Redesigning healthcare to fit with peopleBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4536 (Published 23 August 2016) Cite this as: BMJ 2016;354:i4536
- Kim Erwin, assistant professor, communication design methods1,
- Jerry A Krishnan, associate vice chancellor for population health2
- 1Institute of Design, Illinois Institute of Technology, Chicago, IL, USA
- 2University of Illinois at Chicago, Chicago, IL 60612, USA
- Correspondence to: J A Krishnan
Healthcare expenditures vary fourfold across the globe, from less than 5% to nearly 20% of a nation’s gross domestic product.1 Higher levels of spending, however, have not necessarily produced better results, suggesting that some healthcare systems are more efficient than others.2 These observations have led to various efforts to improve the efficiency of care systems.
In Europe and the US, for example, emphasis is increasingly shifting away from the “volume” of care (number of services) to the “value” of care (quality, outcomes, and costs).3 4 Government and other payers are driving health systems to invest in electronic health records, data analytics, performance improvement, and clinical decision support tools. Unfortunately, these investments are often launched as a series of individual fixes targeting different types of apparent underuse, overuse, or misuse of healthcare, disconnected from each other and from workflows in clinical settings. And thus well intentioned reforms are accumulating on the shoulders of clinicians and administrative support staff, who are being asked to do more with less. Not surprisingly, burnout of frontline staff is emerging in many countries as an unintended consequence of efforts to improve delivery of healthcare.5 6
We know that the progression from discovery to delivery often derails when it intersects the healthcare system.7 Routine use of proved innovations takes an average of 17 years, which may partly explain why people receive only about half of the recommended care. The reach of healthcare services also remains deeply unequal and is least likely to benefit vulnerable populations, including those with lower socioeconomic resources, elderly people, and rural populations. The current approach to healthcare may essentially be hard wired for inequity because those who are not equipped to extract what they need from the delivery system are more likely to be systematically left out.
The slow and uneven translation of evidence into practice has led to a recasting of biomedical research as a sequence of steps, beginning with a translation of discoveries from the bench (preclinical research) to the bedside (clinical research; figure).8 Although this first translational step is necessary for answering questions about what could work in optimal settings (discovery science), we now know that it is insufficient to reliably improve healthcare in typical clinical settings. Delivery science (systematic reviews, guidelines, and dissemination and implementation science) is needed to accelerate uptake and delivery of the right care to the right individual at the right time.
Design methods, which many industries outside healthcare already recognise as critical to meeting the needs of people they serve,9 have the potential to make delivery science more effective. In the past five years an increasing number of healthcare organisations have invested in “human centred” methods from the field of design. The Memorial Sloan-Kettering Cancer Center, the University of Illinois at Chicago, St Mary’s Hospital in London, and others have recruited experts in design to rethink the care delivery experience and incubate new ideas for products, software, and services to improve delivery of care.10 11 12 Designers use in situ observations and interviews with patients, care givers, frontline clinical and administrative support staff, and other stakeholders (eg, payers and policy makers) to understand the context in which individuals make health related decisions in real world settings. Using conceptual frameworks to help make sense of the contextual data (eg, physical environment in which care is administered and level of patient engagement), they then work with healthcare staff to develop visual models, testable concepts, and prototypes for interventions that can be quickly piloted in real world settings, engaging users to assess and improve fit.
By merging the sciences of design and medicine, we believe we can do a better job of translating discoveries into practice. The key is to shift our focus from helping people to fit our care delivery system, to one where we design our care delivery system to fit people where they live, work, learn, play, and receive healthcare. To design solutions that are successfully sustained in practice, everyone who touches the healthcare ecosystem has to be counted. Going forward, we must therefore expand our horizons from patient centred to people centred solutions in which patients, care givers, clinicians, schools, employers, payers, and policy makers are all engaged. We believe that delivery science that is supported by design methods holds the key to redesigning healthcare to meet people’s requirements.
Competing interests: We have read and understood BMJ policy on declaration of interests and have none to declare
Provenance and peer review: Not commissioned; externally peer reviewed.