design Process.
Empathy.
Define.
Ideate.
Prototype.
Test.
@joyclee

Talk to patients
about the pain
points; don’t
make
assumptions
Empathy.
@joyclee

Encourage patients to
define the problem.
Define.
@joyclee

Collaborate
& think of
lots of wild
and crazy
ideas.
Ideate.
@joyclee

Sketch, draw,
glue, code.
Prototype.
@joyclee

Show your
prototype to
users and
get their
feedback.
Test.
@joyclee

Prototype.
Test.
Prototype.
Test.
Prototype.
Test.
@joyclee

Design helps you ask the
right questions, to ensure
that you are solving the
right problem.
@joyclee

If you do not engage with
your users, you will be
doomed to solving all the
wrong problems.
@joyclee

“If the most fundamental definition of design
is to solve problems, why are so many people
devoting so much energy to solving problems
that don’t really exist?
How can we get more people to look beyond
their own lived experience?”

A “smart” button and zipper that alerts you if
your fly is down.
A service that will film anything you desire with a
drone.
A service that delivers your beer right to your
door.
An app that analyzes the quality of your French
kissing.
An app with speaker that plays music from
within a mother’s vaginal walls to her unborn
baby.

Problem: Replace my missing limb with an
artificial limb
Reality: “universal high-tech artificial limbs were a
dead weight”

Problem: Augment
me, by helping me
become a rock
climber”

Cindy calls it her “Darth Vader hand,”
and finds it is hot, heavy, and too
robotic-looking; she finds the
inhumanly long fingers awkward to
use.

The standard tools provided to her…didn’t
facilitate some of the most important things
she wanted to recover—how to write a thank
you note, feed herself, put on makeup and
jewelry, turn the pages in a picture book as she
reads to her grandchildren. So Cindy started to
design and build what she needed.
@joyclee

There is a lot of
bad design
in healthcare.
@joyclee

xxx-diabetes-fax@med.umich.edu
@joyclee

Don’t fix the problem, make the
user do more work
“Do you carry multiple pagers and our phones on your belt?
If so, it can result in pages being missed for jumbled. This is a
documented issue and can have a serious impact on patient
care.
If you carry multiple devices on your belt, please be sure to
keep each device approximately 1 hands width apart.”
@joyclee

Hide Admin Docs
“The EHR made ”Hide Admin Docs” the default
which hides lots of documents.
If you are unable to find something that was
imaged, first look to see if the “Hide Admin Docs”
box is checked and uncheck the box if it is”
Don’t fix the problem, make the
user do more work
@joyclee

“Learning to design
is learning to see.”
- Oliver Reichenstein
@joyclee

@joyclee
Design Flaw #1:
The Needle is Opposite to the Cap

15,000
Unintentional injections from Epi-Pens
in the US between 1994-2007
@joyclee

“Despite instructions rendered on the
package insert, a large number of
health care professionals including
nurses, paramedics, and physicians
inadvertently self-inject while
attempting to administer the EpiPen to
patients. One recent report chronicles a
6-year experience at a single US poison
center that fielded 365 epinephrine
injections to the hand.”
- Greenberg, 2010
@joyclee

@joyclee
Design Flaw #2:
Life or death
is stressful!
Don’t make
me think!

@joyclee
Design Flaw #3:
It’s an awkward
size, & doesn’t
fit in your
pockets

You don’t
know what
bad design
is, until…

Redesign #1
The cap and
needle are at
the same
end!

It’s thinner
and shorter
and fits in you
pocket/purse.
Redesign #3

Auvi-Q serves the exact same
medical purpose as the
Epipen, but the experience
and the outcomes are very
different.
“Emotions change the way the human mind
solves problems-the emotional system
changes how the cognitive system operates”
–Don Norman

The culture of
healthcare
blames patients.
@joyclee

@joyclee
Design Flaw #1:
The Needle is Opposite to the
Cap
“Patients frequently do not
understand how and when to
use [the epi-pen].” -Sicherer, 2011

“Children had only used their
EpiPen device in 29% of recurrent
anaphylaxis reactions. This is
perhaps unsurprising because a
fear of needles / injections is
common.”
@joyclee
Design Flaw #2:
Life or death is stressful! Don’t
make me think!
-Sicherer, 2011

“…patients often forget [the
device], allow it to expire.”
@joyclee
Design Flaw #3:
It’s an awkward size, & doesn’t
fit in your pockets
-Sicherer, 2011

Patient problems
are really
healthcare design
problems.
@joyclee

Fix the design,
and it’s no longer
the patient’s
problem.
@joyclee

A designer
would
never say,
“It’s the user’s
fault”
@joyclee

“When I overheard a physician describe
me as ‘trying to die on us’, I was
horrified. I was not trying to die on
anyone. The description angered me.”
“‘Guys! She’s circling the drain here!’
You know I can hear you, I thought.”
“We’re going to have to find you a new
liver, unless you want to live here
forever.”

“Small things would gut me. Receiving a
bill for the attempted resuscitation of the
baby, for example. My husband took on the
task of reconciling the bill with the lack of a
baby. The billing department explained
that the bill was generated when we had
failed to enroll her in our insurance plan.
No one could explain, of course, at what
exact juncture we should have called our
insurance company, seeing as how she’d
never technically been alive. It took four
phone calls to settle the charges.”

