PROJECT PROCESS JOURNAL
:Design Innovation & Service Design Semester 2 (Spring 2018) Qin Lu ĺ?˘ć˛
OVERVIEW This live project is a co-design project, which aims to develop an alternative NHS 24 by challenging the existing services. As a part of MDes Design Innovation and Service Design course at the Glasgow School of Art, we did this team setting project during over ten weeks. Our project centred on 111 helpline, based on the existing technology, the new 111 channel provides users a more seamless, smooth and individualised experience. Next, I will introduce the whole design process by weekly and also illustrate some of my reflection during each week.
Brief Scoping Desk Research
Field Research Literature Review
Existing User Journey Interim Review
Final Concept Development
Overview of NHS 24 Scottish demographic change Desk research Stakeholder map Ethic workshop
Overview of NHS24 NHS 24 is Scotland's national telehealth and telecare organisation, which provide services for anyone in Scotland looking for quality assured health and care information. Currently, NHS 24 aims to: • Improve health outcomes through the provision of information on conditions, signposting to services and self-help/care information. • Increase access to mental health. • Improve patient experience by reducing waiting times for GP and return outpatient appointments, and to address more health concerns at point of contact to the 111 service. • Reduce pressure on A&E admissions, outpatient appointments, GP home visits, ambulance call-outs. • Integrate healthcare and social care, a focus on prevention, anticipation and supported self-management.
Scottish demographic change • Scotland's population is ageing; • Fewer children aged 0-15 and people aged 16-64; • People living longer; • People living longer at older ages; • More over 50s living alone; • Geographical variations in the distribution of older people; • An ageing population similar to the rest of Europe.
Desk research: NHS
NHS (the National Health Service) , the UK, follows the principle of selective treatment of the poor and advocates the principle of universality. Where income British citizens must participate in social insurance, according to a uniform standard to pay premiums, according to a uniform standard to enjoy the benefits, regardless of the amount of income, the welfare system unified by the government to implement.
NHS system consists of two levels. The first level is community-based primary health care services such as General Practitioners (GPs), dentists, pharmacies and eye examinations. Every resident of the UK has to register with a GP clinic near his home and first meet GP. Any further treatment must be made through the first level of primary care referral. The second level of medical care is hospital-based, including emergency services, specialist out-patient and examination, surgical treatment and inpatient care.
The main funding for the NHS comes from taxes. As the largest project expenditure in the UK social welfare system, the government allocated more than 90 billion pounds in 2009, which is 10 times of the first 9 billion pounds 60 years ago. Serving more than 60 million people across the UK, NHS is arguably the world's largest public health system with 1.5 million employees, including 90,000 hospital doctors, 35,000 family doctors, 400,000 nurses and 16,000 first aid workers. The country has 1,600 hospitals and special care centers.
Telecare is support and assistance provided at a distance using information and communication technology. It is the continuous, automatic and remote monitoring of users by means of sensors to enable them to continue living in their own home, while minimising risks such as a fall, gas and flood detection and relate to other real-time emergencies and lifestyle changes over time.
Telehealth is the remote exchange of data between a patient at home and their clinician(s) to assist in diagnosis and monitoring typically used to support patients with Long Term Conditions. Among other things it comprises of fixed or mobile home units to measure and monitor temperatures, blood pressure and other vital signs parameters (and the answering of targeted questions) for clinical review at a remote location using phone lines or wireless technology.
There are real benefits for both the patient and the clinician. The individual patient has more control and understanding of their long term health condition, and the clinicians utilising telehealth as part of a care pathway can ensure that they are proactively involved in the ongoing wellbeing of their patient, managing timely interventions and helping to improve their patient's quality of life. The following figures explain why increasing numbers of clinicians are offering telehealth services to their patients: 15% reduction in visits to A&E; 20% reduction in emergency admissions; 45% reduction in mortality rates.
AR/VR The technical context our group was given initially was Augmented Reality and Virtual Reality.
Augmented reality (AR) is superimposing digital elements on to an existing environment.
Virtual reality (VR) is a computer-generated scenario that simulates a realistic experience.
Case study 1: Augmedix
Case study 2: Library of ourselves
Technology: Augmented reality
Technology: Virtual reality
Gear: Google glass- remote scribe
Functions: Creating content through collaboration with local communities/grassroots Creating audiences in partnership with local arts/culture institutions Generating new insights on the effects of this content in collaboration with international academic partners
Functions: Hands free charting Real-time documentation End-to-end HIPAA compliance Values: 80% Less EHR(electronic healthcare record) Charting with a Remote Scribe Augmedix gives providers more time to focus on patient care Rehumanize healthcare and enhance the patient experience
Values: As a door into the perspective of others Creating empathy-driven experiences Designed to bridge cultures and to promote mutual understanding Experience impossible things
Services of NHS 24
Quit your way
Care information Scotland
Listening to you Providing information and advice Congnitive Behavioural Therapy 6-9 sessions regular contact Appointment Supporting material Referring you to a physiotherapist or podiatrist Providing information and advice Medical advice out of hours Unscheduled care service Proving advice and plans Free â€˜quit packâ€™ Refering to free lacal NHS service
Providing care information
The Relationship between 111 and NHS Inform
A node linking all the NHS 24 services
A database containing all the NHS 24 services
From analyzing all the current services provided by NHS 24, we found that, some services only provide help for specific illness, such as Breathing Space and Living life, which mainly focus on mental health. Some service care more about the long-term health management,such as Quit your way. However, ‘111’ and ‘NHS Infrom’ provide support for the other NHS 24 services, but play the different roles. 111 providing the urgent but not life-threating health advice out of hours. Giving self care information or directing patients to other medical services. It's the phone call service and also a hub to link to all other NHS services.
