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      Person First, Then Patient...The Real Human Centered Design

      Healthcare Rethink - Episode 53

      In the latest episode of Healthcare Rethink, a FinThrive podcast, host Brian Urban sits down with Dr. Craig Joseph, Chief Medical Officer at Nordic Global. Their discussion delves into the role of human-centered design in healthcare, drawing from Dr. Joseph’s rich experience and his co-authored book, “Designing for Health: The Human-Centered Approach.”


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      Brian Urban:                                          

      Yes, this is the Healthcare Rethink podcast. I'm your host, Brian Urban, and today joining us from Nordic Consulting, Chief Medical Officer, Dr. Craig Joseph. And I was told Your Highness, Your Greatness, Your Lordness. Welcome to the show, Dr. Joseph.

      Dr. Craig Josep:                                    

      Thank you, Brian. And we can keep going on. I don't get embarrassed by the salutations that you're offering up. O Great One. O High One.

      Brian Urban:                                          

      I missed that one.

      Dr. Craig Josep:                                    

      Your Royal Highness is also appropriate. Yeah. Yeah, yeah. I'm not technically a royal, but I still like it. Anyway. So yeah, thanks Brian.

      Brian Urban:                                          

      I do too. Welcome, welcome, Craig. It's so great to have you on the show. We got to know each other a little bit here and there before the recording. Today we're talking about your book that you co-authored with Dr. Jerome Pagani. And this is so exciting, Designing for Health: The Human-Centered Approach. I consider it as a how to in a lot of ways, that you took from lessons learned and you're bringing them to the forefront for a lot of people in healthcare today in a variety of settings. So I'm excited to get into this and really just excited to have you on the show. You've been running a successful podcast for over a year, coming on to a year, maybe just over that I believe.

      Dr. Craig Josep:                                    

      Yeah, about a year.

      Brian Urban:                                          

      And you got a setup. You got a heck of a setup. You got the shield, you got the headphones. I'm now influenced to toss my headphones on just for the look, like you suggested.

      Dr. Craig Josep:                                    

      Yeah. Yeah.

      Brian Urban:                                          

      So well, I want to get to know you a little bit and the podcast. So Craig, take us back before, maybe let's go back before all this stuff, before the MD, Nordic Consulting, the podcast, who are you and how did you get into all the work you're doing today? Let's go way back.

      Dr. Craig Josep:                                    

      Yeah, Brian, let's talk about my birth. I don't remember it all, but there were records. But they were on paper, Brian because it was a long, long time ago. No, I have a rather straightforward and simple story, I think. I was an undergrad and I was looking for something to major in. I knew I wanted to go to medical school. And the dean of admissions where I was going to undergrad told someone that you could major in anything you wanted, but if you wanted to stand out on her desk, do something unusual. So I majored in computer science because I'm a nerd and I thought it would be fun. And so I got my computer science degree and then promptly did nothing with it. Went to medical school, became a primary care pediatrician, practiced primary care peds for about nine years before getting the itch to do something more. And was looking around to see if there was some way I could combine my technical background with my years and years and years of clinical training and experience and managed to get hired by an electronic health records vendor called Epic in Madison, Wisconsin.

      So moved to Madison and that was kind of the heyday of EHRs or electronic health records. There were some government incentives at the time for hospitals and healthcare systems and doctors to move from paper to electronics. And I was there just happenstance happened to be at the right place at the right time. So got to explore that. Subsequently, left the vendor space and moved to the provider space. Worked for hospitals and healthcare systems and helping them implement and optimize and use some of the technology. So I had one foot in the IT world and I had the other foot in the clinical world. And it's a little dangerous. It's kind of like when you're getting on a boat, you've got one foot on dry land and one foot in the water and you can sometimes slip and get wet. And I did that that many times. And for the last three, four years I've been, as you mentioned, the chief medical officer at Nordic Consulting. Again, helping hospitals, healthcare systems, physicians, leverage the technology that's out there and is available. It's a lot of fun.

      Brian Urban:                                          

      Yeah, I love the analogy, the one foot in the boat and one foot on dry land and how you keep yourself balanced or stable or working well with each other. I love your background. I thought it was so fascinating that in your book you wove a lot of, I'd say, development, product testing, prototyping, observations, and then also your clinical background as a pediatrician for many years into a really good how to in a lot of ways. And a lot of really cool quotes that you got from other folks that you interviewed along the way. And you touched a lot on the EHR side of what you just mentioned in your career too, of how it was initially designed and kind of how it's brought us to current state where it is rigid in a lot of ways, whatever vendor you're using, and now it needs to be far more flexible and nimble.

