Design Museum Magazine: Issue 017

Magazine

THE

Healthcare ISSUE

Year in Review

Winter 2020

2020 at the Design Museum

Issue 017

Page 10

US $20

7

04521 51195

2

Modern Midwifery

Bespoke Bodies Book Preview

The Hospitals of Tomorrow

Tiffany Townsend tackles systemic racism in the delivery room

Dr. Shriya Srinivasan and team design new surgical technique

Stamford, CT hospital takes empathetic design to the next level

Page 46

Page 76

Page 84

Magazine STAFF

MISSION

Sam Aquillano, Executive Director

Bring the transformative power of design everywhere.

Liz Pawlak, Vice President Diana Navarrete-Rackauckas, Director of Learning and Interpretation Maria Villafranca, Director of Marketing Jennifer Jackson, Executive Associate Journee Harris, We Design Program Coordinator Ryan Pflaum, Design Producer Sophia Richardson, Graphic Designer Amor Yates, Podcast Writer and Producer

Gaby Mier Leila Mitchell Larry Rodgers Alan Scott Roxane Spears Scott Stropkay Tracy Swyst Matt Templeton Ashley Welch George White Amy Winterowd

We transform, using design to take action and make change, demonstrating its impact.

IMPACT AREAS

Civic Innovation Data Visualization Diversity Education Entrepreneurship Healthcare Play Social Impact Sustainability Vibrant Cities

ADVISORY COUNCIL Meghan Allen Hilary Alter Joe Baldwin Philip Barash Corinne Barthelemy Leah Ben-Ami Megan Campbell Jess Charlap Sarah Drew Katie Gallagher Adam Gesuero Ruwan Jayaweera

We educate people to become creative problem solvers using design thinking & process.

Business

BOARD OF DIRECTORS Austen Angell Jennifer Bryan Tom Di Lillo Ashley Dunn Matt Edlen Jessica Ekong Sana Gebarin Robin Glasco Josephine Holmboe Amy Lalezari Elizabeth Lowrey Kathy McMahon

We inspire people by showing what’s possible through public exhibitions, events, & content.

Lauren Jezienicki Emily Klein David Lemus Sarah Merion Sascha Momartz James Newman Tom Remmers Jamie Scheu Adam Stoltz Jana Stone Shannon Sullivan Shawn Torkelson

Workplace Innovation CONNECT Give • Contribute Expertise • Volunteer Learn more: designmuseumeverywhere.org Reach out: info@designmuseumfoundation.org @designmuseumeverywhere @design_museum

Copyright © 2020 Design Museum Everywhere

When you hit a wall, we're here to help.

Digital marketing support, including: Search engine optimization Paid media Social media management Site architecture and support

madewithbend.com

VISUAL BRAND LANGUAGE PRODUCT DESIGN INNOVATION STRATEGY Join our growing list of brands Nike Seventh Generation Titleist Timberland The North Face Vans New Balance Reebok Converse Tracksmith Smartwool

howandwhy.biz

Contents.

DEPARTMENTS 6

Contributors

20 Recommendations

8

From the Editor

22 Q&A

10

Year in Review

24 Design Activity

18

Shop for Design

FEATURES 28

The Art of Designing for Behavior Change

By Amy Bucher, Ph.D., Vice President of Behavior Change Design, Mad*Pow

38

UnitedHealth Group and Optum Emphasize the Care in Healthcare

By Jen Shaffer, Director of User Experience, Optum and Thomas DiJulio, Senior Content Strategist, Optum

46

Modern Midwifery: Designing Equitable Birthing Care An Interview with Tiffany Townsend, Certified Professional Midwife, Doula, and Certified Lactation Counselor Interviewed by Sara Magalio

6

FRONT COVER DESIGNED BY SOPHIA RICHARDSON

Winter 2020 • Issue 017

The Healthcare Issue

54

Smarter Healthcare Expanding Patient Engagement

By Bill Hartman, Head of Innovation Strategy/Essential Design, part of PA Consulting

60

Community As Medicine Re-Designing Healthcare

By Dr. Elizabeth Markle, Co-Founder of Open Source Wellness

68

How Will COVID-19 Change Healthcare Design?

By Diana Anderson, MD, MArch, Jacobs, Principal and Matthew Holmes, ARB, RIBA Jacobs, Global Solutions Director: Health Infrastructure

76

At the Interface Between Man and Machine A Sneak Peak of Bespoke Bodies: The Design & Craft of Prosthetics

By Dr. Shriya Srinivasan, PhD, Co-written

by Sabaat Kareem

84

Designing With EvidenceBased Empathy The New Stamford Hospital

By Tushar Gupta, FAIA, NCARB, Design Principal

Have a great design impact story? editor@designmuseumfoundation.org

Interested in advertising opportunities? advertise@designmuseumfoundation.org

DESIGN MUSEUM MAGAZINE ISSUE 017 WINTER 2020 (ISSN 2573-9204) IS PUBLISHED QUARTERLY BY DESIGN MUSEUM FOUNDATION. 100 SUMMER STREET, SUITE 1925, BOSTON, MA 02110. POSTMASTER: SEND ADDRESS CHANGES TO DESIGN MUSEUM FOUNDATION, 100 SUMMER STREET, SUITE 1925, BOSTON, MA 02110.

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Contributors.

Diana Anderson, MD, M.Arch Diana is a healthcare architect and a board-certified internist. As a “dochitect,” she combines educational and professional experience in both medicine and architecture. Diana recently completed a geriatric medicine fellowship at the University of California, San Francisco and is currently a research fellow in geriatric neurology at the VA Boston Healthcare System.

Amy Bucher, Ph.D. Amy Bucher, Ph.D., is Vice President of Behavior Change Design at Mad*Pow and author of Engaged: Designing for Behavior Change. Amy designs engaging and motivating solutions that help people achieve personal goals. Amy received her BA magna cum laude in psychology from Harvard University, and her MA and Ph.D. in organizational psychology from the University of Michigan, Ann Arbor.

Thomas DiJulio Tom brings strategic insight and considerable creative and copywriting skills to the development of digital solutions, internal communications and branding materials for Optum. A semi-professional road and track cyclist, Tom regularly competes in USA Cyling events and has proudly raised thousands of dollars riding for the UnitedHealthcare Children’s Foundation.

Tushar Gupta, FAIA, NCARB As Managing Principal, Tushar strategically leverages EYP’s business development, and is an award-winning designer specializing in healthcare. Tushar is currently serving on the board of directors for the AIA Academy of Architecture for Health and served as President of the organization in 2019.

Bill Hartman Bill Hartman is a Partner and senior consultant who leads Essential’s innovation strategy team in product and service discovery and definition. Bill offers a broad background in user-centered design and has led multi-disciplinary, international programs across a range of industries.

Matthew Holmes Matthew is a chartered UK and French registered architect who leads Jacobs’ Global Health infrastructure business. His more recent work includes new facilities supporting the delivery of health services in rural locations across Australia, New Zealand, and Kiribati through to the planning and design of major tertiary facilities such as the new Women’s and Children’s Hospital in Adelaide.

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Monet Elena Levalley-Garcia Monet is an Indigenous Queer nurturer, activist, activator, and guide. As a health coach and Program Manager of Open Source Wellness, with a BA in sociology from the University of California Berkeley, she has dedicated her life to combating health disparities and transforming healthcare.

Sara Magalio Sara is the Editorial Production Apprentice at Design Museum Everywhere, pursuing a Master of Science in journalism at Boston University. Sara graduated from Southern Methodist University in Dallas, Texas with a BA in journalism and BFA in dance performance. Through working with local publications and her background in performance, Sara connects her love for the arts with a passion for sharing impactful stories.

Elizabeth Markle, Ph.D. Elizabeth is a licensed psychologist, speaker, writer, researcher, and Associate Professor of Community Mental Health at the California Institute of Integral Studies. She is the Co-founder of Open Source Wellness, a nonprofit initiative offering experiential behavioral health and wellness via "Community As Medicine," in collaboration with healthcare providers and insurers.

Jen Shaffer Jen is a Director of User Experience at Optum. She has over 18 years of experience designing and developing digital applications. A problem solver at heart, Jen tackles creative challenges by starting with user research, discovering insights that inform effective solutions.

Dr. Shriya Srinivasan Shriya is a Fellow at the Harvard Society of Fellows. She graduated from Case Western Reserve University, and received her doctoral degree in medical engineering and medical physics through the Harvard-MIT Health Sciences and Technology program. In her spare time, she dances Bharatanatyam, a south Indian classical dance form, and co-directs Anubhava Dance Company.

Tiffany Townsend, LM, CPM, CLC Tiffany is committed to educating families about their options and doing all that she can to remove the fears associated with the process of natural physiologic birth. She has served her community as a birth worker, support group facilitator and lactation counselor for over five years, and operates De La Flor Midwifery in Grand Rapids, Michigan.

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From the Editor.

This year is one for the history books; 2020 was not only defined by a global pandemic, but also national uprisings and conversations calling for civil rights for the Black community, and a contested presidential election. While Design Museum is not immune to the effects of these uncertain times, we have found ways to adapt and thrive. This year we changed our name to Design Museum Everywhere—to be the museum that comes to you, wherever you are—and in doing so we’ve become a truly multimedia and global museum.

Elizabeth Lowrey, one of our members on the Board of Directors, recently called me to say, “I don’t know how you all are doing this, but for every challenge in our world, Design Museum has some piece of content, or exhibition, or program addressing it and helping folks understand and see how design plays a role.” That really touched me—I’m so proud of the work we do.

One of our most notable accomplishments of the year was creating an online version of We Design: People. Practice. Progress., featuring the career stories of people from historically underinvested communities who are working across every design field. We recently added 15 designers to the online exhibition, and we’ll continue to grow the group in 2021.

We also researched and curated a list of over 100 anti-racism resources, spanning self-education books, podcasts, organizations to follow, and more. And, in response to growing demands to end police violence against Black individuals, we’ve partnered with a guest editor, Jennifer Rittner, to develop a special issue of Design Museum Magazine to explore the relationship and role of design in policing.

This issue will be published one year after the murder of George Floyd.

We also shared a number of conversations focused on democracy in recent episodes of our weekly podcast, Design is Everywhere.

We discussed the design of voting, political activism, and civic design. I interviewed Dana Chisnell, Director of Project ReDesign at the

National Conference on Citizenship, and Anne Petersen, Director of Experience Design at 18F, a design office within the federal government, just to name a few.

COVID-19 has completely upended our education system. To respond, our Director of Learning and Interpretation, Diana NavarreteRackauckas, is breaking new ground in youth design education. We brought our youth programs online in innovative ways, including sending teens design kits to use on their virtual projects. We will welcome another cohort of teens to our Neighborhood Design Project in Spring 2021. There’s also our Design Together program, a collection of design activities for all learners and classrooms, available for free on our website.

Lastly, we’ve focused significantly on healthcare—the subject of this special, year-end issue of Design Museum Magazine, and a topic that connects to all our lives, especially this year.

In this issue, we’ve partnered with thought leaders across the healthcare design ecosystem. You’ll explore how designers are making a real impact in people’s well-being through human-centered healthcare.

I hope you learn from and enjoy this issue, and all that Design Museum Everywhere has to offer, as we explore the concerns of our time through the lens of creative problem solving.

It’s our supporters who make this work possible. For those of you who can, I hope you’ll consider continuing your support and making a year-end, tax-deductible donation to the Design Museum. To help us continue this important work into 2021, visit our website at designmuseumeverywhere.org and click “Make a year-end donation” at the top of the page. Thank you!

Sincerely,

Sam Aquillano Executive Director Design Museum Everywhere 11

Year in Review.

It’s been a big year for Design Museum Everywhere, utilizing our nomadic structure and responding to the COVID-19 pandemic by creating new programs, bringing the We Design exhibition online, starting the Design is Everywhere podcast, and launching a Diversity in Action training program. We are now more true to our mission than ever before: Design Museum brings the transformative power of design everywhere.

$50k+ in Design Impact Society Gifts

$52,368 Fundraising Events

$145,657 Individual Donors Thank you to all of our individual donors, including our Board of Directors, Advisory Council members, and the Design Impact Society, whose support makes an incredible impact year after year.

$22,399 Ticket Sales

Membership

Other

$242,249 in grants received

REVENUE

$183,811

$5,330

Design Museum received more grants in 2020, from funders like: The Boston Cultural Council, The City of Boston Arts and Culture COVID-19 Fund, The Cambridge Community Foundation, The LovettWoodsum Foundation, and The Barr Klarman Massachusetts Arts Initiative.

$262,400 Program Sponsorship

Thank you to everyone who participated, contributed, and designed with Design Museum Everywhere in 2020. This was a year of growth and gratitude in many ways. From new programs for our virtual reality to new staff members, we didn’t let 2020 stop us.

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ORGANIZATIONAL GROWTH

Growing Team This is the team working to make everything at Design Museum happen, and we could not do it without each and every one of them.

10% increase in Board of Directors and Advisory Council members Remote interns and apprentices from 10 states

3 new full-time staff members Maria Villafranca Director of Marketing

$42,192 Printing

$8,914 Rent

Journee Harris

Amor Yates

We Design Program Coordinator

Podcast Writer and Producer

$26,591 Hospitality

$13,466 Marketing

Finances Without traditional overhead, like a building, Design Museum invests primarily in our team and in our programming. Particularly in a time like 2020, this model allows us to continue delivering on our mission.

$76,716 Supplies

EXPENSES

$134,180 Operations

$587,670 People 13

THE POWER OF DESIGN

Exhibitions Toured We Design and Bespoke Bodies exhibitions to 5 venues across the U.S. and online! Our exhibitions are always free and open to the public, in places people already go.

Design Museum is Everywhere Despite the world slowing down, membership at Design Museum expanded globally. With more virtual events and ways to connect, our community comes from all over the world to celebrate design. Members are able to attend events for free and receive Design Museum Magazine.

10,000

copies of Design Museum Magazine were read in...

44 states

100+ students and recent grads provided with free membership 14

19

countries

In 2020, even when we couldn’t continue in-person events, Design Museum delivered...

DATA

TRANSPORATION

LANDSCAPE ARCHITECTURE

JOURNALISM

CIVIC

SOCIAL IMPACT

PLAY

UBIQUITY OF DESIGN

SUSTAINABILITY BRAND & BUSINESS

BULDING & SKETCHING

WORKPLACE INNOVATION

EDUCATION

DIVERSITY, EQUITY, & INCLUSION

HEALTH & WELLNESS

Content that highlights...

Our events were attended by over 3,207 people from around the world!

ENGINEERING

PSYCHOLOGY & SOCIOLOGY

COMMUNITY IMPACT & ADVOCACY

DIVERSITY, EQUITY, & INCLUSION

URBAN PLANNING

EDUCATION

TECHNOLOIGY

SUSTAINABILITY HEALTHCARE

BUSINESS

ARCHITECTURE & PRODUCT DESIGN

from experts in the fields of...

Design Museum has been a consistent source of thought-provoking and inspiring ideas for me. Even throughout 2020, the opportunities for learning, gathering in community, and making connections has continued… even increased! I’m grateful to have this wonderful spark of light in the world.

– Amy Winterowd, VP of Client Solutions, JE Dunn

21,000 downloads of our podcast, Design is Everywhere, available for free wherever you stream your podcasts.

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DIVERSITY, EQUITY, AND INCLUSION

We Design People. Practice. Progress.