NHS Inform providing people with accurate and relevant information to help them make informed decisions about their own health. It acts as a database where all the information related to NHS 24 are prepared for the patients. We were interested in how the NHS 24 is a very confined method of communication - The 111 is comprised of a directory and phone line. We focused on 111 because it's a hub that links callers to other NHS services. NHS Inform is a database where all the information related to NHS 24 are prepared for the patients.
Ethic workshop During this week we had a workshop with Janet Kelly about Ethics consideration in our design process. Which guides me make desicions in the following field research stage, and help me evaluate the ‘good’ or ‘bad’ from different approaches, such as: consequentialism, denotology and virtual ethics. 09
We can identify these three approaches from their different focus, motivation, and defination of ethic conduct. Ideally, for our designing process to be considered "ethical", it must respect all four of these principles: autonomy, justice, beneficence, and non-maleficence.
Reflection At the first week of the project, our group did a lot of broad desk research on technical context, Scottish heath care, and the NHS 24 services as well. By starting with brief scoping, I should have a comprehensive understanding in the NHS system, including the Scotland demographic tendency and the overview of healthcare in Scotland. For our international student, the National Health Service in Scotland is totally different with my own country, it was a big challenge for me. In order to involve in the NHS system and better understand it, based on the general desk research, I also tried to experience NHS 24 services as a normal user. It helped me to do the following stages. Next, the contextual understanding, the AR/VR. As I was very unfamiliar with this area, I did the desk research on that for a long time. Then I got a very basic knowledge about it. In order to help me understand the technology better, I analysed some cases from their functions, values and operation. When I start thinking how can we utilize the new technology in NHS 24 services, I changed it on my mind to â€˜what kind of value that AR/VR can provide to health care?â€™ By doing that, the task came to a easier way. After the rough understanding of AR/VR, we focused back to the NHS24 services, we split all the services down, tried to found their internal connection and difference. Finally, we mapped out the potential stakeholders in the NHS 24 to prepare for the next researches.
‘Digital Health in 2018 and beyond!’ SimVis visit Online survey User’s feedback from ‘Care opinion’ Literature review
Field research Digital Health in 2018 and beyond!
We know that the future is digital! How can we help people to go digital with health and care and ensure they are getting the information they need to live longer healthier lives? All of developments are based on user need and all content is developed with the users at the centre. We are seeking your support to help us shape this service, ensuring we continue to meet the needs of Scotland. NHS Inform is Scotland's leading digital health and care information service which provides a source of reliable, quality assured information across a growing range of channels including online, telephone, web chat and social media.
After a briefly introduction of NHS and NHS Infrom, we were asked to using the NHS Infrom on three different platforms, mobile phone, tablet PC and PC. And also write down the suggestions and feelings when we view the website on the different devices. An intersting situation here is, most people search medical help online by google it directly, but not the more official and professional NHS inform. But why? By using the NHS Inform online, we found that there are many painpoints that against userâ€™s behaviour. Such as: locating places, catalogue of illness and searching filter.
SimVis Visit Interview with Dr. Matthieu Poyade
Based on the previous research on AR/VR, we had a general understanding of this technology. However, in order to get a deeper understanding on the health care related AR/VR. We might need the technical support and also need some professional advice from the AR/VR experts. Then we contacted Dr. Matthier Poyade, who works in SimVis of GSA, mainly research in AR/VR. Fortunately, he was very happy to show us some VR/AR devices and anwer some of our questions, such as: •Where do you think AR and VR would have a place in telehealth? What different roles could they play? •What is the biggest challenge in AR and VR developing and popularizing? •What are the potentials and restrictions of AR and VR becoming commonly used by many people in the future? •What are the security and privacy issues surrounding the usage of Augmented Reality technology? What would be the implications in healthcare? ...... After experiencing the different AR/VR products, and the interview with Matthiew, I got a better understanding which can help me image how the devices can be applied on the future digital health services. I can see the potential of it, such as the security and immersion. However, we also realized the limitations of the technology, which are not the just the high price for the good set, but also the immature market on these products. Maybe it would becoming very popular such as smart phone today, but for now, it might not be a best choice for the public healthcare.
Online survey Proposal
In order to gain a broader understanding on the NHS 24 service through a cross-section of the opinions of existing and prospective service users. We conducted a online seurvey for public NHS 24 users.
We gathered 7 feedback in total. After analysing these, we found out that, under the out of hour non-emergency situation, instead of seeking help from their family or friends firstly, most people prefer seek help from NHS 24, sometimes they over expecting to it. So they always complain that NHS’s service cannot satisfy their needs.
•What is your awareness of the NHS 24 service? •If you have used NHS 24 services, what is your experience? •If you haven’t used NHS 24, have you considered using it? •Have you been in a position where you have considered it, but decided to use an alternative? What resource did you eventually choose and why? •If you were concerned about your health, or the health of someone you were close to, where would you go to seek further information? •When you decide to seek information relating to a particular health concern, what steps would you go through? •What methods do you use to keep as healthy as possible without seeking advice from your Doctor? •If you have searched for information regarding a particular health concern, how easy was it to find the information you were searching for?
•If you are happy to participate in this study further, please leave your e-mail below.
