What comes to mind when you hear the word design? Probably clothing, sleek new tech, or maybe a vehicle. But design and design choices are a part of things we interact with every moment of the day. From the construction of roads and sidewalks to the curve of your fork, the small details that make an impact are thoughtfully designed in a way that suits their purpose. Designing for healthcare experiences and outcomes should be no different.
In this episode of the In Network podcast feature Designing for Health, ILN Coaching & Consulting’s Chris McCarthy speaks with Nordic Chief Medical Officer Dr. Craig Joseph and Head of Thought Leadership Dr. Jerome Pagani. He discusses his pathway to healthcare innovation, how he was inspired by a Ted Koppel Nightline episode highlighting grocery carts, and how he began using the principles of human-centered design (even before any formal training) at Kaiser Permanente. This episode is the first of two with Chris McCarthy. Make sure to check back soon for the second half.
In Network's Designing for Health podcast is available on all major podcasting platforms, including Apple Podcasts, Amazon Music, Google, iHeart, Pandora, Spotify, Stitcher, and more. Search for 'In Network' and subscribe for updates on future episodes. Like what you hear? Make sure to leave a 5-star rating and write a review to help others find the podcast.
[01:21] Chris McCarthy’s early background
[06:02] Pivoting to Kaiser Permanente
[11:22] The role of technology in population health management
[18:09] Human-centered design and how it’s a vast improvement over business process engineering
[21:27] Leveraging IDEO to incorporate human-centered design to solve complex problems
[28:13] The relationship between innovation and design
Dr. Craig Joseph: Chris McCarthy, welcome to the podcast.
Chris McCarthy: Thank you. Happy to be here.
Dr. Craig Joseph: Very excited to have you here today. I wanted to kind of start off with your background. We were discussing this a little bit earlier, and you've said ever since you were a small child, you wanted to be involved with design and innovation in healthcare. And I think you said something around age three. Now, is that accurate, or did I get that confused a little bit?
Chris McCarthy: You know, I woke up at three with an epiphany. Yeah. No. Far, far, far from that. Although I did grow up being in love with technology, like, very, very early on. I think my dad bought me a Vic-20 and then a Commodore 64. And a lot of people don't remember the Commodore 128. And so, I was a very early tech geek.
Chris McCarthy: And that, I think, started my accidental discovery of the love of new things and stuff that nobody else was experiencing yet. I just always was attracted to that.
Dr. Craig Joseph: Well, let's talk about this. No TRS-80 color computer, it sounds like.
Chris McCarthy: No.
Dr. Craig Joseph: No. A Commodore 64.
Chris McCarthy: That was colored, though. The Commodore 64 was a color computer.
Dr. Craig Joseph: And were you, were you programming? Were you, what kind of programs were you creating?
Chris McCarthy: In basic. Do you remember basic?
Dr. Craig Joseph: Of course.
Chris McCarthy: Yeah, for, for sure. I would like make little countdown clocks like War Games, and you'd have to guess the code and, yeah, all those really, you know Matthew Broderick-inspired moments.
Dr. Craig Joseph: Okay, I'd like to pretend that I have no idea what we're talking about, but that's 100% how I grew up, so.
Chris McCarthy: Yeah.
Dr. Craig Joseph: Awesome. So, when you went to college, you, of course, were a computer science major.
Chris McCarthy: Far from it.
Dr. Craig Joseph: I'm very confused.
Chris McCarthy: Yeah. So, you know, I grew up in a very lower socioeconomic neighborhood and family, and I didn't even know that you could major in computer science. Like, that didn't even remotely seem like a possibility. Didn’t even understand or even know about it. What we did know about were things like, you're going to be a police officer, you're going to be a lawyer, you're going to be a doctor, or like something very basic. So, I had wanted to be a doctor. And equally, like my love of tech, I really did love healthcare. I love the romantic notion of delivering care. I think that which many, most of the world probably believes in, like, you know, the doctor who's going to get to care for his patients in their home. That kind of romantic notion. But I also was really excited just about health and prevention in general. I loved exercising, and I loved all, vitamins and all those things as a teenager. So, when I went to college, it seemed pre-med was a great place for me to be, but it was also the time of HIV and the AIDS crisis. And as a young gay person, you know, it was a really dark, pivotal time in the 80s. And so, I also got very excited about public health, and I, Randi Shilts’ And the Band Played On, I read that book I think my freshman year of college and was like, I am going to be an epidemiologist. Like, I just was enamored with what the epidemiologists were doing and really trying to change the trajectory of HIV. So, I ended up not in medical school, but I ended up going for a master's in public health. So, two different trajectories, one this hidden one, the love of tech, and then one very public one, the love of healthcare and public health.
