Q&A: HxD conference co-founder Amy Cueva talks user-centered design

'Designers by their nature are empathic individuals. They want to use design as a problem-solving tool to figure out, "How do we improve things?"'

As health IT evolves and matures, focus is shifting, if sometimes slowly, from checklists of technical specs to broader challenges related to technology design and usability.

At the Healthcare Experience Design (HxD) conference, which is sponsored by Portsmouth, N.H.-based experience design firm Mad*Pow and takes place March 24-26 in Boston, designers, technologists, product managers and entrepreneurs will explore the ways healthcare and design intertwine, looking for ways to improve the digital interactions of patients and providers alike.

Healthcare IT News spoke with Mad*Pow co-founder and chief experience officer Amy Cueva about the conference, and about the challenges of user-centered design.

Q: Tell me a bit about yourself, and a bit about Mad*Pow.

A: I went to art school, and then got into graphic design. I was the only art student who also took calculus. I'm very left brain/analytical, but have the right brain/creative side, too. I went from graphic design to Web design to information architecture and usability, into what is now user experience and experience design.

The reason that that resonated with me was that it really is a perfect blend of left and right brain thinking. You have to analyze a situation and then come up with creative ways to work with it.

Mad*Pow hired its first employee in 2006, and now we're more than 50 people. It's an experience design agency. What we do is the research, to understand what a business or organization needs, what defines success for them, and then design the solution, which is typically digital. When I say "design," I mean interaction design, info architecture, workflow. Then we do a usability test on the design to make sure that it works, that it's going to be easy to use and meaningful, and derive the sort of results that the business or organization is looking to achieve.

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What we're seeing happening a lot now is that, we work with big corporations across the healthcare spectrum and within other industries. The organizations we've worked with have grown a lot over the years and now they're very siloed. You have one part of the organization handling customer service, the other sales. One owns the public website, the other owns the secure one. Different lines of businesses are sending email communications. And so, when it comes to the customer experience, there's been many different parties managing it.

What we're doing now, more and more, is partnering up with the executive level to say, "What is the state of our customer experience, or patient experience, or employee experience or partner experience? And how do we improve that across channels? When a customer gets an email or goes to a mobile site, how do we get those experiences to coordinate with each other and be considerate of each other so they're incrementally getting customers in the direction where they're going to be satisfied and the organization is going to get those results?"

Working in healthcare for us was really gratifying. Instead of just trying to sell more goods, or make the client more money, there's always something to aim for, which was, "Oh my God, with this project we can actually help people become healthier. We can actually improve their quality of life. In some cases, if we share the right information at the right time, it could actually save a life. That really made us want to get up every day and come to work and do great things.

Designers by their nature are empathic individuals. They have empathy for people and want to make things better for them, and use design as a problem-solving tool to figure out, "How do we improve things?" It's a perfect match. Now, more than half of our revenue comes from healthcare.

Q: What do you do for provider clients, such as Brigham & Women's Hospital and Cleveland Clinic?

A: Brigham & Women's, we helped them redesign their website, so the patient experience, and the prospective patient experience, would be a good one. We did things like creating something on the homepage that would direct people down the right path as quickly as possible. For Cleveland Clinic, we did some support for an ad campaign they had in the Wall Street Journal, we created some micro-sites for that. But the cooler thing was, one of their key tenets is health and wellness for the hospital. They were doing an initiative to get Cleveland walking. We created an iPhone and an Android app that was a pedometer, with some "game-ified" aspects, where you could create these different challenges for yourself.

Q: Usability is something that many people feel is lacking when it comes to electronic medical records. Why do you think that is? And are EMR vendors starting to evolve on that front?

A: We did some work with McKesson. They have a home care EMR, and the user experience was not good. They realized they needed to give it a complete overhaul. The home care EMR market is competitive. And as such, they needed to compete on user experience. The application was getting a bad rap with home care nurses. And they needed us to change that.

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So they hired us. We did field research, traveling around with nurses, home to home, to see what the care environment was like. And we saw that the system workflow did not match the workflow of the care experience, so the nurses were having to jump around to various screens to do things that should be right at their fingertips. In-home admissions were taking two hours. Data entry at the point of care was taking 20-30 minutes. And because of that, some nurses weren't entering data at the point of care, they were waiting till later, which isn't good because errors can be inserted as time passes. That's not a good thing.

