C
H A 111
T
Team Members
2
Qin Lu
Mengxi Yang
Jess Newell
Xaioguang Yang
Annie Tahir
Background in Industrial Design
Background in Architectural Design
Background in Graphic Design
Background in Interaction Design
Background in Computer Science
quiniiiiie@gmail.com
mengxiarch@gmail.com
JessVNewell@gmail.com Yang1458771020@gmail.com A.tahir1@gsa.student.ac.uk
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Process
01
02
03
Explore Brief Scoping Desk Research User Interviews
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04
05
Analyse 06 09 11
Customer Journey Map Consumer Trends Research Insights Case Studies Technology research Systems Mapping
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07
08
09
Develop 12 14 16 18 20 22
Current relationships Systems Mapping
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11
12
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Deliver 22 24
Design Solution References
26 31
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NHS 24 - ALTERNATIVE NOW This project asked us to explore people’s behaviours and interactions surrounding access to NHS 24 in order to develop a richer understanding of people’s lives and learn how personal and social behaviours shape everyday experiences. Through the design process, we were asked to establish a framework within which to address current needs and speculate upon alternative or innovative ways of living. We were to consider ways in which NHS 24 can be accessed by connecting people-people, people-things, people-places and things-things. By the end of the project we proposed our final design solution; Chat 111, an AI chatbot that facilitates a pro-active approach to the self-management of healthcare needs.
NHS 111
Prior to our first meeting, we were briefed by NHS 24. The brief gave us an overview of the organisation, including a brief introduction to the services that they currently provide, the challenging organisational landscape that limits innovation, and the company’s strategic objectives for the next five-year period. Established in 2001 under a Government Act, the first NHS 24 service was introduced as a test-bed in Aberdeenshire before a national rollout took place. Currently, under the larger umbrella of NHS Scotland, the organisation aims to provide telehealth and telecare services to the entire population of Scotland. These services allow people to seek medical advice when their local GP surgery is closed or when things are not considered serious enough to visit A&E. Though there are a number of existing digital touchpoints on offer (such as web consultations and online access to the NHS Health Cyclopaedia), these are, at present, somewhat limited. Through introducing our design intervention, NHS 24’s future strategy would now not only include plans to expand on this offer, but also envisions an expansion in the organisation’s remit, including supporting of formal and preventative care services.
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“By 2020 everyone is able to live longer healthier lives at home, or in a homely setting. We will have a healthcare system where we have integrated health and social care, a focus on prevention, participation and supported selfmanagement.”
Following our briefing from NHS 24, we conducted general research into the services that are currently provided by the organisation. We decided to focus our line of enquiry on the 111 service - arguably the most wellknown service under operation of NHS 24. The 111 service is a ‘free-tocall single non-emergency number medical helpline’ which people are encouraged to access in urgent, but not life-threatening situations. The current 111 system provides help and advice via a single point of access – a clinical hub that links together and centralises all of the out-of-hours urgent health care services. Our aim was to explore the capacity of this current system and investigate how it could be improved to meet current needs. We were interested in how patient’s ability to access help is circumscribed by the limited ways in which you can contact the service. At present, there is only two ways you can get in touch with the helpline to receive advice - by telephone or webchat. To exacerbate this issue, the webchat communication tool is not promoted or advertised by NHS 24, and can only be accessed via the Inform website. During our enquiry into the 111 service, we also researched further into the NHS Inform service – a self-help database which aims to provide ‘accurate and relevant information to help people make informed decisions about their own health and the health of the people they care for’ which can be accessed before placing a call. We observed that there was a relationship of mutual support between the 111 and inform services and we wanted to capitalise on this connection.
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DESK RESEARCH In order to gather some user-experience from different points of view, we researched online on multiple public forums such as Mumsnet and Care Opinion, where users can confidentially share stories about their experiences. We found that the Care Opinion website permits subscribers to tag their stories with ‘keywords’ which describe a positive or negative aspect of their experience. We noted that the ‘communication’ keyword was considered a top priority of the service that users felt could be improved. In order to gain an understanding of what users meant by ‘communication’ and which parts of the service were being negatively impacted by lack of effective communication between 111 and its users, we individually reviewed each story to identify the root of the subscriber’s issue. Our initial impression from the Care Opinion analysis was: that helpline callers experience long waiting times; that patients can receive incorrect information, or misinterpret the advice from the Call Handler/ health care professional; and that people experienced difficulty answering a series of questions from the call-handler which were used to triage the patient. One of our main takeaways was that many patients require a call-back from a trained practitioner as their query is more complex – this routinely took anywhere between one and four hours.
