Electronic health records (EHR) implementations have inevitable challenges and unexpected hurdles. Even when executed successfully, new or existing technologies can exacerbate health inequities and widen gaps in clinical care. Well-intended technological advancements are often not able to reach their full potential due to a lack of intentional feedback from key stakeholders across the care landscape, the voice of the patient being one of them. Leveraging input from both patients and clinicians in the rollout of new technologies will enhance the giving and receiving of care.
On today’s episode of In Network's Designing for Health podcast feature, Nordic Chief Medical Officer Craig Joseph, MD, and Head of Thought Leadership Jerome Pagani, PhD, are joined by Deepti Pandita, MD, chief medical informatics officer and associate professor of medicine at UCI Health. They discuss her background as both an internist and clinical informaticist, and the principles of design that lead to successful implementations. Additionally, they talk about the importance of including the voice of the patient when making technological advancements, how to avoid decision paralysis, and how health equity and design go hand in hand.
Listen here:
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Want to hear more from Dr. Joseph and Dr. Pagani? Pre-order a copy of their upcoming book, Designing for Health.
Show Notes:
[00:00] Intros
[01:13] Dr. Pandita’s background
[07:27] The inherent challenges of EHR go-lives
[10:11] Design principles in implementations
[13:04] Balancing needs of different stakeholders
[15:55] Preventing health inequities in new designs
[19:55] Designing with patient populations in mind
[22:21] Best practices for soliciting patient feedback
[24:08] The value of simply walking around and observing
[25:36] Patient feedback at different stages of design
[27:33] Real-world applications of human-centered design
[28:51] Things that are so well designed they bring Dr. Pandita joy
Transcript
Dr. Craig Joseph: All right, Dr. Pandita, welcome to the podcast. It's great to have you.
Dr. Deepti Pandita: Thank you. Thank you so much for having me on.
Dr. Craig Joseph: So, can you tell us how a mild-mannered internist has become a CMIO rock star? Were you bitten by a radioactive insect? What was it that caused you to become who you are, the accidental informaticist?
Dr. Deepti Pandita: That's a great story to tell right there. I wouldn't say mild-mannered, but yes, very invested in the fundamentals of internal medicine. I always viewed myself as an internist first and an informaticist second, but I think it laid the foundation for what I am today. So, you know, as an internist, we look at the big picture and then whittle it down to what really matters, and I think informatics is pretty much the same. You look at the big picture, what is the problem you're trying to solve? And then piecemeal by piecemeal, get down to what might be the plausible solution. So, I think it's a perfect connection between internal medicine and informatics. However, my journey into informatics was not as simple. I call myself the accidental informaticist, because I happened to be in the right place at the right time where we were transitioning from paper records to EMRs, and while everyone was running away, I was finding joy in it. I was embracing it, and people were like, what kind of a weirdo are you that you know, you find joy in electronic health records because everyone was screaming and kicking. They sort of started looking to me as what we would call today a super user. I was helping people and then I got a formal title to be that helper person. Eventually, you know, got a title of Epic clinician champion, it let me render Epic as a medical record, transitioned onto being the ambulatory lead for Epic and eventually landed a CHIO role at my former organization, and now I am CMIO at UC Irvine Health. So that has sort of been my journey, but I think there have been a few things that have stayed key to who I am today. One is to always think of the big picture and then see what is the problem we are trying to solve, not a square peg in a round hole type resolution. And then two, that the patient and the provider is the center of every solution. You know, if you're not designing solutions keeping the patient and the provider in the center, you're going to fail. So, I think those two things have grounded me. But also, have been sort of the key tenants to what success I've had.
Dr. Craig Joseph: So, no radioactive insects, and I'm glad, but I'm also a little bit sad because I think that would have been a great story. So you accidentally became an informaticist just because you showed up and you didn't hate it, and so you got better at it. Sounds like you've accidentally become a designer as well. You didn't grow up thinking that you were going to be thinking about human-centered design or applying design principles to your work, yet here you are.
