What Medical Device Designers Can Learn From Other Fields

Bernhard Kappe
Bernhard Kappe

This is an edited transcript of the second episode of Orthogonal’s “Patient Engagement & Connected Medical Devices” podcast, featuring Bernhard Kappe, Founder and CEO of Orthogonal, Adrian Pittman, User Experience Design and Human Factors expert, currently Director of Product Design at LinkedIn (previously of Google and Orthogonal), Gia Rozells, Senior Director of User Experience Design at Becton Dickinson, and Christi Zuber, Founder and Managing Director of Aspen Labs. 

You can listen to the second episode of the podcast below, or stream it wherever you find podcasts.

Links to the series of transcripts:

Digital Therapeutics DTx eBook PDF Download

 

Bernhard Kappe:

If there’s one thing that we all learned by watching children and adults shift school and work to a virtual remote format over the last two years, it’s that there’s a huge difference between showing up and actually engaging.

Adrian Pittman:

And just because you attend an online class, it doesn’t mean that you are actually engaging in that class and actually learning and growing your mind.

Bernhard Kappe:

In the same way, there’s a huge difference between a patient properly using, i.e., being compliant with or adhering to the use of a medical device at home and a patient actively seeking to squeeze every ounce of clinical value out of that device to improve their own outcomes.

Adrian Pittman:

Increasingly, the healthcare and MedTech industries are evolving to support remote diagnosis, monitoring and treatment of health conditions by patients and their caregivers, but without the benefit of the doctor’s office, hospital or real-time supervision, this can get complicated.

Bernhard Kappe:

So how do we get patients and their caregivers, not just to use devices, but to actively engage with them in the best way possible to improve their own healthcare? And for those with chronic conditions, how do we make this happen as a regular routine that just happens without intervention by the provider or payer? 

Adrian Pittman:

That’s what we’re going to be discussing in this three part series on patient engagement and connected medical devices presented by Orthogonal.

Bernhard Kappe:

I’m Bernhard Kappe, Founder and CEO of Orthogonal. We’re all about improving patient outcomes faster. We mostly work in Software as a Medical Device and connected medical device systems, and we apply modern methods within the regulatory constraints to build, evolve and scale solutions faster.

Adrian Pittman:

And I’m Adrian Pittman, user experience design and human factors expert, currently director of product design at LinkedIn, previously at Google and Orthogonal. We’d like to thank you for joining us today to listen to the second of a three-part series from our recent conversations with two fantastic industry experts, Senior Director of User Experience at Becton Dickinson, Gia Rozells, and Christi Zuber, Founder and Director of Aspen Labs, a leading human-centered design agency servicing the medical industry. 

We’re going to dive into the art and science of user-centered research and design processes for medical devices. This is a really rich topic since our panelists bring a tremendous breadth and depth of experience to this exciting but also really challenging domain. There’s a lot of ground we’re going to cover, looking at not just UX for medical devices, but for healthcare more generally, and also what we could learn in healthcare from UX in other industries. So without further ado, we’ll jump back into this conversation we had with Gia Rozells and Chrisi Zuber.

Bernhard Kappe:

Gia, I had one question for you. Your background is really interesting. You have Intuit on the one side, which is definitely focused on the consumer and on small business, etcetera, and where you probably have a ton of freedom in terms of how you collect data and how you run experiments on what works and what doesn’t work. Compare that with a highly regulated safety-conscious area that you’re in at BD. What’s the difference between those? Are there things that make you feel, “Oh, I was able to take these things from Intuit and bring them to the current position.” Or things like, “Oh, I wish we could do these things here because we could innovate much faster and get a better product much faster?”

Gia Rozells:

That’s an interesting question. For me personally, getting up to speed on medical regulations for different devices, FDA and outside the U.S. agencies and what they required, was my first hill that I had to climb. But it actually was more straightforward than I expected. What I discovered in manufacturing devices is really the same big problem that we were trying to solve year over year at Intuit, which is the tendency of companies that are trying to move fast and make money quickly to assume that they know what the user needs and who the users are.

That inevitably leaves open the possibility of putting something on the market, going through all that expense and development and marketing, and then realizing nobody wants it. Or, that it solves an important problem, but for the wrong user or in the wrong way. This is getting back to the basics, as Christi was talking about earlier. You’ve got to go and meet the user, you’ve got to be in their environment. That’s the only way to know. I do think that really having a deep understanding of the user is what I took from one industry to the other.

