MICHIE CAO

On May 13th, I celebrated the end of a year-long thesis project by presenting Carebook to my family and friends and the IxD community onstage. I’ll be posting up the video of the talk and the panel discussion shortly.

When it came to creating a logo for Carebook, I wasn’t really sure what I wanted. All I (kind of) knew was that I wanted Carebook to give off a sense of nurturing, trust and love for the people using it. And that it would steer clear of looking healthcare-y.

As wary as I am of relying on symbols that are too widespread and iconic, I still gravitated toward the the symbol of a heart for Carebook for some reason. I wanted to tinker with it in such a way to make it look like a book, because Carebook. 

So that was really all I knew I wanted going in. And to say that there’s a straightforward process in designing a logo—or anything, for that matter—would be a lie. In reality, there’s a whole lot of experimentation and trial and error until you somehow land on something that feels right. Here are the 23409101 hearts I drew out: 

And this:

Three or four hours in, I arrived at something like this:

I liked the direction it was headed in, but it still felt kind of flat and sparse still. A friend’s feedback was that it wasn’t clear enough that the heart was trying to reference a book. One or two hours—and literally, like three grey bars later—I found my logo! That’s my type of design for you.

Not surprisingly, one of the biggest barriers to launching Carebook—and any current digital health product, for that matter—will be fundraising. Who will pay for it?

Aside from experimenting with yet another new color theme (teal and orange felt almost too playful for a healthcare app, pink feels more nurturing), I spent V3 of Carebook re-designing the messaging feature. 

Though I didn’t know it at the time, implementing in a direct messaging channel between doctors and patients as I did in V2 sets me up for a hefty design challenge. To tackle that challenge, I’d have to defend the following assumptions and address the following questions:

Assumption

Doctors and nurses have the time and interest in their day to reliably respond to questions

Doctors and nurses have a device on hand to respond

A direct messaging channel scales well to a hospital

Questions

Would there be a doctor/nurse-facing interface for Carebook? If so, what are the functions?

What’s the framework that would guide patients how to use the message feature? How do you make sure they use it meaningfully (for instance, so that care members aren’t getting the same questions from different people over and over again)?

How much can be discussed over a messaging channel? Any HIPPA policies affecting this?

Ultimately, I decided it wasn’t a direction worth pursuing, because it adds a lot of unnecessary complexity and wouldn’t do the best job at communicating and accomplishing my underlying goal—to encourage patients and families to be more involved and proactive in their interactions with their care team—anyway. 

Even if it does, I realized I still wouldn’t be able to properly defend the third assumption listed, because of what I’d learned from my prior research on hospital communication systems. With no universal standard in hospitals for what devices doctors and nurses use and how they communicate with patients and their colleagues, it doesn’t make sense to technologically enforce a new and single way of talking to patients.

To that end, I scoped things down and pursued a more lightweight and adoptable approach of allowing patients to log notes for themselves. In doing so, the patient wouldn’t have to worry about keeping it in mind (especially when they already have so many other things to worry about in a time of crisis) or forgetting to ask it, as Carebook would smartly remind him/her at just the right time. A quick demo of the flow is shown above.

Because the time we can spend with doctors and nurses is limited, I think this new iteration does well in ensuring patients are prepared enough beforehand to engage meaningfully and productively with their care team. Not only that, it strongly communicates my vision of patients playing a more empowered role in their own healthcare.

My second iteration of Care Planner was driven largely by my intention to make the app feel more human and less “sterile.” 

The first big change I made was thus the revision of the name Care Planner to Carebook, which to me sounds more colloquial and less transaction-y. I also experimented with a new color theme of teal and pink, which I thought might be more playful. Lastly, I made a conscious attempt to pair the care team member’s face with the respective procedure, in order to make the whole app feel less intimidating and to more importantly encourage a more personal interaction when the doctor and patient do meet in person.