We redesigned it to have the flow of the application map to how the care is given. We also tried to insert some humanity to the interface by having pictures of the patients. The nurses have cameras, and we put the pictures in the record so, even though their not supposed to, if they were doing data entry later, maybe the picture would jog their memory.

Also, when caring for patient, when you're looking at a system and a data entry screen, it's hard to remember sometimes that this is about people. We thought the subtle thing of having a picture of the patient would be really good. We also tried to elevate the user interface to something that would align with the consumer expectations that we all have, using Bank of America, or the iPhone, and everything else. The design went really well. It usability tested phenomenally, the nurses were really thrilled, it decreased in-home admission time from two hours to an hour, decreased data entry time from 20-30 minutes to 10 minutes. So that was good. And they actually touted the fact that they hired a design agency in their marketing materials, to say, "We really want to make it better. We've hired this design agency that knows how to do things, such that they'll be easy to use." And they used that to market the product.

But beyond that, we've tried to have conversations with big EMR companies, and there either isn't someone [at those firms] who owns this type of thing, or it just seems to be really IT driven. So we haven't had much opportunity to work with EMR companies. Some startup companies, like ones that just tend to just OB/Gyn practices, but definitely not the big ones.

Q: I've heard first-hand complaints from clinicians about EMR usability. There have been studies that say design is one of the biggest barriers to wider adoption. In a world where everyone has a smartphone that is well-designed and has sleek graphics, how sustainable is it to just not care much about EMR design and user experience?

A: I thought it was ridiculous, when I first heard that we were going to incent people to use new technology. I was like, "Hold on a second. You don't have to pay people to use Facebook or Google or their iPhone. [Laughs.] They use it because it's valuable and meaningful and it gives them something they can't get anywhere else.

I understand the need for structured data and interoperability and all this, but the thing is, I think there was a rush to get all these hospitals on board with EMRs to the point where they're just sort of throwing software out there.

In financial services, systems were being built, and inserting design was something that took years. And now they're very mature in that respect. They have design methodology, they value design, they understand it.

I wonder about the competitiveness of the market. And I'm surprised that that maturity is there in other industries, but in healthcare, specifically in the EMR space, they didn't learn from that.

I know some people inside big EMR companies who want to do excellent design, but in an organization that's owned by IT, it's difficult for even a design advocate to have their voice heard and affect the process.

In order for the EMR companies to change, they're going to need to put someone in charge of user experience that is at the level of a CIO. A chief experience officer? Or somebody that reports directly to the CIO? But design needs to be elevated in the organization and considered in the process.

Q: I don't envy these vendors. They've got a huge long list of technology mandates they need to comply with and have certified. They've got a lot to do, and their software has to have a lot of capabilities. But you can't ignore what the end user is seeing on their screen, day in and day out.

A: Absolutely. And it's concerning too, because there's a big opportunity. There's a company called Iora Health in Cambridge. They're an ACO. They think, "It's the patient's data. In many EMR situations, the doctor is huddled around a laptop, and the patient can't see what the doctor's doing. And they're not meant to. It's specifically for the doctor." Iora takes the opposite approach, and says they want to have a big screen in the room, where the patient and the doctor are looking at the same thing.

To me, that's revolutionary. You have a big screen and you have a patient. You could show them a diagram of the muscle tissue you're looking at. Or, while they're waiting, they could see a video about the tests they have, or the condition they're facing.

In terms of enhancing the whole care experience with digital technology, that's a lost opportunity. And it's turning the doctors into data entry specialists. The laptop, in and of itself, creates a literal physical barrier between the doctor and the patient.

So my hope is that as the iPad proliferates, I know some EMR companies are coming out with iPad EMRs, that that hardware will be less obtrusive, the physicality of it, and that the doctor will be more likely to turn it around.

There are solutions for this stuff. It doesn't have to be so difficult to make it happen: voice recognition software, etc. There are ways to be innovative in this.

EMR companies need to be visionary. They need to be thinking three and five years out, while they're operating on the specific release cycles they're on and focusing all the requirements they have to meet. They need to have a vision of what's out there. But I fear that they have these hospitals and care networks by the necks and that it's going to be very hard for any innovation or evolution to occur.