Dr. Deepti Pandita: That is very true. And in fact, I consider myself the most unrefined designer. Growing up, I had no exposure to computers. I grew up in India. We did not have any computers. When I was in medical school in India. There was one computer which was locked in the library, and you had to sort of know the library and, you know, like close and personal in order to get access to that. So, no exposure to computers. In fact, this is a funny story that my first exposure as a first day as a resident, we were logging into the computer and I couldn't do that. And the help desk guy on the phone said, Hey, that green icon, that's what you need to click. And I said, What is an icon? And there was silence on the other end because they could not believe that there was someone they were talking to who didn't know what an icon meant. But, you know, fast forward now, I know much more than I want to know. But the foray into design came about because we designed so many bad systems and so many bad projects, mainly because we did not capture the voice of who we were designing for. So, you know, I say this in all my team meetings, you're designing with people and not for people. If you're designing just for people under assumptions that you're providing a solution for them, you're always going to be stumped at some point as to ‘what was I thinking when I did that?’ So again, you know, designing with people is where the success lies because there is no one size fits all. I mean, we know this and, you know, every healthcare delivery principle, you know, not two patients are alike. Yes, you know, you might use a certain antibiotic for a certain condition. Your patient, if you're not designing the treatment for them, looking at their allergies, looking at their past patterns of response, you're not going to be successful. So it's the same thing around any user-centered design principle. And this is not just for electronic solutions. This is for environmental solutions. This is for designing buildings, designing clinic spaces, designing even an office space where you're interacting with your patient. Where should the computer face? Where is the patient sitting? How will the patients feel engaged with you rather than feeling like they're engaging with the screen? These are all important things because at the end of the day, healthcare is a human interaction. You know, it's grounded in principles of humanism more than the science. You know, there is the art of medicine, and that's the science of medicine. The science is second nature to you. It's all in your mind. Your computer is helping you with that. But the art of medicine is what is the healing component of medicine.
Dr. Jerome Pagani: Deepti, you've been involved in multiple EHR go-lives. What makes them so difficult to get right?
Dr. Deepti Pandita: Right. So this is a great question, and I'll tell you, understanding the why is the most important thing. So why are you implementing this? Why are you doing it in a big bang manner or a go-live in a phased manner, and then explaining the why. Because, again, remember, when you're implementing EHRs, you are disrupting spaces and understanding that disruption creates a sort of fear among people is very important. At the same time, the other aspect you need to know is who are you implementing for, have you engaged them in the process? It's changing culture in your organization when you implement it. So if you are not cognizant of the fear, the psychology, the culture, and you're just saying we've got to do this because we have to switch to an EMR, that's not going to sit well with people. You’ve got to bring them along on the journey. And again, that starts very early when you are even implementing and you have just a project on a paper, you have to engage the end users. And then when you actually have pilots or you have actually snippets of information that you can actually show them, even though it may not be well thought out yet, you have to keep them engaged in the process. You know, I love patient journey maps. I love engaging our providers in patient journey maps because that gives them a visual. Even if it's just on a paper, it gives them a visual that, oh, my voice is being included in this design and that is very important. And then subsequently when you actually have a system and you are testing it out, your pilot, and this is a funny story, I will tell you. In my organization that I was at previously, we had a set group of pilot users and for every implementation they would reach out to the same subset of pilot users because this was their usability lab, and I was like, You cannot do that because every implementation is for a different purpose or a different user group, and these users are very savvy now. I mean, they will always tell you, you are flying and you're okay to go ahead. It is those other people that you have not brought on as pilot users that are actually going to be having the problems when you go live. So, again, tailoring your usability testing to the actual audience who's going to be ultimately using is very important.
Dr. Jerome Pagani: So I love that you're pulling on some of these principles, designing with rather than for, understanding your why. And the reason is, and I'm going to quote a little Tolstoy here from Anna Karenina, where he says, you know, happy families are all alike, but unhappy families are each unhappy in their own way. Tech project implementations in particular are so painfully bad and each their individual way. So I like these ideas that if you abstract away and begin to think about some of those principles at the beginning, you can, even though the circumstances will be completely different and your system is going to be different than the last system you worked in, then you can still get to the right place by starting there. Are there other ones you would touch on, other principles that you’d say do the same thing?
Dr. Deepti Pandita: Right, and I think one of the key tenants is going to be that ultimately, we are all in care delivery because we want to do right by our patients. So make sure you're including the patient voice and the patient preferences in your design, because even if it's a back-end design, you're designing for, say, charge, capture or something like that, it has to be second nature. Because if a clinician is dropping a charge, it has to come at a time where it's appropriate during their interaction or after the interaction. It has to be in a manner that is non-intrusive to the patient. So, keeping all these things in mind is very important. The other thing is it's not just the software, it's also the ecosystem of the software. So where are you sitting when you are using that software? Are you in an office space? Are you doing virtual care from home? You know, what do you need if you're doing virtual care from home? Is it a quiet space? Do you need a different set of mics? Do you need noise-cancelling headphones? These things are very important to consider when you are designing systems. So it's not just, hey, this is a new modern app and go use it. It's more than that. It is about who’s using it. Where are you using it? Is it culturally appropriate usage for your patient population? Are you acknowledging any downsides that system might have or hasn’t incorporated yet that your patients might raise as a concern? You know, a perfect example, when we are doing virtual care design, there are certain cultures where females don't want to be on video. And if you have a patient population that's predominantly of those female cohorts, you don't want to be designing a system where they are obligated to turn the video on. So that's sort of the user centricity principles that you have to keep in mind.