For long-term healthcare, people prefer follow the instruction from their GP or NHS inform. But the online searching is not easy to access, due to most people lack of proper knowledge which is quite dangerous.
Ethics All of our participants were informed that this online survey is anonymous and we only use the result as the university research. And at the end of the survey, we asked the participants leave their e-mail for further engagement but it is not compulsory.
Users’ feedback from When we did the online research on users’ experiences on NHS24 services, we found the ‘Care Opinion’, which is the UK's leading independent non-profit feedback platform for health and social care services. Users share their experiences with the health care organizations on it. Then, we decided to collect the feedbacks about NHS24 to gain an understanding of what aspect of the existing service people felt could be improved. After we viewed almost 100 feedbacks, the number one aspect that people thought needed improving was communication. Initially, we thought this was between the call handler and the caller, but with further research, we established that it was the lack of communication at certain points in the service which made people feel anxious and stressed e.g. waiting to be connected, waiting for a call back and having to repeat information. It wasn’t that they were misunderstood, but that this was making them feel scared and anxious when they were in a urgent care situation. With further analysis of user feedback we found that the main pain points were delayed access to advice - due to waiting times which are a knock on effect of the volume of patients that need triaging - repetition of basic information, and not acting correctly on advice due to be in a high-pressured situation.
“I expressed my surprise that it had taken so long - more than 48 hours - to get back to me and that they were calling so late at night.”
DELAYED ACCESS TO ADVICE
“I called 111 again that evening saying that it was now more than 24 hours since I had originally contacted them.” “I went through a series of questions with the advisor who then kept repeatedly asking... I was unsure of what they wanted or expected me to say!”
REPETITION OF INFO
“They kept asking me irrelevant questions and I had to spell my surname 4 different times. ” “Twice I've been given what I feel to be poor/innaccurate information with respect to treating my baby son.”
“Both Monklands and nhs24 said I must have been mistake, but I wrote it down when I was given my appointment. I am definitely not mistaken, and was made to feel like a liar. ”
“58% of people will share personal data to power recommendations that match their needs.”
“50% of users only evaluate their care as ‘excellent’, if calls are answered within 30 seconds and call-backs within 20 minutes.”
“Patients are less passive than in the past; they expect more involvement in decisions about their care, and access to the latest treatments.”
“Technological advances, including online banking, smartphone applications, and social networks are altering patients expectations about the availability of medical information and about how and where health services should be delivered.”
In order to figure out the communication problem between customers and service providers, we then conducted a literature review. The main learning from this is that people want near-instant access to healthcare services. In one study, for 50% of users to evaluate their care as ‘excellent’, would require calls to be answered within 30 seconds and call-backs within 20 minutes. Adverse evaluations of care were consistently related to delays encountered in receiving care. People have become accustomed to wanting things at a fingers click. People want more personalised data that matches their needs and are willing to sacrifice personal information to get more tailored advice. Most people really want to seek help from NHS 24, sometimes over expecting to it. So they always complain that NHS’s service cannot satisfy their needs. We did further research on users’ expectation, which showed the growing gap between patients’ expectation and the reality of the current service that was being delivered. We found out in our research that people want more control over their own healthcare - such as access to electronic patient records and a great relationship with their doctor. This can be applied to the 111 journey. We thought we can give back control to people so that they have a greater control over their healthcare journey.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2605546/ https://www.salesforce.com/blog/2017/07/customers-expectations-in-age-of-the-customer.html https://www.kingsfund.org.uk/projects/time-think-differently/trends-public-attitudes-expectations-services
From the tutorial, we were suggested to focus on COMMUNICATION and CONTEXT, such as:
During a whole week filed research, we engaged with people from different area. Firstly, the people in ‘Digital Health in 2018 and beyond!’, they are working in different domain, but all have the awareness about the public healthcare services. This is the reason they came to the workshop together to make effort to improve NHS service. After that, we interviewed with Matthieu, it was very helpful to me, he provided us the newest developing tendency and insights on VR/AR. To be honest, during this stage I was really worried, I still struggle with the technical context. It more like doing the AR/VR design project, our group work developed slowly under this situation. Then we found the “Care Opinion”, started view the feedbacks of the users, as we didn’t gather many useful information from our previous online survey. By reading their story with NHS experience, we found the key points and collected them together to analyse the reasons. So, I decided leave the technical context for that moment, just mainly focus on NHS 24 services. The bad thing is that, from here, our teamwork did not work well as before, some of our group member did not really agree with this decision, they still want to work on the VR/AR technology because of their previous background. After that, they didn’t really make effort on our project.
• Communication aspects • Visual enhancement of conversations • Mediated interactions and also think about: • How people's interaction with NHS 24? • Is there any misunderstandings, frustration or confusion? • How to build trust, relation, sense of control? we can conduct research by using the feedback data online and their personal stories may come later, then put the points from users feedback to the journey map. Additionally, we can try to explore the devices and applications that have already exist in home, such as: smart TVs, smart watches.
User Journey Questionnares Interim review Feedback
User journey of NHS 24 111
Being asked piles of questions
Customer journey starts here.
Urgent medical health concern trigger occurs.
Attempt to self-diagnose.
Low expectation Speak to family and friends/look up symptoms - Not medical professional there is a low expectation that youâ€™re able to diagnose yourseld successfully.
Long waiting time
Patients have difficulty to speak
Placed on hold whilst waiting for an operator.
Introduced to an advisor.
Treatment Unprofessional or wrong information
Useless or unproper advice
Offered support/ diagnosis immediatley.
