How to deliver user-centred healthcare design

‘The cure for the pain is in the pain.’

Rumi

Key to any healthcare intervention is understanding and addressing personal experience. In clinical practice this is done by taking a history, observing, testing, and examining. We manage, assess, and reassess.

The factors forming personal experience are always complex. It’s only once the ‘pain points’ within that complexity are understood that effective interventions can take place.

In technology-enabled healthcare, design-led approaches can be used in a similar way to clinical methods to understand user experience and solve complex problems, as well as considering how best to deliver solutions.

These approaches have a long history in business. Management consultants McKinsey found, for example, that companies with strong design practices increased their revenues at nearly twice the rate of industry counterparts  (https://www.mckinsey.com/capabilities/mckinsey-design/our-insights/the-business-value-of-design, n.d.)

Today’s CCIO needs an understanding of these approaches to effect digital transformation.

What is User-Centred Design?

Human or user-centred design (UCD) is the creative philosophy and associated processes used to understand and address user needs, especially where problems are complex (Snowden, n.d.) (Norman, 2013).

In the ‘Design of Everyday Things’, Donald Norman describes how this complexity often manifests itself as difficulty defining the specification of a product or service.

UCD addresses this by deliberately avoiding specifying the problem at an early stage. Instead, UCD focuses on the iteration and rapid testing of ideas, allowing test results to quickly feed back into modifying the approach and the problem frame.

The design process allows us to ‘find the right problem to solve and to solve the problem the right way’. The result should be products and ‘services that achieve outcomes that solve problems for users’ (Vaananen, n.d.).

The double-diamond approach to innovation

‘Wherever there is decision there is design.’

(Grinyer, 2021)

Figure 1: Version of UK Design Council’s Double Diamond diagram (https://www.designcouncil.org.uk/our-work/skills-learning/tools-frameworks/framework-for-innovation-design-councils-evolved-double-diamond/, n.d.) (Vaananen, n.d.)

Figure 1 depicts a version of the UK Design Council’s double diamond process model for innovation (https://www.designcouncil.org.uk/our-work/skills-learning/tools-frameworks/framework-for-innovation-design-councils-evolved-double-diamond/, n.d.).

It’s divided into four stages, although the process is not linear and there will often be a need to return to a stage as more is learned. It’s often necessary to reframe the problem to get the best solution.

These stages are:

Discover – understand the problem as completely as possible. This might include desk and user research, such as surveys, interviews, empathy mapping and observation (Muratovski, 2016). Observation can be ‘participatory’.

The best design is usually done in the place where it’s needed. If good user research isn’t done, assumptions about the problem can generate solutions that don’t meet user need (Nuckley, 2023).

Define – take a closer look at the challenge by analysing material from the discovery stage. Specific tools can include service interaction mapping and service blueprints (Grinyer, 2021).

Develop – Once the problem is more clearly defined, brainstorming and other divergent thinking methods can be applied. This is likely to lead to creative solutions, especially if a non-hierarchical approach is encouraged to deprioritise the loudest voices in the room.

Deliver – flexible prototyping and testing are central to delivery (Agile and government services, n.d.).

Other frameworks, tools, and processes

Figure 2 Examples of tools used within the design process

There are many other frameworks, tools, and processes within the discipline of ‘design thinking’ that can help explore challenges and generate solutions. The key is to select what’s appropriate for the type of problem being worked on. (Muratovski, Research for Designers, 2016).

Continuous or quality improvement, for example, sits under the design umbrella within the field of ‘action research’. It’s well suited to systems where there is a requirement for existing practitioners to “investigate and evaluate their own work’ (Muratovski, 2016) and where there’s considerable ambiguity around how to make improvements.

Further examples of frameworks, tools and processes are shown in figure 2.

What does UCD mean for CCIOs?

“I wish people would stop trying to sell me solutions for problems that I don’t have”

NHS CCIO

UCD means being able to deliver effective digital transformation

UCD is vital to delivering digital strategy, building team capability, and encouraging a culture of innovation. The CCIO is usually at the heart of this, often acting as the interpreter for multidisciplinary teams. Adopting a UCD approach means that there’s a tried and tested philosophy alongside effective tools and processes that a CCIO can employ in pursuit of effective digital transformation; whether that’s through clinical leadership for EPR implementation or evaluating the latest artificial intelligence tool.