      So it's kind of interesting. I want to get into that book. But I just love your background. I think it just speaks to who you are in a lot of ways. By the way, I told you this before, I love your glasses. That is your brand 100%. We had a physician researcher on our show from a clinical research organization and she had these bright pink, beautiful glasses, but yours are very hip, a little retro in design, kind of remind me almost like '50s diner kind of vibe a little bit, but a little spacey as well. So I had to mention that. Very cool.

      Dr. Craig Josep:                                    

      I'm all about the appearance, Brian. I'm not very good at what I do. I'm not very smart. I'm not very good-looking. I acknowledge all of these things. So if I can get someone to dress me nicely, then it's a win for me.

      Brian Urban:                                          

      Well, it's very posh and I like it and it fits you well. So Craig, let's dive into this book here. Designing for Health: The Human-Centered Approach. So you kick off the book in a very interesting way. It's a nice little story about a young woman who became what the industry knows as a frequent flyer. Needed a lot of care often, and I guess the causal path of her conditions wasn't really diagnosed well or accurately the first several times she had appeared in a hospitalization type of a setting and spent overnights. And the story that you were telling about her was she learned quickly that a lot of physicians, whether she came at a certain day or time, didn't matter, but she started to feel a part of the process. She was a patient, wasn't seen as a person until she started doing some really unique things that helped appeal to the human side of her patient view, which was she was an artist.

      So she started to color her sneakers and then that gave her an in with conversation to the human side. And then it allowed her actually to get maybe get seen faster sometimes, and people recognized her and they got to know her. It was very interesting. And you had shared the story in the book here. I'm curious that type of story probably is everywhere and just untold in a lot of ways, but it speaks to the person needing to be seen first and then the patient in terms of the business of the healthcare model in the United States. So I'm curious of why that story was put up front. Was that kind of a way for you to kick things off and saying, hey, this is how we need to be human-centered, designed in our healthcare model in the US but we're not?

      Dr. Craig Josep:                                    

      I think you hit the nail on the head. She figured out how to design a system that worked for her accidentally, and I was retelling her story of being an anonymous patient, hearing her referred to herself as, "The kid in bed four", really losing the humanity right there. And she got it back after after, as you told the story, people, much like you were looking at my glasses, people are looking at her shoes and, "Where did you get those crazy shoes?" Now she could have a conversation with her doctors and her nurses.

      I don't think it was that they were mistreating her or intentionally hurting her in any way. They were not. But she was kind of just seen as part of their work and not a person with a story and a history and needs beyond getting that IV in and getting her blood drawn. And she learned as a frequent flyer, "Hey, if I can add this aspect of my humanity, maybe people will remember me, but even if they don't remember me, they'll look at me maybe a little differently than some of the other patients." And should that be a need? No. Again, the clinicians that go to work every day are trying to be empathetic and focus on everyone's humanity, but it can get difficult and after a long shift and totally understand where she's coming from.

      So I think the goal, one of the goals of the book was to kind of call out like, "Hey, can we design things like this into the workflows and all the parts of healthcare that we encounter every day to make our lives a little bit better?" And for us, I'm talking about patients, we're all patients, I'm talking about clinicians, I'm talking about billers and schedulers and the operational folks that keep the healthcare systems in the hospitals working. Are there opportunities for us to understand how humans think and make it easy to do the right thing? And so this was one I thought great opening example. And as you kind of referenced, we start every chapter with a clinical example of something that kind of illustrates the points that we're about to talk about in the following chapter.

      Brian Urban:                                          

      I think that's such a nice way to really capture your reader's attention. And then through that storytelling, which is so perfect, so you. Then go into examples and application and give some real world work and lessons learned to the reader as that how-to guide, I saw a lot of your work kind of being on display in that way. But it caught my eye immediately. So I was like, "This is an interesting way to kick off a book." I was waiting for the big ball to drop to say she was a terminally ill patient, but it wasn't so and it was more of a story about how can we, or do we need to have patients do these sorts of things. But it was a very interesting story and made you think from a lot of different angles about the patient and then the model of healthcare. So I thought that was quite unique.