Advisor arranges for a medical professional to call you back.
Unuseful information Long waiting time (Generally 1-3 hours, some may last over 24 hours)
Waiting for an appropriate professional to call you back.
Call is returned from medical professional.
Lack of patientâ€™s records
Referred to pharmacy, Out of Hours GP, or hospital.
Unprofessional or wrong advice
Self treatment and maintainance
Patient wonâ€™t be given any info in that time that will support you to get better, no support, no tools to support you to get better.
Questionnares After we maped out the general user journey of 111 users. We found that there exist communication gap between calll handlers and users. So we decided to go out and ask members of the public questions around communication. Q1: Have you ever had any difficulty communicating your symptoms to a call handler? What restricted your communication? Q2: How confident were you with the medical advice you received? Q3: Did you feel confident carrying out the treatment with the information provided? Q4: Could you describe an experience where you communicated with someone without any barriers?
Then, we asked them describe their experience communicating with NHS24 during each stages.
Feedback We went to shopping mall, boots and local pharmacies to engage with people,. However people around the street not really like to talk with us, as they were busy and not intersted in our questions. Moreover some of questions are not easy to answer, and some questions are confused. Such as the question 4, ‘describe an experience where you communicated with someone without any barriers?’ For people walking around the street, they prefer answer some choice question, so most people didn‘t answer this question. One of the most resonant encounters was speaking to a woman who had struggled to communicate her issue over the phone after she had a stroke. She also mentioned that often, she wasn’t the one placing the call. At what points is communication an issue, what tools can we give people to help and what effect does miscommunication have on the service?
For the interim review, we made an A1 evidence wall to present our researches. The key point is the COMMUNICATION between users and NHS 24. By digging the pinpoints during the user journey, analysing users’ emotion during each stage, we found out the main points are the waiting time during the 111 and the low accessibility of NHS Inform. We also found some technical cases which have potential on the communication improvement. We got some suggestions and inspirations from Brain and Elio, which helped us prepare for the NHS 24 visit, such as: • Visualize the interactions between NHS and patients. Ask about both sides' communication issues. • What's the impact of the pain points on people and what are the consequences? • Presenting problems and issues with more images and less graphical, more humanized.
• • •
• Communication and actions can be also nonverbal.
• Standing from NHS 24 side, any misunderstanding and confusion from call handlers attention.
• • • • • •
Where would VR/AR be better applied and helpful? Who completed these survey? Did you notice a difference based on a person’s demographics? What AR/VR can do? Qualities of AR/VR, how will these impact NHS 24 staffs? Who uses the NHS 24 service the most? Is communication as issue for them? Make sure of your direction and focus, what’s next? Who is your target audience? What interests you found from research? How are these people related? Do they have similar or conflicting values/ideas?
Reflection During this week, we mapped out the user journey which contains user’s emotion and the pain points happens in each section. By this way, it is very clear to see user’s experience when they are using the 111 services, and also helped us to split each communication issue. Around the communication issue, we conducted our second field research by questionnares. In doing that, we expected find out if their frustrations during the 111 journeys as same as the pain points that we gathered based on the desk research. Moreover, the most important insights we found from the field work was a disabled participant, she inspired us that 111 service doesn’t consider the situation that “the patient isn’t the one placing the call”. Then I did the evidence map for the interim review, as the limitation of time, it was very hard for me to do that really well. So we didn’t present all of our researches, just a general map. But the peer review gave us many suggestions, and also asked some questions that we indeed haven’t considered. In order to preparing for the following week presentation to NHS 24, I changed the way of some visualization based on the feedback from tutors. I realized, for our design project, the way of presenting and storytelling a very important part.
- NHS 24 visit - Insights
NHS 24 Visit Presentation with NHS 24
By inrtroducing our working process from: desk research, field research and case studies, we presented our two aspects on communication during the phone call and the empathy between patients and call handlers. About the frustrtions during users’ experience, the NHS 24 staffs also gave as some explanations and insights, for example:
• If somebody's very anxious they’re not always listening to what you’re saying properly, but sometimes they find it difficult to describe things if you’re asking someone. • We’ve seen from the research, what there is, is that what somebody’s been told, or whatever advice they’ve been given, doesn’t land. They don’t act on it the right way. • We have to have use a lot of patience and a lot of time to think about how you reword questions to try and get that information. • The problem that we have with apps is that the majority of people have about ten that they've got on their phone so it’s about forging prime retail space. Once you take out your WhatsApps, your Twitter, your Facebook, your real bigger hitters, you’re maybe left with about three. • From a resource point of view I would argue it would be better tied up within the existing technologies. ......
Interview with call handlers After the presentation, we had a chance to talk with specific NHS 24 staffs individually. We then talked with two call handlers, who have been worked there over 10 years. Following are some key questions:
My thoughts Q1: How do you deal with the situation that patients cannot describe correctly their symptoms, such as which part of body painful? We are experienced nurses/doctors, but we can only receive all the informations by our ears on the phone, we cannot touch or see it. So normally we ask patients put their hand on the body then tell us the reflection. Q2: Why the paitients would have a long time waiting ? Call handlers are very busy, they have to triage patients efficiently according to the patient’s symptom: deliver to A&E or waiting for a call back. For some extremely busy day(christmas, boxing day... ). if the helpline is busy, patients can leave info on Facbook and twitter NHS24. Q3: How can you protect patients’ info privacy? We cannot see every information of the patients, only can access the info shared by GP. Q4: How to avoid some issues like misunderstanding and confusion? Firstly, make sure the language ability is not a problem, and then check if caller can understand info correctly. During the communication, any misunderstanding exist, call handler would ask the patient repeat it.