“WITH 111 I HAVE WAITED AN AVERAGE OF 20 MINUTES FOR SOMEONE TO PICK UP... I HAD TO GO THROUGH ALL MY DETAILS ABOUT THREE TIMES, THEN I HAD TO ANSWER A SERIES OF QUESTIONS WHICH TOOK A FURTHER 10 MINUTES.”
USER NILLYNOLLY MUMSNET
“I HAD TO GO THROUGH ALL OF MY DETAILS, AND THEN I GOT TOLD TO GO TO A GP 40 MILES AWAY. WE WERE GOING AROUND IN CIRCLES UNTIL SOMEONE UNDERSTOOD I WANTED TO TRAVEL 5 MILES, NOT 40.”
USER NEXTPHASE MUMSNET
“I EXPRESSED MY SURPRISE THAT IT HAD TAKEN SO LONG TO GET BACK TO ME - MORE THAN 48 HOURS, AND THAT THEY WERE CALLING SO LATE AT NIGHT. THE DOCTOR SAID THEY HAD COME IN TO A 2 DAY BACKLOG OF CALLS AND WERE WORKING THEIR WAY THROUGH THEM.” PATIENT CARE OPINION
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USER INTERVIEWS In order to gain a deeper understanding of the differences in experience and motivation, and to more fully comprehend the advantages and challenges of using the helpline, we conducted semistructured user interviews with people who had used the service – a student, an art-teacher, and a public servant, to name a few. The interviewees observed that they believed there was no other way for them to access the medical help required without placing a phone call, even though, for one interviewee, this wouldn’t have been the preferred course of action due to a language barrier. One interviewee remarked, “I called three hours before, but they still hadn’t gotten back to me - there was no follow up. I was looking for an indication that my call hadn’t gone into the ether”, expressing a desire to have been kept informed on the progress of her assessment. We were able to identify that, during the waiting period, there is no contact or follow-up process from the NHS 111 service to either establish the progression of a patient’s symptoms, or to keep the patient informed on the status of their query. There is also no way for a patient to check on the call-back service unless they place another phone call, in which case, they would mostly likely be put through to a different call operator. As a consequence of the interviewee-inquestion not being informed of the progress of her assessment, she had rung emergency services – thus putting a strain on an already busy service, and bypassing the aim of the 111 helpline. Another remark that resonated with the team was, “I waited a long time before deciding to call. I thought that the symptoms would go away, but they started increasing. I was waiting for the situation to worsen”, which suggests that, in some instances, there is a period of a time before people take action to solve a developing health concern. This indicated that there was the potential to help patients to better manage a growing health concern before it escalates to the point where professional help is required. In all three instances, accessing the correct help was a difficult process which required either multiple phone calls, or the same information to be repeatedly re-iterated.
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“I EXPLAINED THE PROBLEM THREE TIMES AND MY FRIEND EXPLAINED TWO MORE. I DIDN’T FEEL THE QUESTIONS THEY WERE ASKING HELPED TO DIAGNOSE THE PROBLEM.”
“I CALLED THREE HOURS BEFORE BUT NOBODY HAD GOTTEN BACK TO ME I WAS LOOKING FOR AN INDICATION THAT MY CALL HADN’T GONE INTO THE ETHER.”
GIANINE SERVICE USER
AMRIN SERVICE USER
“I WAITED A LONG TIME BEFORE DECIDING TO CALL. I THOUGHT THE SYMPTOMS WOULD GO AWAY BUT THEY STARTED INCREASING - I WAS WAITING FOR THE SITUATION TO WORSEN.”