We Design brings together creatives from a wide array of backgrounds to examine and celebrate a range of career paths, applications, and impact areas in design. The collaborative, evolving exhibition features career stories showcasing how people have forged their unique paths into different creative professions, emphasizing the need for more racial and gender diversity in design and innovation fields.

This design exhibition is taking a head-on look at representation...

Design Museum Everywhere organizes an important show.

Virtual exhibition celebrates BIPOC and women designers while confronting the the lack of professional diversity.

– Architectural Digest

– The Architect’s Newspaper

1st-of-its-kind publication Bespoke Bodies: The Design & Craft of Prosthetics Features the stories of 44 individuals and companies making change in the lives of people living with limb loss and limb difference, plus 7 original accompanying essays.

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Black Lives Matter and Anti-Racism Resources 106 anti-racism resources spanning design specific and general selfeducation books, podcasts, and organizations to follow, hosted on a continuously updated webpage.

Diversity in Action Launched courses for individuals and organizations to live up to their diversity, equity, and inclusion statements, by designing a culture of diversity in action.

300+ hours

dedicated to consistent anti-racism work, diversity, equity, and inclusion training, and facilitated conversations across the entire Design Museum team.

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YOUTH EDUCATION

DESIGN ACTIVITY (4–12 GRADE)

Custom Chair Learners will consult with a client and create a prototype of a custom chair that fits their client’s needs.

Learners will...

• Conduct research for their client • Design a prototype chair for their client Interview a client • Revise their designs based on feedback

Design Together 11+ hours of Design Together activities, our online catalog of activities that learners can do alone or with family and friends to build design skills Activities for learners from ages 7 and up

Neighborhood Design Project* 60 teens learning from and making relationships with 13 local designers to use the design process to self-identify problems and create change in their own communities. *Includes Summer Design Project, our virtual version of Neighborhood Design Project (NDP), held in Summer 2020 to offer a continuation of where NDP left off due to interruptions from COVID-19.

I’m excited to learn from this younger generation about the type of issues that they care about and how they use design to try and tackle some of that.

– Lauren Smedley, NDP Design Coach

[I liked that it was] an open environment with easygoing people, helpful and unboring mentors, interesting teammates, and a space to learn new things.

– NDP Teen

$18,963 paid to teens for their design work

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[I liked] working on a project regarding an issue that matters to me.

– NDP Teen

We Design 32 creative career options spotlighted in the online exhibit, with resources and interactive media to continue learning about careers that use design.

Future of Construction Free webinar series and design challenge for high school students

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As an accompaniment to the We Design program, we’ve designed a deck of 55 interactive cards to teach young people what’s possible in the design field.

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Shop for Design.

As the holidays near, Design Museum encourages shopping responsibly, shopping locally, and supporting artists, designers, and makers who rely on the holiday season. Check out these platforms, which feature Black, Native American, and Latinx creators!

Black Artists + Designers Guild BAD is a global collective of independent Black artists, makers, and designers throughout the African diaspora.

badguild.info

SheNative SheNative creates leather handbags and apparel that share Indigenous teachings.

shenative.com 20

BLK + GRN BLK + GRN is an allnatural marketplace by all Black artisans.

blkgrn.com

Black-Owned Etsy Shops A collection of over 1,000 Black-owned Etsy shops.

themadmommy.com/ black-owned-etsy-shops

ShopLatinx A marketplace of lifestyle, beauty, and fashion products.

shoplatinx.com

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Recommendations.

Therapeutic Gardens: Design for Healing Spaces Therapeutic Gardens: Design for Healing Spaces by Amy Wagenfeld and Daniel M. Winterbottom, is one of my favorite books about healing gardens. It is rooted in research and explores different illnesses and the gardens that can help each one. The work shows that healing spaces are essential to healthcare and can be enriching for patients and their families.

Juann Khoory Boston Design Leader CannonDesign DIRECTOR'S CIRCLE MEMBER

Empathy: The Human Connection to Patient Care Watch the Cleveland Clinic's “Empathy: The Human Connection to Patient Care� YouTube video. It contextualizes not only the emotions that patients may be facing, but also their family members and the caregivers in the health system. In highlighting clinicians, it is essential to consider and design for improving their experiences in order to also improve the overall patient experience.

Amy Heymans MEMBER

Formula 1 Becoming a fan of Formula 1 has been engrossing. Speed, excitement, drama, the cars! Design is everywhere in F1, from engines, to aerodynamics, to tire compounds. I had no idea about the complex balance between car, driver, engineers and mechanics, and the owners that make up a team. On top of all that intrigue we get to see, the design of a car's livery is one of my favorite parts of the sport.

Michael Dow youtu.be/cDDWvj_q-o8

Senior Vice President Brown Brothers Harriman & Co. DIRECTOR'S CIRCLE MEMBER

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Animal Crossing I would recommend Animal Crossing! I am a mega nerd, and have thoroughly enjoyed the design features in the video game. You can customize your own textiles, design creative spaces and layouts, and the game incentivizes Feng Shui and keeping your island residents happy. I thought the game was tedious at first, but then I saw that money grows on trees and presents float in the sky, and I was hooked!

russellmuseum.org

Leah Ben-Ami Director of Learning C Space

Museum of Medical History and Innovation

COUNCIL MEMBER

The Museum of Medical History and Innovation on the MGH campus is a great place to learn about past medical procedures and tools. New displays come up often, which is why I liked to stop by. I recently moved to Georgia, and will miss visiting this museum.

The Museum of Medical History is not currently open due to COVID-19, but those who are interested can view the museum's online programming at russellmuseum.org.

Aaron Ross MEMBER

The Body Keeps the Score A book that changed my perspective on design is The Body Keeps the Score by Bessel Van der Kolk. Even though it’s about psychology, trauma, and healing, it is important for designers to understand the complex histories each user brings to their experience within a healthcare space, and that we have a responsibility to positively impact that experience through design.

Rachel DeSanto MEMBER

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Q&A. Tell us about a time when someone or something in healthcare pleasantly surprised you. How can healthcare include more of that?

Using BetterHelp for the first time, I remember when my biggest barriers to access—travel time and my work schedule— were nullified with an app. When I video chatted with my therapist Jen for the first time, I couldn't hide behind a phone call or text. A huge sense of relief washed over me then. Nothing was lost in using this virtual tool for remote care as a replacement for an in-person visit.

Daniel Matiaudes MAGAZINE SUBSCRIBER

During a brief hospital stay as a young adult, I’ll never forget how a specialist physician, sensing my anxiety was off the charts, took the time to walk with me through the corridors and lounge areas of the hospital to put me at ease. This special attention in this conversation was effective medicine.

Empathy plus science is the best prescription for improving healthcare services delivery.

Gary Miciunas National Workplace Director Cuningham Group Architecture, Inc. WORKPLACE THINK TANK MEMBER

When the phlebotomist recognized me (even though it had been a year) and had a short chat with me before he drew my blood.

Then I realized that he must chat with everyone to relax them in a somewhat scary setting.

Leslie Saul Founder LS&A architecture and interiors MEMBER • DESIGN IMPACT SOCIETY MEMBER • WORKPLACE THINK TANK MEMBER

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I gave birth to my daughter this year.

I'd never dressed a baby before and had no idea how to put on a onesie. One of the nurses showed me some tips on getting baby arms through long sleeves, and I've held on to that method for almost a year. It still saves me time and fussiness every day. I knew the medical care would be good at the hospital we chose, but the personal care was above and beyond.

Meredith McCarthy Senior Associate Sasaki WORKPLACE THINK TANK MEMBER

One thing that will always stick out to me was the attitude of my plastic surgeon.

When it became clear that amputation was my only option, he delivered the news in a few simple words: “You’re going to be alright. You’ll do great.” His attitude gave me confidence.

He also invited a peer visitor to talk with me.

That experience shifted my perspective of what life with limb loss could look like.

Although I've been designing within healthcare for a decade, I still think about the first time my mother went to Dana Farber Cancer Center to meet with her oncology team. I had been mentally preparing for the work I'd need to do to get her out of the car and into her wheelchair by myself, but the valet took care of everything. One valet grabbed the wheelchair out of the trunk and set it up, while another gently transitioned her into a position where she could carefully slide into the chair. They both managed the foot rests, got her comfortable, collected her things, smiled kindly, and wheeled her into the lobby. I stood there watching in awe, fighting back tears. By taking care of her, they took care of both of us. That 5-minute transaction calmed our nerves, made us feel taken care of, and set the tone for the rest of our day. Everyone who works in a healthcare setting can make a difference in a patient's day, even if they're not delivering critical therapeutics.

Lisa deBettencourt Founder and CXO Forge Harmonic DESIGN IMPACT SOCIETY MEMBER

Maggie Baumer Clinic Manager Hanger MEMBER • BESPOKE BODIES SPONSOR

Every time I walk into Boston Children's Hospital, I feel like I am inside a children's museum. The Boston location used to have a giant kinetic-powered sculpture at the entrance, making a dingding-dong-dong whimsical sound. The colorful interior design, from the waiting area to the MRI rooms, are all cleverly designed to welcome patients and visitors.

Grace Luk Abongnelah MEMBER

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Design Activity.

Letter to Yourself Guided Meditation by Monet Elena Levalley-Garcia, Open Source Wellness

1

Start by closing your eyes, and take a moment to be quiet.

2

Using your imagination, zoom out so that you can see your life from a bird’s-eye view. Notice different domains of life...family...work...body... spirituality...everything.

3

Notice the aspects of your life that are going well! Where in your life are you experiencing power, freedom, ease, joy?

4

Then, notice aspects of your life that are challenging or painful. Where are you experiencing a loss of power or freedom? Where is there pain, or even suffering? Simply notice and acknowledge these aspects of life, too.

5

Now call to mind the most unconditionally loving person or being you have ever known, or never known. Perhaps a friend, family member, or mentor, alive or deceased. Imagine that they can see everything about your life! They know and see your circumstances, thoughts, feelings, and experiences, with kindness and compassion.

6

If this person or being could speak to you, what words of encouragement, support, perspective and love would they offer you? Take a moment to write the letter they would write to you! It starts, “Dear (your name), ...”

7

To end, sit for a few moments and receive their care, wisdom, and kindness.

ILLUSTRATION BY MAKENNA PARKS

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NEW BOOK

Pre-order Bespoke Bodies The Design & Craft of Prosthetics

$5 from every book sold through

January 2021 donated directly to the Amputee Coalition Pre-order now at bespokebodies.org

OPTION 2 Architecture

Construction

Renovation

Development

www.rearchitect-ma.com 617.466.9252

Design-Build

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HEALTHCARE

The Art of Designing for Behavior Change.

By Amy Bucher, Ph.D., Vice President of Behavior Change Design, Mad*Pow Whether they are explicit about it or not, most designers ultimately want to create something that sparks change.

Maybe the change is as small as having people consider a new perspective after interacting with an exhibit about a historical event. Maybe it’s a one-time action, like making an appointment for a colonoscopy the week after turning 50 years old after receiving an automated phone call from a health insurance plan. Or it could be an ongoing new behavior, like making a meatless dinner part of the family’s weekly routine with the help of a meal-planning app.

Yet, over and over, designers get focused on more immediate success metrics. How many people are downloading this app? Visiting this website? Interacting with this exhibit? They reach for tools designed to “nudge” users into quick actions, and for some outcomes, those tools are enough.

However, many of the most significant problems designers hope to solve call for more than a one-time action on the part of the people who encounter the design. Take 401k enrollment as an example, where opt-out choice architecture can dramatically increase the percentage of people opening a retirement plan. People who are nudged into opening a plan are likely to invest only at the default level and ultimately save less than people who enroll with a more deliberate set of financial goals.

For the types of behavior change challenges that require people to opt in over and over, a more robust intervention approach is required. Enter motivational design.

Behind the Motivational Curtain Motivational design leverages the psychology of motivation to craft experiences and products that people are intrinsically interested in using. Understanding the psychological reasons why people engage with some products and experiences and not others helps designers to go beyond thinking about features to consider what function they’re fulfilling for their users, or not. A designer who understands motivation can make better product decisions that are aligned to what actually works for users.

So let’s start with motivation. Motivation always has an object; it’s wanting to do something. When we practice behavior change design, we’re creating the context around that something. We want it to be appealing to people. Not only should our users want the results of engaging with our designs, but they should enjoy the experience of using the products, too. Otherwise, why would they continue long enough to see results?

Good motivational design starts from an understanding that not all motivation is created equally. Motivational quality refers to the source of a person’s motivation. As a rule of thumb, the more autonomous, personal, and IMAGES COURTESY OF MAD*POW

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internal the source of motivation is, the longer lasting and more resilient to obstacles that motivation will be. On the other side of the spectrum, more controlled forms of motivation, originating from outside of the person, are short-lived and unlikely to survive challenges.

The crux of motivational design is that meaningful sources of motivation have to come from the user, not the designer.

The sources of motivation can be arranged in a continuum from most controlled to most autonomous¹. The controlled forms of motivation include extrinsic motivations like rewards or punishments, which may take the forms of incentives or even scolding, and introjected motivations, which are when the self internalizes expectations from others. This contrasts with identified and integrated motivations, which occur when a behavior aligns with a person’s goals, values, and self-perceptions.

People with identified and integrated sources of motivation are interested in doing something because it supports something they already care about. That can be a powerful reason to stick with a behavior.

Intrinsic motivation, of course, is doing something simply for the pleasure of it.

Creating experiences that are beautiful 32

and fun helps tap into intrinsic sources of motivation. Psychologists have long known that the human brain is wired to engage with stories²; now the emerging field of neuroaesthetics indicates a similar human attraction to visual art³. Art’s ability to capture people’s attention is one reason why the science of behavior change relies heavily on it to be successful.

The crux of motivational design is that meaningful sources of motivation have to come from the user, not the designer. The designer can create breadcrumb trails that help users understand how taking a particular course of action will fulfill meaningful goals, express a cherished self-identity, or uphold deeply held values. They can even explicitly make the case that there is common ground between what the product owner and the user hope to achieve, but to actually impose a goal on a user goes directly into controlled motivation territory. I call this the designer’s dilemma.

Creating something truly engaging and effective requires ceding control to the user.

Fortunately for us designers, there are principles we can use to align our desired outcomes with what’s meaningful to the people using our products. The trick is to find opportunities to support people’s basic psychological needs of autonomy, competence, and relatedness. If you consider reaching a goal as a journey, then these needs align to letting people map their own course, helping them monitor their progress, and making sure they are not alone on their way.

Mapping the Course The basic psychological need of autonomy involves people’s innate desire for some control over their own destinies. Designers can approach this by being selective about which choices they offer users. As much as possible, important choices should be delegated to users and less consequential ones can be presented as modifiable defaults. When minor choices are left to users, designers should architect the experience to make the process swift and easy.

Meaningful Choices The word “meaningful” is deliberately chosen here. Choice per se does not fill people’s need for autonomy. In fact, a high volume of low consequence choices can be distracting and annoying. Imagine if you had to choose every setting on a brand new smartphone, from background color to font choice to default battery usage, rather than being able to use factory defaults.

What really drives motivation is big picture choices, things like specifying your goals for participating in a program. Noom, a weight management app, does a particularly nice job of helping its users articulate what’s really important to them as part of the program onboarding. By leading users through a series of prompts and getting them to think about why their health really matters to them, Noom likely boosts their motivational quality, and by extension, their ability to reach weight loss goals.

