While the politicians, insurance companies, and health care providers debate the social and economic problems of health care, ripe opportunities for improvement are going unnoticed. What's lacking in this process is a strong shot of creativity and a dose of good design.
With this in mind I caught up with Dave Cronin, Smart Design's new Director of Interaction Design to discuss the possibilities. Dave's extensive background in designing medical products and services has helped Smart fortify our health care design practice.
Our discussion ranged from ways to improve health care, from the individual viewpoint to home and clinical settings to the health care ecosystem. With subject matter too lengthy for a single post, over the coming weeks we'll offer several perspectives in a series of articles focused on improving health care through design.
Read on, stay tuned, and feel better.?Tom DairDiagnosing The Problem
When we start looking at almost any plan to improving health care, chronic disease immediately becomes a huge factor. The most common chronic diseases, like diabetes, heart disease, and cancer, are simultaneously a substantial cause of death and a substantial source of health care costs. Clearly, a drop in the incidence of these diseases could reduce the load on the health care system, reduce the drag health care costs have on our economy and, of course, result in healthier people.
We can keep people out of hospitals with products that foster healthy behaviors.
Conveniently, it turns out that while these diseases are expensive and deadly, they are also largely preventable or controllable by daily activities like diet and exercise. Less conveniently, these lifestyle "choices" can be very difficult to change. (Current thinking is that around 80 percent of cardiovascular disease and diabetes is preventable, 60 percent of cancers are preventable, and more than 90 percent of obesity is preventable.)
It's pretty simple; an enormous number of people are getting sick and dying because they eat too much unhealthy food and don't exercise enough. As far as I can tell, one of the best ways to improve the results of our health care system is to create products and services that encourage and support healthy behaviors with regard to things like diet, exercise, sleep, work, and play. By doing this, we can keep people healthy and largely out of hospitals, which is by far the most expensive part of our health care system.Five Enablers Of Change
As obvious as this opportunity is, it's a tricky one. People's habits are notoriously difficult to change. Even psychologists? and economists? substantial understanding of human motivations can seem meager in the face of rampant unhealthy behavior.
Research by behavioral economists has found that people tend to make good decisions where action and result are closely tied together, when doing the right thing isn't too difficult, and when a decision is made repeatedly (i.e., the individual is able to practice). People also tend to be highly motivated by making progress toward achieving goals, and by group social dynamics?fitting in with and impressing (or not disappointing) their friends, family, colleagues, and neighbors. (See Thaler & Sunstein's Nudge for a good primer in this area.)
It seems pretty clear there are (at least) five important ingredients for a broad ecosystem that can help change unhealthy behaviors. Design has a big opportunity here to help policymakers and clinical and business leaders see how interactions and experiences can influence behaviors, and to create demand for products and services that help us live well.1. Behavior And Health Data
The starting point for behavior change is good information, which means personally-tracked information about things like diet, exercise, and health data collected at home (e.g. weight, blood sugar, blood pressure), as well as a robust record composed of a wide range of information including data from clinical systems (e.g., hospital electronic medical records).
People tend to make good decisions where action and result are closely tied.
There are many solutions for measuring and tracking behavior and personal health information. The celebrated fitbit and DirectLife sensors have software that helps users track things like exercise, sleep patterns, and weight, but don't really provide a holistic view of data about one's health. Google Health comes at it from the other direction?it's a pretty robust personal health record, but lacking sensors. (One would have to regularly enter a massive amount of data by hand to get any value out of it.)
While some of us have been thinking and talking about it for years, we're still in the early days of "the Internet of things." There are currently only a couple blood pressure cuffs available that you can actually connect to a computer. (Though there is one that can be transfer data to an iPhone, with the promise of another on the way soon.)2. Assessments From This Data
While there's strong evidence that just tracking personal data can have a significant impact on health-related behavior, what is done with and in response to the data is critically important. Interfaces into this personal health information must help people understand what diseases and conditions they are at risk for based upon clinical and personally tracked information. And of course, the information must be presented in a way that people understand, quite possibly with health literacy assistance. (We're not doing well in this department, either).
One of the simplest and most useful implications to be drawn out of all this data is the correlation between behavior and health measurements. Obviously, the relationship between what someone has been eating and their weight gives them good information about whether they should modify their diet. A well-designed system could also tell them how to modify their diet.