      So Craig, you actually start off another part of your chapter. I want to hit this before we got into some of the depth of your content, the forgotten ingredient. And I thought immediately as I saw this little story pop up, you and your pediatric days, you were talking about patients at that time, pediatric patients coming with asthmatics, they needed asthma treatment. Back then you were talking about albuterol, how it needed to be diluted, not so anymore. But there was something that the parents could work with their children or guardians work with their children to treat their children at home. You had talked about how you'd been so well-trained in medical school, residency and now in your professional tenure as a physician to diagnose and show the treatment.

      But you kind of had that missing ingredient, which was the person, what happens? And the story concludes, not to completely be a spoiler throughout your book here, but the patient was getting a dilutant from their parents, not the actual medication. So the whole miss was I guess the education part, the treatment part and making it very simple for the user who does not know how to give an asthma treatment to a child. How interesting of a story. Talk me through that because that probably happened all the time in different scenarios.

      Dr. Craig Josep:                                    

      It happened to different extents, but this was the first the story I write about it's the first time it happened to me. And I have to say, I was clueless because this patient as a young child came in with pretty classic asthma symptoms. We gave some albuterol breathing treatments in the office. Patient did fine, just resolved very quickly. Sent the mom home with a prescription for a nebulizer. And back in the day, this was several decades ago, it was rather difficult to get a nebulizer. You had to go through all these hoops and someone went out and delivered the nebulizer and set up the nebulizer and taught the parents how to use the nebulizer. And as you mentioned, the medicine came in two parts. It was the active ingredient and a normal saline, a dilutant, and you had to put them together. And then the mist came out and the patient breathed in the medicine and worked fine.

      Well, multiple times she came to the office saying, "He's not getting any better. I'm giving him all of his treatments." We give him a treatment, instantly turns around. And first couple times I couldn't explain it. I said, "Well, maybe sometimes it takes a couple extra treatments." And it was my medical assistant who said, "I'm just going to go in and ask her, 'Show me exactly what you do.'" Which is a great thing to do. And I as the physician never thought to ask it at the time. And the mom said, "Oh, I take that little pink ampule, which is I know what that is, that's the normal saline, that's the saltwater. And I stick it in and I turn the machine on." And when we said, "Where's the medicine itself?" And she's like, "Well, that's the thing in the pink."

      So it was a big kind of miss to me. I should have been more aggressive in trying to take it back to the beginning and say, "Okay, yeah, walk me through what you do exactly." Not assuming, which is what I did, but just kind of asking for as much clarification as possible. But also, more importantly, is if we had better designs then that medicine wouldn't have been delivered in two different pieces. It would've come as it does now in one little ampule with the normal saline and the albuterol premeasured and right there. So if it had been designed that way from the beginning, we never would've had this problem because it would've been an impossible problem to have. Much like if you even think about gas tanks, a long time ago there was leaded and unleaded and now there's diesel. If those all come out of the same size nozzle, then we really shouldn't be shocked that people put the wrong fuel in their... Right? But if the diesel is a bigger nozzle, it won't fit in standard cars. Boy, you've just prevented a problem before it could even happen.

      And that's the argument for human-centered design. And that's the point of the book is to kind of talk about leveraging human-centered design in healthcare, certainly in technology and electronic health records and other things. But boy, in so many other places, I think we can make it easy to do what we think is the right thing, what you're trying to do and slightly more difficult to mess it up. And this is an example of that, make it easy to do the right thing. Boy, if that medicine came pre-mixed, as it does now, it's easy to do the right thing. It's impossible. It's impossible to break that. So more examples of those things.

      Oftentimes I see in the United States especially, we all agree on what we want. We want the person to get the flu shot or get the COVID booster or to take their medication on a schedule that's reasonable, yet then we put impediments in their way, not on purpose, that kind of cause them to kind of go astray. And then we wonder, "Why aren't these patients getting their colonoscopies and their other preventative care?" And the answer is, well, you made it hard for people to do the right thing, so we shouldn't be shocked that they don't do the right thing.

      Brian Urban:                                          

      Yeah, I think it's so interesting because you think about the other side of your world, IT, you want things to be as fluid as possible for a UI experience, UX experience. Less clicks, less steps, more speed to it, or more of a meaningful experience to whatever that outcome might be or that next step in the process might be. And not the same with healthcare because of a lot of reasons, and justifiably so. But I think the things that can be prevented, like you're saying, premixing. And the diesel, unleaded fuel examples that you're making there, it's preventable downstream for what could negatively impact the person and their experience and probably their trust as part of a currency really could start to be eroded a lot.