“THEY NEED TO STOP ASKING YOU POINTLESS QUESTIONS WHEN YOU HAVE ALREADY TOLD THEM BEFORE WHAT THE ISSUE IS. I TOLD THEM MY DAUGHTER WAS ABSOLUTELY FINE, BUT THEY CONTINUED TO ASK ME QUESTIONS SUCH AS “IS YOUR DAUGHTER BREATHING?”
JANE SERVICE USER
NATASHA SERVICE USER
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USER JOURNEY Following our customer interviews, we put-together a generic customer journey to understand what a ‘typical’ sequence of events would look like. We identified two main areas that the majority of users were struggling with: the mode of access to the helpline and the lack of follow-up during the waiting period. We noticed that the pain points were mostly prevalent at the points of the journey where users felt that there was sufficient opportunity for less procedures and for more communication.
STAGES
AWARENESS
HELP SEEKING
SELF-CARE
ASSESSMENT & TRIAGE
CLINICAL QUEUE
DISPOSITION
ACTIONS REGULAR GP VISITS
+ EMOTIONS
_
EXPERIENCE HEALTH CONCERN
LOOK UP SYMPTOMS ONLINE
ADMINISTER SELF CARE
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PUT THROUGH TO A CALL HANDLER
CALL THE NHS 111 HELPLINE SERVICE
DESCRIBE SYMPTOMS TO A CALL HANDLER
CALL HANDLER ARRANGES A CALL-BACK FROM A MEDICAL PROFESSIONAL
CALL IS RETURNED FROM A MEDICAL PROFESSIONAL
REDESCRIBE SYMPTOMS
RECIEVE FINAL DISPOSITION FROM HEALTH CARE PROFESSIONAL
REFERRED TO CORRECT CARE/SELF-CARE
SATISFIED REASSURED AT EASE
RELIEF WORRIED POWERLESS
IMPATIENT CONCERNED NERVOUS
PAIN POINTS
SEEK ADVICE FROM FRIENDS AND FAMILY
Without personalised health and care information.
Limited modes of access.
TIRED WORRIED
ANXIOUS
The process is disjointed and patients have to answer inappropriate and repeat questions.
No callback or follow-up process with the patient to check if symptoms are improving or worsening.
Unsuitable advice.
TRENDS RESEARCH We researched current and emerging trends in relation to telehealth and health care services. From our research, we uncovered three main insights: that there is a shift in how people access health services - the point of care is moving from the clinic into people’s homes; there has been an increase in waiting times throughout the NHS service which is impacting safe healthcare delivery; and people have high expectations of UK out-of- hours healthcare services. The most valuable insight from our research was discovering that there is a broader cultural shift in the way that the public access retail, banking, and social media services - this change had, in turn, impacted people’s expectations of health care delivery “Technological advances, including online banking, smartphone applications, and social networks are altering patient’s expectations about the availability of medical information and about how and where health services should be delivered” (Health care beyond medicine: Meeting the demand for new forms of care, 2011) indicates that customer’s expect to be able to take measures to solve problems instantaneously, even if it is related to healthcare. We uncovered that “for 50% of users to evaluate their care as ‘excellent’ this would require calls to be answered within 30 seconds, call-back within 20 minutes, time waiting for home visits of significantly less than 1 hour” (Figure one, Campbell J, et al., 2009) indicating that people will mainly associate a successful service with a quick service. As a group we realised that this was unlikely to be a feasible goal and was also outside the control of what we could change, therefore we felt that we had to find a method to keep users informed at each stage, giving them the impression of a speedy system.
20m Expected call-back wait.
30 sec Expected time to connect to a Call Handler. 14
INSIGHTS
01.
02.
The issue we uncovered is that people have high expectations of UK out-of-hours healthcare services. People antipate that they will be able to recieve advice and reassurance instantaneously, despite the fact that the current service cannot currently support immediate access to medical help.
The second tension we uncovered is that technological developments are providing people with direct access to services and moving the point of care from the clinic into people’s home. However the existing 111 system does not empower patients to access the helpline when and how they want to.