Web apps like Daytum and Open.Sen.se allow people to integrate data from a variety of sources to use visualizations and mashup tools to find meaning in the data. While the services are pretty amazing for a quantified-self aficionado, they're not going to work for someone only willing to spend five minutes a day to stay on top of their health.3. Goal-setting And Progress Tracking
One of the most important components of a behavior change program is proper goal setting. Small, achievable steps towards healthy behavior provide more opportunities for rewards and positive feedback than large, difficult-seeming challenges. As Dr. BJ Fogg of the Persuasive Technology Lab at Stanford puts it, one of the best ways to encourage positive behavior change is to "make the target behavior easier to do."
There's an opportunity to design more emotionally engaging feedback.
Take diet, for example. Dramatically reducing calorie input and switching from high fat (tasty!) foods to a well-balanced diet are enormous changes, and even a couple setbacks can make it all feel like failure. On the other hand, with a more modest goal like eating fruit or veggies three times a day, it's easier to feel a sense of accomplishment. But, it also can have a big impact on diet; those healthy veggies squeeze out less healthy snacks or piles of carbs.
And while "progress tracking" can be as simple as checkboxes and numeric scores, there's a big opportunity to design more emotionally engaging, qualitative feedback. The Ford Fusion SmartGauge presents feedback with a leafy vine that unfurls, growing in size the more fuel-efficiently the car is driven. As the vine grows over time, it creates visible evidence of accomplishment, reinforcing the desired behavior.4. Gentle Nudges
Goal setting and behavior tracking, while critical, are sometimes not enough. People may also benefit from reminders and encouragement along the way to keep them oriented towards their goals. The trick is doing this in a way where it actually has impact.
While repetitious reminders are easily tuned out, appropriate responses to the situations of daily life can be both engaging and effective drivers of behavior.
Imagine a mobile app that knows when you're travelling (thanks to GPS) and reminds you to eat a healthy breakfast precisely at a moment when you're away from your routine and most likely to skip the gym or succumb to the savory side of the hotel breakfast buffet.
One interesting approach is the use of people to provide this component of a behavior change program. The Phillips DirectLife platform includes an actual living, breathing coach along with the activity monitor device and progress-tracking web site to provide a pretty holistic program.5. The Social Component
When we talk about nudges, of course one of the strongest motivations for most people is to impress (or not disappoint) their friends, family, neighbors, and colleagues. Strong integration between personal health tracking and social networks has the potential to encourage healthy behavior changes.
People wait for doctors to tell them to start taking better care for themselves.
This is used to good effect in quite a number of weight-loss communities, LoseIt being one of the best designed. Nike+ and Strava both have become sporting, activity-based social networks in their own rights, and also offer the ability to show-off for friends on mainstream networks like Facebook and Twitter. Healthmonth is an interesting web-based social game that allows people to choose their own rules to try follow for a month, "choose-your-own-adventure-style."
Of course, there are some interesting questions related to privacy here. There's a fine line between sharing a bit of health behavior with friends and feeling overexposed. For my own part, I suspect that if the things I ate after 10 at night were visible to my social networks, I'd probably be much more self-conscious about snacking, but I?m not sure I'd sign up for that regardless of the potential health benefits.Where do we go from here?
In order to significantly reduce the incidence of chronic disease, we need to continue working to making the various facets of a health information ecosystem better designed and integrated into people's daily lives. One of the biggest problems behind many current clever web- and mobile-based experiences is that people need to remember to launch an app or go to a web site to use them. Health-related behaviors (which maybe we should just call ?life-related behaviors?) play out all over the place?in restaurants, grocery stores, cars, airports and hotels. We need to figure out how best to support people in all of these situations. (And the answer better not be that people have to stare at their smart phones all day.)
Right now, people wait for doctors to tell them to start taking better care for themselves. It's fine to blame this on human nature, and very reasonable to expect that public health policy, Medicare and the insurance companies be more invested in preventative care, but can do better than this. By creating compelling, desirable health-related experiences, perhaps we can partially circumvent these issues. By changing the feeling of being health-conscious from a difficult to remember chore to a well designed, engaging experience we can create a future where health care is positive and proactive.
Photos and illustrations by Lenny Naar.