Meanwhile, I also took this chance to start fleshing out the various flows in my app. The first of which is the flow a patient or loved one takes in communicating with the care team. In this first version, they are able to select a pre-populated list of care members that they’ve worked with or will work with, write a note, and send it off to them in a medium the care member has selected. To infuse more personality or “human-ness” into what I know can often be a stressful and cold hospital experience, I thought about incorporating whimsical illustrations at specific touch points of the app.

Here are some sketches I did prior:

Also explored were two new interactions of being able to “peek” at one’s procedure explanations, in case he/she didn’t need or want to read up extensively on what it meant, and to share procedure scheduling information with one’s contacts. I played around with two ways in which this could take form. In V1, one could pull back on a procedure tab to reveal a short one-sentence description and two CTAs. In V2, I wasn’t too clear about what the interaction would be, but it would expand to reveal the description and CTAs directly between the procedure tabs.

Feedback For feedback, I showed this app to a few of my classmates. They were a fan of the illustrations and the new color scheme. However, they were confused and concerned about how the Messaging feature would work out in practice, especially given that doctors and nurses all rely on varied devices and methods to communicate with each other. For instance, how would a doctor or nurse respond if he/she doesn’t have a phone? How do care members select their preferred mode of contact? Also, what type of information can be sent through and how is the app able to automatically get the contact information of each care team member? How do you filter out the urgent messages from the trivial ones? 

Shortly after flying back from visiting my grandma at the hospital, my midterm thesis prototype was due and I found inspiration from that experience to create what I initially called the Care Planner. 

Designed to bring more transparency and patient engagement to the process, Care Planner is a mobile app that shares real-time medical information—specifically treatments and procedures—to patients and their family members. It would show upcoming appointments, in addition to appointments that have happened in the past. Additionally, these personalized procedures and treatments would be paired with user-friendly explanations of what they are, what they mean, and what to expect, etc. pulled from an existing database like WebMD. The video above is a rough click-through prototype I made to demonstrate my idea.

An important design decision I made to separate this prototype from the previous one is the fact that I decided to hone in specifically sharing appointments and procedures. I saw this as a good point of focus, because of the following reasons:

Unlike more granular data like vitals, procedures and appointments are more goal-oriented. In other words, patients and loved ones can and usually will expect to see some sort of result or change in the patient’s health status. (I like to call them “inflection points.”) 

Before any procedure or test can be done, consent needs to be given by the patient or the family. Naturally, this is the time when they will want to inform themselves of what’s happening and what certain things mean. This presents a significant opportunity for good user experience and information design to really make a difference.

As a result of the first two points, loved ones then tend to want to be present for those events. Unfortunately, procedures and appointments aren’t often scheduled far enough in advance (or at all) and this poses a logistical challenge for loved ones with full-time jobs or responsibilities. 

Telling patients what their care plan is for the day would provide huge emotional value, because care providers often come in unannounced with the intent to conduct a test or procedure. This can be stressful and any heads up would really help in emotionally preparing them.

I expanded more on this idea in my midterm presentation, talking about the design opportunity, the benefits and my next steps. Some of my slides are below:

Considering I was lost, confused and circling around ideas over and over again less than a week prior, I was happy with the direction I eventually ended up with. Moreover, even though I clearly had more thinking to do, I sensed that the audience at my presentation understood why this idea would be of huge value and impact if implemented correctly. The feedback I got from them was the following:

Figure out what the technical process would be to port data back and forth from an EMR database to a mobile phone.

How would getting consent work? At what point is this app introduced to a patient in the hospital experience?

Despite my intent to appeal to the emotional needs of the patient and family, the app and UI still feels extremely “sterile.” How do I package the data in a way that is more meaningful and human?

A week after returning to NY from Spring Break (and after my grandma’s admission into the hospital), I received news that my grandma’s health status had worsened to the point where we weren’t sure if she was going to make it. I decided to fly back home again to be with her and for this reason, over the course of another week, I got an even more intimate look into the inner workings of a hospital, specifically the critical care unit.