03. The third problem we discovered is that people want affirmation of their health concern from a medical expert. Although some patients look their symptoms up online, the feedback we recieved in our interviews indicated that most people call the helpline service straight away to recieve reassurance from somebody who they percieve to be ‘in the know’. However call handlers have a limited medical background and clinical back-up is limited due to the high volume of patients calling the service.
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How might NHS 111 give people the tools to self-manage their healthcare needs beyond a phone call?
CASE STUDIES The self-service economy and automation aim to put the control back into the hands of customers so that there can be a better use of company resources and ‘bottlenecks’ can be reduced. We found that self-management is quite common in our daily lives and there is an opportunity to implement this in healthcare services.
Traditional airline check-in desks
From the users’ side, self-management will greatly simplify the steps of seeking help, making the appropriate medical assistance more accessible and streamlined. From the service provider’s perspective - NHS 111 - it will reduce the volume of phone calls and release the pressure on call handlers, allowing them to put effort into dealing with other calls, which could be more urgent or complex. By eliminating the unnecessary conversations, the 111 call team will be able to provide services with better quality and higher efficiency.
Self-service check-ins
The main takeaway from this research was understanding that the model of retail has changed and there is now a culture of selfmanagement that permeates every aspect of our everyday life. An example of this is the evolution of online travel. In the recent past, customers were required to visit a ‘centralised reservation centre’ in order to book a flight, but now booking flights with airlines such as Ryanair or EasyJet can be done online. This self-management continues when the passenger gets to the airport – travellers can confirm their presence and manage specific in-flight preferences by themselves. In some airports, customers are allowed to weigh their luggage, print out the ticket, and drop off their bags, all by themselves. Another example of this would be ordering grocery shopping. Typically, people used to buy their weekly shopping at supermarkets, but convenience stores and the ability to order groceries online have allowed shoppers to schedule deliveries at a time that’s convenient for them, which means they can plan ahead of schedule. We understood that although human interaction is incredibly important in a transaction, and can often bring gravitas to advice given, it is expensive and not always necessary. If a customer has a minor concern, self-service is often a quicker and easier method of receiving support.
Traditional bank counter
Mobile Banking app
Another instance of such changes is in the banking service. While traditionally, customers need to present themselves at a counter to manage their bank accounts, they can now achieve their goals at home using online banking. Newly emerging banks such as Monzo do not even have a physical bank however, the reduction in cost of not having a high-street branch allows the company to provide more services than a traditional bank could aim to offer.
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CHATBOT TRENDS
40%
61%
of consumers stated that they would use Chatbots to help track down the right human assistant.
of consumers (under 24) actively avoid calling businesses to elude frustration.
100.00 Channel Benefits Delivered 84.60
82.52
81.46
78.59
57.70
36.81
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Next we looked at Chatbot technology which can simulate human conversation. We found that many companies were using this technology to help people manage their needs, find solutions to their queries and access help quickly, without the need for human assistance and support.
Chatbots also faciliate instant replies to urgent requests. Their response time is generally just below a standard telephone conversation, this means users do not need to wait for a call to be picked up or spend time logging in to an app, and Chatbots remain online even after you exit the application.
In the Chatbot Consumer Research Study by myclever in 2016, it is estimated that the most suitable application for a Chatbot is answering urgent questions and forwarding information to the right query handler. The research also indicated that Chatbots are an excellent blend of A.I. and human assistance, allowing users to shift between different channels to reach the most appropriate individual to respond to their needs.
Another benefit of Chatbots is that both millennials and baby boomers stated that they would engage with the technology when appropriate, indicating that we do not have to refine our target group to a younger generation but can aim for people of all ages. Users don’t need to learn how to use the software because they are already familiar with interacting via text, which suggests that this technology is highly accessible for the public.