A simple tool in every designer’s toolkit that can bring meaningful choice into the experience is posing questions to the user, without necessarily needing to collect their responses. Regardless of how technologically sophisticated your design is, you can include prompts in the experience for people to reflect on what’s important to them and affect how they orient themselves with respect to what you’ve designed.

Making Choices Easier If you’ve ever used Netflix, you’ve likely spent far longer than you wanted to browsing alter-

natives without deciding what to watch. You may have even decided not to watch TV after all. There’s simultaneously nothing on and so much stuff. This type of decision fatigue that occurs when people are bombarded with too many choices is what designers can avoid with elegant choice architecture.

Want to make choices easier? Think in terms of constrained or curated choices. How can you offer people fewer but higher quality choices?

This is what recommendation engines such as the ones used by Netflix, Spotify, and Amazon attempt to do, with mixed success. While Netflix offers a huge number of suggestions, it does at least narrow down the universe of entertainment for subscribers. Even better is

This screengrab shows one of the prompts that Noom users see when using the app.

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The Roobrik dashboard shown here displays care needs and settings based on data inputted by the user.

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This screengrab shows one of the pages that users see when working through a six-week sleep improvement program through My-Coach Sleep Workshop.

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how Amazon suggests just two or three other items that are “frequently bought together.” A shorter options list can be perceived as more targeted, and is less likely to overwhelm users.

Getting recommendation engines right really matters when they’re being used to help people make consequential decisions, like in healthcare or finance. For example, Roobrik is a tool to help caregivers make decisions about what services to seek for their loved ones. It uses inputs from users to make recommendations among options. One thing Roobrik does explicitly is expose why a particular recommendation was made. This helps reassure users that the options they’re considering are truly right for them.

Monitoring Progress The next basic psychological need, competence, refers to people’s desire to see themselves progress along a course. People are highly attuned to evidence that their actions

Strava allows users to track their fitness progress as compared to others in order for them to more impactfully monitor their exercise goals.

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have had some effect on the world. They’re interested in activities where they can learn and grow (even if they don’t think of it in those terms). The designer’s toolkit for supporting this need includes creating effective feedback frameworks, and identifying ways to minimize or overcome obstacles to success.

High Quality Feedback Feedback is how people know whether their actions are propelling them toward their goals or not. People are remarkably attuned to signals that indicate the effects of their actions.

Designers can satiate this appetite for information by providing feedback at multiple levels to help guide users toward achieving goals.

Immediate or proximal feedback occurs right after someone takes action. It lets them know if that action was successful, and suggests, either explicitly or implicitly, ways to improve if not.

Cumulative feedback helps people see progress over time. It helps to communicate how many small actions add up into larger results.

Pairing both types of feedback can help people stick with a behavior change where they might be expected to have setbacks or plateaus by reminding them of the bigger picture.

Normative feedback compares people to others to help them understand how they stack up against the field. It can be motivating to see that others are having similar experiences. Normative feedback can also help people adjust their performance based on what they see others doing. However, a pitfall with normative feedback is stacking people up who have significant differences. Someone just beginning a walking plan will lose a step count challenge against a marathon runner every time, and may incorrectly draw the conclusion that their efforts aren’t effective. That’s why programs like Strava (a workout tracking app) let people sort themselves into more meaningful comparison groups for providing this type of feedback.

Removing Roadblocks Part of the research that goes into a behavior change design project is identifying anything that might make it hard for people to

complete a behavior. Using frameworks like COM-B (capability, opportunity, motivation = behavior)⁴, designers look for barriers that can then be addressed with the design. There may be opportunities to coach users to avoid a barrier entirely, such as using canned goods as substitutes for weights in doing strength training. Sometimes education or training can help people grow their abilities beyond where they started, so what was once hard becomes attainable. Or there may be practical assistance that designers can provide their users; something like a museum guide helps visitors navigate exhibits and understand their relevance.

Another tactic to minimize roadblocks is to organize the steps toward reaching a goal so that they build on one another. This tactic, sometimes called scaffolding, helps ensure that people tackle each activity with the appropriate prerequisite skills. Duolingo, a language learning program, uses scaffolding to structure its lessons so that at any point, users are able to finish a lesson with their existing skills. Asking learners to self-identify whether they should start from the beginning or take a placement test further reduces any roadblocks that people might encounter to successfully completing the lessons.

Maintaining Contact The last basic psychological need, relatedness, refers to people’s need to feel part of something larger than their own individual selves. Humans are the ultimate pack animal, seeking to feel a sense of community, whether by actually being together or in a more virtual sense by participating in online experiences or faith communities. Even people’s interest in astrology hints of community, feeling aligned with others born under similar stars.

Designers can help people feel connected both by designing emotionally appealing products, and by offering people opportunities to support one another.

Technology for Connection It’s not always feasible or desirable to have direct human support within a product or expe-

Duolingo allows users to choose a path for learning a language based off of their past experience with the language in order to maximize efficiency in their progress.

rience. In healthcare, there may be data privacy, regulatory, or practical considerations that make having a person available to talk to unfeasible. In fact, research suggests that in some cases, people may prefer to interact with a fully digital tool rather than talk to a person⁵, such as when they need to get help with an embarrassing or stigmatized health issue.

Digital can also be the right choice for simple transactional interactions like appointment reminders. In a 2019 survey of UK National Health Service (NHS) patients, 76 percent liked the idea of automated reminders⁶. Finally, digital’s scalability makes it an attractive option to extend services geographically and over longer time periods. People can use a digital service 24/7 without live support needed.

The key is to design digital tools in a way that still fosters feelings of relatedness.

Personalization, where information about the user triggers relevant content, can be an excel37

Row House is one example of a company that has branched out into at-home fitness through providing users with an app interface to view and participate in classes, as shown here.

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lent tool to help people feel understood by technology. It doesn’t have to be creepy; designers can be forthright about how user data is fed into the product to produce personalized outputs. Some of the digital health coaching products I worked on earlier in my career included what we called a “magic moment” transition between when users answered questions about themselves and when we created their personalized output. The magic moment explicitly called out some of the factors we were incorporating into the personalization. We found that including it increased our users’ confidence that the coaching they received from the product was relevant, which in turn made them more willing to engage with it.

Bringing People Together As much as technology can provide support, sometimes there is no substitute for another human being. People can support each other in a variety of ways, whether it’s by helping with a task, providing knowledge or coaching, being an accountability buddy, or just providing friendship and caring.

Designers can include mechanisms for their users to receive expert support. Telehealth is a paramount example, where the core of the experience is interacting with a healthcare professional. Other examples could include enabling social media sharing within an app, crowdsourcing information about how to navigate a challenge, or creating team competitions. With the shift to stay-at-home lifestyles during COVID-19, some companies have brought their in-person services online, such as Row House, an indoor rowing gym now offering virtual live classes.

Behavior Change Design Is Not About Designers All of the tactics shared here are in the interest of creating alignment between what you, the designer, hope to have your users do, and the goals and values your users bring to the experience. Fortunately, for many designers, there truly is a meaningful overlap between what their designs offer and what most users want

to do. Designers may want to reduce healthcare expenditures while users want to feel better when they wake up in the morning; the same set of activities can achieve both.

Talking to users early in the design process is an important step in uncovering where these alignments exist and developing the language to make them apparent. Anyone working as a designer has some expertise in their problem area. That can make it hard to remember what it’s like encountering the topic for the first time, with little experience or pre-existing knowledge. There is no substitute for hearing from people firsthand what their experience with the design area is and using that as input to the design. Co-designing with members of your target audience offers an even more powerful way to incorporate insights from users into whatever you create.

Ultimately, behavior change design is about the user, not the designer. If your products, services, or experiences aren’t built to support what really matters to the people who use them, they will not engage. •

1. Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55, 68-78.

2. Zak, P. J. (2015). Why inspiring stories make us react: The neuroscience of narrative. Cerebrum: The Dana Forum on Brain Science, 2. PMID: 26034526; PMCID: PMC4445577.

3. Chatterjee, A., & Vartanian, O. (2014). Neuroaesthetics.

Trends in Cognitive Sciences, 18(7), 370-375. Doi: 10.1016/j.tics.2014.03.003 4. Michie, S., van Stralen, M. & West, R. (2011) The behaviour change wheel: A new method for characterising and designing behaviour change interventions.

Implementation Science, 6(42).

5. Lucas, G. M., Gratch, J., King, A., & Morency, L. P. (2014).

It’s only a computer: Virtual humans increase willingness to disclose. Computers in Human Behavior, 37, 94-100.

6. https://www.ghp-news.com/2019-nhs-users-want-totalk-to-ai-virtual-assistants-instead-of-humans-accordingto-new-research-from-ebo-ai/

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Participants in the ideation workshop used Post-It™ notes to write down their ideas on “How might we improve the user’s experience?”

They grouped the ideas, identifying key areas of focus for the solutions.

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HEALTHCARE

UnitedHealth Group and Optum Emphasize the Care in Healthcare.

By Jen Shaffer, Director of User Experience, Optum and Thomas DiJulio, Senior Content Strategist, Optum As with virtually every other aspect of our lives, technology has revolutionized healthcare. Over the past decade, patients and healthcare providers began to interact through online and mobile devices.

The COVID-19 pandemic has accelerated that trend, advancing alternative forms of care delivery, such as telemedicine and patient portals. While some healthcare companies have struggled to transition, others have embraced the opportunity to innovate and have discovered that designing digital healthcare solutions is less about technology and more about people.

As the largest healthcare company in the world, UnitedHealth Group’s mission is to help people live healthier lives and help make the health system work better for everyone.

UnitedHealth Group operates two distinct businesses: UnitedHealthcare and Optum.

In the United States, UnitedHealthcare offers the full spectrum of health benefit programs for individuals, employers, and Medicare and Medicaid beneficiaries.

Optum delivers information and technology-enabled health services to drive healthcare innovations and improve overall population health. Operating at the intersection of technology and healthcare, Optum has long prioritized digital design. More specifically, human-centered design.

Optum & UnitedHealthcare in Action It’s a sunny summer morning in Kansas, before the global COVID-19 pandemic, and Rain Higgins is already having an unusual day. She is sitting in an orange folding chair on the green lawn of a rural home, her laptop perched precariously on her knees. Rain, a UnitedHealthcare case manager, is conducting an in-home assessment with a client.

Jen Shaffer, Director of user experience for Optum, is observing the visit. Assessments are made every six months to determine the client’s health status and ensure they’re getting the services and care they need for their Medicaid program. As the name implies, the assessment normally takes place in the home.

However, the client is reluctant to let them inside due a bed bug infestation. Determined to help the client in this unique situation, Rain conducts the assessment al fresco.

Empathy in Technology To better understand how she found herself on a lawn in Kansas, it helps to know what Jen does. As a user experience director with Optum’s User Experience Design Studio (UXDS), Jen is part of a 150-person team specializing in a human-centered approach to research, design and development of digital products. In her efforts to better understand clients and their needs, she sometimes shadows healthcare partners working in their dayto-day environments.

IMAGES COURTESY OF OPTUM

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A UnitedHealthcare line of business focused on community care asked UXDS to identify opportunities for case managers to be more efficient in documenting client assessments. To accomplish this goal, Jen suggested they observe case managers on visits. “After seeing what case managers and their clients wanted and needed, it was obvious that this wasn’t just about the technology itself. It was about understanding the visit and interactions, which led to addressing some very human challenges,” Jen recalls.

Learning Directly from Users Over the next few weeks, Jen and her team conducted additional research, observing eight case managers in Kansas, Florida, and Arizona. Her immediate insight: “Sometimes technology needs to take a back seat.” Building rapport is a key factor in building trust with the client and/or their caregiver. “If the case manager is fixated on their laptop or struggling with a hot spot connection,” she observed, “they're not making eye contact; they're not having the crucial conversations that lead to understanding the client’s current state and needs.” Technology, despite its strengths, can also be a barrier to human conversation and insights into the client’s health.

Jen recalls that the lawn chair assessment, while a bit unconventional, proved to be invaluable. While Rain conducted the assessment, balancing her laptop on her knees and writing notes on paper, it was hard to read the screen in the sunlight. As she later explained, Rain knew the assessment by heart, so it was easier to rely on memory to ask necessary questions and note the answers by hand. She would enter those notes and complete the assessment after hours to help ensure the client continued receiving necessary healthcare support and services. In this situation, the technology wasn’t making things easy. Quite the opposite: it made Rain’s day longer and her job harder, because it wasn’t developed with a complete understanding of her needs.

The software centered on a solution to a technical problem—entering client information 42

during a visit—but it did not address the needs of the person using it, or how it would impact the relationship with the client.

The following day, Jen observed another case manager, Courtney Davis. Together, they visited a young man living with his mother, who was paid by the community care program to be her son’s caregiver. The visit began cordially, but as Courtney asked questions to complete the assessment, the mother started to voice frustration with the program and its reimbursement policies. As her frustrations rose, so did the volume of her voice. At that point, Courtney spoke calming words to deescalate the situation, closing her laptop, so she and Jen could leave quickly after saying their goodbyes. While case managers are trained in how to handle difficult situations, it became apparent that the software offered no allowance for quick departures which can result in the loss of difficult-to-gather client details.

Fortunately, these situations are rare, but they impact both case managers and clients, and they are situations Jen and her team would not have understood without observing case managers like Rain and Courtney.

Journey Mapping, Blueprinting and Workshopping a Solution Case manager research complete, Jen and her team returned to the office and rolled up their sleeves. Their first task was to create a user persona—a fictional character representing the user—to represent the case manager.

The persona provided a shared vision of the user to the project team, helping them understand and empathize with the user's needs.

They named their user persona Melissa. Using information gathered during the observations, Jen’s team then created a journey map—a visual timeline of the user’s process. The map outlined activities that Melissa completed in her home office and during client visits, along with critical pain points. Lastly, they created a service blueprint, identifying touchpoints for the client, to provide the team with critical information around the community care program experience.

Case manager Rain Higgins conducting an in-home assessment outside of the client’s home.

Through its human-centered approach, UXDS is firmly committed to using design to drive innovative healthcare solutions—one human at a time.

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Small teams of workshop participants sketched out ideas identified in the “How might we...” exercise. After each team presented their solutions, participants used dot stickers to vote on features.

With the user persona, journey map, and service blueprint in hand, Jen facilitated a two-day ideation workshop with participants representing the community care program, case managers and Optum Technology. Participants were introduced to Melissa, the user persona, and asked, “What would Melissa hire you to do?” Using this approach, they identified key categories of focus. The next activity involved asking the question, “How might we improve Melissa’s experience with our software?”

This generated a full wall of sticky note ideas. Participants sketched out those ideas in teams, giving everyone an opportunity to contribute to solving Melissa’s challenges.

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At the workshop's end, they had three concepts: a case manager dashboard, an enhanced client page, and a mobile companion app. The dashboard would provide case managers with vital information: a visit map, client list, calendar, and key notifications. The enhanced client page was optimized for the case managers’ needs, providing crucial details such as allergies and medications all in one screen. Lastly, the mobile app made it easy for case managers to map routes, access calendars, capture notes, track mileage, and receive alerts.

Putting Usability to the Test UXDS built prototypes for all three concepts and conducted three rounds of user research with case managers from multiple state health plans. The research gathered design feedback and measured the quality of the concepts, giving the team a chance to iterate between tests. The team also ran tests that compared

the current software to the prototypes, gathering Net Promoter Scores (NPS) and System Usability Scale (SUS) scores. Both are industry-standard techniques: NPS measures customer loyalty to a product, and SUS measures perceived usability. The results? The prototypes exceeded both the NPS and SUS benchmarks. But most impressively, due to time-ontask testing, the team concluded that one state alone could save $1.6M a year in productivity. If applied to all states offering the community care program, the potential savings were immense, even when accounting for implementation costs.

