Technology has done much to change the way healthcare is delivered. However, how those innovations are incorporated into daily workflows and care delivery has not always resulted in true usability. This has created inefficiencies that trickle down to providers and patients. By reframing technology designs around what works best for the end user, there are great opportunities for better care delivery and better patient outcomes.
In this episode of Nordic’s Designing for Health podcast, KeyCare CEO Dr. Lyle Berkowitz speaks with Chief Medical Officer Dr. Craig Joseph and Head of Thought Leadership Dr. Jerome Pagani. Dr. Berkowitz shares his views on how healthcare can adopt an innovation mindset, what healthcare can learn from the gaming industry, ways in which human-centered design can help improve chronic care management, and why SAD and FAATT are the keys to saving the healthcare system.
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Show notes
[00:00] Intros
[05:25] How technological advancements can’t just be a replication of pen and paper
[07:41] Examples of user-centered design done well in healthcare
[11:45] How SAD and FAATT are the keys to saving healthcare
[13:17] Ways in which KeyCare is harnessing user-centered design
[17:29] Instilling an innovation mindset into healthcare
[21:34] Inflection navigator, inflection point, black holes, and fire drills
[25:06] Principles of human-centered design to successfully manage chronic diseases
[26:10] Dr. Berkowitz’s innovation safari and its effect on patients
[28:35] Northwestern’s innovation program
[32:45] Combatting diabetes with user-centered design techniques
[37:40] Well-designed products that bring Dr. Berkowitz joy
[39:18] Outro
Transcript
Dr. Craig Joseph: Jerome and I are here talking with Dr. Lyle Berkowitz. How are you doing this morning?
Dr. Lyle Berkowitz: I'm great. Looking forward to the discussion.
Dr. Craig Joseph: Awesome. So, your background applies multiple aspects of what we're interested in talking about. You've got an academic background. You've practiced clinically for a long time, and you're also an entrepreneurial doctor, which you've kind of leveraged for multiple experiences.
Dr. Lyle Berkowitz: It's true. I've been very fortunate. I actually call myself a lazy doctor. People are like, “Oh, you're so busy with stuff.” All I'm trying to do is figure out how to get stuff off my plate that I don't think a doctor necessarily should do. How do we automate things, how do we delegate things? And as it happens, to make those things spread in scale, a lot of times you need some type of business solution that allows it to have a financial incentive model that can spread. And I've been fortunate to stumble into a lot of things in my life that lets me explore that.
Dr. Craig Joseph: Well, your background is a little unusual in that your undergraduate degree is in biomedical engineering. I thought everyone that wanted to go to medical school had to be a biology or chemistry major.
Dr. Lyle Berkowitz: You know, about a third of biomedical engineers will go into med school. I've actually met a lot of folks in the innovation and informatics space who do have an engineering and often a biomedical engineering background. So, it's not quite as unusual as someone would think, but it certainly sticks with me as engineers, where we're problem solvers. Right. And so, I remember as a med student, asking a lot of questions. And I remember that some doctors hated that I asked a lot of questions or challenged what was the dogma that they said, this is how we do it. And yet others liked it. And I was fortunate. And that this is now the, you know, sort of early nineties period when, because I had computer experience, at the time that meant I could go and use a CD-ROM for Medline. Some of the doctors really favored me because I could do research and do other things, and they were intrigued by technology, and others absolutely hated that I would ever question anything. And so, I learned early on, this is something I tell my kids, is the secret to happiness in life is knowing that you can't please all the people all the time. And I got some doctors who were great mentors and supporters and others who shot arrows at me.
Dr. Craig Joseph: So, do you think your education, your medical school, and residency were significantly different because of your engineering background or the way you thought, which might have been a little different than most of your colleagues?
