In the current Guardian, American novelist Jonathan Franzen writes “What’s wrong with the modern world?” Franzen retrieves cranky German polemicist Karl Kraus from the 1930′s to buttress a literary critique of the cultural evaporation accelerated by Big Capital solutionist appropriation of the Internets. Perhaps because there are so few public techno-critics in literary culture in the 21st Century, Franzen seems to own this space for an epic rant (and new book) that pierce our culture’s enamoration with all things interactive, online, gamified, and ultimately, trivial. In the face of the scale of real-world problems faced by our civilization, Franzen is warning that our distraction with the entertaining and trivial, and our failure to invent beneficial alternatives, is costing us our culture:
“… the actual substance of our daily lives is total distraction. We can’t face the real problems; we spent a trillion dollars not really solving a problem in Iraq that wasn’t really a problem; we can’t even agree on how to keep healthcare costs from devouring the GNP. What we can all agree to do instead is to deliver ourselves to the cool new media and technologies, to Steve Jobs and Mark Zuckerberg and Jeff Bezos, and to let them profit at our expense.”
Franzen nails our obsessions with cool Silicon Valley “fixes” to the convenience problems of life (or perhaps those problems faced by well-off 20-somethings). He wonders whether our enchantment with sleek design (e.g., Apple products) has created an obsession with coolness as defined by Big Tech. You can’t help but admire the reframing of Apple’s design-led capitalistic optimism in this bit of story:
“Mac versus PC. Isn’t the essence of the Apple product that you achieve coolness simply by virtue of owning it? It doesn’t even matter what you’re creating on your Mac Air. Simply using a Mac Air, experiencing the elegant design of its hardware and software, is a pleasure in itself, like walking down a street in Paris. Whereas, when you’re working on some clunky, utilitarian PC, the only thing to enjoy is the quality of your work itself. As Kraus says of Germanic life, the PC “sobers” what you’re doing; it allows you to see it unadorned. This was especially true in the years of DOS operating systems and early Windows.”
As a “Hodgman” type myself, I’d recommend the social truth of that critique. I posted a rail about the Mac interface and closed hardware a couple years ago, but was too timid perhaps to take on the coolness factor. I am perhaps one of the only design professors at OCADU with a PC laptop … to which I’ve affixed the Apple logo sticker to confuse my students and peers into thinking I’m “with them.” But I’m not really, I’m with Franzen.
I’m also with Morozov. If you’ve read Evgeny Morozov’s recent social critiques of technological solutionism, whether in open dialogues or dialectics with columnists or his 2013 book To Save Everything, Click Here, you already know where we’re going. Franzen is joining a backlash against Silicon Valley smugness and monopolization of culture and access that includes Morozov and Jaron Lanier. Morozov enjoins a continuing movement of thinkers since systems theorists Norbert Wiener (Cybernetics, 1948) and Hasan Ozbekhan’s 1968 The Triumph of Technology: “Can Implies Ought”, Ivan Illich, Neil Postman, and yes, Marshall McLuhan.
Technology ethics has seemed something of a suppressed discipline for the last decade or so. As the new wave of Web 2.0 firms figured out how to make themselves extremely rich while making people happy sharing cat photos on Facebook, the North American impulse was to celebrate what looked to be the return of a magical economic and social force. Those urging that social purposes might change the tech rather than tech changing our norms were considered, well, cranks and Luddites. The occasional mea culpa is not going to change that. Morozov’s arguments are certainly a minority view, and Franzen’s points are getting lost in ad hominen attacks (a weird Millennial backlash against his arrogance that we would never have launched against previous generational authors, such as Mailer or Updike).
We should ask at least one critical question of all technological fixes to the supposed problems of our times: “What possibilities are lost with this solution? What value might be destroyed as a possible consequence?” OK, that’s two questions, but I’m sure you’ll have many more if you read these authors with an open perspective toward the social meaning of innovation.
As Design for Care launched in early June, O’Reilly Media kindly coordinated the second webcast on healthcare service design as an integrated practice of empathic design, to a live audience of about 500. The post-webcast video is now online and at your regular YouTube stations:
The webinar maps design practices and methods found effective in the most critical contexts in healthcare (consumer, clinical, institutional), illustrated by current cases and design research. Brief design research studies are presented to prompt rethinking of the meanings of care, of information sensemaking at point of care, and the design competencies sufficient to healthcare’s complexity.
As designers start to make inroads in the practices of clinical healthcare, they are finding institutions have little context to employ their contributions. In my book research I found very few clinics employing design professionals, unless you count the website staff. Yes, academic researchers and some academic design professionals are involved in funded multidisciplinary research, and then they tend to leave the institution and publish research. Designers and design researchers are not involved in the practical programs of integrating information, communication, and community resources with patient care practice, where significant differences in care and patient experience could be made.
