Medical product design can have a profound influence on patient compliance, a fact that takes on added significance in the context of ambient assisted living.
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| The design of the Cimzia syringe and packaging was driven, first and foremost, by patient compliance. |
A few months ago, I sat in on an interesting meeting with our design team and people from a medical device company. The company had recently completed a study with more than 100 patients to understand the effectiveness of a new product they were developing. Having spent months on the investigation, their presentation was full of data, charts and statistical results. The study was unquestionably thorough, well executed and analysed. However, we noticed what we considered to be a fault in their approach—they couldn’t name a single person who had participated in the study.
Instead, they presented distilled information about their average patient. Having been in the business of design and usability for quite some time, we pointed out something that seemed to be a revelation to them: Designing a product or service for the average person is much different from designing a product or service that works for 100 individuals.
The human condition
People are complex—and therein lies the problem. In an apparent attempt to streamline conference room presentations, many companies veer towards oversimplification. Human issues surrounding complicated topics such as personal healthcare are reduced to bullet points, perhaps under the assumption that the audience otherwise wouldn’t comprehend it. Yet true innovation and ultimate success often lie in the ability to understand—and design for—the details that are often left out or overlooked.
Successful home healthcare depends on the patient and it’s difficult to measure by numbers alone. It relies on the knowledge and information available to the patient or caregiver, and the subsequent action he or she takes to help prevent, maintain, monitor or improve his or her health or condition. Quite often, technology—whether a drug or a device—is not the weak link. Rather, it’s the design team’s ability to uncover and accommodate the drivers of patient actions and behaviours—their desires, motivations, pain points, mechanisms of avoidance, habits and willingness to adhere to proper in-home practices. These human elements are crucial to effective at-home health management.
So while technology is important, it doesn’t ensure victory. In fact, you can take the point of view that if technology is not usable, it’s not really technology at all – at least in actual practice.
Healthcare is not about products
Healthcare is not about the products we create. It’s about the ultimate effect the product or service will have on someone’s life. Although this may sound obvious, medical companies by and large seem to know much more about their products than they know about people. It’s not because they don’t care—it’s because most medical researchers and engineers aren’t trained in even the basic elements of human perception, physical ability and behaviour.
Approaching product and service development for the healthcare field should begin with an understanding of two people-centred topics: the impact of design on behaviour and, second, the ways people behave under stress.
We have seen instances where design has been the determining factor in adherence to a regimen and improvement in health. For example, our company worked on the design of a new syringe for use with Cimzia [4], a biologic drug for rheumatoid arthritis (RA) patients. RA patients have limited strength and dexterity, making self-injection an arduous task. In designing the Cimzia syringe and its associated packaging, we set our goals not on the syringe and package, but on compliance. In other words, we asked ourselves what can we add to the design of Cimzia’s delivery system to help patients take their medication successfully?
This approach made a considerable difference in the questions we asked and the design solutions we conceived. The packaging, for instance, wasn’t simply a box to house the medication. It was an opportunity to walk patients through the steps required to take the medication, almost like a storybook.
The power of design to communicate and to affect behaviour is a business opportunity. Unfortunately, our design group is rarely approached by medical companies that aspire to use design to influence patient behaviour to improve the efficacy of their medications or treatments.
Also rare is a discussion of usability and behaviour under varying levels of stress. If you think about it, the simple act of taking a blood pressure reading can induce anxiety in some people. And under stress, the mind and body work differently. So for all the logic that may have been put into a task flow for a medical device, the development of medical devices (and many other types of products for that matter) often takes place without any real-world context. This means a designer or engineer’s logical explanation of how a product works and how it is supposed to be used can make perfect sense in the lab—but not once the product is at home in a kitchen or bathroom. Unfortunately for the patient, it’s extremely unlikely that a medical company will send designers and engineers to patients’ homes to explain the reasoning behind it all.
We all know from numerous pleasant or annoying examples in our daily lives that behaviours are heavily influenced—for better or worse—by the products, services and environments that surround us. Home healthcare products are no different. A patient’s actions will determine to what extent a product or service will work. It also means that a patient’s ability and willingness to operate the device or perform a task will ultimately determine the reputation of that product, service or brand.
The good news is that while the development of a new technology or medication could take years and many millions of dollars, the opportunity for companies to increase the effectiveness of a product or service through design is often much closer at hand. That same attention to design will simultaneously enhance brand equity.