Dr. Lyle Berkowitz: Chicken and the egg. My mom said there's a Yiddish term that they used for me when I was young that said he wants to know from whence it came. I would always take things apart and look at things. And a lot of us, you know, now and later. So, did I learn stuff in engineering, or did I go into engineering because that's how I was? I can't say for sure. But yes, I think that more than anything else, my understanding of what computers could do because as an engineer, of course, you know, I learned how to computer program, started in high school and into college. And that was a factor, and perhaps just my mental thinking. I spent a lot of time on mathematical modeling and thinking through processes, and it just becomes part of you as an engineer. And so, I have to think that made sense. And then the folks that I worked with at undergrad introduced me to folks in med school, the professors in med school, and I became a research assistant for someone who is a fantastic influence on my life, a guy named Arthur Elstein. He founded the Society for Medical Decision Making, and that parlayed into doing research with him on how do computers help doctors make medical decisions and what's the essence of medical decision making. And all of that was a big influence on me over the years to come.
Dr. Jerome Pagani: So that's actually a really interesting place to dive in a little bit because you wrote an entire book about how to get value out of technology that's being brought into healthcare, specifically around the EHR. Why couldn't we just reproduce what we had been doing on paper and use the EHR for that?
Dr. Lyle Berkowitz: One of the analogies I used to start with is video games. When I was a kid, I, and perhaps you, played a game called Dungeons and Dragons, it’s a fun game. It was paper-based, you had graphs, you rolled dice, etc. We used our imagination, and we made something happen. Years later, when the computer industry came, and the gaming industry came, they did not simply take that piece of paper and say, “Let's have a computerized version of graph paper and some dice.” They recognized the power of the computer to expand and create this three-dimensional world that allowed for a lot of usability and interesting ways to do things. And yet what happened in the EHR world was that we literally just took the piece of paper and turned it into a computer. Paper is really good at being paper. Computers are not really good at just being paper for things like this. We lost a big opportunity. I did a talk a number of years ago at the Mayo Clinic Center for Innovation in their conference and said the biggest mistake we made was we didn't bring in designers when we did the EHR. What did we do? We let engineers go to doctors and say, what should this look like? And they pull up their paper records and said, make it look like this. And we listen to them. And we did a really good job of listening to them. But designers know you don't just listen to people. You watch them, you observe them, you understand them, and you get the essence of what they're trying to do. And then, in the case of computers, you take advantage of all the things that computers can do. And we failed. We did not do that, and we're living with that to this day. You know, some of the things I've tried to do or to say, how do we use the EHR as a platform? How do we overlay on top of that? But we're going to be living with that early mistake for years. And I always look for companies that figure out how to really use human-centered design and thinking through how do we use technology to make life easier for doctors and better for patients at the same time.
Dr. Jerome Pagani: So, can you give us a few examples of where that's been done well, somebody has taken the principles of the way that people interact with technology, recognize that it's very different from the way we interact with paper and pencil, and then apply that in a healthcare setting successfully.
Dr. Lyle Berkowitz: Let me give you a couple examples. One is information visualization. I love that concept, that tool where you can take lots and lots of data and summarize and make it very easy to see. We've seen that in other industries. I think we're just starting to see that in healthcare. But the most obvious one would be, you know, using AI and other techniques to improve our radiology imaging. So, to make it more obvious to radiologists that there's a problem, an issue, to recreate tons and tons of data that we get from, I mean, even the CAT scan is essentially taking a bunch of slices of data and representing it differently. And now we're into 3D. A second opportunity was a company I started years ago called Healthfinch, and in that what we did was said that if something is rules-based, then you should be able to automate and delegate it in healthcare. And we did that for refills, and we said, look if a refill request comes in, and it's an if-then statement this is my computer brain thinking, then you don't need a doctor. Yeah. If the refill, you know, is for this medicine, and the patient has been seen in the past six months, and their labs are okay, then okay to refill until this period. You don't need a doctor for that. You can delegate that down to a staff member. If the refill request that comes in is a duplicate that was sent an hour ago by the same pharmacy, which often happens, then, you know, just ignore it. Again, now we're automating something, and that saves doctors’ time. And this is again, not rocket science. Some of the stuff is relatively easy. And yet, in our world, we didn't do that for years. All we do is send everything to the doctor and say, “Hey, doctor, you figure everything out, you be the computer.” And to me, that is a huge waste of time and resources when we have our most important, most educated person doing stuff that is rules-based. It just doesn't make sense to me.