Think about how you use technology and its terminology daily. Now think about how your parents or grandparents use technology. Are they using the same language?

The original rollout of the client management software incorporated input from employees of the state health plans. However, it was only when UXDS observed case managers on visits that they fully realized the challenges the case managers faced. Case managers need to handle unexpected situations, while providing dedicated support to their clients to help meet their health needs and documenting their work digitally. While project teams can determine technical requirements with a group of experts, user research gives the team user empathy and a shared understanding of what they encounter daily. These insights make the work human centered.

Designing End-to-End Experience, Through Service Design To bring empathy to their design process, UXDS uses service design. As defined by the UK Design Council, “Service design is all about making the service you deliver useful, usable, efficient, effective, and desirable.”

Teams are better able to understand what users want and need by observing and listening to them firsthand.

For an organization to design an experience that meets or exceeds the expectations of its users, it must understand what those expectations are. The first priority is to conduct research in order to connect with users’ needs.

From there, the focus is on the journey.

Any journey is made up of different steps.

Every step impacts user satisfaction. For example, a coffee shop’s mobile app that lets you order in advance, or a doctor’s office that allows you to schedule online are touchpoints aligned with expectations and needs. But if there’s a wait to pick up your coffee, or you can't easily get the appointment you want, customer satisfaction is equally impacted.

Typically, businesses concentrate on touchpoints they can control, which makes sense.

Service designers strive to broaden focus and look at every step—even those steps that can’t be controlled—to create a satisfying experience from beginning to end.

It’s no different in healthcare. Using service design is imperative to understanding the expectations and needs of all involved in the health system: patients, caregivers, healthcare providers, health plans and others. “Service design enables organizations to understand the real needs and pain points of users and all other involved people. With this knowledge, teams can effectively improve existing healthcare products and innovate meaningful new offerings,” says Marc Stickdorn, author of This is Service Design Thinking and This is Service Design Doing.

By incorporating service design, teams can design the experience around the humans using it and those delivering it, resulting in a useful and effective experience for the user.

And if the user is delighted, Net Promoter Scores increase, there’s greater customer loyalty, and so on. In other words, service design is the difference between those experiences that users choose repeatedly, and those they don’t.

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Why Empathy is Even More Important Now Think about how you use technology and its terminology daily. Now think about how your parents or grandparents use technology. Are they using the same language? Would they be able to log into a patient portal, set up audio and video, and be on time for a virtual doctor visit without assistance? Further, according to the Centers for Disease Control and Prevention in 2015, one in five persons in the U.S. has a disability, which might be cognitive, visual, auditory, or related to dexterity.

Without careful planning and consideration, you could potentially exclude up to 66 million Americans from using your product or service.

Human-centered design takes commitment, time, and investment, but the payoff of providing a useful, efficient, and effective experience for your user is immeasurable.

It’s not uncommon for designers and programmers to assume they know what users want. But not at Optum, where UXDS designers, researchers, and accessibility specialists wear T-shirts that read “Ask me about usability,” and monthly webinars are presented to the enterprise on user-centered topics. The design mentality is that the team may understand the technology, but the team must also understand the user. A point that hit home for Jen, whose 78-year-old father was diagnosed with Type 2 diabetes shortly before the COVID19 pandemic began. She says, “If he had complications and needed assistance with this new diagnosis, I doubt he would have been able to navigate a virtual doctor visit alone. He’s still trying to master submitting his taxes online.”

She also mentions a colleague within UXDS, Mario, who is blind and has young children.

Mario wants to independently manage his children's health needs digitally through portals. He wants to access their insurance cards electronically, rather than having to ask his children for help when they're checking in at a doctor’s office. “Are the digital technologies Mario's using fully accessible? Are they being built with a 78-year-old diabetic in mind?” Jen asks. If designers are not using 46

human-centered design to understand and empathize with all users, they’re leaving a significant number of people behind. Technology has changed healthcare significantly in recent years, but without the human perspective, it's just a device or a screen. It’s not an inclusive experience, which could keep patients from receiving the care they need.

Doing is the Hard Part By taking a human-centered design approach to projects, UXDS brings awareness of the user’s desires and frustrations to the project team. When a team can empathize with the user to ensure patients’ healthcare needs are met, the result is better outcomes for the organization and most importantly, the people they serve. Dean Barker, vice president of UXDS, continually preaches the gospel of human-centered design across UnitedHealth Group. “Design can drive healthcare solutions,” Dean declares, “but only when that design is based on understanding and empathizing with users.” He points out that design never sleeps and must be continually evolved, evaluated, and emphasized. Simply understanding the theory is not enough. It must be put into practice. He believes, “It’s a journey.”

As Marc Stickdorn points out, “When it comes to sustainably embedding service design in an organization, it’s not a sprint, it’s a marathon.” Dean, Jen, and the team at Optum UXDS are committed to running that marathon every day. Even those days when they find themselves not running at all but sitting in an orange folding chair on a green lawn on a sunny day. •

The design team observed users, and then used the data gathered to create a persona to provide a shared vision of the user and their needs.

UXDS team members used Service Design methodologies to create journey maps, which are a visual timeline of the user’s process, and a service blueprint, which identifies all touchpoints within the experience.

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INTERVIEW • HEALTHCARE

Modern Midwifery: Designing Equitable Birthing Care.

An Interview with Tiffany Townsend, Certified Professional Midwife, Doula, and Certified Lactation Counselor Interviewed by Sara Magalio

Tiffany Townsend is a Certified Professional Midwife (CPM) committed to educating families about their options for childbirth and providing nurturing care well beyond American healthcare norms.

She has served her community as a birth worker, support group facilitator, and lactation counselor for over five years. Having attended over 300 births in many capacities, she feels it is important to be able to offer a more holistic approach to care. In her practice, Tiffany also highlights that pregnancy and birth cannot be facilitated with a one-size-fits-all approach, and that everyone should be cared for according to their individual needs.

As the first Black CPM in the city of Grand Rapids, Tiffany has completed numerous certification and training programs that allow her to approach each birth with awareness and respect for various cultures and belief systems. This includes learning under traditional Mexican parteras (midwives) and studying at the Midwives College of Utah.

Tiffany has also successfully completed the Neonatal Resuscitation Program (NRP).

Tiffany has five children of her own, and has experienced firsthand the benefits and pitfalls of both hospital and home birth, but the thorough, hands-on, and personalized treatment that she herself experienced delivering her last child at home inspired her to continue pursuing midwifery.

It is vital that our clients feel safe, heard, and well cared for in order to establish a safe space for discussing all aspects of care.

— Tiffany Townsend

IMAGES COURTESY OF TIFFANY TOWNSEND

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Sara Magalio: I read that your grandmother was an OBGYN and that you have been interested in the field of care surrounding birth from an early age. What inspired you to go into the field of midwifery?

Tiffany Townsend: I am a first-generation American on my maternal side, my family is from the Dominican Republic, and my grandmother was an OBGYN, who was not a fan of traditional birth. I was always called to birth work, because I got to see my grandmother work with Haitian immigrants in the Dominican Republic. I would spend most of my summers in the DR during my childhood. As a young person, I remember watching my grandmother take care of those who were usually overlooked, and that’s how I realized that I wanted to go into a profession in birth care.

I also got pregnant very young, I was 16 when I had my first child, and the treatment that I received in the hospital for that first birth was just really bad. I was not educated.

I learned everything about my pregnancy

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on my own at the library. I initially thought that maybe they were treating me like this because I was 16, and because I was so young there was this expectation that I could never be a good mom. Then I had two more children while married, and the treatment was the same.

I found over time that hospital birthing was not a professional fit for me, because the lack of compassion and bedside manner was something that I never wanted to participate in.

Also, just knowing the history of obstetrics and gynecology, I just did not see where I could fit in, in a system that has not seen true reform or change since its inception.

Then I had a home birth with my last daughter, and I was amazed by the compassionate care I received, and the ability I had to retain my autonomy and make my own informed choices throughout the experience. It was the first time that I received truly competent care, and I have five children.

I used to think that the scariest thing about having a baby was the action of giving birth,

but I came to find that surrendering to a system that was never really created to protect me was what I really feared.

When I had my home birth with my last child, I was already a birth worker, but the experience encouraged me to start schooling to further my career. I have been recently licensed, and I am the first Black woman in Grand Rapids, Michigan to be a certified professional midwife offering out-of-hospital birth in Grand Rapids.

SM: What, if any, were some of the biggest obstacles that you faced breaking into this profession?

TT: I think it’s very important to note that Black midwives make up just 2 percent of the midwifery population. I think that this speaks volumes to how so many systems are broken.

My being the first Black CPM is not something that I celebrate with joy or excitement, because I should not be the first. There should be more midwives of various races and backgrounds to provide care for their communities. We see the data that shows that when people, especially people of color, are provided for by people who understand their culture, then they have better outcomes.1 I also struggled with purchasing a lot of the materials and equipment that I needed for my schooling. I was very fortunate to start out at the Midwives College of Utah with a full-tuition scholarship, but I still had trouble affording the supplies list, because we were expected to buy equipment like suturing materials and IV supplies. I continued on to finish up my licenseship in El Paso, Texas, where I also had a scholarship, but there was still that struggle of worrying about paying the rent and how I was going to finish my education. A big part of my journey has been acknowledging the hardships I went through to get where I am, and I am also so grateful for my community, who supported me through all of this and helped me to succeed.

SM: For those who are not as familiar with the options available for birthing, can you touch on the differences between a home birth versus one at a hospital?

TT: A general component of hospital birth is that when you go into the hospital, you are often trading your autonomy for provider convenience. I also want to make it clear that I do not think that OBGYNs are terrible people, but I will say that OBGYNs are surgeons, and when surgeons see an issue, the solution is surgery. This is why we see a lot of hospitals with very high rates of cesarean sections. 2 Especially with COVID-19 influencing medical procedure and protocol, I have had a lot of late transfers into my practice, because doctors are telling mothers that they should just be induced at 37 weeks for the sake of convenience for the hospital. There is nothing objectively wrong with doing this, but then we run into the problem of the cascade of interventions, and the issue of progressive decisions being made for the mother that takes away her autonomy.

Of course, the luxury of having the epidural is a pro of going to the hospital, and in talking about the pros of the epidural, we also have to address the cons, and how having an epidural can increase the need for a c-section.3 With a home birth, you are definitely having one-on-one care with your provider. The person that you hire is the person that is most likely going to attend your birth. There is a lot more room for personal attention. My prenatal visits are an hour to an hour and a half long.

For my clients who have already had a child but then change from having a hospital birth to working with me, they are often surprised by the length of their visits and the detailed attention that they receive. We go through everything together, from diet, bowel movements, and sleep patterns to stress level and emotional changes, so that I can connect my clients to resources and be proactive if someone is more prone to having a hemorrhage or having postpartum depression. After the baby is born, my clients are also not waiting six weeks to see someone. I’m there 24 hours after the birth, then at five days, 12 days, four weeks, and six weeks. If there are any issues with breastfeeding or depression, et cetera, it can be addressed quickly and effectively, so that 51

no problems slip through the cracks in that six weeks new parents normally wait before they see a provider.

Also, there is the cost and insurance piece to take into account. I really wish that more insurance providers covered home birth. I am doing so much to raise funds to make home birth as accessible as possible. The con to hiring a midwife is that if you can’t pay the $4,000-$7,000 that it can cost, then you can’t have a home birth. I never want to turn anyone away who may not be able to afford a home birth when they want one. In many states, Medicaid does cover home birth, but Michigan is not one of those states, unless you go to a birthing center. Obviously, there are a lot of hurdles to get through to making home birth fully covered, and it’s especially important to get that moving now, because as we’ve seen with COVID19, there is a skyrocketing rate of women who are not having babies at the hospital anymore.

Midwives are, despite the preconceived notions, trained professionals, and especially with all of the licensing requirements that have been put into place over the years, the level of education is only increasing as the medical field progresses.

SM: What are some of the biggest misconceptions about home births that you have encountered during your career?

TT: A big misconception that I generally get is that midwives do not have adequate training or that we do not have any of the equipment that is provided at the hospital. In reality, I am bringing everything from IV supplies, medicine for hemorrhaging, resuscitation equipment, and oxygen, just in case there is 52

an emergency. Thankfully I have never had an instance where emergency transport was necessary, but of course we know that sometimes complications can happen in a birth that are not anticipated. Midwives are, despite the preconceived notions, trained professionals, and especially with all of the licensing requirements that have been put into place over the years, the level of education is only increasing as the medical field progresses.

Looking at the Black community specifically, midwives have sustained the Black community forever, even before midwives were officially licensed, when the wisdom was passed down through tradition and ancestral teachings.

Midwives have even helped assist with the integration of Black families going into the hospital for childbirth, but at the same time the childbirth mortality rate skyrocketed in our community, which is the opposite of what should happen when receiving hospital care. In essence, just assuming that midwives are not trained and are not able to handle emergencies is the biggest misconception that we face.

SM: You have studied with various organizations involved in the birthing process, including Abuelita Parteras (Grandmother Midwives), Maternidad La Luz, MEAC Accredited, Midwives College of Utah, Indigenous Communities of Mexico, and DONA International. What are some of the biggest takeaways that you have from working with these organizations?

TT: Speaking to my connection with the Dominican Republic, in Spanish-speaking communities, there is a lot of overlap in the practices surrounding birth. For instance, the concept of the “Cuarentena” is basically postpartum confinement to your home for 40 days as a mother, where you’re avoiding the elements and allowing your body to heal. We believe that the “aires” or the wind, can contribute to illnesses in the postpartum period and beyond. In America, it is a very different mentality usually, with mothers trying to bounce back as quickly as possible.

I think that what I have learned mainly from studying other cultures’ birthing practices is the importance of continued care postpartum. Usually the pregnancy and actual birth are focused on as the biggest elements, but the way that we care for mothers postpartum is something that is vitally important for the health of both mother and baby in the future. Looking at nutrition, facilitating the mother’s body slowly recovering, and thinking about mother and baby as a unit and not solely focusing on the child are all components that I have picked up in studying different methods and cultures. I also think that it’s extremely important to acknowledge and respect different people’s cultures and desires when facilitating a birth.

Some of these things may be superstitions and not based in fact, others like the importance of keeping the postpartum body warm and supported, have been used for centuries to facilitate healing. I personally remember being in the hospital and telling my doctor that I wanted to do a placenta encapsulation, and his thoughts on that were basically, “That’s disgusting, why would you do that?” And that is essentially just an example of lacking cultural competence. In essence, cultural competence is having the ability to understand, communicate with and effectively interact with people across cultures, including being aware of one’s own world view and biases and developing knowledge and positive attitudes toward cultural differences.4 As a caregiver, being open

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minded to the mother’s culture, or just her wishes in general, for how she wants the birth to go is to me extremely important.

SM: Have any of your processes changed or been informed by the increased obstacles that COVID has placed on healthcare?

TT: Obviously we’ve been going above and beyond as far as sanitization, we were already quite diligent, but are taking extra precautions for peace of mind both for us and the family.

There is also not as much hugging or closeness in the prenatal care and postpartum care, but I still try to make the experience as warm as possible. One big obstacle has been getting access to the cleaning supplies that we need, because priority has been going to hospitals and other healthcare workers, and midwives were largely left out of this prioritized group.