New technology may be used as a visual guide to tell patients what to do.
Self-guide: info searching action. AR/VR: info given action. They can find the informations patients needed quickly as they are professional and familiar with the “care info”. I think this is the key value of 111 compares with self-guided help.
What if patients can decide which information can be viewed by NHS staff and in what occasions the information can be seen.
om NHS 24
What’s next: • Summarize the information we’ve gathered. • What do we mean by expectation and frustration. • Passage between NHS inform and 111 (info given or searching). • Map out frustrations between call handlers and caller. • Find out the deeper relationship and details between them. • Find web/app with customer chat service, which might share links/pdf at the end of conversation. • Map out communication between call handlers and callers. • Look into existing services/tech, find out as many examples as possible we can.(e.g: Online shopping websites; Chat box in the corner; Mailed pdf of the chat). • Narrow down our focuses by splitting "communication” “expectation" "frustration" into touchpoints and find solutions.
Until this week, we have gathered a lot of insights from both NHS 24 and users with specific aspect: communication. Especially the NHS 24 visit, we can talk with the staffs directly, ask their opinion on the users’ pain points. It was very helpful for us to find out why the expectation gap exist, and what actions they have or haven’t conduct to release the issues. We also asked their opinion about the AR/VR technology, but they didn’t think that could be a good way to solve problem and even bring new issues that we cannot control. Also, according to the users’ behaviour, change their platform to a brand new one would not be accepted by the users. So, from here, our group decided to explore another existing services or technology which have been familiar with public. Moreover, the next step for us was how can we reframing these insights?
- Interview - Case studies - Insights reframing
Case studies on existing technology: 2. IBM WATSON CHATBOT 1. GOOGLE RCS PLATFORM
Values: • Allow more personalized customer experience. • Immediate contact to service providers. • Quick and easy to build for service providers.
3. IBM WATSON SPEECH-TEXT TRANSCRIPTION
Values: • Integrate every messaging channel, all services and businesses into one platform.
• Avoiding ‘app fatigue’. • Faster and easier access.
Values: • Real-time transcription in different scenarios. • Promoting quick understanding of content. • Documenting the conversations.
https://jibe.google.com/ https://www.ibm.com/us-en/marketplace/cognitive-customer-engagement https://www.ibm.com/watson/services/speech-to-text/
4. IBM WATSON TONE ANALYZER
5. DOMINO’S PIZZA TRACKER
Values: • Understand customers’ emotions and
communication style in text. • Help service providers to respond to customers appropriately and at scale. • Build dialog strategies to adjust the conversation and relationship with chatbots.
Values: • Keep users updated of which step they are at and which are the followings. down the gap between expectations and reality.
The desire for a formal professional opinion.
Interview We conducted interviews with people who had used the service again. We found out that because people had to wait long times, with no clear understanding of how long it would take a clinician to get back to them, they made further phone calls, which resulted in further pressure on NHS services. This was further supported by additional research which showed the growing gap between patients’ expectation and the reality of the current service that was being delivered. We found out in our research that people want more control over their own healthcare and a great relationship with their doctor. This can be applied to the 111 journey. We thought we can give back control to people so that they have a greater control over their healthcare journey.
“I don’t know if I can trust the accuracy (of an online directory). I prefer to have a phone conversation with a medical professional rather than fill out an online form.”
Amrin 24 years old Student
Keep informed on the progress of the assessment. “I called three hours ago and they still hadn’t called me back - There was no follow up. I was looking for an indication that my call hadn’t gone into the ether.”
Delay in taking action to solve health concern. Megan 34 years old Art teacher
“I waited a long time before deciding to call the 111 service. I thought that the symptoms would go away, but they started increasing. I was waiting for the situation to worsen.”
& Patients wish for a closer relationship with clinicians.
Long waiting times for There is a gap between patients’ patients due to expectation and the reality of high pressure on 111 handlers. current services.
Pre-notice users’ conditions, feelings and informations before calling 111, in oder to provde a more taillored service.
Keep tracking the updated information, and notice the pickup time .(eg: Domnino’s pizza tracker)
Building a long-term and more intimate relationship between patients and NHS.
Keep tracked the updated information, and notice the pickup time .(eg: Domnino’s pizza tracker)
Contacting chatbots for self management before running into serious problems, If needed, they will receive a call from a person to continue the conversation. People engage with chatbot before engaging with call handlers.
Reflection Through the case study of the existing technical services, we collected many new communicational technologies, which have potential to be applied on the current 111 services. Such as: RCS, Chabot, and real-time tracker. The values of these technologies can solve the problem with current 111 platforms. The current service only based on helpline and self-help online searching. We found that people prefer to seek help from 111 by phoning, even they can search online to self manage their health issues. It can be seen as people prefer to be given the customised information directly, but searching from NHS inform by themselves. In order to reduce the 111 pressures, and provide users more efficient experience. Can we lead this group of low emergency patients to NHS inform directly, instead of always asking help from call handlers?