Dr. Jerome Pagani: I hear a lot of that, the way to begin to think about technology is introducing efficiencies for things that are rule-based, be able to help doctors save time, triaging, imaging for radiologists is another great example. You mentioned how good A.I. has gotten and helping to do that. There also seems to be, and I think you're touching on it, sort of we're storytellers, right? People respond to stories, they store information in that sort of story format. And there seems to be a little bit of a role there as well. I mean, you touched on it with the video games. You know, it wasn't just paper and pencil and dice anymore. Now, there was a rich narrative that people could interact with and create a different experience.
Dr. Lyle Berkowitz: Imagine if when you walk into a room instead of seeing what looks like a word and Excel document for all the data that it looks like a video game and your patient is represented and he's fighting off the evils of diabetes and hypertension, and you're helping him with that. And, yes, the computer’s listening to you and understanding what's going on and you and the patient can together, you know, gamify and have fun actually managing. I mean, how cool would that be? But no one's gone there. And yet that is how the gaming industry and many other industries have thought about how to do these things. In the big picture, I often talk about my SAD philosophy to make doctors happy and patients healthy, and that's how do we simplify, automate, and delegate routine, repeatable rules-based care and a combination of AI, information visualization, using rules to automate, delegate, all these things come into play. And if we do that right, then doctors will enjoy coming to work. Patients will have a way to be able to explore and work within the health system in a way that actually not only makes sense but can actually be fun. So that's the ultimate goal.
Dr. Craig Joseph: So, it's interesting that you brought up SAD (simplify, automate, and delegate). Jerome and I are focused on making healthcare work for humans. And you've written about this and thought about this both at the macro level and at the micro level. Micro level, talking about how to help an individual doctor, via your SAD philosophy. At the macro level, at the health system level, you also have an interesting acronym, FAATT.
Dr. Lyle Berkowitz: Yes. So, I say to save the health system, we need to get SAD and FAATT. So, what does FAATT mean? I spell it F, A, A, T, T, and that's how to use financial incentives, artificial intelligence, automation, telehealth, and teamwork. To me, these are the elements that will let us better utilize our doctors, our technology, etc., and get to a place where we often say we don't have a shortage of physicians, we have a shortage of using them efficiently. Every other industry, banking, entertainment, commerce, travel, etc., has figured out how to use self-service automation, computers, etc., to simplify things. And you only need the expert if there's something unusual going on. And so, I think that is a way and of course, I'm a doctor, so we need acronyms. This is how we remember things. It so many different acronyms that like. So, I did not start out trying to come up with something that was sounded like the opposite of what we usually recommended, but sometimes people remember that better. So yes, let's get SAD and FAATT and save the healthcare system.
Dr. Craig Joseph: I think that's good advice. So, you've taken some of these principles and applied them to companies that you started. You referenced Healthfinch earlier, which was mostly automation, taking things that we really don't need doctor's insights for and delegating those either to someone else or to let the computer do it yourself. Your most recent company that you just started is KeyCare. Can you tell us a little bit about that and how you're taking some of these principles and plowing them into the company?