Bernhard Kappe:

Now you’re singing my song. Because there’s two parts to it. You’re trying to design a product that meets real user needs and that they’re going to buy and all of those things. That’s universal, right?

Gia Rozells:

Yes.

Bernhard Kappe:

That’s everywhere. If you skip those first steps and you skip actually understanding users, and you think you know those users. All of us do that. “I know what these people want. I just know it.”

Gia Rozells:

“I’ve been doing this for years.”

Bernhard Kappe:

“I’ve been doing this for years.” That totally makes sense. I’ve seen that outside of the medical device industry and I’ve seen it in the medical device industry. I’ve seen it in Pharma, everywhere. But one of the things that is interesting, that I’ve at least observed outside of the medical device industry versus inside the medical device industry is, what kind of real-time, real-world data are you getting about your devices and what you’re doing? If you think about a company like Amazon, for example. On their website, they are running experiments on you left, right and center in an automated fashion and in an automated way, queuing up the next experiments in massively parallel form to optimize for whatever they want to optimize. Typically, that’s you buying more things on their site or other things that lead other people to buy more on their site, but they can optimize really quickly.

Even if you design the perfect product, or you think you are through qualitative information that you’re getting through the design process, we all know that in reality, you can’t fully simulate how people are actually using it in the wild. You actually have to see how are they really actually using it. There’s no way to fully simulate it. They’re going to do things that are surprising to you.

Gia Rozells:

Yes.

Bernhard Kappe:

Right?

Gia Rozells:

Absolutely.

Bernhard Kappe:

I assume that those kinds of lessons are the same, whether it’s at Intuit or Becton Dickinson, right?

Gia Rozells:

Often it gets down to the smallest detail. As Christi mentioned earlier, not understanding the word “browser.” You have to look at everything and make zero assumptions about your users. You have to involve them and keep getting feedback from them to keep reducing your project risk and increasing the chances that you’re building the right thing really well. Oddly, when I was at Intuit and we got towards Thanksgiving and the IRS deadline, and we needed to get that product done, people were practically sleeping there overnight. I would say, “We want to do this really well. People’s money and livelihood is at stake.” It’s still tax software, it’s not life and death. At Becton Dickinson, it is life and death, and we have to do it better.

Adrian Pittman:

It’s interesting though. I’ve seen this in a number of industries: the more technical the problem is, the more assumptions are being made at a very early stage. It’s this idea that how you start dictates how you end, and it’s the core job to be done or jobs to be done to the user. Are those really being satisfied? For the Amazon example, that happens later. Once you’ve identified value, then you could productionalize your supply chain to give you real-time data, and you get the value of that because you’re tuning and  iterating. But it’s when you first get started. If you stomp on the wrong pedal, you’re not going to get the results you need at all, because it’s completely the wrong solution for the wrong problem.

It comes back to basic fundamentals. It’s something that we talk about in the article series that we wrote for the MedTech Intelligence Journal: This notion that people use features, but they live with products. If you’re going to develop a product that you expect a person to live with, particularly if it’s life and death, then you really do fundamentally have to start and devote enough time and energy on understanding and building empathy for the user up front. Otherwise, everything else that you do doesn’t matter. The Amazon productionalization model won’t work if they didn’t understand what value was at the transactional level on a daily basis, the sorts of buying experiences people wanted to have. And they started off with books.

Gia Rozells:

Yeah.

Bernhard Kappe:

Right. One of the things I see far too frequently is that people go do some initial research and then they stop getting feedback.

Christi Zuber:

Yeah, right.

Bernhard Kappe:

Or they get feedback, and then maybe do some summative human factors testing and maybe one or two formative human factors testing along the way. But Gia, you mentioned getting feedback and then keep getting feedback. My question for both you and Christi is, what does that mean to keep getting feedback? And how, in an ideal world, would you want to get feedback? How frequently and in what form?

Gia Rozells:

In medical devices, getting that input early and continually feeds right into the human factors validation, the summative work that needs to get done. It’s a way of proving to the FDA and other agencies that we’ve had enough user input and testing throughout this project to help prove that it works for users safely. At that point, if you get frequent enough testing happening, your summative is a piece of cake because you’ve already tested everything.