      So it's so interesting the way you dabble back and forth in the book, Craig. Then you started to go and talk about, post this story, a little bit about having an approach of development, so observations, ideation, prototyping, testing, and then that cycle. So very much it took me back to my product days. So very much a product and a framework when you're designing something, taking something to market, getting early adopters and so on. And you kind of had a really great quote. You pulled from Dr. Lyle Berkowitz, who I believe former chief medical officer of MDLIVE when it was stood up by Randy Parker back in the day before it got integrated into Cigna and then eventually acquired. And he had a really cool quote, which is talking about where a lot of your IT career started in the EHR space with Epic is kind of the design almost being outside of the key user silos.

      So he was saying in his quote that they had initially went to physicians and said, "What do you want this electronic health record to look like?" And they got out their paper records and said "Just like this." So I thought that was so fascinating. Obviously you're close with Dr. Berkowitz and that is a very striking example of how you're not starting in the right place, I think you go into in that chapter. So take us a little bit deeper into your conversation with Dr. Berkowitz and what you mean by starting in the right place.

      Dr. Craig Josep:                                    

      Sure, sure. And Lyle's brilliant and a serial entrepreneur and super smart, so glad that we could learn from him. So basically the chapter that you're referencing is talking about making sure that you're listening to the right people and deciding who the experts are. And I'll give you an example. Sometimes you're thinking, "Well, we're going to start using some technology in the Department of Cardiology. We should go talk to the chief of cardiology and ask them how this thing should work." And that's a mistake right there, because they might tell you how they think it should work, how their mind works, but they might not really be an excellent average person who's going to be using the software.

      In fact, what we often find is some of these senior leaders, they never use the tools. They have trainees. Yeah, they have folks below them that do the actual work, yet we're talking to them and asking them how things should work. So the idea is you've got to know who the folks are that actually do the work. And then instead of asking them, "Hey, how should this technology or workflow function?" The right question is, "Hey, what problems are you having? Let me understand how you're trying to move from A to B." Because if we do what Lyle had suggested, lots of people asked to do is, "Well, here's the paper form. Can you digitize this?" Well, sure we can. Should we? Should that form even exist?

      I don't think I had time to put this in the book, but one of my first implementations when I was on the EHR vendor side was at a very large children's hospital and I'm there and they turned the switch on and we've gone from paper to electronic and maybe day one or day two, there's a hubalub and I get called down and there's a big argument going on about this form that needs to exist before blood can be given out for a patient who needed some blood in an urgent way, but not in an emergent way. And the blood bank was saying, "We're not giving out this blood until we see this form." And the physicians are like, "I don't even know what form you're talking about. We never fill out this form." And of course it wasn't in the electronic health record.

      And as it turned out, the blood bank said, "Listen, there's this form. We've had it for decades. It has to be filled out and signed by a physician or we'll never give out any blood. And so these physicians, I don't know how they could possibly say they don't know what we're asking them for." And then we looked at the physicians and they're like, "I don't know what they're asking for." And as it turned out, the clerks or secretaries up on the floors for decades had been filling out this paperwork and signing it with the physicians' names, just kind of greasing the system to make everything easier. Certainly no ill intent, no harm had actually come. There was an order in the chart from the doctor for what they needed, but this was just kind of seen as mindless busy work. So digitizing that form really didn't seem to make a lot of sense because we didn't really need that form because the place seemed to function great with people just filling it out who didn't really need to be filling anything out.

      So asking the right thing. Oftentimes people come to us when I've had the chief medical information officer role helping to lead the clinical IT departments at various hospitals, and people come to me and say, "I need an order set, or I need this document template, or I need this or I need that." And invariably I just turn to look at them and I'm like, "Well, don't tell me what you need. Please tell me what your problems are." "Oh, well, I'm stuck on this thing and it's very difficult." I'm like, "Okay, I totally understand. You don't actually need what you've asked for. There's something else that's in between what you're asking for. I can deliver that to you, and that's going to be a lot better experience for you and for others around you."

      So again, part of the design is really not counting on your end users to tell you how to design a thing. They are telling you what their problems are. They're telling you what their goals are, what they need to achieve. Whether they be patients or clinicians or operation folks in the healthcare space, don't ask them what they need, ask them what their issues and concerns are. And then you offer them up, "Hey, I think this is a good solution." So often you'll hit that nail on the head and you'll be like, "Yes, this is exactly what I need."

      Brian Urban:                                          

      I think that's-

      Dr. Craig Josep:                                    

      Often you won't.

      Brian Urban:                                          

      Yeah, yeah.