It starts with self-awareness and diagnosis
State-of-the-art healthcare design demands a holistic approach. It needs to consider all of the touch points a person will have with a medical product, service or brand throughout time. This is not unique to medical products—it’s happening in many different types of products and services—but it is especially important in home healthcare, where the needs can be urgent and the consequences serious.
For the patient, the very first step to managing health is simply awareness that he or she may, in fact, have a medical concern. The first—or even the second, third or fourth—diagnosis may not come from a medical professional. Friends and relatives are often the first to be consulted, along with whatever information can be called up on the Internet. This online search can be an individual or group effort, performed not just by the person with the problem, but in concert with others who are trying to help.
Although the reliability of Internet-sourced medical advice may be questionable, some can be credible. In the United States, a Google search for a number of illnesses will take the user quickly to PubMed [5], an information service published by the National Library of Medicine. And a simple search inquiry—such as diabetes, obesity, arthritis, depression or any other specific problem—brings up sites that may not include any medical device or pharmaceutical companies at all. The first pages link to sites run by organisations or government agencies—sites that make an effort to provide impartial or objective information.
Even when doctors personally consult with patients, their authority is not what it used to be. Patients look to many sources for information and guidance. So while a company’s website or product offerings may not be the very first point of contact for understanding a problem, they can be significantly influential in establishing early impressions not just of the products or services that company is offering, but of the patient’s illness itself. If it’s too medical looking or difficult to understand or navigate, the site will scare patients who are new to the illness, as well as scare away interest in that company’s line of products.
Medical devices that blatantly look like medical devices can be intimidating. The patient may be the only person to use the device, but he or she may not be the only person to see it. The same is true of packaging. Visual impact can’t be ignored. A badly designed package or device can make a person feel even sicker than he or she actually is, or it can give that impression to others around him or her. It can also affect a patient’s decision to hide the device in a closet, as opposed to keeping it in a place more easily accessible, which can encourage use. Visual appearance can also affect the willingness of the patient to bring the device when he or she travels.
Therefore, even first impressions, printed materials or websites can predispose the patient to behaviour patterns that may not be in the best interest of that patient’s future health.
Of course, many medical conditions are serious, and the visual communication of a product or service needs to reflect that—but these products and services also need to integrate neatly into peoples’ homes and lives. An illness does not define a person. He or she is very much the same person he or she was before the illness. This is one of the reasons why it is advisable to meet and know patients personally. Without that, it’s easy fall into the trap of imagining a patient, and grouping him or her into an average that can unnecessarily conjure stereotypical and misleading images.
Ramping up to cruise control: the first six months
After first awareness of the illness comes awareness of the products, services or brands that are available. And as a patient’s need arises, so does the willingness to use them. Healthcare companies are in a unique position to initiate emotional connections with patients during the first six months. More than with many other types of products, the relationship can be long term and truly meaningful.
The so-called out-of-box experience—literally the first 20 minutes or so of use—are critical to establishing a relationship between the patient and the product, service or brand. Failing to get started within this time window can lead to product returns. For example, products developed for sleep apnea can be difficult to use. We know of one case where the number of unused, returned products accounted for approximately one-third of sales. The product worked as designed, but the design was just too difficult for patients, who were confused about how to use it.
A patient’s experience using the product in the days immediately following first-time use is also critically important to shaping behaviours and attitudes. Establishing proper behaviour in the first weeks or months of use is a project unto itself, and it should be managed as such.
Patients will be most interested, curious and apprehensive after first discovering a medical condition or starting a new routine. That start-up period, up to the point where the patient is on cruise control, requires special attention. That is, special care should be taken up to the point where the patient has successfully mastered use of the product or service. Not simply by knowing how to use it, but by integrating the product or service into his or her daily, weekly or monthly routine, as required. If you can keep a patient on track for the first six months, he or she may be loyal for life.
The start-up period prior to cruise control provides an opportunity to create a bond with a patient, but it can also be a time when the relationship goes bad. For any number of reasons, the patient can fail to get up to speed on the routine, use the product infrequently or refrain from using it altogether. Surprisingly, a fear of increasing health problems in itself may not provide the patient with enough motivation to continue a prescribed regimen. Better motivators include convenience, ease of use and instant, positive feedback. Good feedback is important, but so is forgiveness when a person stumbles. Other sources of motivation can come from the community. Friends and family can assist, and so can other patients. These could take the form of personal contacts or online virtual communities of people with similar conditions.
