Paul Robare is a second year Master’s candidate at the Carnegie Mellon University School of Design. The Mayo Clinic in Rochester and Design Continuum in Boston co-sponsored a service design course at CMU where students worked on a project called the Advanced Medical Home.
I interviewed Paul by telephone on January 27, 2009 about the design of his team’s LiveWell service.
LiveWell is a service designed for Mayo Clinic that redefines the role of health care in daily life.
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JEFF: Hi Paul, thanks for taking the time to talk with me today.
I thought we might start with a bit of an overview for people who aren’t familiar with the service design course at CMU. You worked on a project for the Mayo Clinic called “The Advanced Medical Home.” Can you tell me about it?
The brief as we were given it was to define and design an “advanced medical home” which was a term that none of us had ever heard before. As we got into the literature and into the archival research we found that nobody really knew what it was. It was this broad concept of “better ways that things could be done” and there was this certain aspect to it that people agreed should be part of any advanced medical home but nobody had ever really figured out how it might happen.
JEFF: The term “advanced medical home” sounds like some sort of ubiquitous computing project.
PAUL: That’s what we were thinking. One of the first things we learned is that advanced medical home has nothing to do with the home. When we heard it we thought it was a “doctor in the wall” or something like that.
JEFF: What was the working definition that you used for the project?
PAUL: Well, basically we took information that the Mayo Clinic had provided to us. The concept behind the advanced medical home was that doctors would work with teams of healthcare professionals that weren’t themselves doctors to provide care in a more holistic sense. The primary care management activities would go on among the non-doctor healthcare professionals.
The future big problem of course is that the population is aging and the number of primary care physicians is shrinking and so it becomes more and more of a question of how do we balance those two things?
JEFF: How did you pick the target for your design?
PAUL: Well in our case, since we were working for the Mayo Clinic and we knew that they were talking about prototyping the things that we designed in a few of their satellite clinics in small towns in Minnesota we knew we were looking at small town midwesterners and I myself actually went to undergraduate in a small town in the midwest so I had some experience with the populations there. I also lived in Iowa for a couple of years. So we sort of focused in on the heartland.
JEFF: This was also a group project, if I’m not mistaken. Can you tell me a bit about who you worked with?
PAUL: Yes, absolutely. There were five different teams and my team consisted of four people, so there was myself and two people in the HCI masters program and one junior undergraduate in communication design [Daniel Lee, Karl Nieberding and Hajin Choi]. It was a multi-disciplinary team.
JEFF: Let’s talk a little about how your group dove into the project. About how you decided where to begin.
PAUL: We took the standard Carnegie Mellon method, or the “Shelley [Evenson] method” of starting with a territory map. We dove right in and asked: how do we map the territory that we’re dealing with, when we don’t really have a definition of what we’re trying to design — well I suppose you never do — but we felt like we had an even foggier than usual picture. And if you look at the territory map in the PDF, it’s the individual and the family and the primary care physician and there’s staff and the satellite services and we initially focused on this relationship between the individuals and their families and their care providers, looking at the important aspects of the relationship. We saw it as “communication, continuity and quality.”
We were pretty broad there, but then when we presented that to the folks at the Mayo clinic, Maggie [Breslin] said — do you know Maggie, Jeff? —
JEFF: Yeah, she was a classmate of mine. A year ahead.
PAUL: We presented to Maggie and she gave us pretty good feedback. Between her and Continuum they were really interested in the “continuity” side of things as we talked about it. And so we decided to focus on that.
JEFF: When you say that you presented this to the Mayo Clinic, were you making remote presentations? Or were you flying up to Rochester?
PAUL: Yes, we were doing remote. We were iChatting everything. Maggie came down once earlier in the semester and then at the end, and the folks from Continuum came out a couple of times. And then at the very end, in December, a few of us flew out to Rochester to present the final designs.
That was one of the most interesting things about the experience. None of us had ever done remote user research before and didn’t really have any idea how to do that. We had done certain things that could be translated to being remote, like journal studies, but it was definitely a new thing and a challenge. But it was also interesting because a lot of the interviews, Maggie and her team would actually do those for us and then we would watch these videos of the interviews they had done. That was kind of nice in a way because you could always just go back and watch them again.
JEFF: So, they were facilitating the interviews; were you writing the questions or providing some kind of outline?
PAUL: We were writing the questions. We developed the protocols that because of time constraints on Maggie’s end, there were five teams here, she had to combine questions and things that we were asking, and then also there’s a Ph.D student, Ian Hargraves, I don’t know if you know him as well—
JEFF: Yep, I worked with him at CMU.
PAUL: Okay, so Ian was also helping us out a lot on this because his Ph.D research involves questions of services, dealing with things that are a bit more abstract but he was actually flying out to Rochester on a pretty regular basis and doing a combination of his own research and research on our behalf. That worked out well because he was always coming back here so we could corner him and interrogate him as much as needed.