Christi Zuber:

I’m a big fan of looking at things from a longitudinal standpoint. If you’re really truly co-designing, your design should be evolving as you’re learning. It’s a feedback loop. If you build it in that way, as you evolve and change your product or service, you need to be finding out – some from new people and some from those that have been with you – how that continues to work for them over time. Has this addressed these issues? How has it not? There’s lots of tools and ways of doing that. Some things are just old school, one-on-one interviews with people, or ethnographic observations in the context of where they are, or maybe utilizing a tool like a Virtual Ethnography, like a dscout or something.

There’s lots of ways of doing that and sort of keeping in contact with people over time, and those kinds of things are really important, and you build that base. Because there’s a learning curve, both for the people trying to engage your user as well as, and this might sound silly, but a learning curve on how to give feedback as a user. “What am I looking for?” If you have a certain subset of the population that you’re getting feedback with, as you continuously do that with them, they’re on the lookout for how things are working at those in-between times, because you’re not with them all the time.

You look at things differently. Once you really know how to critique and what you’re looking for, you can have those kind of a super feedback version of a super user, who can really provide some really amazing stuff because it doesn’t slip past them. They’re always on alert, which is a pretty neat thing. In the spirit of co-design it, your design evolves not just once but many times.

Adrian Pittman:

I hear you saying it’s an operational practice though, right Christi?

Christi Zuber:

Absolutely. I’ve worked in health systems my entire life, and I’ve spent lots of time in the communities that are interacting with the things that we do. There’s the development of the product or service. If you look at it across time, there’s trying to understand the needs, and we’ve spent time talking about if you don’t get the need right, everything else really doesn’t matter. There’s understanding that need, and you’re probably not going to get that right the first time, so there’s evolution that happens there. Then once you actually have that, you start to work with people, work out the kinks, see how those things actually integrate into their lives. Then as you start to scale it, to operationalize it, to get it in a place where it’s actually repeatable at a larger scale, you will have a whole different set of new learnings that you need.

It is this continuous process improvement. This is continuous user engagement over time so that you’re not just tweaking your internal operations, you’re tweaking them and you’re changing them to meet the needs of the people that you’re serving at whatever stage you’re at.

Gia Rozells:

I think early user research was mentioned by Adrian. That is definitely the most important place to invest and the place that gets the shortest shift right now. We are just dying to jump into development.

Christi Zuber:

Yeah. “Get that thing out there!”

Adrian Pittman:

Yeah. 1000%

Gia Rozells:

It’s amazing that we start developing before we know what problem we’re solving and what we’re developing. It astounds me still. Investing in that early user research lets us define what the problem is and what product or feature or functionality we’re going to build to solve that problem. Then as we get into development, we keep bringing users in to do usability tests that tell us whether we’re developing that product correctly. We need to build the right product for the right user and we need to build it correctly. Those are all different phases that happen during R&D, and users are necessary for all of them.

Adrian Pittman:

Double clicking on that, there’s another component to this that I want to get your perspective on: Time. As an example, I worked with the Android team at Google and Android is in 12-18 month releases. You can’t really test an operating system, so all of your information is coming from a prior release and the insights that you gained from that. During the course of your effort, you’re effectively guessing. It’s an informed guess, to a certain extent, but you really don’t know and you won’t know for at least a year. Hardware is very much the same way. It’s very hard to iterate on hardware. To your earlier point, you definitely want to iterate through your process, particularly when you’re into your formative stages, but how do you solve for the time factor when it’s not going to work, and the data signal is so delayed on what you’re doing?

Gia Rozells:

In hardware, the timeframes are very long. That, Bernard, is one of the things that’s different from Intuit. We moved fast. We had nine months basically to get everything right. Whereas a complex hardware product, an infusion pump, robotic pharmacist can take five to ten years.

Adrian Pittman:

Right.

Gia Rozells:

All the more reason though, to keep bringing users in to check ourselves. Because in that long a timeframe, it’s so easy to go off track. There are hundreds of design decisions that need to get made. What we need to do as a team, as we’re going along, is ask, “Okay, what decision do we need to make? What do we need to know in order to design this next piece?” For any part of that piece that’s going to be user-facing, we bring in user input. A hundred decisions don’t require user input because they’re not user interactions with the device interface. But for every decision that will be part of the UI, we need to take the time there to double check with users. Over many years, that is difficult, but the majority of it is happening in the beginning, where we’re defining the problem and defining the product. As we go along, usability testing is actually quite straightforward and easier.