As with my previous visit, I gleaned a few important things simply from being by my grandma’s bedside day-in and day-out, I’ll be sharing that in my next post. For now, though, I thought I’d share two interactions I had with the hospital that week that were pivotal in shaping my next prototype idea.

Sunday, March 15

Hours after landing in LA, I pay my first visit to the hospital since my grandma was transferred to CCU1. It just so happens my grandma is awake and conscious when I arrive for the first time in a few days and we feel hopeful. My dad immediately finds the nurse on-call for an update on my grandma.

We find a procedure has been set up for tomorrow, though we can’t quite pick up the name of it is from the nurse’s unclear pronunciation of it. “What is it called again?” we ask. Something-oscopy. After few more failed iterations of this, the nurse heads to her COW (computer-on-wheels) to bring up my grandma’s EMR on-screen. In it is a digital record of everything that has happened to my grandma thus far at the hospital, including treatments, written observations and health history. With a few clicks back and forth (through what looks to be a dense and complicated user interface), she arrives at a PDF file and gestures us to come look at it.

It’s a consent form for a procedure called a bronchoscopy. Sandwiched between paragraphs of legal and medical jargon in the middle of the form is the thing she’s looking to show us: a two-sentence definition and description of bronchoscopy. While still written in technical terms, it’s enough to glean that bronchoscopy is a procedure of putting a tube down one’s bronchial tube for examination and diagnosing purposes.

Not quite sure we’re satisfied with that explanation, she then closes the EMR and opens another PDF file saved on the computer desktop, titled “Lay Terms.” This time, it’s a spreadsheet of technical terms on the left and their “simple” one-sentence descriptions on the right. Actually, the explanations still are quite technical, but I wonder why she didn’t show this to us first?

I ask if I could have it as a printout for reference. She declines, as it’s only for nurses and doctors. Alternatively, she gives me this advice: “If you want to learn more about it,” she says as she pulls out her personal phone and opens up Google, “you can look it up like this!”

Tuesday, March 17

At 2 PM, we drop by the hospital to see my grandma, who’s condition has since worsened. 

While I cope by fidgeting restlessly, my dad—true to his engineering mind and curious nature— directs his energies toward informing himself about my grandmother’s care at every step of the way. In general, I’ve noticed that he’s spent every chance encounter we’ve had with a doctor asking all the questions he can, never fully being satisfied until a proper and meaningful explanation was delivered. 

Because of this, my dad has since developed a holistic idea of my grandmother’s condition and can explain it as confidently as he would an engineering concept or physical phenomenon. As he puts it, my grandma has two different problems with each of her lungs. Though healthy and capable, the right one is recently infected. The left one isn’t, but can’t work properly because of some mucus build up and hardening in the lung cavity. This means she can’t breath on her own and requires help from a ventilator working at 100%. Should that number lower and my grandma can still maintain a high oxygen rate, he reasons that would mean improvement from her current status.

Coincidently, a specialist lung surgeon who we’ve never seen before stops by during our visit to insert another chest tube into my grandma’s left lung in an attempt to suction out more mucous. He says he’s been dropping by daily to check up on her, but this is actually the first time our visits have aligned and the first time we’ve heard of this planned procedure. After the procedure, we are given the pessimistic news that it didn’t make much of a difference and that he’ll have to defer to the other lung doctor performing a bronchoscopy later in the day. We decide to head home and take a break before coming back for the next procedure.

At 6 PM, the time of the scheduled bronchoscopy, my dad drives to the hospital again with hopes of meeting the second doctor in person to have a discussion at length about moving forward. I stay behind at home, as I’m exhausted and still have some schoolwork to do. 

While visiting my grandma at the hospital in her first week there, I observed two things.

As a family member, there’s a lot of sitting around and waiting despite a strong desire to help. There were moments where my grandma was awake and energetic enough to chat and interact with me, but I mostly spent my time not doing anything that felt meaningful or productive.