Dr. Craig Joseph: That's awesome. And so, after your MPH, you did research for a couple of years I think?
Chris McCarthy: I did a little. I had a research fellowship where I studied tobacco politics. And so really mapping contributions by tobacco firms against the voting records of politicians. And there was no surprise, like everybody took the money, but those who took more of the money usually voted the tobacco way, and it was more of a Republican versus Democrat even back then. But everybody took the money for sure back then. But yeah, so that was a kind of a fun couple of years of exploring the impact on how policy and contributions and all of that stuff really does affect health.
Dr. Craig Joseph: Yeah, yeah. I'm shocked at what you're telling me, but I'm trying to remain calm.
Chris McCarthy: Yes. Yes.
Dr. Craig Joseph: This is my calm face.
Chris McCarthy: That was like that was the big “dun dun dun.”
Dr. Craig Joseph: Yeah. So, it's downhill on this episode after this. That was the revelation, was right there. And so, your first job after that fellowship was at KP (Kaiser Permanente), I believe.
Chris McCarthy: It was at KP. So, I actually started a Ph.D. at Johns Hopkins for 24 hours, and 24 hours into it, basically, at orientation, I stood up and walked out. It was supposed to be a Ph.D. in epidemiology, and I kind of credit that with being the first adult decision of my life is saying no to something that monumental, and all of a sudden, this train track that was in front of me was now missing. And so, I didn't know what I was doing next. My parents were like, “Come home. You got much farther than we ever thought you would.” And then soon after, my best friend was moving to San Francisco and is like, “You have nothing to do. Come with me.” So, I arrived in San Francisco, got off the plane, and I thought I was going to be here for a couple of months. Ended up getting a job at Kaiser Permanente as a temp, just as a, basically as a secretary. There was a thing back then called Kelly Girls. I don't know if you remember Kelly Girls.
Dr. Craig Joseph: I do.
Chris McCarthy: It's very misogynistic.
Dr. Craig Joseph: Horrible.
Chris McCarthy: They changed their name, fortunately. But I was a Kelly Girl, and I got placed at Kaiser. My boss that I worked for very quickly was like …
Dr. Craig Joseph: Did your boss say This Kelly Girl has a master's in public health, which seems unusual?
Chris McCarthy: Yes, I hid all of that because I needed a break. Like, I made this monumental decision. I came to San Francisco to experience San Francisco, to have fun, enjoy what this city has to offer. It did get out soon enough. I had a master's in public health. I remember back then, all the executives got Palm Pilots, and none of them knew what to do with them. And so, like one night, I just set them all up, and they were like, How? Like, how did you do that? Like, how did you get it to connect with Kaiser? And I just like, that was just this little tech background that I like, hid and cultivated. And so, I think between that and the master’s in public health, the department I was in, it could not have been a better landing place for me. And this is kind of one of those universe moments. So, this was a department at the national level at Kaiser Permanente, focused on bringing technology and public health concepts together. And basically, it was population care tools. How can you care for an entire population of diabetics? How do you care for an entire population of people with heart conditions? And I mean, it was just a perfect combination of the two, and nobody was doing that stuff back then. So that was my very, basically, my first professional, real professional effort at Kaiser. And I was there for 20 years.
Dr. Craig Joseph: Wow. So, it all started accidentally.
Chris McCarthy: Accidentally. I had to say no to Hopkins to get to that next step of public health and tech.
Dr. Craig Joseph: And so, I'm very interested in hearing about how you moved on. But before we get there.
Chris McCarthy: Yeah.