Bernhard Kappe:

This is another area again, where if we look to the future in the present in diabetes. One of the challenges is everything is changing so quickly in the ecosystem. Obviously people are relying on smartphones and they’re updated to new smartphones, and there are new apps, new things, new everything. There are new integrations, potentially, and adoption of certain technologies and more closer interoperability between all these things. So even where timelines are long, the software and integration timelines are getting shorter, because you’re relying on a whole bunch of other things that are changing quickly.

Gia Rozells:

That’s true.

Bernhard Kappe:

If you’re designing the right thing for people right now, their behavior and use of technology is going to change during that time period. Your assumptions based on research you did a year ago or two years ago may no longer apply, right?

Gia Rozells:

That’s true, and that’s a big risk that the manufacturer takes. It’s also important in the beginning to stay on top of trends in the medical industry, in the different areas that are relevant, in electronics and batteries, and the ways Christi is improving the hospital and the interfaces between the patient and the doctor. It requires staying on top of as much of those future trends as possible to reduce the risk of building something too late that doesn’t match the currentness of the world.

Christi Zuber:

I’m curious how often this sort of thing happens in the medical device arena. In working within a healthcare system, we would create these very immersive experiences that we would bring in care providers and patients. We’d have a mocked-up home area, for example, and we would sort of Wizard of Oz things all over the place. Blow into your phone and it’ll check your blood sugar level; stuff that really didn’t exist, but you would sort of be immersed in this thing. It would feel like it did work. People would come up on the screen and you’d do a consultation with them, and then something would show up on the screen in the home that you were in.

Of course, it’s all mocked up, but these kinds of things would give us a sense, and then we’d get feedback and we’d see how people would interact and then we’d evolve it again, and we’d evolve it again, and we would evolve it again. Whether it was trying to figure out how you would have a car that would pick you up and provide you care on the way to the hospital through an autonomous driving experience, or different things in the home, I think those kind of immersive Wizard of Oz testing of things gives you a great place to evolve and try things in spaces where it takes a long time. We did that, whether it was the home space or something in a hospital where we’re developing a new way that things would function in a hospital, and it takes years to get a new hospital up and running and the new equipment built up in it and the new technology. I found those immersive interactive scenarios, Wizard of Oz testing, where people can touch it and feel it, to be really helpful.

Adrian Pittman:

This reminds me of Forward Health. They built a lab version of what would eventually be their office model that they would spin out and syndicate. It ran as a living, breathing lab where they were injecting technology. A lot of it worked, but it worked through a bunch of back layer complications. And it was a very evolved and robust investment. It solves the zero to one, but then you’ve got a one to ten problem, which is completely separate, which is how do you scale it?

It feels like a lot of the software and hardware that we’re dealing with in this transitional period is stuck in a one to ten problem: I get how this could be solved, but the investment or the time or the confidence is not there. It’s that sluggishness that I think causes some teams to make more conservative decisions and completely miss the mark. Christi, did you find that once you got through the simulation, there was a moment where it was like, “Okay, now it’s time to put butts in seats and write checks and make commitments.” But they still didn’t want to do it.

Christi Zuber:

Sometimes. But I would say, having ways that people can touch, feel and interact is the best change management and buy-in tool that you could ever have within an organization because it’s not foreign anymore. People have had a felt experience. They feel like they’ve put their fingerprints on something, so they’re much more willing to take it to the next step.

We actually had a much easier time getting things to the scale-and-spread level when we created these immersive experiences, when we were able to bring people in to touch it, feel it themselves, see how patients were interacting with it. Or if they weren’t physically there, videoing the experience, so then they could watch it and say, “Well, I didn’t ever imagine someone would do it that way, or that was not in my purview.” It wasn’t just people sitting around in a room making up what they thought would happen or hypothetically talking about it, it was much closer to an actual lived experience before we could have the lived experience. We found it amazingly helpful. Any place that can have that immersive experience provides far more value than just the step one. It helped us throughout those steps.

Bernhard Kappe:

Did you find a similar experience, Gia?

Gia Rozells:

Yeah. We invest a lot of time in prototypes. We have a simulation lab that works like a hospital. We have an operating room, an ICU, a regular patient room with background noises of busyness and people going in and out to interrupt the user to see what would happen. We build prototypes at various stages wherever it makes sense, and have users get their hands on it. Sometimes instead of the real screen, there’s an iPad where we’ve mocked up a wireframe of what would occur, and we watch users try to use that. Christi made a great point, which is it’s really valuable to watch users do that and to get a video that you can show the executives, but it’s even better to bring the executives in and either have them watch live or have them try it.