      Dr. Craig Josep:                                    

      And so you have to work with them and say, "This is what I think you need, this is what I'm hearing." And then it turns out that you didn't ask the question directly the right way or they forgot, or you talk to someone, as we often do, who's in a leadership position who doesn't really do the work and we're talking to the wrong people anyway.

      Brian Urban:                                          

      And that's such a common misstep. But it feels like an appropriate step to have those that have signed off on something or championing something give their input, and then that becomes the bulk of the input in any kind of design that you're taking to build something. I agree with that, and I think I've stumbled upon that in various ways in my little career too. But I think what's interesting, Craig, is as you were describing this part of your book, I was thinking about just how things are so well engineered in almost a linear way, upstream and downstream. That's it. But really it's the team of users, especially in healthcare. And then when it's missed, like your example here, that those admins weren't involved in the process, then it was missed because kind of a matrix or a tree, not necessarily forward and backwards. So I think sometimes those types of PMO or parts of or an organization can really think, "Okay, this is it. This is the box, or this is the square, this is the line." But it's so far greater and it takes a lot of different perspectives to pull in the right thing.

      But you do talk about continuous improvement. And I think it's rightfully so, we are human, we are going to error as we have evolutions of a product or a process. So you talked about continuous improvement, but you kind of teed it up in a really nice way talking about transparency and predictability. I thought this was a nice... I don't know if you intended to do it as a prelude, but for me it was really nice because you mentioned that there's two big things. There's transparency whenever you're building out a system that someone is going to use. And then it's the predictions of, "Well, what is the next steps or what is someone going to need?" So those two together, does it always have to be transparency then predictability? Is it a process that you see it as? Or you just see it as these are the principles that you have to consider together? Walk me through that a little bit.

      Dr. Craig Josep:                                    

      Yeah, I like to think about, again, with the book, we're focused on healthcare, but I like to think about outside healthcare and examples. And for transparency, the most obvious example to me is an elevator, a button to call an elevator. And there's two kinds, right? There's the kind that you just press it and then you press it again because you're not sure you pressed it and then you press it the third time because, "Where's the elevator anyway?" And then there's the elevators buttons that light up. And once you press it and it lights, you're like, "I know that I have now called the elevator and I don't need to press it any more times. It's not going to help." And so that's the transparency, like, "Hey, I requested this thing to happen and I know it's gone somewhere." And so giving me that kind of feedback to tell me that, "Hey, this request is now sitting at so-and-so's desk, or it's at this area."

      Predictability is kind of like, as you say, the yin and the yang, right? "So how should I know what should happen?" Now if I've never used an elevator? I think I'm kind of clueless. But we all know we're predicting, "Well, I press the button, the light turned on, I will now predict that one of these three doors will open and it'll be good for me if there's an up direction and a down direction to make sure that I get on one that's going in the direction that I want." Because it may not work that way. Same thing in healthcare. Oftentimes a doctor might tell a patient, "Hey, I'm going to refer you to this clinic or to this other doctor." And, "That's great. When should I expect to hear back?" That's a question that we often don't ask. And I'll know, just in the same way that I knew that you needed to put the albuterol with the normal saline, I'll know that, "Well, normal is about a week, 10 days at our organization. That's usually."

      Well after a month when the patient calls back and says, "I don't want to be difficult, but I haven't heard." Often they'll get, "Well, why didn't you call back sooner? This is a delayed referral. We should have done something about this." And almost make the patient feel badly that they didn't know. And so they couldn't predict because they weren't aware of how the system works. And so anything from a design perspective where we can make it easier for folks to know, I don't practice now, but I did practice for a long time, and I used to tell... Again, as a pediatrician, my patients often were brought by these chauffeur people who I think we call parents. And so I would tell them if we ever drew blood, and as a pediatrician, I didn't do it that often, but when we drew blood, I would say, "Listen, I expect this blood result to come back in X number of days." And usually I would add 50%.

      So if I know it typically comes back one to two days, I would tell them four days and they'd say, "Oh, so if I don't hear from you..." And again, this is a design principle, "Hey, if I don't hear from you, everything's good, right?" And I always looked at them, I'm like, "No. If you don't hear from me, everything's bad. It's really bad. It means that I never got the test results and something's broken and you need to call and find out." And so I use them as a backup system for my backup system, for the lab's backup system to make sure that, "Hey, if I draw blood, I need to get those results and I need to communicate them to the patient." Or the parent in this case. And so I would tell them, "Hey, I need you to call me in four days because you probably should hear from me." I didn't say this part out loud, "Probably you should hear from me in two days, but if you don't hear from me in two days or within that four day mark, please call me."