Dr. Craig Joseph: I want to know what was going on at that orientation. What, what—normal humans take some time to figure out that they made a huge mistake, and maybe a semester or two into their Ph.D. program or grad school or whatever it is, you and the first day of orientation.
Chris McCarthy: First day.
Dr. Craig Joseph: And so, what was it that hit you?
Chris McCarthy: Yeah.
Dr. Craig Joseph: Seriously, because that, I wish I had that kind of insight.
Chris McCarthy: Yeah. So I did have something that I think a lot of incoming graduate students don't have, and that is I was a lifeguard for ten years, and I spent the entire summer before getting to the Ph.D. program staring at the ocean for eight hours a day, obviously looking for people who are drowning, but also like it's very meditative, deep, like it's a lot of quiet. You’re focused, but you're also very peaceful. And as it was going like week after week, I felt something not right. And it took me sitting in that orientation to tap into what was happening to me over the summer, which it was just, it was me implicitly understanding this was not the right next step for me, like, the right next step for many other people. But this was not my path. And sitting in that orientation, you know, I had the very classic, I mean, you know, I was shaking, all of the things when you have this big decision to make. And I think I'm about to ruin my life. But I had the whole summer of thinking, and I thought when I got there, it would all dissipate.
Chris McCarthy: It only was validating that this was not the right step for me.
Dr. Craig Joseph: Wow. So, it had been building, and that was really just the—
Chris McCarthy: It had been building. And I think it's also the power of, you know, we talk about like mental well-being and all the things that are happening right now in 2022 and 2023 and beyond, like try and incorporate these practices into your life. I think this is a very early case of what meditation and that spaciousness can do for somebody. And it did clarify for me, although I did have to move to Baltimore and show up to orientation, I wish I actually made the decision before I got there, but at least I didn't sign the loan papers.
Dr. Craig Joseph: That was a good decision.
Dr. Jerome Pagani: So, you mentioned that at KP, this was kind of the first time that you were introducing technology into population health management. Can you say a little bit about what the sort of state of the art was before you began introducing these technologies and what that offered you a chance to do, both on the caregiver side and on the patient side that, you know, hadn't been there before?
Chris McCarthy: Yeah, even back then, what they were doing and what many were doing still felt state of the art. So, it was Excel files, and every caregiver, so whether it was the nurse who was monitoring a population or an assistant, they had their own Excel file and these were elaborate Excel files. I mean, I got a lot of information in them, and the population care coordinator would go through their Excel files, start at the top, and they would work their way through their entire population, and then they would start back at the top again. And, you know, that might take many weeks or many months to get through everything. And often, a physician or a nurse would give the population care coordinator some additional data, and they would enter it into an Excel file. So even that seemed decent, but it doesn't tap into bringing it all together. So, what happens when that person leaves Los Angeles and moves to San Francisco? Like, how does that one line from the Excel file get transferred? It doesn’t get transferred. Like, back then you just start it over, and often that was a solution for many patients and clinicians. When you have a full new intake, and you start all over, and you start all your care plans all over again, you know, you might ask them about what was happening in the past. This is bumping into the EHRs. So, I was a side project to one of the main projects in this department, which was to bring to life an electronic medical record for Kaiser Permanente. And it, back then, there were several competing electronic medical records happening. There was Epic. That was in the Northwest, very simple little system, it was nothing compared to what it is now. There was Oceana, a technology called Wave, and there was a third one called CIS from IBM. Those are all being developed, and we knew all of them would need population care tools. Like, that is kind of the promise of bringing all the data together. So before it was Excel files and the first step to bring it all together was a national database with all of the physicians and population care coordinators having to agree on the data fields and then what would happen on a daily basis, the care coordinator would get a fax from the database, and it would fax them all of the care needs that a patient who is arriving into the clinic that day needed. So, if a diabetic patient was registered for a diabetes appointment, this population care coordinator would get a fax and say they haven't had a foot check, they haven't had an eye check. It would give them all the things to jump right in. And then also, once a week, their file would get updated from the national database and keep in sync if someone changed locations or if they had new members added to it. And that was a big leap forward. Just the fact that that was coordinated. And I remember, like, thinking, wow, fax machine, even back then, I was like what, are we using fax machines? But actually, it was very clever in real-time solution because as the patients were arriving that day, the reception and population care coordinators got their pile of things they needed to focus on with those patients who arrive into the office. So, a big leap forward from something that already seemed like a good leap forward to. Just, we’re starting to bump into the promise of electronic medical records for sure.