In the case of the 111 service, implementation of a Chatbot could allow patients to forward their health concern to the appropriate professional. Patients could immediately take control of a burgeoning health concern by responding to a series of questions that determine what assistance they need, and responses could be recorded for a medical practioner to access afterwards - avoiding repetative questioning from the 111 staff. Meanwhile, users would be able to interact with the Chatbot to gain access to self care information and updates on the progress of their assessment - providing a continuity of care to people who are unsure of how best to manage their own health concern and how long the wait time is to access help. For the reasons outlined above, we believe this could make the current journey less stressful. 21
CURRENT RELATIONSHIP The distribution of triage data from the NHS 111 Minimum Data Set in England states that 13.96% of people were not recommended to another service and, as a group, we felt that it was important to design an intervention so that this section of the population could assess the severity of their own medical issue to negate the necessity of a call to 111. The triage data also stipulatesd that only a small percentage of calls were classified as a medical emergency, with the majority of people (around 60 %) being referred to primary care services, indicating that the main function of 111 is to direct patients to the correct Primary Care service. We began to ask if there was a way in which
people could reach the appropriate service for their needs through alternative channels so that call handlers at 111 can concentrate on more troublesome issues that require greater medical input. We began to imagine a scale from minor to very severe ailments e.g. ailments that could be treated by pharmacists such as coughs, colds, and minor first aid queries; all the way through to breathing difficulties and chest pain, which would require further clinician input. We felt that we could then work out which elements could be automated further, without removing the necessity of a clinician for more major circumstances.
NHS self-help guides
Internet
Google it
Visit NHS 24 website
Phone
Call 111
Call 999
Feel confused and call 111
NHS Inform
12.78%
13.96%
08.64%
04.76%
Personal
Speak with friends and family
Feel calm
Book GP
Feel anxious and call 111 Feel nervous
Suggest calling 111
Recommended to Primary care Not recommended to another service Ambulance dispatch
59.86%
Recommended to A&E Recommended to another service
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Current State
SYSTEMS MAPPING
Future State
The next stage of our project was to make a system map to visualise the current structure and how we imagined an improved structure might look. Through the visualisation process, we could see that the current system was antiquated and focused on ‘dependence’ – all of the service users go directly through the call handlers who then make a referral to another person or service – a signpost. We felt that the system could be reconfigured to ease pressure on the call-centres and give patients direct access to the correct medical service without having to go through the over-burdened central point.
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NEW USER JOURNEY
Our final design solution is Chat 111, an AI Chatbot that helps patients to pro-actively manage growing health concerns. Chat 111 can chat with patients about burgeoning urgent medical concerns and forward symptoms and additional medical information on to call handlers to review in out-of-hours periods. It’s aimed at smartphone users living in Scotland and can be accessed through existing chatting applications; users can chat with 111 on the application of their choice, as everyone has their own preference. Depending on the outcome of its digital assessment, Chat 111 may provide patients with the opportunity to schedule a call with an appropriate medical professional from the 111 team. In the meantime, the bot can talk to patients to monitor symptoms and provide self care instructions. Chat 111 will also be able to inform patients of the rough estimated waiting time to recieve help. We believe that providing patients with the opportunity to interact with a Chatbot throughout their patient journey could provide comfort and reassurance during vulnerable circumstances and nudge people toward taking more ownership over the management of healthcare needs.
Invitation
Join Chat 111
People find out about the Chat 111 service through posters at the local Pharmacy or GP. If you have registered with a GP, or left your phone number with another NHS organization, a text message will be sent to you, inviting you to add Chat 111 to your favourite messaging platform such as iMessage, WhatsApp, or Facebook Messenger through a unique phone number or by searching ‘Chat 111’ on the messaging application of your preference.
Add Chat 111 to your contacts on your preferred messaging application.
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DURING THE WAITING TIME Waiting Tracking
Feeling unwell
Assessment
Schedule a call
When you’re feeling unwell, but it’s not an emergency situation, you can start chatting to 111 about your symptoms...
You will be asked a series of questions, and your case will be assessed and triaged depending on how you answer.
If your symptoms seem serious, Chat 111 will suggest that someone follows up with you about your condition. Chat 111 will schedule a call for further assessment and the information provided will be sent on to the right medical professional to assist with a diagnosis.
Chat 111 will give an indication of the estimated waiting time to recieve a call back.
Self care
Call back
Get result
You will be asked to attatch a photo to help the handler with triage and you may recieve advice from the bot on how you can relieve your symptoms.
When your call is returned, you can chat to the medical professional in a more meaningful way about your concern, as they have already had access to the information you’ve provided - avoiding the need to repeat any information in high pressured situations.
