My Favorite UX Tool

I have enjoyed watching the maturity of the UX field over the years. When I went from curious observer to Usability Engineer, the only tools I had were PowerPoint for design and a Usability Study template to test those designs. Over ten years later there are a wealth of applications and research techniques available in the UX Designer’s toolbox. As exciting as it is to see this growth, it can be be overwhelming as well. Like a plumber or carpenter, it takes years of practice to know what to grab out of the toolbox for the task at hand. Through my years of experience I have found my favorite to pull out of the UX toolbox are Personas. 

It may seem interesting to some that I would pick a deliverable which causes debate on how much value it truly adds. I believe when created well and utilized appropriately, Personas are a key factor to building a successful User Centered Design process. In a way, it is logical: Personas are representations of actual users. And User Centered Design is…well, design that is centered around the users and their needs. 

I have had a lot of success using Personas as a way to train my teammates on our users. When I present a new one to my teammates, I make sure I explain who provided the inspiration behind them. Their goals, their frustrations, and why they are using our product are all highlighted. A well presented Persona can save everyone a lot of tedious usability study recordings, and yet still get a feel for what makes the users tick. 

Not only are Personas great for raising user awareness on the development team, but I have seen them used successfully in other departments. Service and Support managers utilize Personas I have written as part of their new employee training. One of the coolest and most bizarre moments of my career was watching a Product Manager put on a wig and act like one of our Personas as part of a Sales Training course (he nailed it). Admittedly, watching one of our salesmen sweat during this exercise while painfully losing "the deal" with one of our more sassy Personas was kind of fun. 

I am not going to spend a lot of time on the basics of writing Personas. There are plenty of templates out there that serve as a good starting point (just Google Persona templates). I will provide 4 tips on how to make your Personas great:

Make sure your Personas are based on people you have met:

This may seem obvious, but it can be obvious when a Persona is based on assumptions and second hand information. Using only secondary research and assumptions will lead to a generalized Persona that is hard to relate too. A big part of the reason to use Personas is to help the team identify and empathize with the users. There is no need to make the difficult climb to a User Centered Design environment that much harder. It is also difficult to identify and prioritize user needs around a Persona that is too general. Generalized Personas are usually a sign of a lack of focus on priorities. 

Get out there and talk to the people living and breathing your product on a day to day basis. I actually believe you can create a great Persona just talking to 1 or 2 people. Some will say you need to talk to 5-7 people, but I would suggest creating a second Persona so you can capture some of the differences in personalities of your user base. Face to face interviews are ideal, because it is easier to pick up on the personality quirks that make each and every one of us unique…and thus making your Personas unique. 

Capture the Emotions:

To quote Amy Cueva, “Emotions matter”. None of us are robots, and neither are any of your users. (Although, it might be cool if we re-check this statement in about 10-20 years.) Sticking to the facts about a job does not really capture the reality of the situation. People get frustrated when things do not work well, and get a great feeling of satisfaction when they accomplish a difficult task. Avoiding the negative emotions and finding ways to trigger the positive emotions are part of the goal of good Experience Design. 

Capture these emotions as part of the Persona write up. Tie them to their work goals. Write a narrative about their daily life. What makes this person get out of bed in the morning? What are their aspirations? How can the experience you are designing make their day better? A great story captures the attention of your audience and helps get better buy in for a design. The most powerful healthcare presentations I have attended usually involve a story of how a medical error damaged someone’s life. 

Now you have some Experience Goals to focus on along with your prioritized user needs.

Do not let your Personas get stale:

People change and so should Personas. As a product matures and changes, so will the use of the product. A mistake I have made is putting up Persona posters in my office, and then leaving them there. If it appears that I forgot that I put them there, why should I have expected my teammates to remember them as well?

Ideally, Personas are called out in requirements and user stories so they cannot be forgotten. Regular check-ins with teammates to make sure they understand which users and their needs they are addressing helps as well. I recently started writing, “what am I thinking today” thoughts for my Personas as a way to share recent feedback from User Research Interviews. If you have a Persona named Beth, then start a “WWBD” campaign to raise awareness. 