I fortunately had enough stocked to make it through until the shortages improved, but it was a real concern that I wouldn’t be able to do my work, because I would not have the necessary sanitization resources.

SM: Delving deeper into systemic inequalities in birthing care, racial inequity in the quality of care that a woman can receive when giving 54

birth is a significant concern. What are some of the ways that the field of midwifery can help address these systematic problems?

TT: I think it’s very important to stress that the solution to the Black morbidity and mortality rate in childbirth is having competent providers. And how do we accomplish this? By funding Black midwives, helping them to get through school and acquire their supplies, and helping them to be able to go back and serve those in their communities who may not be able to pay for their services. Sometimes our allies will try to come in and help our communities with their own answers, but will not listen to our solutions. It would be the most helpful to just help us with our own ideas and the information we have from actually being members of the community who have experienced the issues firsthand.

If the same hospital system that was practicing gynecology and obstetrics on Black bodies without anesthesia is the same place that we are going to today without any significant reform, then automatically we are going to know that there are biases in that place. I think it is also important to clarify that everyone in the medical field does not have malicious intentions, but that does not mean that

they are not inadvertently causing some form of harm. Some of the most racist things that I have seen happen in a medical context have come from amazing doctors who call themselves allies, but sometimes they are just not aware of inherent biases and the need to correct past practices that were considered acceptable. For instance, recently a news article polled residents and compiled data that suggested that Black people have thicker skin and do not feel pain the same way is something that was circulating in the not-toodistant past.5 Advocating for more Black midwives is not the only answer; however, reform has to happen in the hospital setting as well. Everyone cannot have a home birth for various reasons, and hospitals should be a safe place for people to go and have their babies if that is what they want and need. Until that is the case, we need more midwives of color, we need more midwives that are culturally competent, and we need people to support the causes that we are advocating for in our communities to level out these morbidity and mortality rates. It should never be the case that women are giving birth unassisted because they are not able to pay for a midwife and are too scared to go into a hospital to receive care, and this is a very real decision that women in our community have to face.

A lot of people are saying that in our community, the ultimate solution to inequalities in hospital births is to make home birthing more accessible, but in reality, everyone cannot have a home birth, so the hospitals must find ways to have culturally competent providers that can change the practices that discriminate against certain demographics of people.

ing all of the pros and cons of every decision that you make for yourself and your baby. It is not just signing a paper that is presented to you and accepting that because the professional says that everything is going to be fine that it definitely will be, because unexpected complications can always arise, and no two births are the same. I think that a lot of people have the mentality that the primary person who makes the decisions is the healthcare provider, when it is actually the parents. No one should be having the final say in decisions about the pregnancy and birth except for the family. I think that it is important to empower parents to make their voices heard, because ultimately we as healthcare providers are just passing through their lives, but the health and well-being of the child is something that they as parents will be responsible for, for the rest of their lives. • You can learn more about Tiffany’s work at: www.delaflormidwifery.com IG: @delaflormidwifery FB: facebook.com/delaflormidwifery You can support Tiffany’s efforts to provide low-cost or free services to mothers in need: www.gofundme.com/f/GrandRapidsMidwife

SM: What is one piece of advice you would give to expectant mothers who are unsure of where and how they want to give birth?

TT: My advice is to always trust your intuition, if something doesn’t feel right in the type of care you are receiving. Also, it is crucial to be as informed as possible on the different options available as an expectant mother.

True informed consent requires understand-

1. academicworks.cuny.edu/gc_etds/423/ 2. ncbi.nlm.nih.gov/pmc/articles/

PMC3615450/#S6title

3. ncbi.nlm.nih.gov/pmc/articles/ PMC4718011/#jpe.1058-1243.24.4.209.s02title 4. makeitourbusiness.ca/blog/what-does-it-mean-beculturally-competent 5. aamc.org/news-insights/how-we-fail-black-patients-pain

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56

HEALTHCARE

Smarter Healthcare.

Expanding Patient Engagement

By Bill Hartman, Head of Innovation Strategy/Essential Design, part of PA Consulting The quest to improve American healthcare has traditionally focused on finding new drugs, producing more powerful diagnostic tools, and building medical centers with ever-expanding footprints. Despite these investments, costing 5 percent of GDP in 1960 and over 18 percent of GDP in 2018, the U.S. healthcare system is fundamentally broken, if not unsustainable.

On a per-capita basis, the U.S. spends more on healthcare than any other nation1, but health outcomes rank only 11th among peer countries.2 Life expectancy in the U.S. is about five years lower than it is in Japan, Italy, Switzerland, or Spain,3 and maternal health, on average, lags even further behind many more countries.4   These sobering statistics point to the fact that the U.S. desperately needs a more patient-centered healthcare system, one that encourages people to maintain wellness, avoid risk factors, and better manage chronic conditions/comorbidities. We believe in improving the healthcare system by redesigning it to work smarter for patients. While the pandemic quickly led to creative workarounds and new solutions in a range of industries, this is an opportune time to also experiment with the entire system of healthcare in this country, pushing new solutions further and faster.

Pillars of Patient Engagement To work smarter for patients, U.S. healthcare needs to move away from its break-fix mentality, with healthcare feeling like a series of disjointed transactions. Instead, we need to design a simpler, more proactive, continuous-care environment in which people are partners with their care team, rather than consumers in need of services.   To achieve this, we envision six pillars, working interdependently, of a Patient Engagement Strategy: 1. Transform Points of Care 2. Leverage Technology 3. Apply Behavioral Economics 4. Turn Data into Wisdom 5. Shape the End-to-End Experience 6. Find the Value and Transform It If broadly conceived and implemented, design offers high-potential impact to improve health and longevity, while reducing the cost of care. In our long-running national healthcare debate, many solutions have been proposed (Medicare for All, expansion or abolition of the ACA, single payer), yet none can succeed unless people are put at the heart of the program.

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Victory to Policy Design During the past decade, healthcare providers and payers (insurers) have explored a shift toward Value-Based Care and Accountable Care, where providers are compensated for the outcomes—keeping patients healthy— rather than the usual fee-for-service or volume of transactions, treating illness more than maintaining wellness. Fee-for-service also brings far too much administrative overhead and expensive infrastructure, with too little patient engagement and empowerment, forcing patients to focus more on their health plans, not their actual health.

More people were getting routine checkups, having their health conditions diagnosed sooner, and visiting primary care clinics rather than hospital emergency departments.

From 2013 to 2018 alone, avoidable Emergency Department visits have decreased 14 percent.

Aside from the national comparisons above, there is already validation in the belief that expanding access reduces costs. After Massachusetts enacted healthcare reforms in 2006 (the model for The Affordable Care Act) which incentivized annual checkups, the total cost of healthcare in the state declined and health outcomes improved. More people were getting routine checkups, having their health conditions diagnosed sooner, and visiting primary care clinics rather than hospital emergency departments. From 2013 to 2018 alone, avoidable Emergency Department visits have decreased 14 percent.

But a vastly smarter healthcare system is possible, owing to the data science revolution that is transforming every industry.

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Increasingly affordable and available technology can further enable patients to collaborate with their care teams, focusing on prevention and early detection rather than diagnosis and treatment or acute care. This brings us to the first pillar: Transform Points of Care.

Boosted by Product Design What if, instead of once a year, patients could also be monitored passively for signs of ill health? Imagine all the serious disease and comorbidities that could be prevented or addressed sooner, plus the costs that could be averted.

COVID-19 has already brought telemedicine to the forefront, but other technologies that have been maturing for a while can help to focus doctor-patient-payer relationships on prevention rather than intervention. Wearable devices and health apps provide persistent monitoring to detect problems early, while also encouraging mindfulness and behavior change. Smart watches already able to track heart rates and blood pressure now offer blood oxygen monitoring. Blood sugar monitoring has become far more convenient, too. Even hydration, which affects strength, endurance, and cognition, can easily become part of this personal health panoply. And so, the second pillar is Leverage Technology.

Shifting the provider-to-patient service dynamic toward one of shared value and effort benefits both parties, because accountable patients not only experience better outcomes, but also incur less cost. This would be the logical argument for a more collaborative relationship with one’s healthcare team. But to gain widespread buy-in and lasting behavior change, healthy choices can be presented to patients in ways that make them more attractive or less burdensome. Meet the third pillar: Apply Behavioral Economics.

Behavioral Economics, the intersection of psychology and economic theory which studies the economic decision making of real people as opposed to economic theorists alone, is easier said than done. Anticipated results are anything but, and unintended consequences

THE PILLARS OF PATIENT ENGAGEMENT

1

Transform Points of Care Orchestrate the value across various care settings We can expand the purview of home health, enabling patients to provide more of their own monitoring and care through managed telehealth services that include diagnosis, therapy, wellness, and even clinical trials.

We can think outside of traditional care settings like clinics to embrace and enable “health anywhere.�

2

Leverage Technology Finding the right role for the right technology Technology has accelerated the sensing, transmission, and interpretation of data at an exponential pace.

Technology, applied appropriately, can offer new opportunities to personalize medications and devices, establishing best practices continually for patients and providers.

3

Apply Behavioral Economics Personalized medicine informed by behaviors, attitudes, and public health objectives Using principles from cognitive science, we can propel people beyond their own aspirations or defined goals by using choice architecture, coaching, and feedback loops. People can more willingly choose to effect change, rather than being pushed onto healthier pathways.

FOOD FOR THOUGHT Where and how might patients and providers be more collaborative?

How might healthcare be supported in places where people spend their time and attention?

FOOD FOR THOUGHT How might platforms be better integrated, making them accessible and relevant to patients?

FOOD FOR THOUGHT What existing behaviors should be steered in new directions? What are the determinants or decision points underneath those behaviors? What actions should be turned into irresistible alternatives?

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THE PILLARS OF PATIENT ENGAGEMENT

4

Turn Data into Wisdom Moving beyond data by turning insight into action Like other commercial endeavors, healthcare can leverage unstructured information, using natural language processing, machine learning, and artificial intelligence, to yield greater insight. The progression from data, to information, to knowledge, and ultimately to wisdom is now itself becoming automated.

5

Shape the End-to-End Experience Goal-directed customer experience design Address gaps in knowledge, skill, and attitude using customer experience as a digital microbiome interfacing people with needed services, resources, and interventions by meeting people where they are.

6

Find the Value and Transform It An innovative solution can only succeed with sustainable funding New solutions to systemic problems are offered faster now than ever. But to be successful, they must also prove a way to capture the value. Identifying the prosumer, the professional consumer, as opposed to the consumer helps innovators better understand the value drivers and formulate a sustainable growth and business model. Recognizing the well-grooved financial flows and finding creative ways to address new opportunity spaces is part of transforming health ecosystems.

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FOOD FOR THOUGHT In your own work, does data currently add noise or bring clarity to developing personalized strategies?

What hidden gems are still buried? If your product’s or system’s data could talk back to you, what would you ask it?

FOOD FOR THOUGHT How do today’s customer journeys compare with potential or ideal ones?

Where are the breakdowns and implied opportunities?

How can we transcend remits, reimbursements, and restrictions to instead rethink and rewire the healthcare experience?

FOOD FOR THOUGHT What has value to the prosumer and how much could it be worth if exploited? How can the value be transferred to other applications? Who will initially pay for this solution, and what is the financial model for sustainability?

become the only results people pay attention to. But, patterns can be identified, cause-andeffect more clearly understood, and the system becomes that much more efficient—if we can capture, interpret, and iterate the system.

Pillar 4: Turn Data into Wisdom.

So, with healthcare considerations being delivered more ubiquitously, and with algorithms mediating the pursuit of those goals, what makes people actually want to use products, systems, and touchpoints? Here is where design’s role becomes a lot more familiar: packaging the data to create a tool which supports constructive, caring dialogue.

Experience Design Makes it Solid History and science show that people behave according to how they are challenged or rewarded, meaning that they will require the right challenges and incentives to embrace a more proactive approach to care, drawing their own conclusions rather than being told what to do. Incentives such as discounted health insurance premiums and subsidized fitness or nutrition plans can help motivate patients to embrace technology, sharing health data with providers to unlock these perks. Devices and apps must be simple and friendly, with new users needing the right onboarding: education, motivation, and technical support.

There is proof that continuous, well designed connection between engaged patients and their providers can fundamentally improve U.S. healthcare.

These types of solutions can also appeal to the individual in motivational terms, helping them embrace digital health and wellness services, monitor vital health or risk factor data, or enable them to confidently manage their own therapies. For example, many biologics

are already moving to self-administered platforms: patients manage their own therapy at home, dosing according to recent biomarkers, and avoiding repeated trips to infusion centers. It’s a textbook example of prospect theory: the convenience and lifestyle benefits of self-managed therapy outweigh its perceived risks or complexity, and the idea of losing the privilege of self-management further heightens the value, creating an added mechanism for medication adherence. Everyone wins.

In pillar 5, we can: Shape the End-to-End Experience.

A teamwork approach between patient and provider, technology-mediated where applicable, means more than telemedicine visits.

Dashboards, progress reports, and immersive yet personal data visualizations that make the abstract more concrete can dramatically improve engagement, outcomes, and control over the cost of care. Which brings us to pillar 6: Find the Value and Transform It. The hurdles to redesigning our system remain formidable. But there is proof that continuous, well designed connection between engaged patients and their providers can fundamentally improve U.S. healthcare. By redesigning it to be a more collaborative process that empowers patients, we will be able to vastly improve health outcomes while also reducing financial burden.

This is where a better-designed system can take us all. •

1. https://data.oecd.org/healthres/health-spending.htm 2. https://www.commonwealthfund.org/publications/fundreports/2014/jun/mirror-mirror-wall-2014-update-howus-healthcare-system 3. https://data.oecd.org/healthstat/life-expectancy-atbirth.htm#indicator-chart 4. https://www.mhtf.org/topics/maternal-health-in-theunited-states/

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Open Source Wellness participants enjoy a meal and small group coaching.

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HEALTHCARE

Community As Medicine.

Re-Designing Healthcare

By Dr. Elizabeth Markle, Co-Founder of Open Source Wellness I’m Dr. Elizabeth Markle. I’m a psychologist, an innovator and entrepreneur in the fields of human health and well-being, a scholar of Intentional Community (literally, community shaped by design), and Co-Founder of Open Source Wellness.

Behavioral Prescriptions My co-founder at Open Source Wellness, Dr. Benjamin Emmert-Aronson, and I have worked and trained in many different healthcare delivery systems: tiny clinics, federally qualified health centers, massive hospital systems, and the Veterans Administration. Our jobs were to provide mental and behavioral health support to patients, and consultation to doctors struggling with the behavioral aspects of their patients’ care—in clinics, hospitals, and even emergency departments. It was wild, wonderful, and profoundly challenging work!

During this time, we started keeping track of what we now call “Behavioral Prescriptions.” Back then, we just called them, “things that doctors tell their patients to do.” And here’s what we found: no matter the patient’s diagnoses—diabetes, hypertension, depression, anxiety, heart disease, etc.— and no matter the provider’s professional identity, (primary care doctor, specialist, therapist, case manager, etc.), 80 percent of patients were receiving the same four behav-

ioral prescriptions: exercise more, eat better, reduce your stress, get some social support.

These big four behaviors and practices underlie human health and well-being broadly, and they are appropriate “prescriptions.” But here’s the part that made us apoplectic: the doctor would deliver these instructions, and then say something like, “Good luck with that! Take care now!”