UCD gives CCIOs ways to deal with complexity

In healthcare, the relationship between cause and effect is often not linear, e.g. implementation of an EPR and the impact on patient safety. Key features of UCD, such as user research and iterative methods are geared towards dealing with complexity (Snowden, n.d.).

UCD means being able to deliver concurrently

Figure 3 Concurrent Development Browne, 2023

Well-functioning modern digital teams in any industry need to be able to develop their strategy, design, and delivery concurrently, rather than in sequence (fig 3 (Browne, 2023).

Adopting a UCD approach allows CCIOs to move away from continuous pilots towards working practices that are more likely to uncover bias and generate truly new ways of working (for example, see Royal Free London’s approach to intelligent automation – (Ali, n.d.)).

How can CCIOs implement UCD?

Bring the user in

Implementation of UCD can begin simply with a commitment to making steps to bring in the user. For example, by ensuring completeness of stakeholder mapping and conducting interviews with users early in the design process.

Increase design capability

Design capability can be increased internally through education and recruitment of professional designers, as well as exploring engagement with external design specialists.

In user-centred work we did in NHS England, for example, our discoveries informed an education programme aimed at building design capability in one team. Through surveys and interviews we established a curriculum that would increase the user-centredness of our work via individual practice and team culture (figure 4.)

By adopting similar practices, CCIOs can discover how best to implement UCD in their own healthcare organisations.

Figure 4 Design Capability in the Digital Care Models Team, NHS Transformation Directorate 2022

Credits for figure 2 & 4 to Helena Traill , Healthcare Designer

Thanks to Tero  Vaananen , Tony Browne and Pete Nuckley for their help with the preparation of this article

Works Cited

(n.d.). Retrieved from https://medium.com/wardleymaps .

(n.d.).

Agile and government services. (n.d.). Retrieved from https://www.gov.uk/service-manual/agile-delivery/agile-government-services-introduction

Ali, L. (n.d.). Retrieved from Innovation Collaborative Blog: https://gbr01.safelinks.protection.outlook.com/?url=https%3A%2F%2Ffuture.nhs.uk%2FInnovationCollaborative%2FmessageShowThread%3Fthreadid%3D10678606&data=05%7C01%7Clia.ali%40nhs.net%7C69c103ec10d34b6fd40c08db2a2e6deb%7C37c354b285b047f5b22207b48d774ee3%7C0%

Browne, T. (2023). Digital Transformation – personal communication.

Grinyer, C. (2021, October). Lecture on Service Design. MSc Healthcare and Design, Royal College of Art.

HBR. (n.d.). Close the gap between designing and delivering a strategy that works. Retrieved from https://hbr.org/sponsored/2017/10/close-the-gap-between-designing-and-delivering-a-strategy-that-works

Holmes, K. (2020). Mismatch: How Inclusion Shapes Design. Cambridge MA.

https://www.designcouncil.org.uk/our-work/skills-learning/tools-frameworks/framework-for-innovation-design-councils-evolved-double-diamond/. (n.d.).

https://www.mckinsey.com/capabilities/mckinsey-design/our-insights/the-business-value-of-design. (n.d.).

Loosemore, T. (2017). Retrieved from https://public.digital/definition-of-digital

Muratovski, G. (2016). Research for Designers. SAGE.

Muratovski, G. (2016). Research for Designers. Los Angeles: Sage.

Norman, D. (2013). The Design of Everyday Things. Cambridge, Massachusetts: MIT Press.

Orton, K. (2017). The Sweet Spot for Innovation. Retrieved from https://medium.com/innovation-sweet-spot/desirability-feasibility-viability-the-sweet-spot-for-innovation-d7946de2183c

Smith, R. (2021). Retrieved from Making content about skin symptoms more inclusive: https://digital.nhs.uk/people/nhs-digital/blog-authors/rhiannon-smith

Snowden, D. (n.d.). The Cynefin Framework. Retrieved from https://thecynefin.co/about-us/about-cynefin-framework/

Vaananen, T. (n.d.). Retrieved from https://digital.nhs.uk/blog/design-matters/2020/design-is-the-strategy

Vaananen, T. (n.d.). Retrieved from https://digital.nhs.uk/blog/design-matters/2022/products-deliver-outputs-services-deliver-outcomes

Everything a CCIO needs to know about Cyber Security

The risk of a cyber-attack in healthcare has grown dramatically over the past 20 years with many, such as WannaCry and Log4J, affecting the NHS directly. As a result, the question is now when, and not whether, a cyber-attack will ever happen to you!