JEFF: This sounds interesting. It seems like you were working very closely with the client, in this case the Mayo Clinic, and really had a distributed design team.
PAUL: Yeah, definitely. That was kind of a new experience. Prior client work, we had done the Studio II project with Microsoft and Motorola and with that it was really just checking in with them and giving a presentation once every six weeks or so but in this case it was just constant back and forth to make sure that we were getting what we needed to really explore this question.
JEFF: You talked just a little about journals and interviews for research. Did you use any other methods for the project?
PAUL: We did a few different things. We sent journals — my team actually did two different journals and sent those out mostly to employees because in the medical industry there’s always great concern for confidentiality and so with the Mayo Clinic pretty much all of the employees are also clients of the clinic and so the journals were passed out to employees who had volunteered to take part in things who were also chain doctors at the Mayo Clinic.
We also did interviews, and were mostly sending questions on to Maggie and Ian up in Rochester who were then shooting videos back to us to take a look at.
Also, we did some directed storytelling sessions with folks here in Pittsburgh, just to make sure we were wrapping our heads around the right issues because in the end the advanced medical home is supposed to be something for everybody, so while there are certainly differences between the folks you’ll find in Rochester and Pittsburgh they shouldn’t be differences that would necessarily impact the design.
And then we also did some generative research and collage sessions where we asked people to model their ideal healthcare experience and to tell us their lifetime health journey.
JEFF: What was the big picture that came out of your research?
PAUL: We pulled a number of interesting findings out of it. The biggest one for me, it was one of those design implications that in hindsight seems so blaringly obvious but was still such a big conceptual leap for us at the time was model of the current versus the preferred model of healthcare [page 11 of the PDF]. What we saw was that healthcare providers and the patients and the clients themselves currently think of healthcare in this binary way, where you’re either “healthy” or you’re “unhealthy” and if you’re healthy it’s the job of healthcare to keep you from falling into the unhealthy bucket and if you’re in the unhealthy bucket it’s the job of healthcare to push you back up into the healthy one.
We started looking at that and said that it didn’t really make any sense. There are lots and lots of levels of healthiness and no matter where you are you can always improve your health and we saw that one of the great opportunity areas — because right now healthcare if you’re healthy just treats you as healthy, and sort of sends you on your way. Why isn’t it doing more to proactively support the kinds of things that people do on a day-to-day basis to impact their health? And when we did these journals and had people filling them out we had some questions about: tell us some of the health concerns you had today or did you get an answer? And inevitably, and not too surprising, but everybody constantly talked about nutrition and exercise. These were the two things that people were thinking about all the time. And yet hospitals don’t really do anything for people on those terms. Or at least very little.
JEFF: So you were trying to find a way to bring that back into the conversation?
PAUL: The conclusion we came to was that the Mayo Clinic needed to support all healthcare related activities proactively. They needed to be looking at how they encourage their patients to really engage with their health on a day-to-day basis. And that includes those healthy people. Because one of the interesting things about working for the Mayo Clinic is that here we have potentially the best healthcare facility in the world. I mean, this place was amazing. And they do a really, really good job of taking care of their patients and so in a way it’s a little difficult: how do we help them improve their service? What we found was that the services that they were doing, they were doing really well. The issue wasn’t so much how they improve their existing services as what related services are they not currently providing that would really round out their offering.
JEFF: What sort of ideas did you present to Mayo and Continuum about how that might happen?
PAUL: For a couple of iterations, we looked at this idea of a wellness coach where there was this non-doctor healthcare professional who was coaching people and things like that in nutrition and exercise and not necessarily giving them advice directly themselves but pointing them to the right places so that they could get answers to questions and encouraging them to engage with their own health.
JEFF: How did Mayo respond to that?
PAUL: We hadn’t quite gotten to the point of presenting it to Mayo, but we discussed it at one of our directed storytelling sessions and we talked to a guy who had worked for one of those startups out in the Bay and he said: Oh yeah, we had one of those. Their company hired a woman who was a personal trainer and a certified nutritionist and she came into their office every week and she would go so far as to come to their cube and say: hey are you going to go exercise today? And when they first hired her on everyone was really excited but within a month everyone had just given up and no one was taking advantage of it.
Then we were suddenly like: okay, obviously there are some issues here. I actually have a personal theory that all wicked design problems come back to questions of human motivation. So that’s what we started to struggle with. So okay, how do you motivate people? We developed this idea of “wellness teams” as we called them that were essentially support groups headed up by one of these wellness coaches. But the team would help support each other and motivate each other. Some sort of technological mediation, some sort of networking, but more importantly people would actually be with each other on a fairly regular basis and the idea was that it would help people help each other move to a stage of self-sufficiency with their health where they had developed these healthy habits and could continue them on their own. They no longer needed a pat on the back.