Dr. Lyle Berkowitz: Yeah, so KeyCare was started with the premise that, particularly with COVID, you know, the demand for virtual care, you know, went up immensely in 2020 because of COVID. Health systems went from doing a very small portion to, you know, majority of telehealth in the nation. They went from, you know, what would be a couple of million a year to 200 million visits, etc. And the truth is that that it's some people will say it's, you know, the genie is out of the bottle, whatever you want to call it, patient demand continues to be high. This is something that works, that makes sense. Doctors recognize, okay, this works as well. However, for most health systems, their doctors, you know, are ready to go back to the office. They are, in many ways, officeologists. They're used to the benefits and pleasure of working in an office. Everyone in the office is geared around making the doctor's life easy, and it makes sense for them, and that's what they're trained to do. Whereas virtualists are a whole different breed of doctors, similar to how we had hospitalists, in the 1990s, come up, virtualists now are doctors, providers who are not only used to doing things online but also understanding that the, you know, the pros and cons of that, much easier access for the patient, maybe you'll have a little less information because you're not in front, but there's still plenty of ways to take care of them. And it's particularly good for more routine type of care. So, we said, well, for the health systems to do this, you know, I could either create this wonderful platform that's trying to optimize around virtual care and then figure out how to integrate with all the health systems. But again, I'm a lazy doctor. I don't want to have to start from scratch. And I look around, I say, well, hey, you know, over 60% of health systems in the U.S. are using Epic and I don't need to start from scratch. Why don't I get the platform that everyone's using? And the truth is, I was talking to friends at Epic, and see if there's anything I could do to help in helping them work with health systems to improve virtual care, and this idea just bubbled up and made sense. So, we basically have started this company where we have an instance of Epic, and we are loading up with virtualists, optimizing our Epic instance for virtual care, and optimizing our Epic instance to serve other Epic sites. Because Epic actually has very good interoperability between two Epic instances, so that not only is data transferred bidirectionally, but another other Epic instance can use technology Epic's created, called Telehealth Anywhere and Book, Anywhere to schedule appointments. There's ability to move orders and messaging, etc., across two instances. And so all of a sudden we can support other Epic sites, we can actually support non-Epic sites as well using standard interoperability functionality, but it's particularly attuned right now to other Epic sites. And the result is that the experience is much more seamless for patients. You know, we are of service to the health systems. We're not trying to create our own brand. We want patients to go to their health systems. We feel health systems are extremely important and still be able to access virtual care options 24/7 that the health system themselves might not be able to offer. And the result is not only a better experience, but better quality because data is shared, because we felt the fundamental issue of good telehealth is not having a good video experience. It is having the ability to talk to or work with another provider and ensure that the data is being shared so that they can make the most appropriate decision. And anything that they do is transferred back to the primary care providers so that they know what's going on.
Dr. Jerome Pagani: The pandemic was a big driver of technological adoption, but as you mentioned, innovation is happening in other industries outside of healthcare all the time. But healthcare is by nature a little bit conservative. So how do we get that innovation mindset into healthcare?
Dr. Lyle Berkowitz: Well, I do worry sometimes a lot of health systems fall into the trap of being victims of their own success. When demand outreaches supply, you don't really have to think about do we have to do things better. We just try to deal with demand. And what I think, and one of the reasons we created KeyCare was not simply to take a few visits, you know, virtually, but to really help health systems fundamentally rethink how they manage a population. I don't think of KeyCare as a telehealth, a virtual care company, as much as I think of it as a population health enablement company. And the idea is how do we take as much of the routine care as possible in the big population pyramid and automate and delegate as much as possible to a partner like KeyCare so that we, in the end, want to be able to go to a doctor, primary care or even a specialty doctor and say, “Hey, how would you feel if we can increase your salary because you're the executive at the top of the pyramid, decrease the number of patients you have to see in person every day, and enable you to see a larger panel and improve the quality. Would that be okay with you?” Every doctor in the system would probably say, “Yes, that would be great. What's the catch?” We say, “Well, the catch is you've got to go back to SAD and FAATT. You've got to embrace the idea of team-based care and feel comfortable using analytics and other technologies to understand your population, to understand who needs to see you today, and who is okay being monitored via remote patient monitoring, who is okay to do a visit with a partner that may be a lower-level provider based on rules that may perhaps you've created?” How do we get the doctor to be the top of that skill set? How do we do what every other industry has done? Again, think about banking and consulting and many other industries and put the doctors, the CEO of their panel, and how do we think about increasing the panel size from a typical primary care of 2000ish to 5000? Because if we do that using this technology and these philosophies, everybody wins, right? You've got, patients have easy, convenient access.