“If it needs a Sign,
it’s probably
Bad Design”
@lenagroeger
@joyclee

Signs signify a
lack of respect
for the user
@joyclee

“If it needs a Sign,
it’s probably
Bad Design”
@joyclee

The Current Health System
@joyclee

“We envision a transformation from the current
state to one in which research, improvement,
management, and patient care are intentionally
integrated. In such a health system, “learning while
doing” is the default, thus ensuring that the right
care is provided to the right child at the right time,
every time.”
The Learning Health System
@joyclee

The Singularity!
The Artificial Pancreas
@joyclee

Goodbye
Pediatric Endocrinologist!
You have been eliminated!
The Singularity!
The Artificial Pancreas
@joyclee

The Singularity!
…not really
@joyclee
Suboptimal
glycemic
outcomes
<10%
adoption of
Artificial
Pancreas
Systems

Diabetes tools are very expensive
and insurance companies don’t like
to pay for them
$1411 Starter Kit
$596 Transmitter
(every 3 months)
$349/month for Sensors
$70-80 Starter Kit
$120-150/month
for Sensors
@joyclee

Patients can’t afford their insulin
let alone the technology
@joyclee

Patients don’t trust a black box
“I don’t know what
it’s doing so how
can I trust it?”
“I wouldn’t give up
my DIY AP”
@joyclee

Clinicians fail to embrace
technology at all levels
@joyclee
”It was unacceptable to me in 2002 when my
son was diagnosed to be given needles, an
insulin vial, and a piece of paper”
-Jeff Brewer, Bigfoot CEO

Clinics are tired of the Sisyphean
Process of Prior Authorization
20,028 calls in 2017
DME
Insurance
Family Conflict
School Forms
Pharmacy
Child Protection Services

The Design of the Technology
Sucks
“Consider a Suspend: It literally
takes 10 clicks (including opening
the screen and scrolling)…ten
goddamned clicks I think it’s safe
to assume that I actually do want
to do this, don’t you?”
“My sensor needs to be recalibrated
in the middle of the night when
I'm sleeping. So the alert sounds
on my pump…Every hour, on the
hour…”
@joyclee

Quality
Improvement
Implementation,
Sustainability,
Outcomes
@joyclee

Aim: To decrease the %
of the population with
HbA1c ≥ 9% and increase
the % of the population
with ≥ 0.5% HbA1c
interval improvement
Preference driven
treatment and
effective self-
management
Enhanced registry population
management & Pre-visit planning
Peer/community support
Education/training to support
technology use and patient
viewing and problem solving with
blood glucose data between visits
Interventions/toolkits for
addressing barriers to adherence
Efficient use of
technology and data
to support care
Access to care and
regular follow-up
Screening for depressionPsychosocial
Support
Shared decision making
Partnership between
engaged patients
and the care team
Effective use of EHR by diabetes
team for population management
• % of pts. testing ≥4 times/day
or using CGM (6/7 days/week)
• % of pts. giving 3 or more
short-acting boluses/day
• % of pts reviewing data
between visits
• % pts setting, documenting,
and reviewing goals
• % completed pre-visit
planning
• % with ≥ 4 visits per year
• % of pts with annual
CDE/RD/SW visit
• % of pts on case mgmt.
pathway
• % pts screened for depression
Developing a Clear Measurable
Aim and a Theory of Change
Care Process Measures
@joyclee

Quality
Improvement
Implementation,
Sustainability,
Outcomes
Health IT
@joyclee
Big Data,
Reducing
Garbage
Data

The EHR is a combination of
Microsoft Word and Pinterest
Clinicians are
inputting
data in unstructured
format in the notes
Patient paper
questionnaires and
diabetes data are
scanned to PDF
@joyclee

@joyclee
Clinical Interface Redesign
Flowsheets/Smartforms
Portal Questionnaires
Population Reporting

“No one is going to use that tool
if you can’t BOLD the text!”
Rogue commas
Tool for Data Input
Insulin sensitivity
12AM 90
2:30 AM 110
4 AM 230*
10 AM 160
Patient Instructions
Insulin sensitivity 12AM
12AM 90
2:30 AM 110
4 AM 23, 0*
10 AM 160
@joyclee

Collaboration
and
Co-Design
Quality
Improvement
Implementation,
Sustainability,
Outcomes
Human-centered
Design
Health IT
@joyclee
Big Data,
Reducing
Garbage
Data

Data Literacy Interventions
and E-health Models of Care

Examples of Bad
Healthcare Design
@joyclee

Prior Authorization Rejections

Examples of Good
Healthcare Design
@joyclee

“Hostage bargaining syndrome” (HBS)
In the presence of clinicians, patients and their
families may behave like hostages negotiating,
from a position of fear and confusion, for their
health.

Health Designers,
Which users will you
engage in design thinking?
What will your Parking
Sign Project be?
@joyclee

Joyce Lee, MD, MPH
doctorasdesigner.com
https://medium.com/@joyclee
Twitter:@joyclee
joyclee@med.umich.edu
Jacob Dwyer, Ashley Garrity, Valeria Gavrila, Emily Hirschfeld
Dorene Markel, Ram Menon, Amy Ohmer, Lilia Verchichina,
Michelle Wichorek, Pediatric Diabetes Team, The Nightscout
Foundation, T1D Exchange
Acknowledgements

On Norman doors, sign design, and why you need to think like a designer!

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