It’s hard to find someone that can always reliably give a comprehensive update on everything that has happened with my grandma between my visits. Typically, one doctor won’t know know if another doctor had dropped by or an incoming nurse won’t always know if a procedure had been done on my grandma earlier in the day. I found once that I was the only person in the room able to answer the question of whether my grandma already had a blood transfusion or not, just by virtue of being there with her continuously.

For prototype #4, I designed a lightweight solution to said problems and observations called the Patient Passbook. A family-centric booklet located at the patient’s bedside, the Patient Passbook would allow doctors, nurses, loved ones and patients to collectively document the patient’s general well-being, activities or status throughout the entire care cycle. I created and test this in Early March, right after Spring Break and my grandma was admitted. My hope was that this would encourage a practice of open information sharing, despite people’s differing schedules.

The first section of the Passbook would contain basic background information about the patient.

Titled “What to Expect,” the second section would give a broad explanation of what a typical care cycle would look like, so that the family and patient could prepare for each phase as they moved forward. The admission and discharge process is pre-filled, but I created a space for doctors and nurses to write notes for what the planned/anticipated in-patient care process would look like for a specific patient. I’ve been told that usually, when a patient is admitted, the hospital will already have a good sense of what their plan of action will be and how many days the patient will be admitted for insurance and billing purposes.

The third section would be the “Activity Log”, where family members, doctors, nurses and the patient could log observations or things that have happened throughout the day. To encourage a sense of playfulness in the process, I had my classmates testing the book denote their different roles with stickers.

The last section would be the section for the patient and family to log their concerns and questions - something my parents had really wanted at the hospital and openly requested upon hearing my idea. 

Though I was confident that the Patient Passbook would be of significant value and interest to the patients and family members, there were still a lot of questions and concerns about how I would actually execute this idea. Specifically: 

Would it be too much of an ask to give doctors or nurses another thing to log stuff in?

If not, where in the doctor or nurses’s workflow would the information logging happen?

How do you incentivize doctors, nurses, patients and family to contribute to the booklet?

What type of information would family members want to see in this booklet?

Would there be any HIPPA issues associated to having doctors and nurses share patient information to family and to having a booklet by the bedside that potentially anyone could access without a passcode?

ROLE PLAY TESTING

To explore what the interactions could be with this booklet, I conducted a quick and fairly unstructured role-playing exercise with my classmates, Sneha, Trent, Amy and Mini.

First, I set it up so that Nurse Trent would first introduce this booklet to Mini, patient Sneha’s family member.

After I asked Mini to leave the room, I brought in Nurse Trent and Dr. Amy at different intervals to inspect Sneha. Each time, I asked them to form a made-up observation of Sneha’s condition, then log it down on the booklet. (No verbal guidance was given on how the information should be recorded.)

Finally, I had Mini come back in and examine the logs that were written in the booklet by Amy and Trent.

Findings Because this entire user scenario was made up on the fly, there wasn’t any real way for me to see how a logged patient story would compare to an actual patient story. Still, I was able to make the following discoveries:

Having to write stuff down really slowed Amy and Trent down. This would probably mean the same for doctors and nurses, who have even more things on their plate to worry about.

Having people log stuff by hand means there’s always the risk of illegible handwriting. Mini found it difficult to decipher certain notes in the booklet.

The cute stickers were brought a playful aspect to the process, which everyone appreciated.

For most of my thesis year, I’ve tried to answer these two questions: How is patient care coordinated in a hospital setting? And how can we make this better, especially given routine challenges like shift changes and med teams communicating via different devices?

I’ve always been interested in creating an improved tool, process or service specifically for people delivering care, but I since changed my mind after my grandmother was admitted into the hospital over Spring Break and I suddenly found myself a participant/recipient of the care experience as an anxious granddaughter.