Dr. Jerome Pagani: What I think I hear you saying is using those data to generate the kind of insights that allow everyone to operate at the top of their license while improving the patient experience and their outcomes.
Dr. Lyle Berkowitz: Correct. So, we start with exactly that promise. You know, we understand the patient better. And we understand, by the way, and this is some human-centered thinking. We understand that patients are different in different situations. When they have a routine issue, they're often quite happy with having a convenient, commoditized experience, just like booking an airline ticket. Right. They don't need to talk to anyone. But you want to do a, you know, an amazing experience to Bali or Greece, you're more likely going to talk to a travel agent. If you have a complex medical problem, you want to be able to talk to your doctor. So, patients win both ways. They have an easy issue, they go online, take care of it as quickly and easily as possible. Some combination of self-care, virtual care, etc. The more complex problem though, they know, hey, my doctors can be available for me. I'll be able to do a virtual visit with my doctor or get into the office to see my doctor because they have more openings, because they are not being overwhelmed by all the routine stuff at the bottom of the pyramid. Right? In the same time, the doctors, you know, now, their life is getting easier, but they're getting appropriately compensated for building a big panel. The health system's happy because whether they're fee for service or value-based, a large panel size always works out. In a fee-for-service, well, large panel size means more overall downstream revenue in a value-based world, of course, bigger panel size, larger capitated payments.
Dr. Craig Joseph: So, Lyle, you wrote the book on innovation in healthcare. And one of the chapters, you talk about an inflection navigator, and you use the terms black hole and fire drill, which is curious in a book about healthcare and innovation. So, could you talk a little bit more about what an inflection navigator is, what's an inflection point, and how black holes and fire drills are related?
Dr. Lyle Berkowitz: Yes. So, a lot of times I do like language that sort of explains things. So, this now gets back to my engineering background, right? Every engineer knows whether an inflection point is everyone who took, you know, math in high school might remember the inflection point is where there's a sudden change. Right. And I saw this as a primary care doctor for 20 years. Someone would be going along, everything's fine. And then, boom, you know, they have appendicitis, they break their leg, they have some abdominal pain, a CAT scan finds liver cancer. All of a sudden, overnight in a matter of minutes, your life completely changes. That's an inflection point in your health. And at that point, your healthcare needs go up dramatically. At that point, your quality and your quick access to someone is extremely important. And yet what we often find is that during this fire drill, not everything goes as smoothly as you'd want, even though we know exactly what should happen. There are very specific things that should happen when you have, you know, a heart attack, get diagnosed with cancer, find some abnormal lab finding. Why does that not always happen? Because sometimes people are moving too quickly. They forget things. People are fallible, computers are much less fallible. And when there's a checklist approach, which our friend Dr. Atul Gawande has highlighted, etc., same idea, doesn't have to just be for surgery, it can be for medical issues as well. So I brought that approach in because, otherwise sometimes you fall into a black hole and the black hole is where not everything gets done, things get missed, people forget things, etc. And so the inflection navigator was based on when something bad happens, we assign a navigator, not a licensed professional, you know, a coach of some sort, it could be a nurse, but not a doctor, to make sure these five things happen. So if you get diagnosed with cancer, there are certain things that can and should happen in a short period of time. And we actually focused on a couple issues. One was cancer in general, another one was hematuria, blood in the urine. When you have red blood in your urine, that's a significant change and often is related to a diagnosis of cancer. And if you don't take it seriously, if you don't get everything done in a short period of time, you know, there's a risk to that. And so, we created a checklist. And then that checklist was, as soon as a patient has that, you can initiate this inflection navigator system with one order in our EMR, and that would then set off a chain of events that ensured you got a CAT scan, the right type of CAT scan for that condition, that you would have a follow-up with the urologist, that you would have urine sent for cytology, and that, you know, two weeks after this process started, you would get a call from a nurse to make sure everything happened. We actually published a paper. As a result of that, we were able to decrease the length of time it took to get a final diagnosis, which was much of the time, cancer, by a month. That month could be life-saving some time. And it just decreased the chance that something would get missed, that something would get delayed.