Are cyber-attacks growing?

Since the introduction of Electronic Patient Records (EPR), the risk and severity of cyber-attacks has increased. Although EPRs improve transparency and patient care, they have the downside of increasing digital exposure and reliance on digital processes.

Cyber-attacks on healthcare organisations can come in a variety of guises. For example:

• A direct cyber-attack on a specific NHS Trust, such as removing connectivity to a network or system. This may be done using malware, such as ransomware.
• A cyber-attack that spreads across multiple organisations preventing access to devices that become infected with malware.
• A cyber-attack on a product supplier, impacting multiple systems across multiple organisations that may include health, social care or both.
• A cyber-attack against systems to steal data for the purpose of extorting funds.
• Cyber-attacks that involve the hijacking of business processes to redirect funds from valid financial transactions to attacker’s accounts.

Cyber-attacks can have a huge impact

As cyber-attacks are a risk and not a certainty, it can be easy to deprioritise them in favour of higher-priority pressures. These might include an infection outbreak or needing spend money on a new medical device.

However, if you’re thinking that, you should consider the question, ‘what happens if all our Health IT suddenly becomes unavailable?’

Will:

• You know which patients are due to attend for appointments?
• You be able to admit or discharge patients and see their previous clinical records?
• Reporting be available to show operational pressures?
• There be visibility of your hospital beds and who is in them to manage patient flow?
• You be able to access diagnostic tools for critical healthcare interventions?

If digital workflows become unavailable, this impacts every process – from clinical work to finance, with a major impact on patient safety. Being vigilant and aware of the threat posed by poor cyber security, and keeping systems safe, is everybody’s responsibility.

Why do attacks happen?

But why do people carry out cyber-attacks, and why attack your healthcare organisation? There are several possible reasons, with the most common being financial, or a desire to disrupt systems and core services.

The most common motivation for attackers is gaining wealth at your expense; by stealing your data, holding your systems to ransom, or hijacking your processes to divert funds. These attackers are often well-organised criminal groups with well-established ways of working, and they can act quickly.

Where funds are not the goal, the most likely motivation is disruption. Disruptive attacks can be undertaken by anyone interested in causing harm, and can include hacktivists, or anti-governmental organisations. Hacktivists tend to be less well-organised and impactful.

Cyber attacks – are you ready?

Someone will always press on a ‘dodgy link’ in an email, and we need to engage and train staff to prevent this. However, we also need to adequately fund and support robust infrastructure. It’s essential to consider clinical safety when implementing any process involving access to clinical information.

Key points that should be considered include:

• Are staff adequately trained to reduce the chances of a cyber-attack? Ongoing awareness activities are needed to keep everyone alert to the risks they face.
• Are staff ready to respond appropriately when a cyber-attack happens? The period where an incident is being managed is generally the worst time to try to devise new actions.
• Are all your products up to date with patching to prevent an attack?
• Is your desktop estate fit for purpose? There should always be a plan and a budget to replace devices. Machines can become extremely slow and along with causing frustration for staff, this potentially creates vulnerabilities.
• Can your software update with new patches? Windows 7, for example, is no longer supported by Microsoft and can’t be patched if a vulnerability is found. This makes it easy for an attacker to get into your systems.
• Do you have the appropriate technologies to defend your organisation, such as firewalls, anti-virus and anti-malware products?
• Are Business Continuity Plans (BCP) in place and rigorously tested? Testing is vital to ensure your plans are functional and can support your organisation through periods of unavailability.
• Have full timescales been considered from recovery to business as usual (BAU)? Do your plans cover up to six months of unavailability? It has happened before and will happen again.
• Do your recovery plans account for data accumulation outside of your digital platform? If you have 6 months of data collated on paper for an entire EPR system, how long will that take to repatriate back into the system and what administrative resource would that require? The sheer volume of data created from one week of BCP means paper is not the solution. Options may include a failover data center, a simple eforms platform, or even the ability to revert to a backup.
• Have you assessed how vulnerable your organisation is to phishing attacks? Tools are available to audit the likelihood of a staff member pressing a link by, for example, sending a deliberate phishing email.
• Do you have your data backed up?