After the call, you will receive a summary of the conversation - including important information that was passed on during your call.All your historical summaries will be archived for you to review at any time.
It will also check in with you to see how your condition is developing. Any significant change in symptoms will be sent to the medical professional as supplementary information to help with a further assessment.
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REFERENCES
FEATURES
Agius, A. (2018). 7 Outstanding Examples of Omni-Channel Experience. [online] Blog.hubspot.com. Available at: https://blog.hubspot.com/service/omni-channel-experience [Accessed 1 May 2018].
Assess Symptoms
Schedule a Call
Chat 111 allows users to assess their own symptoms and, when necessary, forward the evaluation on to the team at 111 for review.
Depending on the result of the evaluation, it can schedule a call from the correct medical professional.
Campbell, J., Roland, M., Richards, S., Dickens, A., Greco, M. and Bower, P. (2009). Users’ reports and evaluations of out-of-hours health care and the UK national quality requirements: a cross sectional study. British Journal of General Practice, 59(558), pp.8-15. England.nhs.uk. (2018). Statistics » NHS 111 Minimum Data Set. [online] Available at: https://www.england.nhs.uk/ statistics/statistical-work-areas/nhs-111-minimum-data-set/ [Accessed 1 May 2018]. The Economist. (2018). A revolution in health care is coming. [online] Available at: https://www.economist.com/ news/leaders/21736138-welcome-doctor-you-revolution-health-care-coming [Accessed 1 May 2018]. Imaginingcareanywhere.org. (2018). Imagining Care Anywhere Stories. [online] Available at: http:// imaginingcareanywhere.org/html/journey.html#page/6 [Accessed 1 May 2018]. Katherine, K., Skinner, G., Duffy, B. and Watling, C. (2018). Great Expectations: Are service expectations really rising?. [online] Available at: https://www.ipsos.com/sites/default/files/ct/publication/documents/2017-11/greatexpectations-are-service-expectations-really-rising-2017_0.pdf [Accessed 1 May 2018]. The King’s Fund. (2018). Public expectations and experience of services. [online] Available at: https://www. kingsfund.org.uk/projects/time-think-differently/trends-public-attitudes-expectations-services [Accessed 1 May 2018]. McGovern, G. (2018). Business Case for Digital Self-Service – Gerry McGovern – Medium. [online] Medium. Available at: https://medium.com/@gerrymcgovern/business-case-for-digital-self-service-72a030cd4772 [Accessed 1 May 2018]. mycleveragency - Full Service Social. (2018). Chat Bots, A Consumer Research Study. [online] Available at: https:// www.mycleveragency.com/whitepapers/messenger-chat-bots-research [Accessed 1 May 2018].
Follow up support
Self care advice
The Medical Futurist. (2018). The Top 9 Augmented Reality Companies in Healthcare - The Medical Futurist. [online] Available at: http://medicalfuturist.com/top-9-augmented-reality-companies-healthcare/ [Accessed 1 May 2018].
It will ask the user a series of follow up questions to monitor the development of their symptoms. It might also ask the user to attach supplementary photos to aid with triage.
It offers advice on how to manage health symptoms whilst users are waiting for a call back.
Performance Statistics For March 2017 Were Released At 9.30Am On Thursday 11 May, Following:, 2., Service;, T. and Indicators;, A. (2018). Monthly performance statistics, March 2017. [online] Available at: https://www.england. nhs.uk/statistics/wp-content/uploads/sites/2/2015/08/Monthly-performance-statistics-summary-Mar-17-FINAL-1. pdf [Accessed 1 May 2018]. Salesforce Blog. (2018). How Your Customers’ Expectations Have Changed in the Age of the Customer. [online] Available at: https://www.salesforce.com/blog/2017/07/customers-expectations-in-age-of-the-customer.html [Accessed 1 May 2018]. TechCrunch. (2018). More than 40 carriers now support RCS, the next generation of SMS. [online] Available at: https://techcrunch.com/2018/02/22/more-than-40-carriers-now-support-rcs-the-next-generation-of-sms/ [Accessed 1 May 2018].
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