- Self management research - STEP cards - Our visions
Self management: Defination According to the previous research we found that people have the demand of self manage their health. And by this way, the high pressure on 111 would be reduced. Firstly, the term of self management in health care is the actions taken by people to recognise, treat and manage their own health. We conducted the desk research about self management, then we found it’s quite common among our daily life. Customers increasingly expect self-management options in every aspect of their lives. So, many companies have introduced their users the self-manage services. For example, McDonald’s self service kiosk allows more staffs move away from cash registers and into the kitchen to help speed up customer service. Amazon lockers which can help by providing a safe and convenient way for staff to receive their Amazon parcels without adding to post room volume. But, how can NHS 24 give people the tools to self-manage their healthcare needs beyond a phone call ?
McDonald‘s Self Service Kiosk
Online Customer Service
Self Management and Co-Production Hub
In order to gather people’s behaviour and opinion about the healthcare self management, we attened the “Self Management Network Scotland's national networking event” and did the interview with people there, following are some insights we gathered: • There are no links between any of the Apps and any of the medical professionals. • The most useful tools are the ones which provide two-way support, such as tracking apps that can tailor advice based on what you’re inputting. These are tools that I input information into but that also provide two-way information - such as Headspace. • Actual self-management is quite difficult because they don’t know me or my self-management journey. • The Buteyrd Method is a breathing practice and I didn’t have access to it unless I was referred via the consultant – There is a restriction in accessing it even though it would help you self-manage - You have to be a certain level of unwell because of the way its funded, but it’s a way of self-managing without medication. • There’s no way of tracking your information to send to professional – It’s not a need or a big thing but obviously I do track my data.
• Patients want increased access to medical data so that they have more knowledge, control and direction over their own health outcomes. This will lead to a shift from ‘provider’ to patient-led care and from doctor support to data assistance.
• The essential principles of customer service are timeless, but consumer expectations are not. Customers have always wanted a friendly, efficient and reliable service, but with the development of new technology, their expectations have been raised.
• Continuity of care is important for patients.
• The data-driven online world means consumers expect a personalized service
• Users have high expectations of UK out-of-hours healthcare services.
• Our mobile-focused culture means customers expect your site and customer service to be “mobile-friendly”
• Healthcare is being revolutionised by technology which gives patients more direct access to qualified GP’s and moves the point of care into people’s home.
• Patient waiting times are impacting the delivery of safe and effective care.
ST EP • The disconnect in customers fulfilling expectations via self-service really is the crux of the requirement for a holistic engagement across channels, resulting in the reality of ‘Omni channel’.
It’s important to build out a digital self-service experience that is able to predict what customers are trying to accomplish and then guide them through that process.
• The rise of self-service has led to a generation happy to help themselves
Population aging, technological advances that have altered people’s perceptions around accessibility (online banking, smartphone applications, social networks etc.), and a shift in how people view themselves from ‘passive recipients of medical treatment’ to ‘consumers of health care’ are changing demand for care.
http://www.health.org.uk/sites/health/files/PatientPublicExperienceNHSChartbook.pdf https://www.salesforce.com/blog/2017/07/customers-expectations-in-age-of-the-customer.html http://hub.careinspectorate.com/media/268698/sg-report-of-independent-review-of-primary-care-out-of-hours-services.pdf https://www.thetimes.co.uk/article/nhs-helpline-callers-wait-13-times-longer-jgzj5hqnn
Our visions Long-term
Improve users self management to reduce presson on 111.
Give patiants a more accessible way.
Passive info given
Active info searching
Out of hour GP
We generated our visions from two stages in the future. First of all, we hope give patients a more accessible way to receive information. After that, we will focus on improving usersâ€™ self management and by this way to reduce the pressure on 111. Currently, patients receive medical advices through online searching by themselves. However, NHS 111 provides the medical advices by a more accessible and customized method. So, how can patients receive online information in a more accessible way?
For the long-term vision, in order to release the pressure. Once users dial 111, they could be led to a system firstly, they would be asked their symptoms and personal information. Then the system would analyze and triage users to direct them either to 111 or link them directly with medical treatments. This system will also provide care information to users by learning from the database of NHS inform.
Reflection During this week, we mainly focused on usersâ€™ self management behaviours and the literature reviews which could support our field research. We found the big possibility on self-service 111 with the proper technical support. The modern people affected by data-driven world, they used to access services very quick and very personalized. So, this is the reason why they have the expectation gap on the 111 services. The key value of self-service is that offers 24 hour-a-day support, and immediate access to information without having to wait for an email response or a return telephone call. By answering the previous question, we imaged two potentials in the future 111 service changing. Firstly, according to usersâ€™ behaviour, people prefer seeking more personalized medical advices. But because of lacking medical knowledge, itâ€™s hard for them to select the right information. So, they have to seek help from 111. Moreover, we hope to provide 111 users a platform that could provide help for them to self manage their unwell situation. Which might be more efficient than human assistant.
- Key insights - Concepts development - Concepts wall
Concepts wall Before we moved into the concepts developmet, we summarized our five key insights. Then under each insight, we started develope our concepts :
People have higher expectations of 111 than reality.
People want to see an improvement in the patient and clincian relationship.
• Providing users the time tracker, which lets you know where you are in the process.
• Users needn’t repeat their basic information many times. • When they talked with call handlers, their basic information have been sent to 111 in advance.
WHAT • Giving users care information and instructions in rich media, such as video, image and animation.
• The historical records can be shared in the whole NHS system.
People want increased access to medical data so that they can make more informed choices.
People want to be more involved in the healthcare process in order to have more control over their own health outcomes.
People need more continuity of care.
• Users can interact with different touchpoints during the calling process.
• Chatbot responds are built on a script set of branches created by platform, which based off the historical care.