Taking things forward

As senior management, it’s never been more important to prevent cyber incidents and to know what actions to take if one occurs.

Whether you’re working to achieve CCIO status or an experienced CCIO already, you need to have the defence and resilience required to ensure the safety of data and – more importantly – the clinical safety of patients.

After all, in this ever-evolving digital world, patients still lie at the centre of  everything we do.

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First 100 Days in the Life of a CCIO

Sarah Thompson and Ramandeep Kaur are amongst the first pharmacists in the country to become Chief Clinical Information Officers (CCIOs).

Sarah was recognised by the Pharmaceutical Journal in 2022 as a Woman to Watch, and Ramandeep was Highly Commended for the Dedication award for the NHS Year of the Digital Profession Awards 2022.

Both pharmacists have known each other for over eight years, having first become acquainted in 2014 after communicating about electronic prescribing and medicines administration. Their friendship has since grown and now they are determined to raise the profile of digital pharmacy, while embracing a concept of multidisciplinary working within digital teams.

They are passionate about inspiring the next generation of digital leaders and, after appointments to new roles during 2022, here they share their guide to the first 100 days of life as a CCIO through poetry and art.

“Sarah and I opted to do something a little bit different and fun,” explains Ramandeep. “I love writing poetry and Sarah has recently started sketchnoting, so this is a great opportunity to showcase our views through creative media.”

Poem 

First hundred days: the ingredients for the CCIO cake

F irst CCIO role or a seasoned pro, each adventure a rollercoaster

I n at the deep end, new Trust and role, battling the feeling of an imposter

R unning to never ending meetings, tip 1, diary management is key

S eek out time in first 3 months to determine where your attendance is truly a must- see

T ip 2, complete your mandatory, systems, and clinical training, it will pay off

H andover from a predecessor is vital, if possible, tip 3 will save you

U nder your frantic glaze or bewildered stare your digital handover will be your cue

N ew beginnings means rest and reflection is a must, tip 4 plan and book leave within first hundred days

D etermine your line management responsibilities and eroster access as tip 5 amongst the newbie haze

R olling to tip 6, book in your 1:1s, team meetings and your no-meetings time

E mbrace your inner child and plan a team bonding activity for tip 7, with a dash of soda and lime

D igital, clinical and operational team engagement for tip 8 is fundamental

D on’t pigeonhole yourself in the digital shell

A las tip 9, take time to listen to others and their stories

Y our time will come to fix the world but, right now, people will just want to share their worries

S eek out the positives for tip 10 in their tales so you can share their joyous moments too

T ip 11 don’t forget your own personal development, with everything else being so new

I nvest time in getting to know your seniors and peers, face to face meetings is up there at tip 12

P eople, positivity, priority and passion for me are essential ingredients to the initial CCIO role delve

S o take mine and Sarah’s tips, add your own flavour and icing and take a bite of the CCIO cake!

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History of the CCIO – who, what, why, and where?

The rise of the Chief Clinical Information Officer (‘CCIO’) as a recognised role within the NHS has been the most influential change in how technology is applied to healthcare in the last 20 years.

As recently as the early 2010s, it was rare to find practising doctors who also pioneered digital healthcare. Developing and improving the use of technology was often seen as eccentric by NHS colleagues, who viewed the doctors pursuing it as harmless cranks.

However, such doctors were also often seen as “good with computers” and rapidly became familiar with colleagues asking them for advice.

The forerunners of CCIOs

There were formal opportunities in the NHS and some clinicians found it simpler than others. GPs, for example, found it relatively easy to trial new technology because their practices were small and they owned the business.

The major primary care systems, such as EMIS’ Electronic Patient Record (EPR), were all coded by pioneering GPs. Doctors working in secondary care with similar skills, however, didn’t have the same opportunities.