Our patients, alone in a tiny sterile room, intimidated and disoriented next to their fasttalking, rushed, and authoritative doctor, would look down and meekly say, “Yes, ok, I know, I should, I will, ok...” and that would be the end of the visit. Until the next time we saw that same patient, often in the emergency room, for a predictable worsening of their chronic condition, and the conversation would repeat.

Healthcare providers are asked, and heroically trying, to meet unmeetable needs: to generate and deliver enough care, resources, support, and even love for patients and communities. They are doing so in tightly timed individual visits, in resource-strapped clinics, with ever growing responsibilities and ever-tightening constraints. Shrouded in veils of confidentiality, privacy, and even shame, rapid oneon-one visits don’t necessarily build resiliency, community strength, or capacity to generate health and well-being for our patients. Instead, they can further segregate our healthcare from our daily lives and communities.

IMAGES COURTESY OF OPEN SOURCE WELLNESS

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Over time, as we watched this choreographed vignette play out, my conversations with Ben started to take on the tone of weary disbelief, and ultimately disgust. I remember saying to him, "Can you imagine prescribing insulin, and saying ‘Good luck finding that!

I’m sure you’ll figure it out?’ Of course not. We say, ‘Your medication will be ready for you in an hour at the pharmacy nearest you, paid for by your insurance, and a pharmacist will make sure that you actually know how to take it!'"

lines of wealth and privilege. Patients with privilege (financial and sociocultural) shop at Whole Foods, hire personal trainers and therapists –and those without experience predictable and painful entrenching of chronic physical and psychological conditions.

Healthcare is miserable. Its recipients are isolated and fearful, and its providers are exhausted and demoralized. And it doesn’t have to be like this.

Another Way

Can you imagine prescribing insulin, and saying "Good luck finding that! I’m sure you’ll figure it out?" Of course not.

We say, "Your medication will be ready for you in an hour at the pharmacy nearest you, paid for by your insurance, and a pharmacist will make sure that you actually know how to take it!"

Unlike our extraordinary infrastructure for delivering on prescriptions for medication, our nation has no delivery system for Behavioral Prescriptions—the simple, universal practices and experiences that underlie health and well-being. Instead, outcomes divide along

MOVE 64

NOURISH

We imagined this alternative: A doctor informs a patient that she has diabetes. Instead of saying, “Eat better, exercise more, try meditating, here’s a handout. I’ll see you in six months!” the clinician says, “I’ve written you a prescription, but it’s not for medication. It’s for participation in a community dedicated to well-being. They cook healthy food, do fun physical movement, practice stress-reduction, and support each other in making and meeting the goals that matter most to them. Once you’ve completed your four-month initial dose, which is fully covered by your insurance, they will help you connect with other graduates in your neighborhood who get together to practice, and your whole family is always welcome to join you.”

Ben and I set out to transform the standard of clinical care by creating Open Source Wellness (OSW), so that every Behavioral Prescription would be backed by a Behavioral Pharmacy, a comprehensive delivery system for human health and thriving across each of the four behavioral prescriptions: MOVE

CONNECT

BE

Physical activity at Open Source Wellness is designed to be playful, social, and expressive, leaving participants feeling connected and invigorated.

(physical activity), NOURISH (healthy meals), CONNECT (social support), and BE (stress reduction).

Open Source Wellness is a nonprofit initiative supporting people and communities in living healthy and happy lives by leveraging “Community As Medicine” in collaboration with healthcare providers and insurers.

When we started, we had a few core design commitments. Open Source Wellness would be:

human challenges of health and well-being, focused on the same universal practices of Move, Nourish, Connect, and Be. • Powered by Connection: Rather than expensive licensed medical professionals, who are typically trained to dispense information from the perspective of an objective expert, OSW is facilitated by culturally relevant health coaches and peer leaders, who engage with warmth, vitality, vulnerability, and humanity.

• Experiential: Rather than telling people what they should be doing, via a lecture, a class, handouts, or even a fancy app, we actually DO the practices together, in community. The experience, not the information, is the medicine.

• Democratized: Rather than replicating the boutique wellness industry, OSW was designed to be affordable and accessible to those who need it most, via mainstream healthcare.

• Transdiagnostic: Rather than having “Depression group” and “Diabetes group” and “Hypertension group,” we have Transdiagnostic groups. These groups are diagnostically and demographically diverse groups of participants and coaches who practice together, working with the

The Patient Experience As soon as a provider prescribes participation in OSW, the patient gets a phone call from a OSW coach. This is not a quick scheduling or administrative call: this is a spacious, friendly, relationship-building conversation, in which the coach and patient explore the challenges the patient is facing, what they most value in 65

OPEN SOURCE WELLNESS BY THE NUMBERS Mental Health 16

Mental Health Self-Score*

14 12

13.6 11.1

10 8 6

6.8

5.9

4

5.3

4.9

2 0 Depression

Anxiety

Loneliness *PHQ-9, GAD-7, and UCLA 3-item Loneliness

Acute Care

Blood Pressure

25

160

ER Visits & Hospitalizations

140 20

22

120

148 127

100

15

80 10

84

60

79

40 5

5

20 0

0 ER Visits & Hospitalizations

Systolic BP

Pre-Program 66

Diastolic BP

Post-Program

their health and in their lives, and how OSW might be of support. Because of this initial relationship, participants are ready and eager to join their weekly OSW group. And although there is tremendous variation across OSW groups, according to population demographics, location, language, and culture, the basic structure of every OSW session is the same. While in the past these groups ran both in-person and virtually, because of COVID-19 we now run all groups virtually, and provide extensive support to participants who need orientation to videoconferencing.

We start each weekly session with a warm, friendly welcome, very intentionally cultivating a context that feels more like a community block party than a medical group! The group of 20 to 30 participants and three to five coaches begin together with an icebreaker, followed by 20 minutes of fun physical activity. This “exercise” is playful, interactive, and designed to give participants the lived experience and visceral memory of physical activity being fun, enjoyable, and socially rewarding. We then transition to five minutes of stress reduction or mindfulness practice. We share and facilitate practices from no particular tradition and with no dogma, just basic practices for transitioning from high activity, external focus to quiet, inner focus, and stillness. Next is the SPARK, a highly experiential/interactive lesson on a topic related to one of our four pillars (Move, Nourish, Connect, Be), such as eating well on a budget, setting boundaries in interpersonal relationships, or structuring daily routines during a pandemic.

At this point, the large group breaks into small groups which consist of six participants, one OSW coach, and one peer leader.

This small group spends about 45 minutes in conversation. It’s not psychotherapy, but it is highly therapeutic, as these intimate groups share about their health and about their lives: their families, their dreams, their aspirations, their traumas, the challenges of their worlds.

Every OSW group ends in a similar way: the large group reconvenes for expressions of gratitude, sharing of offers and requests (in

which participants ask for and offer support in the form of accountability or resources), and lastly declarations, in which participants commit aloud to a practice or task they will accomplish during the week in support of their health and well-being.

Frequently, these self-prescriptions are overtly related to health: “I’m going to walk three times this week,” or, “I’m going to cook greens tomorrow night,” or, “I’m going to

EXPERIENCE OPEN SOURCE WELLNESS How are you doing with each of the four aspects of the Universal Prescription?

Try rating each one on a scale from 1-10, with 1 being “I’m nowhere near meeting my goals for this,” and 10 being, “I’m feeling great about this, and my behavior is totally aligned with my values.”

MOVE

NOURISH

CONNECT

BE

Which ones do you already incorporate effortlessly? Which ones might need a bit more attention, more practice, more cultivation? Then, pick one to focus on first: how might you structure it into your days?

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Meals at Open Source Wellness are plant-based, and designed to give participants the experience that whole foods can be delicious!

reach out to a friend that I’ve lost touch with.”

But interestingly, we also hear declarations like, “I’m going to tackle my credit card statements this week,” and, “I’m going to floss my teeth every night this week!” While at first we were perplexed, noting that financial health and dental health appear nowhere in our curriculum, we’ve come to understand that when participants start to get traction in the program, experiencing success making and meeting goals, they are naturally moved to take on other meaningful realms of their lives.

They develop self-efficacy, confidence, a commitment to their own integrity about doing what they say they will do, and that translates broadly to creating quality of life.

In between weekly sessions, participants are on group text threads with their peers and their coach, and are giving and receiving support and accountability throughout the week.

If a patient makes a commitment to exercising every day, the next day her group members will be reaching out and saying, “How are you doing with your exercise today? Any support you need? Send us a photo!” It’s an immensely high-dose, high-touch, socially-supportive 68

intervention that kickstarts proactive, generative, empowered self-care and life-care.

Ultimately, this is what we are committed to. If someone’s blood pressure drops, or their blood sugar comes down, that’s fantastic! If we are able to jumpstart a life, to help someone move from demoralization, passivity, a stance of helplessness and disempowerment toward an active, empowered, positive reward-seeking approach to life, the implications are immense.

Outcomes OSW uses industry standard measures to track a range of outcomes including depression (PHQ-9), anxiety (GAD-7), exercise, diet, and blood pressure. Outcomes include reductions in depression, anxiety, social isolation, and loneliness, increases in physical activity and fruit/vegetable consumption, and a 77 percent reduction in Emergency Department visits and hospitalizations.

Clearly, these significant outcomes can radically transform the current health and wellness of our country, if a model like ours can be accepted and adopted.

The implications of these outcomes, if taken to scale, are staggering. What if small-group support, health coaching, and experiential medicine formed the foundation of a national clinic-community care strategy?

Revenue Models Key to our commitment to transforming the standard of clinical care is affordability and revenue/reimbursement structures that make OSW accessible without ongoing grant or philanthropic funding. OSW partners with health insurers, healthcare provider organizations, Federally Qualified Health Centers, low-income housing providers, employers, governments, and other entities to support both patients and staff, and a variety of funding streams are utilized.

One key to sustainability in our partnerships with healthcare delivery systems (clinics and hospitals) is delivering the OSW model as a Group Medical Visit in partnership with clinical providers. OSW contracts with clinics and healthcare delivery systems. The OSW health coaches deliver our signature high-vitality, high-impact weekly program that patients love, while one clinical provider from the clinic conducts short, focused individual visits with each participant, then charts and bills for every patient seen. This enables a clinical provider to see (and bill for) double the number of patients that they would see during the same amount of time in individual visits. The OSW Group Medical Visits (virtual or in-person) generate far more revenue for clinics than they cost to run, and deliver excellent clinical care while improving provider experience. In this way, the OSW model is an example of deep, next-generation clinic-community integration, bringing the community (health coaches, peer leaders) to sustainably animate the clinic as a platform for human thriving.

Clinic Meets Community

tionships! As a field, we need structures that liberate, animate, and activate the power of community, where support and care are mutual and self-sustaining, not extractive.

The good news is that humans are hardwired to do this.

This is what we’ve learned at Open Source Wellness. Our work must be generative, both socially and financially, for it to thrive. By utilizing health coaches, peer leaders, and patients’ own experiences and wisdom to foster a culture of care and support, we liberate medical providers to focus on the true medical needs of their patients. Meanwhile, coaches provide the social scaffolding, the “starter culture” that gives rise to the framework, context, and safety for community care to arise naturally.

They key to transforming an exhaustive and extractive clinical system is not more clinical care, or more “self-care.” It’s intentionally-designed social structures that call forth and uplift the resources within and between our patients. It’s bringing clinic and community together, leveraging the synergistic abundance found in partnerships to deliver excellent care, generate revenue, and promote well-being, health, and resilience.

Open Source Wellness cares about health, but beyond that we care about humanity, about creating avenues through which human goodness can flow. James Rouse is famously quoted as saying “A community is a garden in which to grow people.” Open Source Wellness creates communities and cultures in which the natural expression of humanity is health and well-being. • For more information on our work www.opensourcewellness.org Curious about implementing Open Source Wellness? Connect with Liz: liz@opensourcewellness.org

Clinical care needs to be one small part of a comprehensive and generative ecosystem of support for well-being. Resilience is a team sport and a resource that is cultivated in rela69

Blacktown Mount Druitt Hospital, Sydney, Australia. Completed 2020.

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HEALTHCARE

How Will COVID-19 Change Healthcare Design

By Diana Anderson, MD, MArch, Jacobs, Principal and Matthew Holmes, ARB, RIBA Jacobs, Global Solutions Director: Health Infrastructure Globally, the COVID-19 pandemic has tested the overall resilience of our health system infrastructure to cope with increased demand. It has also brought the importance of design and the built environment to the forefront when considering emergency preparedness and infection control. Now, nine months into the pandemic, there have been lessons learned from the immediate challenges of medical facility design, in addition to ongoing discussions of the long-term changes which are likely to impact how, where, and when we access our care.

The Here and Now: Short-term Design Changes The pandemic has made it clear that our current healthcare facilities were not necessarily designed or configured to support the increased patient volumes. Therefore, controlling infection spread across the health workforce was difficult. Some of the capacity constraints included inadequate provision of donning and doffing space, engineering infrastructure that could not distribute the needed volume of life-saving medical gasses such as oxygen, and short supplies of personal protective equipment (PPE) and medical equipment. These capacity constraints required temporary response planning of pop-up accommodation, and rapid design and deployment of alternate care sites.

Reimagining Shipping Containers: Emergency Intensive Care Units At the outset, as the COVID-19 pandemic progressed, hospitals around the world were grappling with shortages of Intensive-Care Unit (ICU) space to treat a growing number of patients in need of respiratory care and ventilators. One innovation focused on turning shipping containers into plug-in ICU pods, equipped with all the necessary medical equipment to treat intensive-care patients. The pod design focused on speed of deployment in addition to biocontainment and safety for patients and medical personnel. Pop-up care sites present clinical challenges and delivery difficulties; nevertheless, many of these initiatives have brought together architects, engineers, clinicians, and others in order to collectively innovate solutions.

Clinician-inspired Design Changes “Here-and-now” makeshift solutions by on-site clinicians brought to the forefront unforeseen design issues during a time of crisis. For example, the need to visualize high-acuity patients placed in standard hospital rooms yielded on-site alterations to solid room hospital doors in the form of cutting out sections to create vision panels. Medical equipment such as medication drips, IV tubing and lines, which are generally placed at the bedside in intensive care rooms, were moved out into the hallway to allow providers to make changes withIMAGE © BRETT BOARDMAN

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Example of Emergency Intensive Care Units called CURA (Connected Units for Respiratory Ailments), which translates to “cure” in Latin. Jacobs, in partnership with the World Economic Forum and individuals from the Massachusetts Institute of Technology, have spearheaded this design project.

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out the need to don and doff PPE and enter the patient room itself. It is conceivable that these on-site, clinician-led design changes will be considered as long-term requirements, with the potential to impact our minimum standard design guidelines.

we hope to return to this model (see New Roma Hospital sketch). However, design changes ensuring that health space is convertible should infection or disaster arise are needed. Of note, visitation pods as described above could connect to existing lobby or entry spaces.

Balancing Contagion and Connection Clinical measures to control the spread of the virus have introduced new ethical and healthcare dilemmas for service providers, patients, and families. By decreasing contact to potentially or confirmed infectious patients, we must be cognisant of the fact that isolation and lack of human interaction also yield significant health risks, and therefore a balance must be sought. Birthing and dying experiences should always allow the option of loved ones being present in some capacity. Design ideas related to visitation in hospitals and long-term care sites have focused on digital/virtual networks and temporary visitation pods, which could allow socially distanced connections.