• Users can be tracked even after the phone call, the after treatment advice can be provided.
• Before access to human assistant, users might access through a virtual call center pathway.
• Users can get more help from others except from 111 staff.
•“Have your syptoms changed since last time?”
Final concepts After the anaylizing of our 50 insights sheets, we generated our three key insights: Databad, Omnichannel and Chatbot.
A database that shares information between the patient and the clinician.
Omnichannel access to services. Patientâ€™s information is packaged and sent to the appropriate service.
Chatbot assesses your health and makes triage for a proper disposition under the urgent situation.
The database sharing and storing patients previous medical information and the current symtoms.
It not only helps people long-term manage their health, but also provide them the customed services when they use 111 service. In order to protect usersâ€™ privcacy, the permission of sharing and accessing should be comfirmed by users.
The omnichannel is an approach that aims at providing users a smooth, seamless and individualised service. It gives users access to information at all stages of the experience.
The secret of a successful Omni-channel is customer involvement, omnichannel system can improve customer engagement.
AI Chat Bots go one step further, providing simple but intelligent automated responses and / or services within a messenger platform. This allows you to ask a Chat Bot simple questions and have it deliver a helpful response. It can be applied on some messenger services we have alresy familiar with, such as Facebook Messenger and WhatsApp.
Reflection This was the most important week for our project, we collected all of our insights and restructured them. Every team member has own interested insights and direction want to move forward based on own desk researches. Thus, we combined and redefined some of the insights to be more specific. After doing that we finally generate five key insights which contain most of our valuable findings. In order to do the concept sheets, we redesigned the format of the original concept sheets. We started by writing ten ideas on the different coloured stickers, the different colour means it based on the relevant insights. Then we came together to presentation our own ideas from each insight. After the presentation, we chose some good ideas from each insight, and then continued develop on the concept sheets. Personally, I think through this way to develop our insights, we can generate the best ideas as we can. Because when we listen the other people presenting their ideas, we can stand in the new perspective to think. It is the most excited part of team work to me.
- 111 pathway - Omni channel
111 pathway In the current relationship between patients and 111, even when people try to solve the health problem by themselves, no matter they search online or seek help from other people, everything leads back to calling 111.
NHS self-help guides
Feel confused Internet
NHS 24 website
Call 999 (in accident and emergency)
friends/family Feel calm
Feel anxious Feel nervous
Suggest calling 111
Current channel Cross channel The current access to medical services is highly dependent on 111. All health issues, no matter urgent, like the A&E and Ambulance dispatch, or non-urgent, like the recommendated to self careand primary care, all have to go through the call handlers by phoning.
111 disposition data When we looked at the data of triage distribution, we found that emergencies such as ambulance dispatch and recommendation to A&E only take up about 20% of all the callers. So, if the 80% patients can manage their own health issues through other channels, it will greatly release the pressure on 111.
Recommendated to self care
50.2% Recommendated to primary care
Recommendated to A&E, Ambulance dispatch
Not recommendated to another services
New channel Omni-channel In the new channel, in the case of non-emergency issues, users can be referred to different medical services through a system according to the levels of the seriousness of their concerns. Only the really urgent cases where patients need a human's assistance will go to 111 call handlers.
OUT OF HOURS GP AMBULANCE DISPATCH
SYSTEM HEALTH CONCERN OCCURS MINOR INJURIES UNIT SELF-CARE ADVICE
DENTAL MENTAL HEALTH SUPPORT
Reflection After we framed our work into the filter system, which supported be by Chatbot. We then remapped current 111 channel, based on the previous research, we redesigned the 111 channel system to an Omni channel system. We did a lot of drawing and tried to find a best way to visualize our concepts. For example, we image the 111 users are the candy with different shapes. When they go through the 111 service, the system would triage them by different shapes (different medical treatments actually) to the different destinations. It really was a creative and imaginative task. The most tasks we did in this week were preparing for the presentation, we needed visualize every thing we had. From this aspect, I realized that a service design project outcome should not just be an idea in our mind, but a very completed idea contains the research proof, the visualized diagram and even an animation or a movie comes later.
- New user journey - Senario
User journey of Chat 111
Future scenario BUILDING DATABASE SMS
Receive a digital or phyhsical invitation from 111
Go to website to register
Fill in your basic info and health data
Add NHS 111 to your contact on your phone
Open the SMS on your phone
The clinician will give you instructions and prescription
Start chatting about your symptom
The bot will forward your prescription to the pharmacy
The bot will package your information and forward to the clinician
Get the guidance to the pharmacy
Get your medicine
Get a call back from a clinician
Receive a message from 111 asking your conditions
It was clear that the key points of our project:
Through considering different kind of patients and contexts, we did many conversational interactions from different situation/users (young, elderly, disabled, for somebody else, mental illness, injury, dental, non-emergency, low-emergency, high emergency) to show the different response on the platform.
• Triage • Self-management • Reduce waiting time Considering the motivation to use and data protection, we decided stop keeping the Database concept. Instead of link users to NHS 24 number as account, by phone number, e-mail address by the Chatbo/RCS text message. By asking users leave their email address and phone number, when assessment is down, then send them transcription by email or text each time after using. We were struggled with the waiting time issue, how can we provide service for the users during this gap? We got the inspiration from Elio, that the meaningful actions users can do during this period. Such as playing a video, or leave tasks to do, like take a picture or the other actions follow up.
Then we mapped out the new 111 user journey, which covers many types of users’ triage result. By just simply answering questions, patients would be triage to the proper medical care quickly. The highlighted route in the user journey was a typical care we chose as a sample to explain in the following step.