      That's a design. And so we're kind of putting backup systems in place to make sure that nothing falls through the cracks. I'm adding transparency and predictability to that workflow and so that the parents know when they should hear me. They know that they're going to hear from me. I would also tell them that I'm not allowed to leave results on voicemail or answering machines back in the day, "So don't be worried when I say it's Dr. Joseph calling with your results. Give me a call back at your convenience. That doesn't mean anything's good. That doesn't mean anything's bad. It just that's the way it is. I'm not allowed to leave those results there."

      So that's the transparency part. And it lowers everyone's stress level and anxiety, right? Because you now know what to expect. So again, as some of the ideas in the book, how can we build some of this in where we can to make things a little bit easier? Some healthcare systems have the technology incorporated into their electronic health record, even on the inpatient side, to tell people who are sick enough to be in the hospital but not sick enough to be in the ICU like, "Hey, here's an iPad. And one of the functions on this iPad is to tell you what we think your day is going to look like. Oh, you have a CT scan ordered. You know that. We hope the doctor told you they're going to order a CT scan. We've tentatively scheduled it between 2:00 and 5:00 today."

      So now again, you don't know exactly what your schedule is because the CT bay doesn't know exactly what their schedule is, but you have some sense now. And so there's some transparency going on. So again, these are kind of ways you can lower the stress level for folks, but also setting expectations that say like, "Hey, I didn't tell you 2:30. I told you between 2:00 and 5:00. And that's the best I can give you." And so you have some sense of what's going on, but you're still not holding us to these high standards that we know we'll never meet because that'll just upset folks. If I tell you 2:30 and it turns out to be 4:00, you're going to be very unhappy with me. I would be very unhappy with you if you did that to me. So basically, that's what the book is about, applying these principles.

      Brian Urban:                                          

      I think it's so interesting as you're describing this, I think of a lot of things in medical education that are inherited either by culture or behavior, not necessarily academic curriculum, but things on top of what you're learning with physiology, biology, et cetera. And I'm wondering, this is just pure curiosity, Craig, do you think your book would exist in the way it does now if back in your medical education or even your residency, you would've had training that was what you're suggesting, human-centered? Do you think if that approach was evolving earlier on, it impacted the way that you approach... Not like you approached your patients in a bad way, you approached them in the way that you learned and then you educated. But would this human-centered approach change the way that your book would look today? Would your book exist if you would've had this in your medical education?

      Dr. Craig Josep:                                    

      I think the hope would always be that no, it wouldn't exist because it wouldn't be needed because people would be, "Of course, we apply these principles, we know how humans think, we know how their brains function, and we've incorporated that into everything that we do." Unfortunately, we don't do it that way. And I think one key word, if anyone were to take home a key message from a design perspective, it's intentionality, right? We need people to start thinking intentionally when they're designing a thing, whether it's a piece of technology or the way the phone tree is going to work when you call our healthcare system or the way that voicemail is going to function. No matter what it is, intentionally sitting down and saying, "Okay, what are we trying to achieve? So who are our end users? Who are the folks that we're going to be dealing with? And how can we make it easy for them to achieve the goals that they want to achieve and that we want them to achieve?"

      I think if you look around, there are times, lots of times, in fact, probably the majority of times where things are well-designed. They do work the way you'd expect them to do. There's transparency, predictability. We make it easy to do the wrong thing, we get rid of stupid stuff. Those are all the things we talk about as part of human-centered design. But often it's when you kind of go like, "Hey, so how did you think about this when you did it?" And they're like, "Well, it just seemed like the right way to do it." "Okay, that's great. You scored on that one, but I'm not sure you were intentionally kind of making it work this way. You kind of stumbled upon it, and that's terrific." And again, with continuous improvement, often that offers that opportunity to go like, "Well, we didn't hit it out of the park when we first started, but we went back and reassessed after three months and noticed that we were missing this aspect or that aspect or that user voice, and we've put that in and now it's better."

      So adding those things really can make a difference. But being intentional, I hope if someone reads the book, they walk away with, "Okay, we are going to add a step when we're designing things or contemplating things to make sure that we're kind of taking a pause and trying to apply some of these very basic principles of design.

      Brian Urban:                                          

      And I like that you actually can't see my screen, but you took my question, Craig. I was going to go into the human-centered care approach that you're saying needing to point toward intention, not toward a solution necessarily. And that goes toward that continuous improvement that you then walked into after that. So you took that from my head or my screen. I don't know how you did that, but you did that very well. And my thought behind that was wanting to know how you consume feedback in the most appropriate way.