While open spaces with close proximities to one another are not necessarily safe during the current COVID-19 pandemic, in the future

Looking Ahead: Long-term Design Strategies

IMAGE © CURA

While it is likely that post-pandemic life will return to a state of close physical proximities, including communal dining, socializing, and in-person workspaces, we will likely see healthcare space changes to allow for flexibility in the event of future infections. Waiting rooms, public lobbies and dining areas will require rapid subdivisions in the form of flexible designs to accommodate social distancing if needed. In addition, new and smart technologies will likely come to the forefront: • Biocidal surfaces—materials that help kill pathogens, in addition to cleaning protocols; • Touch-free technologies for commonly used surfaces such as sinks and doors;

• Smart furniture that could assist in the flexibility of space conversion to promote social distancing without major redesign or manpower to reconfigure.

The Future of Work in Healthcare The means and methods by which clinicians and staff work within healthcare environments have been challenged by COVID-19. Changes related to how and where healthcare work is conducted are being accelerated by the rate of technology innovation, shifting demographics of the healthcare workforce, and the desire for choice and flexibility. The pandemic has been an inflection point in this trajectory, transforming clinical care models virtually overnight.

This change was embraced through the rapid conversion to telehealth. In terms of challenges, IT infrastructure and connectivity to support extensive use of tele- and video-medicine will no doubt be a component of health design projects in the future.

Going forward, we will need to move beyond and shift the paradigm of healthcare work and place. Increased spacing, higher panels and more dividers just make facilities harder to

maintain and make safe. A reevaluation of the value of place is needed to support how work really gets done and the needs of on-site personnel. Most likely, redefining the future of healthcare may include a mixed, distributed model consisting of central headquarters workspaces, with dispersed hubs and centers coupled with remote, virtual work. This model may allow for easier staff and patient access, flexible working, and organizational resiliency. Opportunities exist to create collaborative workspaces for staff that incorporate outdoor spaces and fresh air, focusing on well-being for those who provide care and the spaces that can promote periods of respite.

Will we return to prior models of work and care, or will our future clinical workplaces look and function differently?

Healthcare buildings will likely focus on outdoor spaces when possible, such as the

Entrance Sketch of the New Roma Hospital, QLD, Australia

IMAGE © JACOBS

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Ambulatory Courtyard of the Proposed Tungaru Central Hospital, South Tarawa, Kiribati 74

PHOTOS BY FIRSTNAME LASTNAME

courtyard of the proposed Tungaru Central Hospital—allowing wayfinding, socially-distanced gathering and fresh-air access to interior spaces. Open courtyards, operable windows, and fresh air are design strategies to mitigate the spread of infection. An additional design idea to maximize the efficiency of outdoor areas focuses on eliminating the need for corridors by having healthcare rooms open directly into outdoor courtyard spaces, facilitating infection control.

Paging Architects and Engineers In the ongoing battle against COVID-19, it is imperative that architects and engineers continue to collaborate with health systems to address design improvements and operational changes, in order to make provisions that further bolster building resiliency. Some of these topics include: • Optimizing operational efficiency; • Energy and water conservation; • Flexibility in the use of space, operations, and facilities (for example, provision of medical gases, isolation spaces, and negative pressure zones); • Provisions for cutting-edge emerging technologies and solutions, such as automation; • Use of simulation modeling and predictive analytics to better understand and model how a system could function in a pandemic or surge emergency.

Health and Wellness Beyond the Hospital While healthcare facilities have been experiencing a surge in use during the pandemic, we cannot overlook the fact that many other building types such as schools, offices, and public/private spaces have remained vacant while people shelter-in-place and work from home. Buildings and engineering systems that are left idle can also present health risks and challenges that require ongoing mitigation to maintain occupant safety.

Unused buildings may experience water and air stagnation, uncontrolled humidity, and dry sanitary systems that could lead to health risks IMAGE © JACOBS

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Te Nikau Hospital & Health Centre, New Zealand

when occupants return. Significantly reduced water flows and prolonged stagnation have the potential to deteriorate water quality and significantly increase the risks of Legionella bacteria in the water system—safeguarding water quality within building water systems is paramount. Building mechanical systems, during times of limited use or no occupancy, may have periods of reduced outdoor air ventilation. In these cases, indoor air pollution has the potential to concentrate as chemicals, including volatile organic compounds (VOCs), which are 76

PHOTO © SARAH ROWLANDS

released from indoor furnishings, carpets, building materials, and cleaning products.

Humidity levels left uncontrolled can also contribute to mold growth.

These are all public health issues that if not addressed could negatively affect human respiratory systems and overall health, making architectural, engineering, and operational attention critically important.

External Environments Managing infection control at a large scale requires new approaches to space design and

use. The benefits of natural ventilation and external space provision have been resurrected as design strategies to reduce infection risk. In addition to infection prevention, the advantage of outdoor spaces includes promotion of physical activity and the ability to capitalize on nature’s restorative effects. These are opportunities for affirmative health and wellness design changes—benefiting staff by providing additional access to the outdoors, with balconies or porch designs providing a transitional space between indoors and out. Perhaps more care activities can take place in outdoor spaces going forward, depending on climate and location.

Te Nikau Hospital & Health Centre is an example of how open courtyards, operable windows, and fresh air are strategies to mitigate the spread of infection. Benefits of outdoor spaces also include mental health, staff respite, and additional access to light, views, and nature.

Resiliency Beyond the Façade Building system designs must also be resilient; for example, designing the mechanical system to allow the floor of a healthcare facility to be converted into pandemic or emergency mode, potentially having one air handling unit per floor. This configuration grants the hospital more flexibility to compartmentalize/isolate the floor space as needed. In addition, provisions for high-efficiency filters and trying to minimize any cross contamination of air flow are at the forefront of resilient building system considerations.

The pandemic has pushed us to consider both here-and-now design changes, and the long-term design considerations of coping with the next emergency or pandemic in our changed world. Recent trends have focused on delivering community models to support patient/provider interaction and collaboration around health and wellness, but COVID-19 has shifted the trend to keep people in smaller bubbles of operation and therefore necessitates smaller distributed amenities. Providing modifiable solutions will be paramount.

We must also consider resiliency beyond the scope of a pandemic, where the goal is to prevent the spread of infection. Other emergency scenarios may require rapid evacuation of patients and staff, such as in the case of a natural disaster. Overall preparedness is necessary to establish hospital readiness in a variety of situations and provide a proven response and recovery framework—before, during, and after an emergency. In addition, design solutions must also consider ongoing base population health needs, even in the midst of an acute pandemic.

Architects and engineers play a key role in the resiliency of short- and long-term healthcare. It is imperative that we continue to collaborate with health systems at the building and policy levels to address design issues, alongside public health challenges, in order to further bolster our built-environment resiliency and emergency preparedness. •

Toward Resilient Health Design What COVID-19 has made clear is the need to increase and maintain resilient healthcare systems through a holistic approach to disaster preparedness and response. Resilient building systems are capable of absorbing, adapting, anticipating, and transforming when exposed to external threats, while retaining control over their area of responsibility, in order to deliver on their primary objectives and functions.

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PROFILE • HEALTHCARE

At the Interface Between Man and Machine.

A Sneak Peak of Bespoke Bodies: The Design & Craft of Prosthetics

By Dr. Shriya Srinivasan, PhD, Co-written by Sabaat Kareem About the Book Bespoke Bodies: The Design and Craft of Prosthetics is our latest book being published here at Design Museum, which is now available for pre-order. This anthology of case studies delves into the historical evolution of prosthetic use around the world, takes a look at the cutting edge innovations that are being made currently in the field of prosthetic design, and showcases the life stories of individuals who use these prosthetic devices every day. Included in this issue of Design Museum Magazine is an excerpted essay from the book, which highlights the incredible surgical innovations of Dr. Shriya Srinivasan and her team, who have developed an unprecedented technique for amputating limbs that allows the patient to still retain sensory function that is vital to more seamless, coordinated, and nuanced movement, while also reducing the discomfort that can arise from phantom limb syndrome.

2020. Her doctoral research focused on the development of novel neural interfaces utilizing tissue engineering to better interface human limbs with prostheses, in the context of amputation and paralysis. She developed the Regenerative Agonist-antagonist Myoneural Interface (AMI) that will ultimately enable patients to control their prosthesis with native neural signals. She also explored optogenetic techniques to create novel strategies to accelerate and improve neural control. Shriya has been awarded the Delsys Prize and the Lemelson-MIT Student Prize for her innovative work. Shriya was a former director of MIT Hacking Medicine and works passionately on global health projects.

Shriya is currently designing devices for gastrointestinal neuromodulation in the MIT Langer Lab in collaboration with Dr. Giovanni Traverso. In her spare time, she professionally dances Bharatanatyam, a south Indian classical dance form, and co-directs Anubhava Dance Company.

About Dr. Shriya Srinivasan Dr. Shriya Srinivasan is a Schmidt Science Fellow and Junior Fellow at the Harvard Society of Fellows. She graduated from Case Western Reserve University with a BS in biomedical engineering, with a concentration in biomaterials. Shriya received her doctoral degree in medical engineering and medical physics through the Harvard-MIT Health Sciences and Technology program in January

Surgical Amputation’s Slow Evolution Life-saving amputations are accompanied by a vast set of emotional and physical consequences. Prostheses and rehabilitative therapies have evolved greatly over the last few decades to help amputees readjust. Despite the immense technological and scientific advancements achieved in our time, the actual technique for surgical amputation has remained

PHOTO (LEFT) BY JOHN SOARES · IMAGES COURTESY OF SHRIYA SRINIVASAN

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Preserving joint motion and sensation: The Agonist-Antagonist Myoneural Interface (AMI) is comprised of an agonist and antagonist muscle pair connected in such a way that contraction of the agonist muscle induces extension of the antagonist. For an above-knee amputation, 3 AMIs are constructed for the knee (blue), subtalar (purple), and ankle (green) joints and positioned in the thigh.

largely static. In fact, the procedure has hardly changed over the last 200 years.

A team of researchers at the MIT Media Lab and Brigham and Women’s hospital, including Drs. Hugh Herr, Matthew Carty, Tyler Clites and I, used interdisciplinary thinking to reimagine the amputation process, test it on the benchtop, validate the working mechanisms, and implement it in human beings.

This amputation methodology specifically focuses on restoring the communication pathways between the brain, the peripheral limbs, and prostheses.

The Need for Sensory Feedback We know that sensory feedback from our skin and joints plays a central role in our development, communication, motor control, and psychosocial well-being. The body’s innate ability to sense the position, speed, and forces of our limbs enables balance, fine motor control, and 80

trajectory planning. As a professional dancer, this sensation, called proprioception, is something I’m critically reliant upon; knowing where my hands and feet are, how quickly they are moving and the forces acting upon them helps my body automatically execute jumps and turns at the right time, with the right power. It allows my dancing to be fluid, timed with the music, and free from my visual attention.

Proprioception is orchestrated by specialized receptors in muscle pairs, called agonist-antagonist muscle pairs, which work together to signal the brain. With current amputation techniques, these pairings are severed, leaving the patient with little proprioception after amputation. This makes it difficult to operate even the smartest prostheses and heavily limits mobility, decreasing the daily quality of life for persons with limb loss.

Over the past four years, my doctoral work utilized the lens of engineering to redesign

amputation techniques to restore the sense of feeling and enable enhanced communication with prostheses. This was targeted not only at patients who were undergoing amputations for the first time, but also for patients who had already undergone amputations, giving them a chance to “upgrade” their residual limb’s functionality.

A Design Framework The design of new architectures for sensory feedback, through grafting, regenerative, and “spare-parts” surgical techniques, represents a novel approach to bridge the communication between the human body and synthetic devices. Utilizing biological tissues as the “hardware,” in terms of sensors and actuators offers valuable advantages. Tissues possess high energy density, autonomous repair and regeneration, biocompatibility, mechanical robustness, and the incorporation of highly-evolved mechanotransducers. Their sensing and signaling infrastructure are resilient to surgical manipulations. By leveraging mechanotransduction, these organs circumvent the need to synthetically encode complex sensory data and transmit it with specificity into thousands of nerve channels. As a biomedical engineer, entering the realm of surgical innovation, I was excited to apply these principles to address the challenges faced by individuals with amputation.

Proprioception is the body’s natural way of relaying information about one’s position in space to the nervous system. During an amputation procedure, the agonist (contracting) and antagonist (relaxing) muscle pairs, responsible for proprioception, are decoupled, making it difficult for the person to sense their phantom limb’s or a prosthesis’ position. When we move, the agonist and antagonist muscles stretch and contract, sending electrical signals to our nervous system and allowing us to sense our bodies in space. The AMI procedure reconnects those muscles during amputation in order to save proprioception. With an AMI, when an individual moves his/her leg, their AMI muscles contract and stretch just like the

What does the brain perceive? Amputation normally leads to reorganization and sometimes the loss of brain structures responsible for movement and sensation of the given limb. A study of the brain’s motor and sensory circuitry carried out by Dr. Srinivasan and the team reveals that the AMI amputation paradigm can preserve sensory feedback signals in the brain and restore more normal sensorimotor connections.

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muscles originally would have. The AMI muscles send the natural electrical signal to the nervous system and inform the body of the leg’s position.

What is the Problem?

Since the late 1800s, the surgical procedure for amputation has largely remained unchanged. The surgery entails making a circular cut around the entirety of the limb and severing the muscles, nerves, and bone at the amputation site. The residual muscles are then wrapped distally to create ample soft tissue padding for comfortable prosthetic socket use.

Since the muscles are buried differently for each patient and sometimes deep within the residual limb, the ability to send EMG (electromyographic) signals to command a prosthesis are limited. Often, muscles will contract together or not contract at all, making it difficult to decode a patient’s intention. Thus, even with the most sophisticated prostheses, patients struggle to command them. Patients also don’t receive any sensory feedback, which limits mobility.

What’s the Solution?

We designed the agonist-antagonist myoneural interface (AMI), a system which reinstates agonist-antagonist muscle pairs, to enable proprioceptive feedback. During a primary elective amputation, native agonist-antagonist pair muscles are surgically connected by the tendons and channeled through a tunnel created on the bone, functioning like a pulley. Contraction of the agonist stretches the antagonist and gives rise to the sensory feedback signals.

These muscles have the capacity to move individually and signal to a bionic prosthesis more clearly the way in which they’d like the prosthesis to move. In addition, stimulation from the prosthesis to the muscles can help inform the individual where the prosthesis is in space and how it’s moving. Throughout all of these processes, the agonist-antagonist muscle pairing works to send natural signals back to the brain regarding the phantom or prosthetic limb.

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The AMI muscles mimic the function of the agonist/ antagonist muscles. When an amputee moves their leg, the stretching and contracting of the AMI muscles send electrical signals to the brain and to the prosthesis.

The brain can then calculate how much force should be applied to the movement as well as the location of the prosthesis.

From the Benchtop to the Bedside Translating our method to the clinic, over 25 patients to date have received AMIs during amputation through a clinical trial at the Brigham and Women’s Hospital in Boston, MA. Functional testing demonstrates that these patients have significantly greater sensation of their phantom limbs and much greater phantom mobility. When paired with bionic prostheses, they are also able to control them more intuitively, with greater resolution, and receive feedback about the prostheses’ movements.