- Design proposal - Blueprint - Storyboard
Design proposal Chat 111 Manage your own healthcare beyond a phone call. Our final design proposal is called Chat 111. It is a Chatbot which enables users to assess their own symptoms. It is designed for all NHS111 users who living in Scotland with a smartphone and is accessible at any time. We imagine this Chatbot will be built into different chatting platforms so users can choose according to their own preferences.
We imagine that the Chatbot will ask the user the same questions as a call handler would if they rang them. The user might receive a text message from NHS asking them to add their contact information into their messaging applications. When people have an urgent health concern arises, and feel that they need health advice, but itâ€™s not an emergency situation. There is more than one way to access that advice. Rather than waiting for their health concern to escalate, they can address the situation head on - means that peopleâ€™s concern can be directed to the correct person. When the call is returned, they wonâ€™t have to repeat their information, as it will already be recorded. Even during the waiting time, Chatbot will ask a series of questions to monitor the progression of the users health concern and tell users the approximate waiting time. After the phoning, the report would be forward to the next medical setion.
Blueprint of Chat 111 DURING
BEFORE HEALTH CONCERN OCCURS
HELP SEEKING FROM CHATBOT
SMS; Facebook Ads; posters
Receive invitation from 111
Brief introduction of the ‘Chat 111’
Contact users by phone numbers
Mobile operators; Facebook
Chat app (e.g:Messenger, WhatsAPP, Wechat)
Search for ‘Chat 111’ on chat app
Add ‘Chat 111’ to contact
Greeting message User guidance and settings
Message 111 about health concern
Answer questions to describe symptom
Questions with answers to select from
Identify the patient’s information
Medical database (e.g: NHS inform)
Receive triage result
Triage result and suggestion
HELP SEEKING FROM HUMAN
Chat app In-app link/media
HELP OFFERED FROM CHATBOT
HELP OFFERED FROM HUMAN
Chat app In-app link/media
Wait for call back from 111 Book a call from 111
Receive call back from 111
Describe the development of conditions
SelfAsk for confirmation management guidance to call 111
Push-up messages (queue tracker; ask conditions)
111 call handler or clinitian
Add patient to the queue and keep traking
Record the conversation
Forward information to clinitian
Convert conversation to text
Clinitian receive and analyse the information
Receive a summary
Receive the prescription
Go to the pharmacy
Link to the summary
Map and opening hours of the nearest pharmacy
Archive the summary
Forward prescription to pharmacy
Get the proper medical treatment
Pharmacy prepare the medicine
BEFORE HEALTH CONCERN OCCURS There are three ways that people can be invited to join ‘Chat 111’.
Meet New NHS24 Chatbot
MANAGE YOUR OWN HEALTH BEYOND A PHONE CALL Available on multiple chat platforms:
Search for ‘chat111’ on any one of these chat apps. Add it to your friends list. Start chatting about your health concerns!
Poster from local pharmacy, GP, Boots...
The AD from website or social media
Message from NHS 24 Scotland
Search for â€˜Chat 111â€™ on chat app and add to contacts
Receive a welcome and simple guidance
HELP SEEKING FROM CHATBOT One mid-night, Emma feels serious headache but doesnâ€™t know why?
She decides to ask help from â€˜chat 111â€™
Not really serious, seeking for self management firstly.
Under a serious situation.
Answer a series questions.
Get triage result and scheduled for a call.
Get the estimated waiting time and self mangement advice.
Open it and read the instruction.
After 10 minutes, Emma receives a new message from â€˜Chat 111â€™.
Follow the instruction, lay down and have a rest.
Tracking for conditions and update in the queue.
HELP SEEKING FROM HUMAN
111 call back
Clinician is reading Emmaâ€™s report which is sent from Chat 111, and calls to ask Emma further questions.
Emma is answering more specific questions.
HELP SEEKING FROM CHATBOT
Get the summary and prescription
Ask if want to send prescription to pharmacy
Give a list of the near pharmcy information.
HELP SEEKING FROM HUMAN
Medicine is available for her to pick up.
I want to assess symptom for someone else?
I want the voice interaction support?
I want to view my historical summaries?
Reflection At the last presentation in the studio, we were given some feedback. It shows we still have some work should be improved. Firstly, as the limitation of time, we didnâ€™t really finish the user testing of our final design. We donâ€™t know if users really like this new system, but I believe there are still some details could be improved. Moreover, in the deliver step, we missed some situations of different person using process. The conversational interactions we presented was just one very specific case, but under the different context, the responses and triage result are different. We just had considered but didnâ€™t present them all. We considered present our final design by a video or animation, but as lack of the experience in animation making, we gave up this way. However, we decided to try to make a little video for the next presentation with NHS24. Which could be easier for audience to understand.
CONCLUSION First of all, I must to say I am very proud of what we did as a group in this project, even it was not perfect. From this long project, I learnt a lot from my teammates. Jessica was always passionate in everything, and she is very cautious about every research data. Thus, she contributed many valuable and reliable research data in our project. Mocha is very good at group work I have to say, she is my best partner in our group, we communicated a lot about our own interests and ideas, which helped me expand my vision to a large extent. And also, Yang and Annie, they were very nice and tried to contributed as they can. At the end, many thanks to my teammates. And special thanks our tutors, they gave us many helpful suggestions and feedback, which guided us the direction during the whole process.
GSA & NHS24: chat 111