Bernhard Kappe:

Because as you said, it’s surprising how, even in this day and age, products oten get built because people assume they know what the user needs. “I know it. I don’t need to do any research.” And then lo and behold.

Gia Rozells:

Yeah. The biggest part of my job is convincing executives and subject matter experts that they actually don’t know as much as they think they do.

Christi Zuber:

The expertise trap is for real.

Gia Rozells:

It is.

Bernhard Kappe:

How do you go about doing that? What’s worked for you in terms of convincing those executives? It’s one we’ve all faced, right?

Gia Rozells:

In a situation where, as you pointed out earlier, we sometimes lack quantitative data, we need to use our qualitative methods to prove things. And the only really reliable way that I’ve seen that basically never fails is running tests with users and proving that the user can’t do what the executive thinks they can do. It always works. The engineers, the executives, the marketing people, they all think they know the right way to do this. The only way to really make sure everybody gets it is to have them watch users fail.

Christi Zuber:

In talking about that, I remember one time we were working on patient discharge processes. It started out very focused on, “How do we reduce readmission rates?” Basically, that means when people go home, they go home safely and are ready to go home. How do we know that they’re ready to go home, and how do we make sure they’re not coming back into the hospital for the same thing? Which nobody wants. A health system doesn’t want that, and insurance companies don’t want that, the patient doesn’t want that, nobody wants that. 

When we started, it was very focused on the conversations, based on what was being pulled out of the medical record. We had these conversations before they left, how they got their medications, there are all these things we were working on. Then we literally hopped in the car with the patients and started riding home with them, and we would film it. “Okay, here we go. Now you’re home.”

We got all this footage of people getting out of the car with their walker, hobbling up and then not being able to get into their home because they have to go up 18 steps. It became this simple breakdown of, “Okay, well maybe now we actually need to think about how the transition happens at home. Do we know what the home situation is?” There’s no amount of conversations that would’ve gotten us there. The conversations were very focused on protocol and etcetera. But as soon as you can show that example, show a video of someone standing there at a complete loss, not knowing how to take that literal next step, that’s worth everything.

Gia Rozells:

It is.

Christi Zuber:

Whether it’s fumbling with your product or trying to take another step in the journey of whatever they’re attempting to do, those things are so powerful.

Gia Rozells:

It’s the only way.

Bernhard Kappe:

Sometimes though, the starting point could be quantitative data. I remember for one product we were developing a while ago, it was around all the perioperative processes before an operation and after an operation. The data showed that there were a lot of readmissions because the incision wound opened back up. It’s like, “Why did it do that?” You have at least the starting point of “Something is happening.” So we went in and observed things. It turns out, one of the things that was happening was that when people got home, they would start to rearrange their furniture and how they were living so they could be more comfortable after this operation or with this wound. That process of moving the furniture around was, in some cases, what caused that wound opening back up. That turned into, “Okay. One of the steps you could do before this operation happens is go move those things around or get help moving those things around, because your life for at least a month or so is going to be quite different and you want to be comfortable.”

Gia Rozells:

That’s a great example. We do have quantitative data. I can see every button push, every entry that every nurse makes on a million infusion pumps that we have, and I can tabulate where the problems are. Then I have to go to qualitative to figure out why that’s a problem. Why on earth is this wrong medication amount getting inputted? Why is that happening? You get back into the qualitative where you have to watch and look.

Bernhard Kappe:

That’s the whole cycle of getting quantitative, then qualitative, then quantitative and qualitative again. If you can have a short cycle, then you can improve a product really rapidly. But if you have a long cycle, then as Adrian said before, then how do you build those things up? Because you only know qualitatively if what you did is actually going to move the needle and change something until you know it quantitatively.

Gia Rozells:

Right.

Adrian Pittman:

Yeah. A lot of times, you’re dependent on second or third party sources if you don’t have quantitative upfront. I always tell my teams that the qualitative is for context, quantitative is for scale. You have a trend, but to understand exactly what that trend means, it may not be evident by looking at the raw data. You need to apply, “Why are people doing X” or “Why are people not doing Y?” It’s the qualitative data that always provides that understanding. It’s one of the reasons why I always try to encourage teams to think in terms of compatibility between user research and any performative data that comes out of a system, because you’re going to need to pull those two things back together and cross-compare that data.