Dr. Craig Joseph: Yeah, that was like just in time, as you were describing it, I thought that's actually pretty good, you know, giving me the information that I need the day that the patient is scheduled to come in is today sometimes a difficult thing to get. So, I'm fascinated by that. And that was all just fax paper. I'm thinking of that shiny fax paper back in the day, and you took that into the room and saw the patient or the nurse did prior to the physician going in. That solves a problem.
Chris McCarthy: And immediately, all of the quality scores just dramatically started going up, because no longer did the clinician or the nurse or anybody have to go hunt their paper chart to see what was needed. It was automatically presented to the care team to do the right thing in the right time. So that was also a pretty amazing leap forward too.
Dr. Jerome Pagani: What I find really interesting about this is that you're talking about digitization of the right kinds of information, care, continuity, and interoperability. Three issues we still are working on today, and it's not a complete circle. Obviously, there's progress constantly being made.
Chris McCarthy: Yeah, for sure. And that was 1997. Which I mean, it's just remarkable to think that that, that's what was happening even then.
Dr. Craig Joseph: Yeah. So clearly, from a design perspective, what you're saying is we need to go back to faxes, and I support that. I think that's right. And the major problem is the fax server. We need to go back to the paper because the paper was the key.
Chris McCarthy: That, oh yeah, that, that really flimsy —
Dr. Craig Joseph: And you could actually mark on it with your fingernail.
Dr. Jerome Pagani: Not as good as the mimeograph paper. But what I really like about this is, is inherent in your story is this idea that innovation isn't a destination, it's really what you're really doing is constantly looking at how do I take this set of things and apply it in new ways to problems and just keep pushing forward?
Chris McCarthy: Absolutely. And with the very things that you have in front of you. Like, it's not necessarily, you don't have to wait for five years or ten years for the next thing. Like we had fax machines for sure. Those could be connected to a database pretty easily. That wasn't complicated — well, it was complicated, but it was pretty doable. Like these are solutions that were already out there, and it was just assembling them and having the political will to say, well, the hardest part, as I said earlier, was getting everybody to agree just even on what we're going to call it, these data fields, that's what we're going to name them. And these are the ten things that are most important for all of our patients. We don't care about the differences of L.A. versus San Francisco or Colorado. What's common for all of them? And so that's the political will. So sometimes it's less about technology, and it's more about just really the focus and political will to make the decisions.
Dr. Jerome Pagani: I know we're going to come back to this a little bit later in the discussion, but one of the things I think I hear you saying is the reason this was so successful is that all of the stakeholders were focused on a particular shared objective,
Chris McCarthy: For sure. Yeah, for sure.
Dr. Jerome Pagani: Larger than just process or technology.
Chris McCarthy: Yeah, well, you brought up the P-word. So, I will say that this is where everything kind of fell apart. So, in some way, the technology, like I said, was almost the easiest part of this. But process ends up being quite complicated, because workflows and just because of space configuration, all of those things are quite different, and part of my role I would describe as a business process engineer. So really thinking about like what are the current workflows, and then start thinking about, well, what would be the optimal way of doing this? And we would work very hard. I would go to clinics and watch people work and interact with the systems and then think about how this fax machine is going to change their lives and then design a whole new workflow, and everybody would be like, “This is awesome.” They would sign off on it. And then I would come back months later, and nobody was doing it, like everybody was using the fax machine or somehow fitting the technology into their whatever workflows that did work for them. And they didn't care about optimizing and they didn't. And I have to say it was deeply dissatisfying to spend all of this time redesigning processes and the ability to implement new processes. I think there's a gap between designing them and then implementing them. And this is where, like, I started getting very interested in, like, well, how do you do that? Like, there's got to be better ways to do this, and in some way, and I think I share this with you before, like, business process engineering is almost like human-centered design, but it's neither human-centered nor designed very well. But they both want the same thing, like they're both trying to design something that's valuable and meaningful and doable. And I think business process engineering bumped into culture, and that's where I think human-centered design does a little bit better job than what business process engineering did in the nineties. Yeah.