Even as innovation centres start to spread in the US and Canada, they are generally staffed by the traditional health disciplines seeking a better return on process improvement. Except for Mayo Clinic, Kaiser Permanente, and a smattering of forward-thinking institutions, “advanced practice designers” are not engaged in the trenches in healthcare yet. Yes, its easy to understand that with the history and risks of healthcare, hospitals are averse to the risks new skillsets might introduce, and the healthcare culture does not invite the radical creativity expected of design school graduates. But even as newer, advanced facilities are being built, decentralized community care has become the trend, and population changes require new approaches to care, healthcare practices continue to manage their operations with the same staff as in the 1960′s.
We might start to consider the most effective roles and responsibilities for advanced design professionals in healthcare. Even architecture firms, traditionally heavily engaged in the front end planning of new facilities, are unequipped to integrate clinical service design into planning and post-occupancy research. Designing for care complements clinical care practice, improving services and creating innovative and systemic responses to complex human system problems. The book offers many starting points for clinical practice to integrate design research – such as the discussion of research methods associated with individual care needs based on levels of the hierarchy of needs. A simple, effective checklist of research questions for understanding people and patients (health-seekers) and the best methods for investigating these questions in an integrated, yet rigorous epistemology.
Slownovation in Healthcare?
Atul Gawande travels back in time through the lens of the history to uncover biases in sociotechnical practices and finds an archetypal problem: Fixation on technology, while ignoring the simple field fix. He compares two medical practice innovations from over 150 years ago, in the recent New Yorker article Slow Ideas. The invention of general anesthesia allowed doctors to spend enough time working on a patient to actually get the job done. Modern surgery was impossible without it. But nearly coinciding with this invention was the discovery of antiseptic (and thereby sterile technique) by Joseph Lister. Using carbolic acid to clean hands and instruments saved patients the horrible death by infection following a reasonably successful surgery in the late 1800′s. Dr. Gawande asks “why did it take so long for antiseptic practice to diffuse into practice?” Its a good question. Read it. Then solve the puzzle for yourself of innovation’s diffusion.
I thank Anne Aretz (on her Tumblr Shouts and Mumbles) for bringing this article to my attention on Twitter. (Even though I follow Atul on Twitter, Twitter has never addressed its ‘value that scrolls off the timeline’ problem built into activity streams. So I never saw his discussion of the article.)
Anne’s added points have real value. She nails the point I make several times in Design for Care:
The problem is not just the complexity of the solution, but the jarring, disruptive introduction. We are infatuated with disruption. But guess what? It is called disruption for a reason?—?it is a conflicting, diametric change from the existing. It can be fabulous, but it is unknown.
Anne links Don Norman’s recent post to Gawande’s Slow Ideas to hammer it shut:
Don Norman on the Paradox of Wearable Technologies. Wearable technologies, namely Google Glass, provide infinite benefits to the wearer that are a step ahead of our heads-down Smartphone-centric behaviors. While the benefits are clear, the adoption and reactions to it are mixed. “We are entering unknown territory, and much of what is being done is simply because it can be done.”
We are doing things just because they can be done. Its short-term, feel-good pseudo-innovation. That’s always been the case in our culture – Hasan Ozebkehan wrote a seminal critique of this mindset in 1967 The Triumph Of Technology – Can Implies Ought. Evgeny Morozov’s recently published To Save Everything, Click Here eviscerates the triumph of “Solutionism,” which has morphed beyond technology and technique to a general mindset directing Silicon Valley style management of “open government,” media production, and civic engagement. I write in Design for Care:
Disruptive innovations that we see in other industries may have less of a role in healthcare, even though the opportunities for new technology are clearly present. Healthcare facilities are not early adopters. New software, devices, and systems take time to learn and socialize, and the investment of professional time and budget in training and ramp-up is quite expensive. The expense of these social costs can outweigh the benefit of adoption. For example, desktop computers took years to infiltrate hospitals, and by the time they were ubiquitous in the clinic, they had become common in homes. Minimal training was necessary because the technology was already pervasive. The use of mobile devices is following the same late adopter cycle, allowing for a more natural (less forced) introduction of new devices into high-performance, high-risk clinical environments.
I’m aware not everyone agrees, and I’d say that’s fine. After nearly ~20 years experience in designing (and seeing into production) dozens of global, corporate, professional and web-based information products and services, I’ve learned how to research innovation risk. That’s my day job. And I try to advise my clients not to build things they or their customers don’t really need or want to buy. (That’s why I don’t design retail.) Different domains have their own cycles of adoption, and their diffusion into enriched work practices. Healthcare is slower than most domains because every decision must account for the increased risk of lives and costs.