Personas are not a Primary Research replacement:

The interviews have been conducted, the Personas are written, and the development team is buying into them. No need to keep up the User Research, right? Wrong! User Research never stops, and nothing can replace the power of interacting directly with your users. The market is always changing, meaning the goals of your users are probably evolving as well. Getting complacent can cause a big miss in learning about new user needs and requirements. Get out of the office!

In Conclusion:

Following these steps can help create a very powerful tool to pull out of the UX toolbox. My favorite aspect of Personas: they are a great empathy builder. Telling a good story, capturing emotions, and even role playing have made this a very fun way to help my teammates realize there are real people out there relying on us. And ultimately for UX, it is about the people we’re designing for.

The Ebola Miss: A System Breakdown

Unless you have been living under a rock, you probably have noticed there has been some panic over the ebola virus making its way to the US recently. One of the major aspects of of the coverage has been around the case of Thomas Duncan, the patient who died from ebola after the ER initially missed the diagnosis. 

Naturally, there has been a lot of blame going around on how such a thing could be missed. What intrigued me was the initial statement from Texas Health Presbyterian Hospital Dallas blamed their EMR for the miss, and then the statement was retracted days later.  The follow up statement from EPIC saying there is “no flaw” in their system has caused strong reactions, ranging from scathing to defensive to general eye rolling within the Health IT community. 

It is no secret that there is a lot of dissatisfaction with EMRs and Health IT in general. I have already written about the AMA jumping in with their recommendations to improve EHR usability. To add to this, a new report is indicating that nurse satisfaction with EMRs has hit a new low. Through my many years as a UX designer in healthcare, I have personally heard all kinds of horror stories of poor EMR design. These problems make it is very easy to point the finger at the EMR vendors. The reality is, poorly designed health IT systems are just part of the problem. 

Healthcare is a system: it consists of various clinicians with various specialities, working together in high stress environments, using different tools and technology (including EMRs), with different rules, regulations, and reimbursement policies hanging over their heads. Oh yeah, and the most important piece at the center of all of this is the patient needing treatment. The University of Wisconsin SEIPS model provides an easy way to see the complexities of a healthcare system.

Let’s look at the Environment piece of the situation. The ER is an overwhelming place to work. A patient with a fever is not going to stand out in such a crazed environment where mistakes can easily be made. Add the cultural aspect where doctors are trained not to assume rare diseases and “look for zebras”. Let’s be fair - when have we ever discussed the issue of ebola in the US before this (and no, the movie “Outbreak” doesn’t count.) These factors were just part of the systemic error that caused the ebola miss. 

Vamsi Aribindi explains the systemic breakdown of the situation very well. He points out four (not one) errors that led to Mr. Duncan being sent back home when he should have been immediately admitted. A lying patient, missed communication, a crazed environment, and a key piece of information not on the physician screen of the EMR were all holes in the swiss cheese. 

What bothers me about the situation is that there continues to be a blame culture in healthcare after years of Patient Safety research have shown errors such as this are to system breakdowns. There is usually not “one throat to choke”. I realize that pointing blame is basic human nature, but the discussion should initially start at how can we avoid this from ever happening again. Once the appropriate investigations are done, the key lessons need to be shared for the entire healthcare system to benefit. 

It is important to remember EMRs are just a tool in the healthcare system meant to treat patients. Many have treated EMRs and technology in general as a “silver bullet”. Unfortunately, silver bullets rarely fix big systemic issues, especially when they have their own set of flaws. 

Prioritize Design with Principles

In the world of software things rarely work out in an ideal fashion. This is especially true when operating as a UX “army of one”. My experience as the lone UX Designer has taught me that I cannot accomplish everything UX in the same manner as I did when I was part of a great design team. User Research reports turn into executive summaries, fewer design concepts get developed, and other UX deliverables become nice to haves that just don’t happen. Through the frustrations I have learned the importance of prioritization and focus. 

One of those UX deliverables that becomes a nice to have is a UI Design Pattern Library. Design Pattern Libraries are a great tool to promote consistency across a product or an enterprise of products. When done well it can lead to a smoother, easier to learn user experience. However, they take a very long time to develop making it very hard for one UX designer to give it the focus it needs. 