While these functional results were promising, I was still very curious as to how the brain received and integrated the signals of proprioception from the limbs. It’s well-known, and easy to imagine, that losing a limb causes significant changes in the brain, some of which are thought to cause phantom pain. As such, I wanted to know whether preserving limb physiology could also help preserve the brain’s structure and functioning. Thus, we embarked on a journey that involved imaging the brains of patients with the AMI and comparing them to patients with traditional amputation and no amputation. This was a journey into unchartered waters for many reasons: our lab had never done such imaging studies, very few labs had imaged the brains of patients with amputation, and very little is known about proprioception in the brain.

Comparing the brain activity in regions associated with proprioception, we resolved to determine how exactly the AMI worked and if we could preserve more brain anatomy and function with the new amputation method.

Following hundreds of hours of functional magnetic resonance imaging (fMRI) and data

When Engineering Meets Surgery: Shriya with collaborators Dr. Matthew Carty (pictured on page 76) and Hugh Herr (pictured here).

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A world of difference: Shriya works with Madison, who received an above-knee amputation incorporating AMIs, to characterize her limb’s functionality and signaling capabilities as well as her brain’s perception.

Dr. Srinivasan works with her patients on functional testing in a lab setting.

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analyses, we were amazed by the results. In the area of the brain responsible for sensory feedback, patients with AMI amputation had no difference from patients without amputation, while patients with traditional amputation had a significant decrease. Moreover, we saw that the brains of AMI subjects were relatively unchanged to the normal brain!

The journey to this point was a colossal collaborative effort. It couldn’t have been possible without the futuristic thinking of Hugh, the technical prowess of Matt, and the tireless and creative work of Tyler, other graduate students, and me. Seeing the improvement in patients’ lives, their transformation from a life of limited mobility and chronic pain to one of much greater mobility and psychological freedom was incredibly rewarding.

Using a design framework that holistically captured the continuum between the person and the machine revealed not only scientific advances and technological evolution, but also benefits for patients’ daily experiences and quality of life. Thinking about the valuable effect of reengineering hundreds of years of clinical habit motivates me to make translational research a responsibility for the biomedical engineer; to question the status quo and to urge the community to make clinical care parallel and incorporate the technological advances we have.

Harnessing Regeneration Unlike most machines, the human body has the capacity to regenerate function as cells die or lose functionality. With the right cues and structure, even nerves can be nurtured to regrow into the desired targets to enable signaling and neural communication. Putting a spare-parts methodology to work again, I designed the regenerative AMI–a surgical process in which we take nerves that are normally orphaned during amputation and have them grow into small muscle grafts. These grafts take on the function of the nerve’s original target. By connecting these grafts with their agonist-antagonist partners, we can recreate original signaling pathways to restore sensory

feedback and communication with prostheses. Working with small animal models and cadavers, we designed and tested this system.

What is impressive about the technique is that a person with an above-knee amputation can still maintain control of their knee, subtalar, and ankle joints and receive sensory feedback from all three! It’s also a rather simple surgical process that can be done not only in well-resourced hospitals, but also in battlefields and low-resource settings. Through a collaborative effort, we recently implemented this procedure in the first human subject and have a larger clinical trial underway.

Next Steps Based on what we are learning, we are continuing to refine our methods, gather more data, and disseminate this information to the broader biomedical and surgical communities for widespread implementation. The success of the AMI stemmed largely from transdisciplinary collaboration. Historically, there has been a disconnect between the fields of medical engineering and clinical medicine. Our team was able to adopt a holistic design process, harness diverse expertise, and learn from each other. In doing so, we have come farther than I would have ever expected. Notwithstanding, there’s a long road ahead and we are eager to continue the journey.

Following my graduation, I’ve started a postdoctoral fellowship at the MIT Langer Lab, where I’ll be acquiring expertise in medical device design and tissue engineering.

Ultimately, I hope to merge these skills with my passion for re-engineering physiology to restore functionality in cases of disease and dysfunction, to seamlessly blend the powers of biology and technology, and to make the line between man and machine ultimately invisible. • If you are interested in learning more about Bespoke Bodies, please visit: bespokebodies.org

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A wood clad entrance frames the glass lobby with access to daylight and views.

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HEALTHCARE

Designing with EvidenceBased Empathy.

The New Stamford Hospital

By Tushar Gupta, FAIA, NCARB, Design Principal Healing, Reimagined Stamford Health in Stamford, Connecticut, set out to reimagine healing, using design to drive empowerment, dignity, compassion, and person-centered care. While Stamford Hospital has the most progressive technology and latest in medical innovation, it is the enriching spatial experiences that stand out to patients, visitors, and staff alike. Starting from the entrance of the hospital, the design moves people through a series of welcoming and healing experiences: a medical library providing consumer health information, a non-denominational chapel, natural light and outdoor terraces, Zen spaces for surgeons within the sterile operating zone, and even fireplaces with intimate seating for visitors.

In fact, the impact of design reaches beyond the hospital walls. Sited adjacent to downtown Stamford, the hospital sought engagement with the community to create revitalization. Today, Stamford Health is exceeding its institutional and neighborhood goals.

EYP was the Architect of Record for the new Stamford Hospital, from master planning through the design of the hospital. Through a collaboration among clinicians, administrators, and the EYP healthcare design team, they were charged to “reimagine healing.”

Stamford, Connecticut is a little over an hour’s drive north of New York City in heavy traffic. Stamford sits along the Long Island Sound and has a beach of sorts, a botanical

garden, art museums, outdoor concerts, and a thriving foodie and nightlife scene. In response to Stamford being the fastest-growing city in the state, Stamford Health recognized the need for a larger, modern, well-equipped hospital. After multiple years of planning, construction began and the new hospital opened its doors on Monday, September 26, 2016.

It’s no exaggeration to say that the residents of Stamford consider the local hospital their own—whether they or someone they know was born there, works there, or receives treatment there. It is a reassuring landmark, a place where patients aren’t numbers or diseases, but named and known. A modern hospital for which the community and the staff claim bragging rights. The architects, designers, and medical planners behind the new 647,000 sq-ft facility kept this responsibility in mind.

The new Stamford Hospital provides us the ability to recruit worldclass physicians and partners, improve the Emergency Department, and achieve higher satisfaction scores.

PHOTO BY ROBERT BENSON PHOTOGRAPHY

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A comfortable terracotta and wood inglenook offers a place of respite along the concourse.

“The EYP team helped us to think futuristically about the master plan as opposed to the immediate need for a replacement hospital,” says Kathleen Silard, President and CEO of Stamford Health. “EYP also helped us to think about the impact on the city of Stamford and not just the hospital community. The new Stamford Hospital provides us the ability to recruit world-class physicians and partners, improve the Emergency Department, and achieve higher satisfaction scores.”

Point of Pride Four years since the opening, Stamford Hospital stands like a beacon at 32 Strawberry Hill Court, focusing on stellar patient care provided with compassion and empathy in a warm, welcoming environment. The hospital is an impressive 12-story, terracotta and glass 88

PHOTO BY ANTON GRASSL/ESTO

structure. It looks like a place you’d want to visit, which may sound strange to say about a hospital. But it is actually a byproduct of thoughtful design that embodies the philosophy of putting people first.

Conceived around three words–embrace, care, and heal–the hospital’s design evokes empathy for patients, their families, care providers, and the community. The building’s concept sketch consists of three squares nestled inside two dynamic curves, metaphorically referencing the hospital’s emblem and the three words.

Sunlight pours through expansive windows.

Stunning modern sculptures catch your eye as you walk through the foyer. Illuminated ceilings light the way to the elevators. Stone and wood features are prominent, reflecting the local landscape, while the use of glass strikes

the balance between connecting people and technology, to reflect a sophisticated and modern environment. A café offers fresh, healthy, seasonal foods.

Walking paths connect the hospital to the neighborhood park. The hospital has engaged the community by revitalizing housing and creating wellness outreach programs.

A vibrant residential and commercial district has sprung up at the doorstep of the new hospital—with mixed-income residential areas, thriving businesses, and even a communal urban farm.

Designing and creating a place of healing for a specific area takes more than resources and an experienced team. It takes a core philosophy, a deep understanding of the surrounding community, an abiding responsibility to hospital staff and caretakers, and a long-term promise to patients and families.

Revitalize, Restore, Regenerate These are healthcare terms, certainly. But they can be applied more broadly, not only to a patient, but to a family, a workplace, and a community. Planning the new hospital began by taking the pulse of the community: Who and what surround the site, and how can we support the local neighborhoods while enhancing the community’s health and well-being?

The old hospital was surrounded by fences topped with barbed wire. Canine guards roamed the grounds at night and gunshots

Emblem

Metaphor

Concept Sketch

could be heard on the streets. It was an island apart, not a welcoming beacon. But the hospital was also surrounded by a diverse community filled with hope and a desire to become something better: a place to raise a family, gain employment, and live in safety. By embracing a philosophy of empathy and community engagement, the hospital became a catalyst of change, stimulating growth and development, reaching out to neighborhood schools and service organizations, and promoting and assisting community revitalization.

Community Investment Meetings were held with key community and staff stakeholders, identified by leadership as a series of focus groups, to help guide process improvement strategies, as well as concept and design. These conversations determined the prioritization of how space was allocated within the environment of care, with the intent of creating a plan of action.

The outcomes of this engagement effort were: • A high-level demographic analysis and evaluation of the surrounding community and catchment area, in coordination with a community needs assessment.

• An interactive question/answer awareness training presentation.

• Evaluation of qualitative data gathered

Form

Stacking Diagram

Concept sketches illustrate the design process.

IMAGE PROVIDED BY EYP

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The cantilevered wood clad canopy marks the entrance to the Emergency Department.

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during focus groups and identification of key environmental attributes that stakeholders voiced as important to their care experience.

• A final report of stakeholder feedback, evidence-based design recommendations, and guiding principles for ongoing master planning.

Engaging all stakeholders was a vital part of Stamford Hospital planning and design.

Leadership empowered its staff by facilitating plan reviews and extensive multiphase mockups. Groups from facilities, to IT, to medical staff played a critical role in informing and improving their future work environment.

Every comment was collected and carefully reviewed in building the facility.

Feels Like Home Healing must be embedded in a hospital’s very structure and, ideally, should begin when you walk through the entry door. Not only physical needs, but spiritual and emotional needs must be met. Stamford Hospital’s double-height lobby, soft natural light, and decorative stone and wood surfaces bring the healing power of nature inside. Hospitals can be stressful, so the hospital’s design is stress-reducing, with noise control, terraces, gardens, water elements, and scenic views. Not only are disruptions minimized, but an atmosphere that promotes healing is created.

For many who enter the hospital, it is an emotional time, whether confusing, painful, exciting, scary, or joyful. Navigating is made easier through intuitive wayfinding, with clear and tasteful signage, directional lights and colors, and other visual cues. Hundreds of unique pieces by local artists are installed throughout the hospital, supporting the connection to the community.

The surgery and ED areas are also soothing, with cove-lighting and contemporary furniture, feeling more like a hotel than a hospital. The second floor, which houses the heart and vascular center and ICU, emphasizes daylight and nature, with etched-glass dividers in the waiting room for privacy, as PHOTO BY ANTON GRASSL/ESTO

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Caring for the caregivers, the staff lounge offers access and views to a roof garden dedicated to staff.

well as green family terraces. The hospital is designed to feel like a deep breath, a safe place, and a protective space.

Pivots Around Patients Each of the 185 private patient rooms has floorto-ceiling windows, a pull-out couch, cove lighting, and a tranquil bathroom. Rooms are restorative, but they are also treatment spaces, holding most of the equipment and technology needed for a patient’s care to reduce the need to transport patients for tests or imaging. They are larger than normal, so that medical teams and specialists can come to the patient for a consult instead of the other way around.

Person-centered care also means creating environments in which frontline practitioners can thrive as well. Staff respite areas, small and private as well as larger and more communal, are organically included on every 92

PHOTO BY ANTON GRASSL/ESTO

floor and unit. Many have breathtaking views—all part of caring for the caregivers. A favorite space for staff is the ICU lounge, with an accessible green roof and stunning views of the Long Island Sound. Collaboration, conference, and education spaces are distributed throughout, allowing for activities close to where staff work.

Stamford Hospital was the result of a collaboration among clinicians, administrators, and the EYP design team, who were charged to “reimagine healing.” The aim is for visitors, patients, and staff to have a feeling of warmth and reassurance as they make their way through the building. It’s all part of Stamford Health embracing Planetree’s holistic philosophy of healthcare, a commitment that leadership made from the start. Planetree was founded in 1978 to demystify and humanize hospitals. Now, Planetree International part-

This diagram illustrates a transition of the hospital campus from an island to an integrated part of the neighborhood.

Not acting as an island

Serving the community

ner offices and Planetree Designated Hospitals exist around the world. The new Stamford Hospital is a Designated Planetree Leader and Innovator in Person-Centered Care. We are human beings caring for other human beings with kindness and compassion in a welcoming, safe environment. This means creating workplaces that energize and inspire joy, unite communities, and improve health outcomes.

We are human beings caring for other human beings with kindness and compassion in a welcoming, safe environment.

Patients are posting higher satisfaction scores, and are being treated more quickly and effectively. The hospital is also reporting success attracting new staff. Stamford Hospital received an "A" from the Leapfrog Group, a designation that recognizes its performance in protecting patients from harm and providing safer healthcare in areas such as infection prevention and preventing medical errors, injuries, accidents, and other hazards. The hospital’s design took into consideration every person involved with the facility, and it also took into account the facility's impact on, and influence by, its natural surroundings.

Providing urban infiltration

The Healing Power of Nature The campus is envisioned as an arboretum, with strategically chosen plant materials to help define spaces, provide wayfinding cues, and give access to a variety of outdoor spaces and views to nature for patients, families, and staff. This encourages connection with the community, through time spent outdoors, socializing (even if at a distance), relaxing, and exercising. Hospital staff can take a quick run over lunch, eat outside in the sunshine, or hold a staff meeting under a towering oak.

Outdoor terraces, landscaped and south-facing to the Long Island Sound, are immediately available for the surgical, cardiology, and critical-care staff members. Other staff members are welcome to these areas of respite. Upper tower nursing units have south-facing lounges, as well as quiet spaces for regeneration.

As a good steward of the environment, Stamford Hospital was the largest and first hospital in Connecticut to be awarded a Certified LEED for Healthcare rating. Compared with figures from the previous hospital, water use was reduced by 32 percent, energy use by 12.5 percent, waste diversion was increased by 86 percent, and the use of sustainable materials was increased by 59 percent. The building was designed vertically for optimal utilization of the existing site, preserving land for future growth, and allowing all patient rooms to have exquisite views.

IMAGE PROVIDED BY EYP

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Personalized Care Humanizing, personalizing, and demystifying the healthcare experience, the main elements of the Planetree philosophy, are at the core of Stamford Hospital’s design. For example, when a patient comes to Stamford’s ED, they are immediately welcomed, triaged, and assigned a “track” (designated by color, such as red for someone in need of emergent care). The same care providers stay with them for their journey.

Continuity of care, familiar faces, and family involvement are key healing elements that help to personalize the patient experience.

Ready access to information, including a patient’s own medical charts, is paramount.

At Stamford Hospital, patients and families can use the Resource Center/Medical Library, which has a wealth of information on specific illnesses and diseases, medicines, and treatments. This allows patients and families to be their own advocates and demystifies what can be an intimidating process. This personalized care pays off through improved health outcomes, lower readmission rates, and shorter stays. The unwavering constant is that each person who comes through the doors—patient, family member, staff, or visitor—is treated with respect, dignity, and compassion. •

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PHOTO BY ANTON GRASSL/ESTO

Intensive Care rooms offer a place for families, and access to nature.

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