But the cultural dimensions of healthcare practice are significant drivers here. Gawande’s article points to the different social practices that quickly accepted anesthetic (increased time to operate) and the trade-offs with antiseptic practice. Some hand-washing was done, and instruments were usually cleaned. But these practices were based on effects, not causes. Physicians still had limited knowledge of actual microbial behavior and infection vectors. There was little training in practice. “Alpha doctor” norms were dominant for decades (and still are!). And so on.
Now consider a truly disruptive technology – not another mobile app, but the Da Vinci robotic surgery system. But how did that disrupt practice actually?
We might reframe the purposes of disruptive innovation in institutional healthcare based on the experience with platforms and devices. The da Vinci system performs operative functions that surgical teams can understand and integrate within well-defined routines. It doesn’t disrupt the function of surgery, but rather the way routine operations are physically performed. Information technologies tend to disrupt clinical work in ways that may reduce efficiency of performance. New systems require training and ramp-up time (away from patients). Additional time must be allocated for electronic entries for the purported benefit of administration, not patients.
As an innovation research consultant working with healthcare services, I’d say one of the most significant trends in the last two years has been the creation of multidisciplinary, cross-service healthcare innovation centers. In a recent interview with Clinical Innovation and Technology magazine, I learned about their recent issue which featured this trend and revealed new developments I had not encountered in my book research (most of which was more than two years ago!)
All Rise with Innovation (by Beth Walsh)
A number of US institutions are establishing innovation centers for organizing clinical and knowledge competencies across the organization for internal enterprise-wide impacts. While some of the rationale for their development is attributed to the changes caused by the Affordable Care Act, some hospitals are getting into innovation because others are finding it valuable.
In another article in the same issue, Lyle Berkowitz supports my thesis in Design for Care by indicating the emerging drivers for innovation are being driven by cost and reimbursement, repeatable value propositions, rather than devices and technologies (which may add value and costs). New care practice models and workflows will be necessary as organizational and financial models change over the next 3-5 years as well. Healthcare practices take more time to validate and scale than, say, IT systems which have less risks to life and insurance with their deployment. I definitely agree that business model innovation will become a necessary and critical design process.
I’m not as optimistic about claims for informal “design thinking” approaches and rapid prototyping by teams that haven’t the experience in design and innovation. Unlike process improvement, what is meant by design thinking isn’t a set of methods to follow to result in better outcomes. Its a mindset shift similar to the gap between science and design. Contrary to the myth of “creativity” and invention, innovation consists of at least 50% research, with many of its methods quite unknown in most clinical settings. Innovation has serious discipline, skills learned in practice, and is not a project management tool for doing today’s work better. I’ve found that many clinical organizations are skeptical of the value of in-house innovation. There are opportunity costs for ineffective projects. There may be credibility issues if the innovation proposals are not measurably significant.
I think each organization’s approach must differ, if it is to be aligned with organizational competencies and the regional patient profiles. While the value proposition of each center is different, the universal theme is moving the larger organization toward the patient-centered paradigm and whole-person care.
One of the case institutions is the University of California Center for Health Quality and Innovation in Los Angeles, which consolidates knowledge and expertise from across the UC research centers. Their director is Terry Leach, a registered nurse (a good sign) who told the magazine:
Among its five medical centers, UCLA had expertise in virtually every field and could support a multidisciplinary innovation center and began to do so in October 2010. The bumps in the road have come in cataloging where that expertise lay and learning how to identify and disseminate best practices.
The center does not aim to reward researchers for autonomous behavior, she says. “The only way we’re going to survive as a system is if we inculcate collaboration into our mission. But there is no science of teamwork or collaboration.”
One of the major questions for all projects is how to work with patients as partners in their healthcare. “That’s a whole new paradigm for academic medical centers,” Leach says. RFPs are geared to rechannel the “vast intellectual capacity at the University of California and help us create a cadre of innovators.” Those that receive funding are expected to mentor others, take advantage of the institution’s leadership training and participate in the center’s annual colloquium to share their work.
These articles show that care practice and business innovation are emerging across the field in the US and beyond. However, the demand will soon outstrip the supply. The need for design, technology support, training, development, and facilitation overwhelms capacity. Clinics are not hiring design and innovation talent to support the desired competency, they are often trying to build the competency organically, which will essentially reify process improvement regimes. Moving clinical staff into innovation roles is similar to moving designers into clinical roles. We need experienced preceptors and “innovation attendings.” (I recommend something like this for engaging designers at the deep sociotechnical level of clinical work). It can be done, but with a huge helping hand from experienced consultation.
The shift to innovation management is a serious challenge for commercial product development firms that design and build technologies for sale in a competitive market. How much more so for institutions who are also in the midst of a patient-centered care shift, a community care shift, and an Obamacare shift? And whose mindsets have not changed substantially in decades?