Dr. Jerome Pagani: We've talked a little bit about human-centered design. Can you give us an example of a principle of human-centered design that's been successfully applied to the management of chronic diseases? And I'm thinking here of that principle of starting with the end user in mind.
Dr. Lyle Berkowitz: Yeah, the front line is extremely important, you know, whether it's the patient, the doctors, etc. And what's also important is not simply asking them, you know, what they think. Ask them what they feel, watching them, and seeing what they do. Is that consistent with what they say and what their feelings are? And in the end, clarifying what problem are you solving for them? Because people aren't going to change their behavior if you're not solving a problem for them in some form or fashion. And the more you understand the essence of who they are, who they are, what they think, what they feel, how they act, etc. That will help us solve a lot of things in healthcare, from designing EHRs to improving diabetes to any other sorts of care that we provide to them.
Dr. Craig Joseph: So you've been talking about being on the front line and you would say it's very important for you to get in to see what the patient is doing at home, because sometimes the story changes a little bit when you're actually able to see. That sounds very similar to me to these innovation safaris that you have gone on. And I would love to hear you tell us more about what an innovation safari is and how it helped you and the patients.
Dr. Lyle Berkowitz: I mentioned I was part of this group called the Innovation Learning Network. We met twice a year, and we learned about innovation techniques. We shared stories about innovation from new techniques and wins to get interviews sometimes for trying to change something. But we also went on innovation safaris. And this is where you go to places that are different than healthcare, they’re non-healthcare related, and you learn about how they think about innovation, how they and they may not call it innovation, they may just simply be part of how they work, how they improve things, etc. As an example, you know, a group went to a NASCAR garage and found that at the NASCAR garage, every single piece of equipment, every nut and bold that went into a car, have your initials on it, whoever put it on. Right. That's accountability. You know, that is accountability. You want to talk about accountability. Think about that. So that something broke, you know, you know who screwed that in. And of course, they have incredible efficiency gains from how they figured out how to work together as a team. So you take from that. We looked at Tom shoes, right. We have this marketing campaign, buy one and we’ll give one to someone less fortunate. And that drives people to do something they might not normally have done. And we said, how can that be applied in healthcare? You know, we've seen Walgreens do that with vaccines where you get a vaccine, we'll give it to someone less fortunate. We said, what if we could do it with colonoscopies? You get a colonoscopy, and we'll make sure someone less fortunate gets one. Like there are triggers that help you feel better about doing something for yourself if you know it benefits others. We go to Nordstrom's and talk about customer service. I actually did this here in Chicago with executives from Northwestern. And, you know, they loved it, right. Because the type of customer service you get at a place like Nordstroms is incredible. And we think as a health system, patients first, we’ll give great customer service. We learned a lot that day when we learned how they empower their people and individuals to make decisions that are right for the end user. And how do we take that into healthcare? So, it's a great thing to do. Every health system out there can and should be thinking about all the businesses in their community. You can learn something from all of them, guarantee you, every day. They may not think they're innovative, but they're doing something that you can learn.
Dr. Craig Joseph: So tell me more about the innovation program that you created at Northwestern.