I was glad to see Peter Hornsby’s recent UX Matters article on using Design Principles over standards and patterns. Not only is creating a Pattern Library a lot of effort, but I have to agree that patterns can lock designers and developers into the way things have always been done. I believe that User Experience is a group activity. Which is why I like to encourage developers to challenge my designs, and find ways to deliver the best possible user experience within our technical constraints.

Design Principles create a foundation for the open ended discussion that pushes for a better experience. They become a guide during design reviews. When tied to specific emotions, they can help build empathy for the users within the team. And ultimately, they can help create a desirable design culture.

Here are a few simple design principles that I particularly like to live by. These are inspired by Lean UX principles, the HIMSS elements of a usable EMR, and over 10 years of design experience:

• Safety First: This one is the most important principle in the healthcare domain, as patient lives are at stake when software or a medical device is not run properly. Design solutions need to make sure we protect our users from causing themselves or others harm. It should be hard to make errors, yet easy to recover from them.
• Know who you are designing for - This is one of my favorites as it focuses on the importance of User Research. Know the personas, their goals, their workflow, and have empathy for the roadblocks they come across. 
• Build what is relevant – A good design solution solves a specific problem or problems that have been well researched. Do not build “cool” features that do not solve an actual problem - that seems to only work for Apple and social media applications. This principle goes hand in hand with keeping the designs simple so as to not overwhelm users with information overload. 
• Prioritize! – Once you know what is relevant, focus on the primary tasks and the important data needed to complete those tasks. Make the most critical data easy to see and access, and show anything secondary elsewhere to reduce clutter. This is another principle that relies heavily on solid User Research and keeping designs simple. 

This is by no means a complete list. These principles are some of my favorites that I work with to deliver usable designs. I like to keep them simple, sweet, and easy to explain. I also make them easy to see by placing the list in places where the development teams have their meetings. 

Bottom line - a solid set of principles are very important tool in the UX toolbox, especially for the lone UX designer.

AMA Makes Usability Recommendations

It is no secret that the usability of many healthcare IT systems are subpar and causing a lot of users headaches and anxiety. This is especially true with EMR systems. For years, I have heard complaints first hand from nurses and pharmacists about how much extra work it takes to navigate these systems. It seems an even larger voice is speaking up about it: doctors. 

The American Medical Association (AMA) caught my attention recently when they released a framework for their top 8 usability priorities for EHR usability. This is coming not long after a RAND report showed increased physician dissatisfaction with EHRs, and a lot of talk about health organizations wanting to switch vendors. 

The 8 recommended ares of improvement listed are (view the full report here): 

• Enhance physician's ability to provide high-quality patient care
• Support team-based care
•  Promote care coordination
• Offer product modularity and configurability
• Reduce cognitive workload
• Promote data liquidity
• Facilitate digital and mobile patient education
• Expedite user input into product design and post-implementation feedback

Two things caught my attention when I read the report. The first was a strong call for better User Research from the vendors. In order to reduce cognitive workload and enhancethe ability to provide high-quality care, there needs to be a real understanding of the clinical workflows that need to be supported. The AMA specifically calls out bringing user input in the product design lifecycle - that is a recommendation for User Centered Design. UX Researchers everywhere rejoice! 

The other item that caught my attention was the item on product modularity and configurability. In other words, we need better interoperability between systems. This is a hot topic of discussion in the Health IT world right now. The reality is, not one piece of technology can do it all well. AMA President-elect Steven J. Stack, M.D states this nicely: 

 “Now is the time to recognize that requiring electronic health records to be all things to all people - regulators, payers, auditors and lawyers - diminishes the ability of the technology to perform the most critical function - helping physicians care for their patients,”

For a while it seemed usability was just checking a box or a competitive differentiator in healthcare. But there has been a push to improve health IT usability coming from the ONC and NIST standards. The AMA has a lot of influence, and now they have evidence to show this needs to be addressed. In my opinion, the AMA report is a signal that we have reached the point where good health IT usability is an expectation.

I’m glad to see this tipping point has been reached. What concerns me is how the industry is going to overcome years of technical debt to really provide usable, streamlined clinical solutions to all caregivers. It appears to be time for third party Health IT vendors to shine.