Dr. Craig Joseph: So, you know, balancing the needs of certain users is key is, as you've been saying. Do you encounter times where the you have the patient on one side and the provider on the other side and you can make it very easy for one of them, but you struggle to make it easy to do that thing for both and I think one example that Jerome often references is that we've made it very easy for patients to message their physicians. We said, this is great. This will solve all of our problems. And in fact, now we've overwhelmed many physicians with messages. He always says, again, I'm speaking for him because he's not so good at English, he's good at Russian, apparently with the Tolstoy reference. But, you know, you’ve smoothed out a wall that's got a brick shooting out and you push it back in and you're like, this is great. But now on the other side of the wall, that brick is pushing out. So how do you find that balance or do you ever do it?
Dr. Deepti Pandita: Yeah, I do. And it's very hard. So, I'll give you another example. So, I was designing for self-scheduling for mammograms for female patients because this was something our operations folks wanted it because they wanted more volume. Our patients wanted it because it was ease of scheduling. Yet on the physician side, the chief of radiology, the chief of primary care, said this will never work because X, Y, Z, you know, it'll overwhelm my radiology techs, it'll be too many mammograms to read, all of that. So, you know, again, that push and pull, there was a demand side, there was a strategy side, there was a volume access side. And then on the other hand was the physician burden side. So got into a room, got the patient group in the same room as the radiology chair and the CMO. And I said, talk it out. Here's a need. Here is the solution. And honestly, once the chair of radiology understood the pain points, that people have to wait six months for a mammogram, or they were holding the phone for one hour while they were also taking care of three kids at home, and it was just impractical to actually be on the call, to be able to schedule their mammogram. They understood it. And at the end of that meeting, it was like, yeah, let's try it out in a couple of our mammogram locations and if it's successful, we'll roll it out everywhere. We didn't even have to wait two months. Within a month we had rolled it out everywhere. So, you know, have to think outside the box. But having all the interested parties around the same table, sometimes that's the simplest solution.
Dr. Jerome Pagani: Deepti, there are enormous disparities in health outcomes in the United States, and if you design a system so that everybody, it works the same for everybody, then really, you're not addressing, you're not helping to address that problem. And I think I've heard you say that health equity and design go hand in hand. Can you tell us what you mean by that, and how it looks in practice.
Dr. Deepti Pandita: That's really something that I'm very passionate about because, you know, when we get sort of, let's take the example of an EMR, you get the EMR, you get the foundational system. I think of it as a house, you know, you get the house, you have the roof around the walls and everything, but how you're arranging the furniture, how are you arranging the pictures, how you're arranging what gadgets in your kitchen, that plug in where, that's all up to you. Right? So, I think the same thing applies when you're designing solutions. You have to understand who's the audience you're designing it for. It is not just, and this user-centered design for equity is not just for patients alone. It is for our clinicians too. No two clinicians practice…similarly, yes, a certain discipline might practice in a different, in a certain way and another discipline might practice in a different way. My first eye opening moment of this was back in the days of meaningful use, we’d have to reconcile outside medications. And the CMO tasked me with go, you know, these three departments are not engaging in this, and one of them was the anesthesia department. Go make sure that they are reconciling outside medications because we need to do this for meaningful use and there are X, Y, Z number of dollars on the table. I actually went and spent an entire day with the anesthesia folks, and I looked at the workflow and the pace of their workflow and I said, there is no way in the way the anesthesia model was structured that they can reconcile outside medications. And in fact, if they did that, it would actually result in patient safety problems. So, I came back and told the CMO, cut your losses. This is not the workflow. Even if we have to lose this amount of money, you will lose more if you make them less efficient by actually forcing them to follow something that is not in their workflow. And it made sense, you just have to connect the dots. So that is something that you have to keep in mind when you are making sure that so that, you know, no two systems that are alike, again, you know, you mentioned health equity. When I was designing virtual solutions, you know, we all kind of, you know, we can go live overnight. All you need is a Zoom link and scheduling, and of course, everyone will embrace it. And, you know, we have had this clinic for teen adults that were Hispanic, and no one was using the virtual care platform. And the director of that clinic came to me and said something is wrong in the way we are doing this because no one is using it. And all it took me was to talk to one teen and I said, show me what you see and tell me why you are not able to do virtual care. Because she was, even in the peak of COVID she preferred to come into the clinic to be seen. And I said, you are putting your life in danger. Show me what's the problem? And she said, ‘I don't know, I got this something on my phone, but I don't know what to do with it.’ And it struck me that the link we were sending was in English and this patient was purely Spanish speaking, did not read English. I came back, put the design team to work and I said, ‘can we auto-translate the link into the patient's proper language?’ We did that and adoption went up 80%. So very simple, insightful, just by observation, but designing for equity.