      So I think a lot of people designing products or new services or even are becoming some sort of technology bridge for patient care coordination, et cetera, they think really about getting feedback from just the users and they may not be the actual experts. And you talked about that a little bit earlier. So I guess what would your advice be for making sure that you're focused on intention for those developing things in healthcare, technology, services, et cetera, but how do you effectively consume feedback? Because I think everyone takes feedback, they push it together, they blend it, and then they try and almost make everybody happy. And I think it's tough to throw some things away. There's probably some junk that you can throw away. But how would you suggest that I'd say anyone in the development side, the dev side of a product or service would consider consuming feedback in the most appropriate way for continuous improvement?

      Dr. Craig Josep...:                                    

      Sure. So the step number one is making it easy to give feedback. And there's a little scenario, a little story in the book about taking my daughter. All of these are just things I've stolen from my life. I took my daughter who had had... Yeah, well, she had frequent headaches, and so of course I was concerned. Took her to the child neurologist and watched over the nurse's shoulder as they typed in kind of rooming my daughter. And there was a question that said, "Reason for visit." And there was a list of dropdowns, so you could just choose a pre-configured thing. And there was also a free text box, and the nurse wrote, "Other." And then she moved to the next box and wrote, "Headaches." And I looked at her, I'm like, "Hey, I'm no brain surgeon here, but at this pediatric neurology clinic, do you see a lot of children with headaches?" And she was like, "Yes, we do." I said, "Yet, I don't see one of the frequent choices here as being headaches. In fact, you had to choose this generic other and then type in the word headache." And she's like, "Well, that's just the way it is."

      Now I happen to work for the vendor that made the electronic health record at the time. And I'm like, "It's actually not the way it has to be. You're right, that's the way it is. But it could be very easily fixed by the healthcare system." I said, "Did you tell anyone that this thing is missing?" And she was like, "Oh, no. No, I don't even know how to do that. And we used to, when we first went live, we had a piece of paper and we used to write things that were broken, and every week they'd come and get them, but they all stayed broken. So we just stopped giving feedback." Okay, well step number one, make it easy to give feedback. Step number two, read the feedback. Step number three, let's talk about transparency and predictability, respond to the feedback. This is a great suggestion. We need $3 million to do this. We have $0. This is not going to happen, but thank you.

      So giving that feedback where even if it... Or, "Yeah, this doesn't really make any sense. You've asked for X, but we already got Y, and Y really solves the needs. Did you know about Y? Would you like us to send someone up to show you how to use that?" So asking for feedback, making it easy to give it and then responding to it, I think is very helpful. You could do the best job on implementing some of this technology, and then things change on a dime. Brian, I don't know if you remember, we had this pandemic thing a couple of years ago. You remember that? I don't know if they had that where you were. Yeah, they had that? Okay. Things changed on a dime. And that's obviously an extreme example. But we get new leaders or there are new laws or different kinds of people move into our community with different needs. And that thing you designed two years ago was perfect until a bunch of people came in who don't speak English. And now we've got a problem that we didn't anticipate that we were going to have.

      So that kind of continuous improvement is very important, but you do need to be kind of cognizant of it. One last thing I would say for folks who want to make improvements is I've heard many people call this, I think Jack Welch was the person who was most famous for it, but he called it management by walking around. You learn so many things by not asking your folks how things are working, but in fact, going and watching how they work, "Hey, I'm just sitting in the back here. Don't mind me. I'm just watching. Hey, I saw that it took you 20 clicks to get this thing to happen. Is that normal?" And so really by walking around asking frontline staff, the doctors and the nurses and the therapists and the receptionists and the schedulers who are doing the work, watching them, listening to them, asking them questions, they will tell you what's working and what's not working.

      And again, sometimes it's, "Hey, this really is horrible." People have told me that, "Hey, this aspect of the software is really horrible." And I have to look at them and say, "You live in the United States, so I'm sorry. There are certain constraints that we have to deal with that we don't..." I mean literally in Canada, in Europe, completely different. And that's not to say one's better than the other. I'm not making those assertions. I'm simply saying they're very different. And the tools that we use have to acknowledge that. So sometimes you can't fix the problem. But even explaining that, I think it's a big deal. Like, "Hey, I would love to remove this step that you think is dumb. I think it's dumb too. But there's a law that says we have to do this, and so we have to do this. And we've tried to change the law and it's not going to get changed anytime soon. So we thought this was the least horrible way of implementing." A lot of what I do is, "Let me try to get the least horrible implementation out of this."

