Guest Column | November 27, 2018

Cows, Butterflies, And The 4 D's Of Digital Success In Healthcare

By Dr. Graham Hughes, Sutherland Healthcare

Sales Success With Reviews

Getting to “easy” is extremely hard – Dr. Graham Hughes details the four steps healthcare organizations must follow for successful digital initiatives.

Have you ever had a life-changing moment that didn’t feel very significant at the time, but grew in importance as the years went on? A couple of early game changers for me occurred during the implementation of an electronic health record system at a greenfield tertiary referral center hospital in Glasgow, Scotland. Although it was nearly 30 years ago, I remember the experiences vividly to this day and they have influenced the way I have approached every job since.

It was early in my career and I had recently moved from full-time medical practice into a chief medical information officer (CMIO) role. As the CMIO, I was the primary IT liaison with the medical staff – a role described rather disparagingly by my less sympathetic colleagues as the “doctors’ little helper.” Among other duties, I was responsible for delivering small-group, or one-on-one, training on the electronic medical record (EMR) to very senior physicians who had been recruited from across the globe. I knew the entire system inside and out, and it appeared obvious to me that the benefits would be clear to clinician and patient alike.

The Cow

On this particular day, I had just completed the results review section of the training and was now deep into the physician order entry module. I felt that all was going smoothly, until the surgeon started frowning and said, “This doesn’t make any sense to me. Let me explain. My 3-year-old daughter has a computer game that she loves. It’s simple, you have a big cow and a little cow, and big boots and little boots. It’s obvious to my daughter what she needs to do. She drags the big boots onto the big cow and the small boots onto the little cow, and both cows let out a satisfied ‘moo.’ However, I have been ordering labs, radiological exams and medications for more than 20 years and I have no idea how to use this system. It’s useless and clearly wasn’t designed by anyone with clinical experience.”

My initial reaction was that he just needed more time to familiarize himself with the EMR application and all would be well. However, the more I thought about it, the more I realized that he was right – the EMR simply hadn’t been designed to align with his professional experience, the specific demands of his specialty or his workflow expectations. This gave me an early appreciation for the need to strive to make workflows – and any associated software – transparent and delightful. It should be ridiculously easy to accomplish the basics, and more complex tasks should add value that rewards any extra effort required.

This was the first spark of realization that “easy is hard,” a mantra that ignited a lifelong passion for user experience design, whether for software, physical products and devices or workflow re-engineering.

The Butterfly

The second game changer came while I was working in the same role, but on this occasion, was helping an anesthesiologist in the intensive care unit. He asked if I could help him create condition-specific views of results and other parameters for patients with renal failure or sepsis. When I asked him what sort of view would be useful, he pointed to the screen, which included a form of “thumbnail navigator” to quickly move around the large virtual space of the patient’s results. The high values were shaded in red and the low values were in blue.

What he said next blew my mind: ”Do you see that butterfly?” And there it was… a beautiful winged pattern of reds and blues that stood out against the background of normal results. That visualization had never been planned for in the system design – it was essentially an unpredicted “meta effect” that emerged as a higher-level property of an existing system.

What I learned from this was that “meta effects” are everywhere and happen when you introduce change. Sometimes these “meta effects” are a pleasant surprise, as was the case for the butterfly, while others are not. Interconnected systems are not fully predictable and, as one colleague of mine was fond of saying, I think of software design as a perpetual beta experience. In other words, there will always be surprises and nothing will go exactly as planned. Flexibility, iteration, learning and adaption are critical to any change management initiative.

Easy Is Hard: The 4 D’s That Lead To Digital Success

In their own way, the above examples reinforce to me that when you deeply understand your customer, it’s possible to create workflows and interactions that just feel natural. When they don’t feel forced in any way, friction dissolves away.

But getting to “easy” is extremely hard. As you think about how digitization can help to improve any use case, whether clinical, administrative or financial, consider the following four D’s:

Discover: Start by ensuring you have a champion who can drive and lead this initiative. Adopt user-centered design (UCD) techniques to gain a deep understanding of the “as-is” processes as well as the variety of different customer and user archetypes, their expectations, preferences and responsibilities. Next, identify the pain points as well as the opportunities for improvement. You should end up with some form of a visual “journey map” of the current processes and interactions. Figure out how you will measure your baseline/s as well as the improvements achieved, so that ROI can be calculated at some future date. At this stage, also resist the urge to impose your expert opinion on the topic and don’t jump to the solution before you really understand the needs and opportunities.

Tip: Most organizations don’t have world-class talent in this critical area, so consider how to upskill your staff or recruit from other industries.

Design: With the opportunities in hand, now you need to assemble a cross-functional team of designers working with real users to generate a handful of prototypes, which should start with a back of a napkin or a whiteboard. Think about what would feel completely transparent and natural, and whenever possible, bake in some carrots – things that reward the more advanced user’s exploration. Once you have one or two strong candidate “to be” designs, follow the same process identified above to revise the journey map and consider all the ways that digital technology – e.g., platforms, data, mobile apps, robotic process automation and analytics – can be leveraged.

Tip: It may sound obvious but start with discovery and design and then apply technology, not the other way around.

Develop: As you start to develop the solution that has been identified, take the mindset that it is likely to be wrong (at least initially) and that you are embarking on a perpetual beta process. Don’t let yourself get too wedded to any one approach and check in with your target users as frequently as feasible and prepare to adapt your approach. You should plan to adopt some form of agile methodology during this phase, encompassing all the aspects of the project, from software creation to workflow redesign through to measurement. Where possible, simulate the experience in a usability lab to catch any major design flaws.

Tip: Avoid monolithic projects. Make sure you deliver value early and often and adapt based on what you learn.

Deliver: Even the most elegant digitally-enabled solution will crash and burn if you don’t have a rigorous approach to delivery. Start with a pilot site or pilot set of users and use them as your petri dish. This is the critical time and, as mentioned above, you should assume that you have at least one flaw in the initial solution approach. Keep your ducks in line by having the right champions and sponsors engaged in preparing for the rollout. Ensure that your users are well prepared and aware that you are ready to support, respond and adapt rapidly, based on these early experiences. If all goes well, you can begin to roll out and scale the solution.

Tip: No process or design is perfect, and therefore the 4D process should be planned as ongoing and iterative.

The Bottom Line

When it comes to improving our healthcare system, organizations need to think of it as a marathon and not a sprint. Pick a pain point, wallow in the problem and make it better. Incremental change is good, particularly when you deeply understand what will delight your users and customers. While approaching digital change can be very daunting, with a user-centered mindset and expertise in the 4 D’s, we all stand a better chance of making a meaningful impact on healthcare.

About The Author

Dr. Graham Hughes serves as the chief executive at Sutherland Healthcare, where he provides global leadership for operations, sales, management and strategy. He is a physician with more than 30 years of U.S. and international experience leading teams in the development and delivery of innovative healthcare IT products and services. Prior to being named chief executive, Dr. Hughes came to Sutherland Healthcare as the chief medical officer and head of global analytics. Before joining Sutherland, he served as chief medical officer for SAS Institute, responsible for strategic portfolio planning and leadership of the Center for Health Analytics and Insights, an incubator group for creation of new advanced analytic offerings. He also has held senior strategic and operational roles at GE Healthcare IT, leading the advanced technologies innovation team, as well as spearheading the annual strategic planning process for GE’s enterprise portfolio of IT products. Dr. Hughes holds a B.S. in Developmental Neurobiology and earned his medical degree from Kings’ College Hospital in London.