Dr. Jerome Pagani: Deepti, earlier you talked about designing with a patient population and I think I've heard you give an example of doing this in the women's health space around mental healthcare during the postpartum period. Can you tell us a little bit about that and what you went in thinking and then what came out of it?
Dr. Deepti Pandita: Yeah. So we had a design team that was designing a center for postpartum mental health care, and the design team was like, What do these women want? And we were basing this on pure assumptions. So, this is females who are designing, you know, and they've been through childbirth. And so, they said, ‘oh, what would we want here? Oh, we want a spa-like atmosphere. We want, you know, water available, we want mood lighting.’ We want, you know, and all this conversation was going on, and then there was this very smart medical assistant who said, why don't we ask our patients what they want? And remember, we were setting this up in an inner-city hospital, which is predominantly African-American patients of very low socioeconomic status, and this is privileged physician women trying to design. So that disconnect was already there. We brought these patients in and said, hey, you know, wouldn't it be nice, we will have this kind of lighting here and calm rooms and you can listen to, you know, pleasant music and we'll have water and beverages … and they said, you know, I'm going to take two busses to get here, and I'll have three of my other kids along. All I want is someone to take care of those kids while I can actually have a conversation with the physician. It was such an eye-opening moment for us. We were like, oh, we totally disregarded all that. We need some toys in the waiting room for the other kids to play with. They need little mats where the other toddlers can, you know, roam around. And by the way, wouldn't it be nice if we have some volunteers here who could take care and play with those other kids while the mom is having their visit. It was a game changer. I mean, we gave up on all those mood lightings and the music and all of that and pivoted completely to a more user-centered design.
Dr. Craig Joseph: So how do you get those patients to be, you know, it sounds easy to me. Well, we should just ask the patients. But how do you find those patients? How do you interact with them? Are they volunteer? Are they coming to regular meetings or is this ad hoc? You've obviously done it. How does it best work?
Dr. Deepti Pandita: So it best works If you have a designated patient experience team and you build a patient panel that is specifically dedicated. And remember, patients are more than happy to volunteer themselves and make sure these are not just the happy patients, you know, you have to have, you get patient complains and you listen to these patient complaints. The patient experience team has a running list of these patients. Include, you know, the disgruntled ones, the happy ones, the middle of the road ones, and create a patient panel that you can tap on for all these kinds of resources. At my prior organization, actually, I would go once every other month in front of the patient panel to just get insights on, you know, how are you using MyChart, what could we do differently? And they would tell me things that I had never thought of. I mean, I would have never thought of saying, okay, the nodes should be on the top and the letter should be on the bottom. I mean, just the configuration of how when they open MyChart and they look at things, versus how I would approach it was eye opening to me. So, it's just having those conversations on a regular basis with a dedicated patient panel. I would encourage all health systems to have that.
Dr. Craig Joseph: So, you're doing two things though, at the same time. At first, you're bringing folks in, and I think it's especially key that you're not just bringing happy people in, right? Because then you just often get the answers that you expected to get, that folks are happy with the work that you're doing and that makes complete sense. But the other thing is that you're kind of practicing, I think it was Jack Welch who said, you know, management by walking around. Just randomly kind of walking around and seeing how things are working in the real-world as opposed to how you're told things are working. Because oftentimes, you know, managers and other leaders will tell you this is what we do and this is how it works, and you're like, that's great. That workflow is awesome. And then you get there, and you find oftentimes that may not be the case. Sometimes it's a training problem and sometimes it's just, oh no, we never got that piece of equipment. So, we couldn't possibly do that thing. You know, I've certainly seen it where you'd ask, well, how long is that been? You know, six months. Wow. Okay. So this thing hasn't been working for a long time. And so, it's both of those things are seemingly required.
Dr. Deepti Pandita: Right. And that's what I tell my team. Travel the distance between what should be happening and what is happening. It’s a very, very difficult thing because you need boots on the ground to do that. But it is the right thing to do.