‘Computerisation’ in hospitals often consisted of putting large mainframe computers in the basement to process administrative data. Although some trusts succeeded in this wasn’t recognised at the regional or national level.

Nonetheless, these pioneering individuals were the forerunners of the modern ‘CCIO’.

The National Programme

The digital maturity gap between primary and secondary care worried the Blair Labour government who, in 2002, launched the National Programme for IT (NPfIT). This was, at the time, the largest public sector IT programme ever attempted in the UK, and had the aim to bring NHS information technology into the 21st century.

Much has been written about how local innovation largely halted in the face of such a large-scale national programme. A few heroic figures tried to avert disaster but, in retrospect, too much emphasis was placed on big technology companies, and the role of clinical experts was overlooked.

As the NPfIT drew to a close, most health care providers had made little progress, and the idea of digital transformation was largely discredited.

The CCIO role emerges

However, at grassroots level, change was brewing. People who disappointed by the National Programme nonetheless felt it was a missed opportunity, not a bad idea, and were keen to take the good ideas forward.

They latched onto a small, but vocal, website known as ‘e-Health Insider’ (now Digital Health), who had begun to socialise the US concept of a ‘Chief Medical Information Officer’ (CMIO). This was a senior doctor responsible for overseeing the design and operation of clinical technology.

The term ‘Chief Clinical Information Officer’ was soon coined and the EHI CCIO Campaign to lobby for “every NHS provider organisation to appoint a CCIO to provide clinical leadership on IM&T projects.” Unlike CMIOs, who were senior medical staff, the CCIO was intended as a role anyone with a clinical background could fulfil.

The rise of the CCIO

The campaign proved successful. People began to turn away from the NPfIT’s failures to look ahead. The promise of CCIOs was to bring clinical leadership to the fore and, through doing so, ensure every aspect of technology applied to clinical work was driven by those with a clear understanding of need.

Moreover, the CCIO could use their clinical understanding to engage staff at large. And, thus, improve engagement compared to the NPfIT.

While an interest in technical matters was clearly desirable to the new CCIO role, it wasn’t essential. The most important skills were in communication and managing change. Some described the CCIO as akin to a translator, responsible for explaining clinical requirements to IT staff, and articulating IT concepts back to clinicians.

The CCIO Network forms

This new group of CCIOs began to naturally join networks, which were nurtured by eHI. An active discussion group sprang up on Google Groups which, over time, matured into a mature web forum.

These communities were further bolstered by conferences and day events, with the first Summer Schools held in 2012. These have continued to the present day.

eHI also mounted a formal campaign for every NHS Trust to appoint a CCIO and, as part of this, the Secretary of State for Health formally launched the CCIO Network in March 2012. As interest grew, more NHS organisations launched large implementation projects and appointed clinical staff into leadership roles.

The Wachter Report

An important milestone was the 2016 publication of ‘Making IT Work’, popularly known as The Wachter Report. Bob Wachter, an American physician and internationally-recognised expert in digital healthcare, was invited by the Secretary of State to review NHS IT and make recommendations for further change.

Three of his recommendations relate directly to the workforce, recommending a national CCIO be appointed, as well as developing a workforce of clinician-informaticians, and investing in digital literacy among the broader workforce.

A national CCIO was appointed, and there followed a rapid series of reorganisations, including the brief existence of NHSX as a central organisation leading digital transformation. The national CCIO role continues to exist, but is currently vacant.

Education and Training

Wachter’s recommendation to develop a digital workforce has been pursued more unevenly, although the NHS Digital Academy was established and offers a few training places on a Digital Health Leadership programme.

Other schemes, such as the Topol Fellowship, also offer a training programme but, again, places are limited. The main requirement for working in digital health remains enthusiasm for the subject, with informal help and support available through the Digital Health networks for those at all stages of their careers.

The CCIO role today

The role of CCIO has become increasingly well established. While not every organisation has a formal CCIO position, it is now increasingly rare to find NHS Trusts without clinical leadership of systems and technology in some form.

For those with a passion for digital healthcare, now is a time of opportunity for developing a career, as the CCIO develops into one of the most important clinical leadership roles.

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