Gia Rozells:

I like how you explained that.

Adrian Pittman:

This takes me to another question. It’s a theme that’s sort of interwoven through a lot of the comments in our session. If we think about the person, the end user, the human being who’s actually using the product. We’re not talking about the practitioner in this particular instance, we’re talking about the patient, the person receiving the care. Obviously, adherence and compliance are big ticket items in the medical industry. We talk about this concept in our article series about lifestyle integration, and the importance of people being able to live with the product. It fits within the confines of the world that they exist, the way they prefer to do things, in maybe not an optimized way. It affords different levels of technical literacy, and so forth. 

When we talk about that as a concept, Christi and Gia, what does that mean for you? Does lifestyle integration resonate? Is that a part or a signal? Maybe it’s an analog for something else that you do in your practices? And how do you ensure that component makes its way into the product design work that you do?

Christi Zuber:

First, you would need to have some understanding of what that person’s lifestyle is, which we’ve been spending a lot of time talking about. You can’t really have lifestyle integration of your product, if you don’t understand their lifestyle in the first place, and what that means to someone. People are willing to do some small things for a value that comes out at the end of the day. What they’re not willing to do is to feel like their life is revolving around whatever device, whatever flow that that equipment forces upon them.

You see that a lot. People don’t want to feel sick. People don’t want to feel like they’re tethered to something. They want to live the best healthy life that they’re able to where they are. When I think about life integration, really at the end of the day it’s about their perception. Do they feel like they’re still able to live their best healthy life, even though they have to collect this cycle? If they perceive that they’re not beholden to something, and they don’t have to give up important things in their life, then I think it is lifestyle integration.

Gia Rozells:

For all of the wearables and home technology that we’ve been talking about, there are aspects that we basically never have to consider when we’re creating a device for a hospital setting. If it’s a user who’s going to be using it at home, or if they’re going to be wearing it or carrying it with them, we have to think, as Christi and Adrian, what’s their lifestyle? Where are they going to be using it? What kind of motion will be happening? Will it make noises that will let other people know that something’s going on? It needs to be discreet. It needs to be simple. It absolutely needs ease of use. There’s no place where we need it more than any kind of device that the patients themselves are going to have to use on their own. There are lots of lifestyle aspects that we need to solve for that we don’t have to use hospital devices, and we’re not used to considering them as part of our requirements.

Christi Zuber:

Another example of lifestyle integration is the Veterans Administration. About 30-35% of the veteran population lives in a rural area, hundreds of miles away from a larger medical care facility. In trying to understand how to serve that population, the VA started asking, what is the lifestyle? Where are those veterans going? What are they doing? They had, to your point earlier, quantitative data on what they needed and what their conditions were, etcetera. One of the things that came up is the VFW posts. They had the communities that the veterans were part of, the VFW post that they would go to, where they would socialize with each other. So, the VA put some of the ability to do remote visits and testing, etcetera, in those places, because their constituents were already going there for other things.

Leveraging something that might have been unexpected yielded big implications for them. The VA also looked at the number of veterans that were within a certain distance of a Walmart. They partnered up with Walmart to be able to put healthcare things in that setting. That’s also an example where it might not be something that’s wearable, it might not be something in their home, but if you understand the natural paths of a person’s daily habits, daily routines, daily lives, you might be able to integrate something into that. Something that won’t fit on their wrist, that won’t go into their home, but they come across it in their natural path and it could make a really big difference.

Gia Rozells:

That’s a great point.

Bernhard Kappe:

I remember, not that long ago, I was visiting my mom in upstate New York. We went to the grocery store and there was one of those Higi machines. I learned that part of her process of going to the grocery store was that she sat down and measured her blood pressure and pulse. The machine gave a printout of that. I was like, “Oh, do you do this every time you go to the grocery store?” She said, “Yeah, I just do it. I just want to know.” It’s like, okay, there it is. It made sense for her, and it was leveraging what she was already doing. It was one additional habit that she could easily attach to one she already had. If you think about things like habit formation, it’s a lot easier if you’re adding something to a habit that they already have, rather than creating something new or whole cloth.

Christi Zuber:

You must also be a BJ Fogg fan.

Bernhard Kappe:

I’m a BJ Fogg fan, and I’m a James Clear fan.