We presented that to Mayo and got sort of a lukewarm response. We felt really good about it and we weren’t really sure what was the problem. And then the one trip that we made during the project to Mayo, my teammate went up there for a couple days and they basically had a system just like this already for their employees. It didn’t extend to all of their patients but they had basically already implemented this and we thought: okay, that would explain why they aren’t that excited about this idea. And Maggie really pushed us to think about this as: what if the whole community was the wellness coach and where does that lead?
So we took that and really ran with it and that’s how we came to the final design of the Live Well service system.
JEFF: Let’s talk about that a little. I came across “Bob’s Story” when I was looking through your documentation.
PAUL: That video is a short exposition of the different parts of the service. As I’m sure you well know one of the great challenges any time you’re dealing with a service design like this is: how do you communicate it because there are so many different pieces and they’re not necessarily in a linear, chronological order in the way that people move through them.
JEFF: As I understand it, there’s basically this distributed system of stakeholders. You’ve been fairly comprehensive in addressing how the service would play out through the different stakeholders.
PAUL: What we were looking at is that if you do think of the entire community as the wellness coach, particularly with these small towns and midwestern communities there are certain things that are always there that play a large role. Churches for instance are huge in these communities and as for employers there are usually just a couple of really big ones and there’s usually one supermarket or maybe two. One school, maybe two. So how do you bring these groups together so that they can coordinate their efforts in a system like this? That was the question we were struggling with.
When I lived in Iowa I was in Des Moines and I worked for a non-profit. I did a number of different things there. We often found ourselves trying to tie together different community resources to get things done. So this became a similar question; I was drawing on some of my own experiences. It became this question of how do you make sure that it’s working and so focused on these four themes that I mentioned here. Connecting people, because connected people will support each other. And building health habits, and really “habits” are the important part of that because again we’re always focusing on moving people to self-sufficiency so you don’t have to keep helping them along. Then enabling healthy decisions and the idea there was that the people we looked at and the people we talked to want to make healthy decisions, but they’re not necessarily going to go out of their way to do it. So we were thinking a lot about how do you make it really easy for people to make the correct decision at the time when they’re making it, which was how we came up with ideas such as the Live Well branding put on menu items in restaurants. When you sit down and you see it, it’s right there in front of you, it’s a lot easier to say: okay, maybe I shouldn’t have that triple burger.
And then all of these things, our methods, tied together to create a “culture of wellness” which is just about: how do you create — how do you get it so the entire community is thinking about these things? I’ve seen some changes like this occur already when I was living in Iowa when The Biggest Loser show started up and there were Biggest Loser competitions all over the place in Iowa, usually employer-sponsored. People were really getting into that and I saw of the volunteers my organization worked with lost huge amounts of weight and improved their health.
When we were designing the website component of the service we asked: how do you keep people engaged? Oddly enough one of the models that we looked at were slot machines. Because if you think about it, slot machines do a pretty fantastic job of getting people to maintain a pretty high level of engagement, without ever really giving them much in return. Which is part of the problem with trying to encourage healthy living habits is that it take a very long time to get a payout.
There was a New York Times article a while back that talked about the design of slot machines that talked about: you’ve got Bob Hope slot machine and rather than giving you money back, every once in a while it plays you a little clip of Bob Hope. It apparently works quite well. So we were looking at that and we were looking the Xbox Live and gaming paradigms; how do those things keep people engaged? We came up with several ideas which we tried to combine together one of which was little trophies which don’t have any real value of course but then again neither should Linden Dollars in Second Life and yet people pay for them.
JEFF: What was your design for Mayo’s involvement in this overall system?
PAUL: We saw Mayo as sort of the “project managers.” They would have to be the ones on the ground, and of course there’s a certain amount of effort that needs to be expended to start a system like this. When we designed it we believed that it would become essentially self-moving in a lot of ways but that certain things like educational materials would need to be developed by Mayo and printed and as far as going out and talking to community leaders and getting them involved in the system– again, someone needs to do that and we saw Mayo as a particularly good place to do that, being a highly respected non-profit organization in the community.
JEFF: That’s a pretty good overview. Do you know if Mayo has gone forward with any of the designs from the class?
PAUL: I don’t know. One of the interesting things was that when we went out to present to Mayo Clinic in December I was a little nervous because okay, we’re going to have a room full of doctors. Lots of incredibly rational, analytic-minded people. We were expecting criticism and we were really surprised at just how open and receptive they were to the ideas that we and the other teams presented. They were really excited. I imagine that the SPARC team, Maggie’s office, will take some of the ideas from some of the teams and directly implement them. I would be surprised if any of our designs in their entirely would get implemented but I know that also the Mayo clinic is continuing to work this semester with another course with the school that is being co-taught between Shelley and a couple of people over at the Tepper school.
JEFF: Thanks for taking the time to go over the project with me. It sound like it was a great undertaking.
PAUL: It definitely was; I think we learned a lot. It’s always great to work with clients like the Mayo Clinic who are interested in the way that we do things.
JEFF: Good luck with the rest of your thesis.