The semi-anonymous nature of Internet support groups can have its advantages. Online, patients can openly discuss problems yet remain discreet. They may feel freer to discuss issues they would otherwise be shy about addressing in person. Sites such as patientslikeme.com put patients in touch with other patients who can offer unique support to those seeking to understand and get through their medical problem.
The first fight: resolving conflicts
The ease with which a product, service or company resolves a problem or conflict can affect subsequent behaviour. It’s what we call the first fight, and like a problem in any relationship, the way it’s handled and resolved can have a big impact on that relationship’s future.
Within many companies, the department that manages this patient touch point can be different from the group that develops the product or service in the first place. Good customer service is imperative.
Some preplanning in the event of a conflict can help speed its resolution. Design details such as readily identifiable shapes or colours can help patients troubleshoot problems discussed over the phone with a customer service representative or a healthcare provider. Ideally, potential conflicts should be anticipated and not left as an afterthought.
During the design stage of a medical device, product development teams seldom incorporate what we call traps into their usability studies. Traps are problems with the device that are intentionally presented to users. Understanding these situations can provide great insight into how a person can fail to carry out an intended task. From our design-and-behaviour point of view, it is helpful to see how a patient would try to overcome a problem with a device. It gives us a sense of what solutions they may devise to work around the issue. It also helps us get a sense of when they may either make a phone call to a company’s help line or give up completely.
The definition of product failure needs to include usability issues even in cases where there is nothing technically wrong with the product itself. In the United States, US FDA’s [6] newly drafted guidelines on usability are offered to help reduce or prevent failure that is usability related.
But reducing failure is a minimum requirement. The guidelines do not address making it look nice. Our purpose as a design group involves more than simply eliminating errors. Our goals include encouraging use and making the experience as pleasant and painless as possible.
Behaviour under stress: instincts and preconceptions
Stress can certainly occur when a product fails to perform as expected. It can also occur at any point during a self-care procedure. Even mild stress or slight apprehension when using a medical product or service can make usability unpredictable. The mind will act differently, even when that stress is a result of self-imposed anxiety. Actions often revert to more primal impulses.
Philips points out in the product information that its HeartStart FRx defibrillator’ [7]s on-screen guide, which is directed towards emergency response workers, is designed to “help the stressed user recall their training.” This was clearly a conscious effort of the company’s design team, which recognised that even the minds of trained users may not work as well as usual under actual emergency conditions.
Under stress, people first will act on instinct, a force that can sometimes override even extended training. A simple example is the way humans are prewired to recognize red, the colour of blood, as a common warning indicator. Using blue instead to indicate a warning, even with training, can be less effective.
People will next react according to individual preconceptions of how they think a product may work. These are very difficult to predict, since different people will base their thought process on something they have seen previously, perhaps a much different product they once owned. There is no immediate solution for overcoming preconceptions other than to use design to make the proper use of the device so self-evident that its communication of use presides over those preconceptions.
After instincts and preconceptions, people will react to physical cues, making three-dimensional design a powerful tool. Communicating proper use through 3-D design is a stronger driver than even text. Common examples are door handles, a problem we have all experienced. We are likely to pull on a handle if it is shaped like a pull handle, even if it clearly says, “push,” especially when we are in a hurry. Simple graphics, simple text and other types of colour-coding also can be effective in directing behaviour and usability, but to a lesser extent.
Designing for extreme usability
There are many good reasons to move healthcare tasks from hospitals and clinics to the home. Cost and convenience are at the top of the list, and technology continues to make this possible. However, the move to the home will be most effective when those technologies are extremely usable.
The future of home healthcare, and the speed and extent to which it will develop in the next decade, will depend on the ability of patients to successfully use and understand the products we provide. Our ultimate goal is extreme usability, allowing untrained people to use the advanced-technology products that we make available, without problem.
Companies have an opportunity to help patients comply with health regimens by realising that design affects behaviour. Good design takes into account both the physical and psychological needs of the patient. The fact that design can heavily affect success or failure means that influencing the attitudes and behaviours of patients should be well within the definition of responsibilities of a product development team. While this approach can be applied whenever a new technology becomes available, the approach also can be used right now by leveraging existing resources.
Dan Formosa
is a Founding Member of Smart Design, Trafalgar 38-42, 1st floor 08010 Barcelona, Spain
Tel. +34 93 5846 615
e-mail: dan.formosa@smartdesignworldwide.com [8]
www.smartdesignworldwide.com [9]