Dr. Craig Joseph: I just love that you paused a few minutes ago about the P-word, and I just want our listeners to realize that if we had commercials, which we don't, that's where we would have placed our first commercial. Right after you said, oh, the P-word, we would have just had some, some silence, and then we would have inserted some sort of advertisement.
Chris McCarthy: For Depends.
Dr. Craig Joseph: Yeah, for Depends or something else. So, listeners beware. That might be coming. So, you were working at Kaiser Permanente as a business process engineering professional. That's the term that I want to come up with, although it's probably not the term that you use. And you were dangerously close to applying principles that have now been called human-centered design.
Chris McCarthy: Yeah.
Dr. Craig Joseph: And you thought that, hey, this design thing is a little bit better than what we're doing, but it's still not perfect. And at some point, it seems that you were interested in learning what others were doing outside of the Kaiser Permanente system, and so, what happened at that point?
Chris McCarthy: Yeah, well, I didn't even know the word design either. So, you know, just like earlier, I didn't know about I could have studied computer science. Design was clothes. That's all it was to me. So, I didn't even appreciate that there was another way of doing it. All I knew was what I was doing was both interesting but also dissatisfying. And so, I ended up taking night classes at San Francisco State. I took a business ethics class, which just got me really excited about business because up until this point, I thought business was a joke, and I just thought the worst awful people went into business, to business school. But I'm in this class of very interesting people really getting deep into ethics and decided to quit and go back full time. So, I ended up back at Rensselaer. So, I went to RPI (Rensselaer Polytechnic Institute) twice for undergrad, and then I went back there for my MBA. So now this is in 1999 and 2000 where e-commerce is starting to happen, and the word innovation is starting to be said more. And I was in one of the classes, and it was design, manufacture, and management, DMM, and as a capstone class for the MBA. And the design portion of this blew me away. Like, I remember sitting on the edge of my seat as they were showing the original Nightline Ted Koppel shopping cart video from IDEO. Are you familiar with this video? So basically, this is about an 18-minute news clip where Ted Koppel challenges IDEO, who's this like hot up-and-coming innovation firm, to take something as mundane as the shopping cart and to re-imagine it. And I remember watching the IDEO team working in this news clip, like going and watching people use shopping carts and interviewing them using shopping carts and prototyping. And in the back of my head, I was like, I was doing all of that at Kaiser Permanente for business process engineering. The difference is they were like really connecting with the users in a much more meaningful way than we ever thought of doing for a basic process redesign. So, in my head, I was like, God, this is what I want to do. But also, my head was this is my second master's, and it’s not in design. I just need to, like, get excited and let it go and finish my MBA, which I did. I did half in upstate New York, half in Copenhagen business school, and that also was an important moment because Scandinavia, but especially Copenhagen, has a big design community, has a very strong community values centric way of thinking about business. So that started planting some future seeds as well. But then I came back to the United States when I finished, the dotcom thing fully imploded, recession, difficult time. I didn't think I wanted to go back to Kaiser. I kept looking for other places, and after six months and KP kept saying, “Please come back, we want you to come back.” And finally, I relented. And I'm glad that I did because within six months of coming back, my boss was kind of scratching her head, and she was like, “There's this thing called IDEO, never heard of it. I just feel like you'd be somebody who it might jive with.” And I was like, “That's my brass ring on the merry-go-round. I am never letting go of this brass ring.” And that was the rest of my career at Kaiser Permanente. From that point forward, it was human-centered design exclusively as a way of solving complex problems. Yeah.
Dr. Craig Joseph: Wow. So, it all went from that video to actually working with IDEO. Tell us more about how IDEO worked and how you leveraged them while you were at Kaiser Permanente.