Christi Zuber:

As we were talking, I was thinking of the concept of putting a hot trigger in the natural path of people. That same thing is the natural path that they take. Is there something that they can do right away in that path that they’re taking? I think all those behavioral change things are just quintessential when we’re talking about that lifestyle integration.

Bernhard Kappe:

Yeah. It’s meeting people where they are.

Christi Zuber:

Yeah.

Bernhard Kappe:

You can do just about anything for a week. But all of these chronic conditions are not, “Do something for a week.” They are, “Do something for the long haul.” That is really hard to do. Half of what you’re doing is trying to make things easier to remember and more satisfying. All of the things that you do for habit formation are the kinds of things that you need to apply for chronic conditions.

Adrian Pittman:

Have you seen any good examples of lifestyle integration? Either ones that you’ve seen or experienced, or been a part of designing?

Gia Rozells:

Diabetes wearables are the first things that come to my mind. An important thing is everybody on the development team needs to wear the device for a week themselves to see what the user is going to be going through to really get that. Then, we need to have real users use prototypes of the device in the real world as much as possible so that we know that we’ve captured as many of the lifestyle issues as we can. Because once we manufacture and sell it and a user has it, what Bernhard said starts to come into play, which is, I’ve got a week, a month to get them to make this a habit. If it’s not easy enough and it doesn’t work well and fit into their lifestyle, we’ve lost that opportunity to have them make a habit out of it. They’ll just stop. You can build the greatest device technologically, but if users won’t use it, it’s pointless.

Bernhard Kappe:

Going back to diabetes. You have folks that are Type 1 diabetics and you have Type 2 diabetics. Type 1 diabetics are born with it and that’s their life. They have to deal with it. There’s no, “I’ve lived my life a certain way, and now I’m being asked to change my behavior.” That’s what makes Type 2 diabetes more difficult, because people have built habits that, in many cases, have gotten them to this point. Whereas in Type 1, it’s like, “Habit shmabit. I was born with this.” Those are two very, very different attitudes, and it’s really hard to unlearn behavior as well. The problem for Type 1 diabetics is obviously they need insulin and all of these things. It’s a difficult medical condition and the technical problems are greater in many ways. But for Type 2 diabetics, the behavior change problem is really hard.

I’m not sure I’ve seen anyone who’s really solved the Type 2 diabetics problem because it is so hard. But I’m starting to see at least more experiments around some of those things, again, using some of the habit change techniques that are starting to happen there. Things like potentially a greater use of CGMs, which make the measurement, as long as you have one on, much more obvious. You can make correlations between behavior and what’s actually happening because you’re getting the data for free. You don’t have to do a finger stick every so often.

Gia Rozells:

That’s a place where something like gamification might come into play. Creating a habit by providing some sort of positive feedback that users get used to. Instagram makes sure that you get a dopamine hit every time you scroll through their feed. We need to find a way to give that kind of reward to people who are using medical devices.

Bernhard Kappe:

Make it more satisfying, right?

Gia Rozells:

Yes.

Bernhard Kappe:

That’s really what it boils down to. I’m not sure that people actually designing medical devices often think, is it a satisfying experience? Is it a clinically effective experience? They ask if it’s a safe experience, but not necessarily whether it’s satisfying.

Adrian Pittman:

To add to that, I think that if you look at satisfiers and maximizers, most people in the medical space are probably, patient-wise, satisfiers. They’re going to look for what gets the job done without a whole lot of upheaval. It is a matter of softening the blow when the behavior does not change sufficiently enough. That’s also a high bar for medical device when the blow is something to do with your own body. That’s an important signal for good UX design in general.

There’s no real dead end, there’s just soft turns and things of that nature if you make a choice that is suboptimal. Figuring out what that experience is like for people who are using devices needs to be more regular. It reduces the pushback that behavioral change programs tend to induce, which is, “You’re trying to make me do something that I consciously do not want to do,” and they’re actively working against it. As an example, what’s the name of that app that helps you learn how to speak different languages?

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Christi Zuber:

Duolingo.

Adrian Pittman:

Thank you very much. Duolingo.

Christi Zuber:

There you go.

Adrian Pittman:

There’s a few others, but that’s the one that comes to mind. There’s a certain type of user that’s going to follow through that pushed behavioral change, and it is trying to change your behavior. And there’s a percentage of users that just won’t do it. We need to figure out what the soft exit ramp is, if there’s an alternate path of, “Look, I’m just not going to do that,” so that it isn’t so brutal when you don’t meet up to the happy path standard.