      Brian Urban:                                          

      I think that's such a funny story because most of my career has been on the health plan side of the world, so heavily regulated also the biggest profit margins that you have in terms of the healthcare ecosystem sit in the payer world. But it's so interesting because even if you have these really great ideas, they make sense in terms of the need that you're filling, the outcome that you'd want, that would benefit in terms of the economics involved, but also the societal good, can't always happen because there are some laws in place that would inhibit that. So working within your thresholds, but still finding ways to improve continuously, I love that as your theme toward the end of the book in particular.

      So I'm thinking beyond this book, Dr. Joseph, say we look ahead five plus years and we don't have any major economic downturns or another pandemic that hits the world or parts of the world, what is your hope, whether it's on the education side, whether it's on healthcare, technology, new models, new payments, what's your hope that human-centered design will play in a part of the ecosystem in healthcare? Pick your place in the healthcare ecosystem, but what's your hope that this approach will be integrated? Maybe how will it be integrated, maybe what will you see from it? Any predictions around this?

      Dr. Craig Josep...:                                    

      I think the big thing is what we in IT would call interoperability. I think most normal humans would call it data sharing or information sharing. It's getting easier and easier for us to take information from one kind of silo and distribute it. And the explosion of generative AI in the last year has given me hope that that's actually a thing. Folks want everything to work, at least in healthcare, they always say, "Hey, it's like the ATM. I can go and take my card and pop it into any ATM in the world practically, and I get money. Why can't healthcare work like that?" Well, I wish it could. It's a lot more complicated than financial transactions.

      However, I think we're moving closer. And so right now, we're right at the cusp of making it easy to send information from one place to another. What we really struggle with is translating it. Hey, it's in this format and you can't consume it that way. And your technology works slightly differently. And this was written for a primary care doctor and you're a super sub-specialized cardiologist. And how do we give you the information in a way that you can consume it?" I think AI's are ready. And so that's what I think is going to be the biggest change in the next five years. And I'm hopeful, again, humans, we always say we want more, or at least physicians, clinicians, we want more information, we want more information. And then we pile, we just bury them with facts. And then they're like, "Stop with the information. It's too much."

      Brian Urban:                                      

      "Stop messaging."

      Dr. Craig Josep...:                                    

      "I can't communicate." Exactly. "Stop messaging me all the time. Stop telling me about your problems." "But you said you wanted to know." And they're like, "Well, I did to some extent. But you've expanded that." However, I think that we are getting close to the point where we're going to have technology that's going to be able to help us sort through the stuff and go like, "Wow, you've said a lot of things. Two of these can be handled by my medical assistant. One of those is going to be my registered nurse and my third one is going to come to me." And that's what everyone really wants, like, "Hey, help me help this patient by letting me solve their problems that are within my domain. And for other problems, I can't help them. Let me see if I can find other folks on the healthcare team." So that's my biggest hope, is that data sharing and generative AI's are going to combine to get the information from one place to another, from the healthcare provider to the payer, back to the patient in ways that the patient can consume, that the payer can consume and the provider can consume, and generally.

      Brian Urban:                                          

      I think that's the most brilliant example of how your approach and all of your lessons learned will come to an application with data exchange. And I think you're right on so many ways. I think us closing gaps on interoperability will help be able to predict needs and be able to solve needs faster and create a nonlinear process and more of a matrix of who's using what, who's interacting with who, and how can we help the individual that we're trying to serve the best we can? And hopefully that changes a few policies or puts a few new regulations in requiring health plans to be able to not only consume claim data, but external data to be able to show a whole person view as a good example.

      There's so much buzz and rage about a whole person view, but that view doesn't really exist in the most clear way. It's not 2020, it's maybe 2050 at best. We're a little blurry. But that's an ophthalmologist view there. I don't know my vision test very well. So hopefully that's a good example. But in any regard, Dr. Craig Joseph, Chief Medical Officer of Nordic Consulting, author of Designing for Health: The Human-Centered Approach, so thankful to have this book in my hands and have this discussion as well. I just think you're brilliant because you make complicated things very simple. Thank you so much for being on our little show today.

      Dr. Craig Josep...:                                    

      You're kind, and I appreciate the opportunity to get some of our ideas out there.

      Brian Urban:                                          

      Your Greatness, yeah, I love it. Thank you so much again. And for more fun excerpts and insights, please visit us at

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