Chris McCarthy: Yeah, so it started off just as a simple, small, I want to say it was like a two-month project, something very, very simple. There's a woman, her name is Christi Zuber, my long-time innovation partner at Kaiser Permanente. She was asked by several executives. They had all seen the shopping cart video a few years earlier, and it had been percolating like, should we do something with IDEO? So, they asked Christi. She worked in finance at the time at Kaiser, and she was a former nurse. She had a nice health background as well to head up this small team to assess, could something like human-centered design the way IDEO does it, can that work in a place like Kaiser Permanente? So, she's the one who put together the first team. So, she pinged my boss. And this is when my boss was like, “I heard of this thing called, would you be interested? So, Christi convened the first meeting. It was me, another woman named Adrienne Philpart, the three of us at a bar in Oakland, California, to talk about design and healthcare. The three of us did not know anything about design, and the fact that Christi even convened a meeting in a bar blew my mind. It was so anti what KP normally does that I was like, I am in. And now I have two brass rings, and I don't want what's happening here to end. So, the three of us partnered with IDEO. It was supposed to be for a few months, it was two years. So, there was four of them and three of us full-time for two years. Like, we basically had an apprenticeship in human-centered design. And it was the same four people from IDEO as well. So, they had an apprenticeship of what it was like. We were one of their first clients of not just co-creating with, but transferring their abilities into our organization. So, at the end of that two years, the ball was rolling to create our own department and to grow the department. And each year, we were designing more and more solutions to complex challenges. It just kept going, but it was a really special time. I'm not sure anybody could afford to do a two-year endeavor with any design firm these days, but back then, it was a really special moment.
Dr. Jerome Pagani: You mentioned you were a part of an innovation team at Kaiser.
Chris McCarthy: Yeah.
Dr. Jerome Pagani: What was innovation, or how were you thinking about innovation? And then once you had begun to get some of those ideas about doing human-centered design, how did those two things intersect?
Chris McCarthy: Yeah, I would say it was more starting with human-centered design than starting with innovation in general. So, I, as I said, like I was on, you know, on the corner edge of my seat during that Ted Koppel Nightline clip, and it was how the work was being done that was most interesting to me. And when we started our work at Kaiser Permanente, using human-centered design approaches, we employed those exact same methods, like really engaging users. To me, that was innovative, like what it later became as our sophistication level came up, the way we even talk about innovation became smarter and smarter. We realized that we were creating novel solutions that were providing deep value because we were rapidly scaling them across the entire system. But that, in some way, was after the fact. So those first two years, we didn't even have a name for ourselves. We were all donated from different departments. I was donated from the electronic medical record. It was called KP HealthConnect. We were just getting going with Epic, so I was donated from them to make sure that we don't innovate away from Epic. Christi was donated from finance; Adrienne was donated from organizational development. So, we were all coming together to try to create better ways for Kaiser. And at the time, it was Kaiser Nurses. That was our first few projects, for Kaiser Nurses, to do their work. Can it be more joyful? Can the patients get more satisfaction for how we're doing this work? And towards the end of that, we understood we were innovating, and that became, our name was the innovation consultancy. But we didn't start with “We need to innovate.” We were saying, we have a problem, like, nurse communications are a challenge. Medication administration is a challenge. Let's build something new. And it was later that we said, “Oh, we're innovators.”
Dr. Jerome Pagani: I know we'll dive into this deeper, but what I like about what you're saying is that there was an aspect of the design that was really focused on the process and making that as efficient as possible and as joyful as possible. But there was also an eye on value to the organization as well. And so, two goals, both of which were being driven by this process and methodology.
Chris McCarthy: Yeah, for sure. And I would say there was a very explicit goal that we needed to add value, like, that was clear. Like, why do you exist in an organization if you don't provide value? But then there was a very selfish value goal that I think both all three of us, Adrienne, Christi, and I, we knew this is how we wanted to work the rest of our lives, and so we were surely going to implement and do everything that we could to bring this to life and add value to Kaiser Permanente for sure. So, there was an organizational goal for sure, but we were also individually driven because we were so passionate that this would make a huge difference in the way that we understand clinicians, how we understand patients, and how we can design things that truly meet their needs, like we really implicitly felt that. So, a little bit of selfish, but a lot of organizational reasons that scale up were so important to this.