And again, there are concerns with the patient view of this data. How are they viewing it? Can they annotate it? The data is important, making it available and interoperable, but there are so many things that can happen to elevate the care experience and the patient experience that could hook off the EMR as a foundation. But it's always like, "Oh, that's way long-term, we're not even there yet."

Q: You wonder if it's eventually going to be an imperative for them, because the marketplace will force their hand.

A: That's my concern, though: Because the first pass at this was so troublesome and problematic and painful and expensive, are you going to switch to another one? Because you're going to have to go through the same thing again.

Q: It just seems like it has to change at some point, because people won't put up with it. When you have an iPhone in your pocket that's just so intuitive, and does what they want to to, when they want to do it, how willing are they going to be to spend their days fighting with these machines?

A: And I also wonder about how care is changing, the way it's delivered, with more and more ACOs sprouting up. I feel like EMRs are more akin to the transactional way medicine has historically been delivered: you get the data when you want it, you enter it at point of care.

But the way ACOs operate, it's going to be, "OK, here's the patient over time." And look at all the health applications! There's an app that's been clinically proven to lower A1c levels. All of this behavior change stuff happening in mobile environment, with technology and apps being prescribed to help patients manage their conditions – having that data filter into anEMR and engines turning so interventions bubble up … it shouldn't just be an input/output tool. It should be almost like an engine that's running on behalf of the patient as they go and they input it.

As how care is delivered evolves, how will these EMR companies evolve? How will the EMRs themselves evolve, to accommodate that? Hopefully that shift will enable a paradigm shift in the interface and the way the software is designed.

Q: It will be interesting to see how the patient side of this influences the way the technology evolves.

A: The possessiveness hospitals have, not wanting patients to see the data, or if they do see it, not letting people edit or update or annotate their data. That's problematic. HIPAA doesn't say you can't share anything. It says you need to get the patient's permission so they know what's being shares, with whom and when. Enabling sharing is a good thing, but many companies don't want to do that.

One more thing about the EMR companies: If they just witnessed people using their software, if they just integrated usability testing…. Forget meaningful use, and checking the check boxes, which I think can be a distraction to actual meaningful use and usability; if the government mandated how GAP should sell their sweaters, I wonder if they'd actually sell more sweaters, or if they'd just be running around figuring out how to meet those requirements. I love how meaningful use has elevated the concept of usability in the industry, but I wonder if it's a distraction from real good design and usability.

But if the companies took one big step in the right direction it would be to watch users using the technology, on a regular basis, as part of the release cycle. Not just as something at the end, as a QA measure, but early enough in the process so you can make improvements and not throw the whole thing off track.

Q: In closing, maybe just a word or two about HxD. You founded this conference – what's been gratifying for you to see as people have attended over the past couple years, and what are you hoping to see grow from what they learn there?

A: It clearly needed to happen. The first year we had 300 people, the second year we had 400 people, in 2013 we'll have between 400 and 600 people. Most of the healthcare conferences are government- or technology-focused. There wasn't a conference that focused on design and the importance of design in the healthcare space. In the design conferences, a session or two would touch on healthcare, but there wasn't really anything like this.

I think what people get out of it is the idea that, "OK, there are other people out there like me." It's a source of inspiration. I've heard of people networking and meeting people who have shaped subsequent steps in their career, or their now doing business together.

It's part inspiration, part networking and part really practical tips: OK, here's how you can get design to have more value inside your organization. Or, here is a good new design method. Or, here's how we should approach behavior change as an industry, since half our medical issues are lifestyle-related.

And also we're focusing on patient stories. We're all in these boardrooms and meeting rooms, faces at computers all day, designing these technologies. But the voice of the patient, the voice user, needs to be present. Since human-centered design is sort of the mojo of the conference, we have a patient stories track, where designers who are also patients talk about how they approach design now.

There are panels of patients who have hacked their healthcare. There's a public health and health literacy track. There's condition management, point of care improvement. We designed the agenda so there's something for everyone – whether you're a payer, a provider, a vendor, a designer, a product manager, a technologist. There really will be something for everyone there.

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