Dr. Lyle Berkowitz: So, around 2005, I was asked by my group to help set up our executive health program. I was known in my group for doing new things, being willing to be that guy and just willing to take on the new things. So I was happily excited to do this and help set it up. In the course of that, I met some really interesting folks who, of course, were executives. And I met this one guy, Peter Salozey. He was one of my favorite patients ever. By the time I met him, he, unfortunately, had been diagnosed with some cancer and heart issues, etc. He’s only like 55, the age I am now. Peter has asked me to share his story and has since passed, but at the time when I met Peter, he was essentially the chief innovation officer, even though he didn't have that exact title, for a local businessman, and he was just inherently one of the most innovative people I've ever met. And he was always challenging. He would say, “Don't tell me what you can't do.” And he and I would meet almost every week because he had so many issues, and we would, so the cancer folks would change one thing that would affect his diabetes and his heart and etc. And every week we would fine-tune him. And every week I'd hear about these horrible stories of having to navigate the system. And the idea of the inflection navigator came out because he himself had suffered because they didn't diagnose his renal cancer quickly enough. The idea of the cancer care in general, heart disease, a lot of the things I did were actually based on this one human being who was meaningful to me, who had a lot of experiences and always asked, “How could this have been done better?” And he wanted to make sure others did not go through all the inefficiencies and issues that he went through. And when he passed, we had spent a year or two, you know, just always trying to talk about how to improve the system. Some of his friends and colleagues provided funding for us to start what became the Salozey healthcare innovation program, we called it the SHIP program, and that was one of the earlier innovation programs in a health system in the U.S., and it enabled me to actually have the time and some money to learn about innovation. That was a springboard for me to go out, join the Innovation Learning Network, take courses and learn about human-centered design, and understand that innovation is both a concept but also a science. And how do we bring that into healthcare and how do we think differently? And that funding continues to enable us to do new things and springboard and educate others. One of the things we did, for example, was pull our process improvement team, who initially said, well, this seems just the same, but we recognize the real difference was there were some new tools and techniques that we could incorporate the process improvement. But the essence was a process improvement team takes a process that's working well and tries to make it better. It's 95%. Let's make it 99%. An innovation team, particularly process innovation, is a team that takes something that is not working and just starts from scratch and tries to do it over. And that essence was a different way to look at things. So, there were processes that the process innovation team could not fix or could not improve because they were just so bad to start with that it wasn't actually something that just needed the fine-tuning that they could do, the Six Sigma type of work, even the lean work. And in those cases we would just say, “Hey, let's start from scratch and let's rethink something.” And so it brought into Northwestern these new concepts and ideas, and I'll be forever grateful to Peter for really helping me take sort of my energies and the concepts that I knew sort of and thought about inherently and really learn and think about them more, have a human who could help me think about exactly how we could improve it as well as eventually, you know, take my fate into this, this new world.
Dr. Craig Joseph: So we've talked about a few examples already of how you've applied user-centered design techniques to patient care. Are there any other insightful examples that you could share with us?
Dr. Lyle Berkowitz: And so one of my favorite projects was what we call the Extreme Diabetes Project, and it bothered me that a number of my patients had poorly controlled diabetes. They had a hemoglobin A1C consistently over nine, and to the medical professionals, that means that's poor control. It should be under seven. Yeah, seven to eight is poor control, eight to nine is worse control. Over nine is really, really bad control. And yet these patients seem to be feeling okay. But we knew that their long-term prospects were not great and I wanted to understand what the heck was going on. I was at a conference for the Innovation Learning Network, which was a nonprofit consortium that I was involved in, and we learned about something called video ethnography. And that is where you go in and you interview a small number of people and videotape them, take notes, etc. And from that relatively small sample size, you're actually able to get some really good conclusions. So I said, Let's do this. And so I funded a project internally at Northwestern, and I asked my colleagues to nominate some of their patients who had a consistent hemoglobin A1C over nine and would be willing to talk to us and we would pay them a little money. We