There is a lot I’ve taken away from being immersed in the hospital environment for two weeks so far. The most important is that there’s a huge emotional side to what I’ve previously researched that I was never fully capable of grasping until actually experiencing it myself. To say it is emotionally overwhelming and draining is an understatement. On top of the uncertainty, fear, and helplessness, I felt frustrated with how medical information was captured and shared to us. As my parents and I sought a more comprehensive and detailed understanding of my grandma’s health story, there was often a lack of clarity regarding who to go to for questions, whether the on-call nurse would know my grandma’s health updates, and what certain vital readings or test results meant toward her overall health outcome.

Michie Cao’s “Teddy Tracker”

Last week, my instructor Gary introduced me to Joyce Lee, a doctor-turned-designer who’s done lots of design research on the universal problem of resident sign-off processes in hospitals. She share some of her behavioral and workflow-related insights with me, by way of a presentation deck, and it was enough to get me excited to further explore the problem, even if only as a design exercise. Primary user research data like this doesn’t come around often! 

Turns out this care coordination process touches upon a lot of themes I’ve already uncovered through my previous interviews. To name a few, cognitive overload, information funneling, and the importance of situational awareness. Here’s some notes I made as I was doing some work on this:

I also realized halfway through that the seemingly discrete problems I had observed through my interviews were very much built on top of one another, kind of in a Maslow’s Hierarchy type of way. For thesis purposes, I don’t think I’ll need to solve all of them, but it does give me a better sense of how I’d need to frame or put boundaries on the problem I’m looking to solve and subsequently position my idea.

From there, I sketched out a few ideas for how patient information could be presented to an incoming resident doctor.

These past few months, I’ve had the opportunity to connect many people immersed in the healthcare space. Working in a wide range of capacities, they include: doctors, nurses, a nurse navigators, a nurse practitioner, a software engineer, an MD-turned-hospital workflow consultant, healthcare designers and administrative leads. Besides it being simply fascinating to talk to so many experts in so many disciplines of healthcare, these conversations have collectively helped me get a better sense of the overarching trends that plague our healthcare systems and workflows.

That said, it wasn’t up until recently - when I did a huge post-it braindump and organization of my findings - that I became capable of clearly articulating those trends. I started off with just writing down all the key points I gleaned from my interviews (at this time, I only had 5 extensive interviews to work off of) and color-coding them based off the person that shared them.

Then, I started grouping them together according to trends. As it turns out, many were related, sometimes as causes and effects of one another (in which case I arranged them top-down).

The 4 categories that emerged are listed below. (Keep in mind these insights are direct results of the people I’ve chosen to interview, as well as the systems in which they work.)

1. Roles and Responsibilities Across the board for all positions, especially nurses, people are expected to fulfill a wide array of responsibilities, ranging from charting to admitting patients to coordinating care arrangements to conducting medical procedures. This means that many of them end up spending more time on logistical tasks and procedures than on meaningfully interfacing with patients as trained. This has one big effect, which is that they start experiencing cognitive overload and find it increasingly hard to stay updated on the cases of all of their patients.

2. Tools and Technology The biggest insight in this area was the fact that hospital communication systems across the board are asynchronous and fragmented ones. That is, they don’t work off the same device type and/or IT system and this therefore presents a barrier to immediate information flow between people. Here’s my sketch of some scenarios demonstrating this:

Concept

A consumer-level patient-centric platform for nurses and doctors that facilitates care-coordination and messaging and surfaces information to them when they need it. Would be able to integrate with EHRs and adapt across different devices, including pagers.

Use cases:

Colleen is a nurse in her 50’s at a trauma center, usually tending to 4-5 patients at once per day. Her primary role is that of a patient advocate, someone who can simultaneously get the needs of the patient taken care of properly and serve as the liaison between the patient to the rest of the patient care providers. Care providers include a set of doctors that specifically service her floor, but sometimes will also include visiting specialist doctors like physical therapists and pharmacists. Her responsibilities are varied and extensive, ranging from following up with doctors on orders to patient discharge planning to organizing insurance needs. To keep track of everything that’s going on, Colleen manually records it all with pencil and a piece of paper that she keeps in her pocket, using an organizational system of lines and squares that she devised all on her own. Without it, she says she’d feel incredibly lost.