Gia Rozells:

That’s interesting.

Christi Zuber:

When we talk about design of products, one of the areas that I’m really passionate about is clinicians as a part of the team, and also clinicians when they’re being trained as clinicians. This is finally starting to happen, but it’s very slow and isolated: Clinicians are learning about human-centered design and co-design practices when they’re going through their clinical training. It’s not just about the specifics and the technicalities of their clinical training, but how do you learn from people? How do you evolve ideas that you have? I’m personally passionate about this particular area as a nurse myself, but when you think about the individuals in those roles, the more you can understand how that happens, then I think you break that mindset, which exists in clinical practice for so long, that it’s really about compliance.

If I say someone needs to do something, I know they need to do it, because my data tells me if they don’t, these 20 bad things will happen. But that’s actually not how the change is going to happen. That is a rare case that you can educate somebody into a change. As we start to look at product development going forward in the future, of course it’s important. The medical device companies and all of that, how they do the work and how that looks. It’s equally as important for these clinicians and other care providers to be a part of it, acting as the eyes, the ears, the arms, the legs and understanding, what is happening? What are those needs? How do I speak to people in a different way about behavior change? How do I bring these products in? How do I give feedback to these manufacturers when I’m seeing things that go awry and what that looks like? 

For example, I’m on the board for the American Nurses Association with the innovation focus. One thing that’s become really important in the ANA world is, how do we begin to build up the confidence and the skills and the mindsets of the nursing workforce across the country, as innovators, as co designers, as we’re bringing these things forward? I think that’s such a cool space. When we look at the possibilities in the future, I imagine a clinical workforce that has built that capability.

Gia Rozells:

That’s fascinating. I’ve never thought of it that way.

Adrian Pittman:

That’s the theme I’m picking up, that the care team is a part of the lifestyle integration. How they’re integrated into the workflow is a part of making sure that it fits with people’s lives, because they need help.

Christi Zuber:

Yeah.

Gia Rozells:

Yes.

Adrian Pittman:

And that care team might not necessarily just be physicians and clinicians. It could be a care provider in home, a family member.

Bernhard Kappe:

For CPAP machines, how a lot of that works is that you have third parties that are setting these things up, and helping people get everything going. It’s not necessarily a clinician, and it’s also not the medical device company, it’s a third party. Someone along the way is getting paid for usage as opposed to just selling a device, and proper usage as well.

Gia Rozells:

There may be new types of personas that come into play. There are companies that are setting themselves up as technology centers. The hospital lets them know, “We’re implementing these devices for this user in their home,” and the tech company sends somebody out to set it all up. A whole new kind of user will be in play. When you’re dealing with individuals who are working on their own healthcare through devices or software or whatever that we’re developing for them, we have to remember the lifestyle issues, getting into many different users’ homes to really see what their world is like. One example that Randy Horton loves is a device that we had tested on many people and we put it in homes. We thought it was pretty bulletproof, the user couldn’t possibly make an error. It hadn’t occurred to us that there would be users who have kids in the house. All kinds of unexpected things could happen.

Christi Zuber:

I have no idea what that’s like. I don’t know what you’re talking about.

Adrian Pittman:

Right.

Bernhard Kappe:

Kids, and dogs. That’s right.

We’d like to thank our awesome guests for this podcast. Christi Zuber, the Founder and Managing Director of Aspen Labs and Gia Rozells, Director of User Experience at Becton Dickinson. I’m Bernhard Kappe.

Adrian Pittman:

And I’m Adrian Pittman. Make sure to come back for the third and final episode in this series. In it, we’ll talk about what the future might hold for patient engagement as it relates to connected medical devices. We’ll cover where we see real breakthroughs coming from in the future, and some of the challenges we’re still going to have to collectively tackle as an industry.

Bernhard Kappe:

If you enjoyed this podcast and want to hear more content like it, you can check out Orthogonal’s website at orthogonal.io. Our Insight section is regularly updated with fresh content related to connected medical device systems, Software as a Medical Device and Digital Therapeutics. You can also reach out to me at [email protected]

Adrian Pittman:

Or reach me at [email protected]. We look forward to hearing from you.


 

This is an edited transcript of the second episode of Orthogonal’s “Patient Engagement & Connected Medical Devices” podcast.

You can listen to the second episode of the podcast at the top of this page, or stream it wherever you find podcasts.

Links to the series of transcripts:

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