Dr. Jerome Pagani: Deepti, how do you know when to bring people in to design with them? Because you don't want there to be so many options that you end up with decision paralysis or the team just ends up spinning forever. So, do you bring them in when you're almost done or when you have, you know, one or two things for them to choose from, and there's sort of limited options?
Dr. Deepti Pandita: I would say probably, it's not so much when you bring them in. It's what do you present to them. So, I would say bring them in at every stage. So, when you're just conceptualizing, when you are actually having one or two concepts that are going forward, and then when you actually have a product, you need to bring them in at every stage. But it is the nature of the engagement with them that drives success. So, you bring them in and you say, Hey, we have noticed that these two or three things are pain points and we are trying to design the solution. Would you help us? So that creates engagement and excitement. Then you work on that, iterate and say, we heard you. (That's important to say) We heard you, and based on what you said, we have whittled down to feasibility of these one or two solutions. Which one would you pick? You may already have a solution in mind from the get-go. It is just that getting them to that decision-making versus you telling them that this is the decision is a game changer. You know, and then once you have the solution, you can say, hey, would you test this for us? You were instrumental in getting us here. Now, would you test this for us and, you know, help us with the training goal and all of that. So, I would say it's at every stage.
Dr. Craig Joseph: Deepti, we've just scratched the surface of applying some of those principles of human centered design. Any further thoughts on how people could apply some of these things in the real world?
Dr. Deepti Pandita: Well, I think the couple of other things I would add is, you know, when you talk about human-centered design, you know, there is so much written about it and all that. But you have to actually practice it to learn from it, because everything that you read in journals, books, all that will only get you so far till you actually start using it in real life and realize, oh, that was fine for that workspace with that patient population, but that's going to quickly fall apart here. So again, it's an iterative process, so don't get disappointed if you fail a couple of times because one human-centered design principle does not fit for every situation. You know, you have to sort of create your own journey towards it. The important thing is to have it in mind, you know, have user-centered design as a tenet, rather than getting stuck on one principle of user-centered design versus another.
Dr. Jerome Pagani: So Deepti, at the end of the podcast, we ask everybody the same question, which is to share with us two or three things, and they can be outside of healthcare, but two or three things that are so well designed that they bring you joy to interact with.
Dr. Deepti Pandita: Well, I can think of a couple. I think I love the electric fence. You know, it's there, but it's there for a very specific purpose and it's not to be seen, not to be heard. That's how, when I talk to physicians, you know, interacting with the EMR, they said it just needs to be there helping me, but not in my face interrupting me, and I think that electric fence is a great example, like we can play in the yard, but as soon as they're sort of going outside the guardrails, there's a little something to stop that. So that would be one. Another great example would be, you know, how these food delivery apps work in terms of picking a la carte menus, so they know after a while what I want, where I want it delivered from. I can also pick from two different places and combine it. I think patients really want something like that. They want my primary care doctor here. But you know, tomorrow if I want my mammogram at a different location because that's closer to work, I should be able to pick that menu. And by the way, day three, I am at a different place and there is a lab for the same organization right there. But I just walk in there and get my lab while I'm shopping, you know, in between two errands that I think that would be awesome. If we can design healthcare to be like picking a food menu.
Dr. Jerome Pagani: I love those answers, and I guess I'm showing my Gen-X roots because every time somebody says Electric Fence, I think of Ren and Stimpy. But those are both great examples of how design can really work for people.
Dr. Craig Joseph: And I’d like just to clarify, Dr. Pandita, that you’re not talking about applying electric charges to physicians who don't fill out their charts correctly, because I was a little confused there.
Dr. Jerome Pagani: Don’t talk about my dissertation like that, Craig.
Dr. Deepti Pandita: No, because I have actually thought about how Epic could have a little arm that reaches out and catches you by the neck if you're not doing things right. You know, it actually did occur to me, but we're not there yet.
Dr. Jerome Pagani: Little Three Stooges Action.
Dr. Deepti Pandita: Yeah, yeah, yeah. Slap on the wrist.
Dr. Craig Joseph: Well, there's some design work there to do. If anyone’s listening, if they want to start working on that. I personally am now working on the ‘I heart patient journey maps’ t-shirt that I want to buy for you because that's not something I commonly hear: ‘I love patient journey maps.’ But you do, and if I can get you a t shirt that says that I'll be working on that design.
Dr. Deepti Pandita: I would love that.
Dr. Craig Joseph: Deepti, this has been great. Thank you so much for your time and your thoughts and we really appreciate it.
Dr. Deepti Pandita: Thank you so much for having me on. This has been a pleasure and a joy being here.