would go to their house, because going to the front lines, whether it's talking to doctors, nurses, or patients, it's all about the front lines. We would go to their house, we would videotape, we would have a professional interviewer, ask them consistent questions, and we'd see what we learned. And that's what we did. So, we had about eight patients who agreed to this, this is what we needed, and we went to their homes. I went once as a, not as a doctor, but simply as a photographer. I took a couple of pictures. Right. And we learned so much. The interviewer was great. And they would ask them, you know, do you understand what diabetes is? Do you understand that you have diabetes and that's not well controlled? And I remember one of the first ones we went to and talking about this and say, well, do you, you know, do you take care of yourself? Oh, yeah, I got an exercise machine. And like we panned the camera over to literally that exercise machine covered with layers of clothes. Like no way that that's getting used, right. But if they answered in another setting, we'd say, “Oh, great, he exercises.” And then they pull all of these together and they spent a couple of weeks distilling it down to a number of themes. And then I invited, of course, my team, but also a variety of folks from our Endocrinology Diabetes Clinic, from our engineering school, etc., to sit down and listen and then break out into workgroups and brainstorm based on the themes that we found. And the themes we found were this, when we asked patients about diabetes and to understand what diabetes is, we assumed, of course, they don't understand it because otherwise they’d take it more seriously. We were wrong. They all looked at, oh, diabetes, our glucose is high. We understand what can happen. Yes, it can affect your organs and your kidney and other things, and you could die earlier. So, they understand it. But then we asked, do you understand that you have diabetes? Well, my doctor says I've got a touch of diabetes, and they're worried about it, but I feel fine. And it hit me, oh, my God, we talk about hypertension as a silent disease. Diabetes, in many cases, is a silent disease. For whatever reason, not every patient has a lot of symptoms. And then, we really started to brainstorm around this fact and came up with ideas. We don't need to scare patients about how bad diabetes is. One, they know it. Two, they don't respond well to that. What we did instead was created a very simple piece of paper that said, “Know your numbers: green, yellow, red. Hemoglobin A1C.” All we’re going to do is focus on that. Keep it simple. If your number is nine above that, that's red. That really is important. You have to discuss that. You have to think about going on medication for that, etc. And we instituted that. We also came up with ideas, idea of a Diabetes Tune-up project, where we would nominate a patient with poorly controlled diabetes to go in and meet with our diabetes clinic, the diabetes educator, the endocrinologist, adjust their medicines, learn, and understand. And most importantly, the use of a continuous glucose monitor today is being used more frequently. But 15 years ago, was not being used frequently. We had to get special permission, essentially from the insurance company to pay for it because when patients saw what their glucose was consistently, it made a difference. And in the end, this is the essence of human-centered design. We didn't go in thinking we understood everything. We asked the end user what they thought about stuff and what was going to make a difference for them.
Dr. Jerome Pagani: So while we've been talking about how to make healthcare work for humans, and we've had some great examples from you about what's happening within healthcare, what are up to three examples of a process or an experience or a product that sits outside of healthcare that are so well designed that it just brings you joy.
Dr. Lyle Berkowitz: So I'll tell you one, is one of my favorite apps, I'm surprised more people don’t have this, it's called Captio. The app is so simple. All it does is you open it up, you type whatever you want, and it emails whatever you type to yourself. Because to me, that's easy. That's one step as compared to going in and pulling out my email, typing in my name, etc. I'm an efficiency nut. And so I love that app. It's my favorite app. It's my front page. I use it multiple times a day. Second, my friends and family make fun of me a little, but I love TikTok. I think TikTok is extremely well-designed. Yes, it's a little addictive. I learn a lot and I actually apply this. I follow TikTokers who, you know, sometimes it's cooking or interesting historical events, sometimes some dad jokes, etc., but it's fun for me in the downtime to be able to relax. It knows what I want. It's surprisingly good at doing that, so I'm a big fan. The third, I have to say I'm a huge fan of Disney, Disneyland, going to Disneyland is one of my favorite things. I don't do it enough, but to be able to take my kids, etc., is just, it's such a throwback and such a well-designed place. That's it's one of my favorite experiences overall.
Dr. Craig Joseph: Well, Dr. Lyle Berkowitz, thank you very much, a healthcare innovation expert. We appreciate your insights and really enjoyed this conversation.
Dr. Lyle Berkowitz: I'm glad to share. Keep up the great work.