Jenny is a 20-something Resident Doctor at a teaching hospital in California. Her days last as long as 16 hours and consist of many responsibilities, including pre-rounding and rounding with her medical team, teaching sessions, fulfilling daily logistical tasks and procedures, and admitting patients. She communicates with her team and other nurses via a pager, which she admits is “so backwards” and a pain when trying to arrange meetings with other people. One of the things she wishes she could do is track where her nurses are, as they tend to disappear and it’s hard to get things done or stay updated on patient reports when she can’t reach them. 

Questions to address:

What’s a specific medical workflow I can study and apply my designs to? 

How might we manage patient care handoffs between two different med providers?

How might surface information and notifications to involved actors that is contextual and actionable?

How can we reduce mental cognitive load for doctors and nurses, so that they can better focus on the tasks at hand?

Ideas for functionality

Direct communication channel between team members

Holistic view of a patient’s care journey and involved actors

Contextually-relevant information surfacing and notifications, particularly as it pertains to patient handoff between two actors and follow-ups on lab and test results

Design Sketches

Ideal User Experience

Haven’t quite figured this out, but I do know I want my design to adhere to the following principles:

It’ll help streamline non-medical duties, so that doctors and nurses can focus their time and energy on more complex, medical ones.

It’ll prioritize transparency and accountability in a patient’s care cycle

It’ll display only the necessary and relevant pieces of information, but still make more comprehensive data accessible if desired.

Road Map

Week 1: Feb 15 - 21

Settle on a specific workflow to work off

Research the workflow

Create experience journey map with touch points and involved actors and devices

*By the end of this week, hear back from organizations or hospitals if I can partner up with them.

Week 2: Feb 22 - 25

Sketch ideas / storyboard

Wireframe and iterate 

*By end of this, set up agreement / plans for partnering with a group

Prototype Draft Due Feb. 26

Week 3: Mar 1-7

Fix-ups/iteration based off prototype draft feedback

Figure out touch points of the system for a doctor, nurse, and patient

Prototype with sensors / notifications

Week 4: Mar 8-14

Prototype with sensors / notifications

Wireframe and iterate

Week 5: Mar 15-22

Design

Build in interactivity

EPIC is a company which creates software for mid-size and large medical groups, hospitals and integrated healthcare organizations and according to most of the people I’ve talked to, it provides one of the best healthcare software systems in the world. 

To better understand the capabilities and constraints of healthcare software, strictly from a technological standpoint, I reached out to Drew, a former software engineer at the company, with the help of my classmate Melody. Here’s some highlights and stuff I took away from our conversation:

Electronic medical records (EMRs) are intended to document patient data as well as facilitate communications between doctors. In practice, Drew pointed out there are always gaps in communication, which are then supplemented with email and phone. There are also always things which can’t be formally documented, but still need to be communicated to a healthcare provider, such as a patient’s demeanor and background and treatment tips.

Usually, EPIC software is adapted to address the needs of a particular hospital, depending on factors like hospital specialty and whether it’s an inpatient vs. outpatient facility. Thus, no EPIC software system is completely identical.

EPIC is available on tablets and cell phones, but it’s not quite optimized for that. Thus, one possible area of opportunity.

It’s possible to track the progress of a patient care cycle, based off interactions with the software. We can see when a patient has been admitted, when a room, physician and nurse has been assigned, when doctor care has been initiated, when a diagnosis was determined. This tracking allows hospitals to create performance metrics and measure departments against one another. 

According to Drew, my idea of leveraging indoor real-time location tracking and integrating it with EMRs is actually something of a “holy grail” for healthcare-based software systems. It’s heavily desired, but still hasn’t been successfully implemented as of yet.