Building Empathy to Reduce Load Times

I don’t think anyone would debate with me that we live in an inpatient, instant gratification society. Technology has come such a long way that we get frustrated whenever something requires waiting. One of my favorite comedians, Louis CK, hilariously explains it: 

I will admit, a few extra seconds to wait for my fantasy football team to come up on my phone is really not the end of the world. But there is evidence that slow load times to access a site or application can lead to a poor experience. This slowness can cause someone to give up, leading to a lost sale on a retail site. In healthcare, this could mean less time a physician is focused on a patient during a visit or a pharmacist reviews fewer potential medication interventions during a day. 

Improving application performance and load times usually means tackling technical debt, which tends to be pushed backwards in product priority. So how does one go about showing the importance of fixing these issues? 

Make the product managers, developers, analysts, and testers really feel the pain to raise the level of empathy for the users. I have tried a little activity to help show the pain caused by slow load times. I call it the “Stop Watch Game”:

I presented a few colleagues a user scenario that involved running a search. I started simple: assume you are one of our users, and you need to create a list of patients on a specific medication in your facility. I instructed them to imagine they have pushed the Run/Load button when I say “go”. They wait and tell me when they would expect the result to load by saying “stop”. This was not done with the application up and running - just hypothetical. Using the stop watch on my phone, I timed the “go” and “stop” commands. My colleagues typically would let the simple queries only go between one and two seconds. I informed them of the reality by starting the stop watch, saying “go”, and then letting the clock run until the real average load time on our application came across. 

I could start to see the awareness by their impatience during that second round of this game. This exercise was even more powerful when I presented a search scenario involving a complex report where load times are naturally going to be longer. Once again, they expected quicker load times then the current reality. The Nielsen/Norman article states that at 10 seconds the user will get distracted and want to move onto other things. So naturally, I said “go” and made everyone sit there for 10 seconds. Talk about a fidgety group. I finally asked the group if they thought that maximum allowable load time was really good enough. 

I’ll admit a couple things: this really isn’t a very fun “game”, and there are other ways to build empathy for users in UX. Ideally, I would have everyone sit in on my usability studies and listen directly to the feedback from our users. Outside of how uncomfortable it would be to have 10 people watch you do your job, the reality is not everyone outside of UX has the time for observing that many studies. Sharing the results and videos from a study can also help, but I have found that is not as engaging as seeing it real time. 

I did the “Stop Watch Game” in a requirements meeting when acceptable load times for a feature became the topic of discussion. At the end of the meeting I had buy in from the team that they would include appropriate, yet realistic load times in the acceptance criteria and they would test to the metrics. I was able to sell the importance of taking on some technical debt in 10 minutes, without having to show videos of inpatient users. 

I like to call activities like this “empathy builders”. Building empathy with colleagues is such an important part of the User Experience process. I have found sharing the pain users have with not so usable software seems to resonate with colleagues more than metrics and usability requirements. 

If playing with a stop watch for 10 minutes is a way to build that empathy to improve the usability  of a product…then I’ll take it.

The Best Career Advice I Recieved

I was recently asked by a friend what was the best advice I have received in my healthcare career. My first thought was “wow, that’s a tough question!” As I was racking my brain, I could have come up with something cliche like “be passionate about what you do” or “be comfortable saying you don’t have the answer”. As I was cycling through my brain, I suddenly flashed back to an early point in my career:

“If you don’t spend time in their environment, how will you know how users really use your product?”

To give some context, I was very new to the world of User Interface design and was the lead Usability Engineer for a critical care ventilator. I was working with designs coming from the anesthesia device product line to promote consistency between the products and to ease the cost of development. The Product Manager shared his Respiratory Therapy experience by sharing the common ventilator settings that needed to be programed. Here is what the RTs do, here is what the other development team is doing, figure out where it goes on the display - no problem! 

But there was a problem: I had never set foot in an ICU. I heard a lot of stories, seen a few pictures, but I was designing off a lot of assumptions and from my knowledge of observing a few surgeries in the OR. Enter Terri, a former ICU nurse and great colleague and friend of mine that felt the need to not so gently guide me on the right path. I honestly can’t remember if those were her exact words, but the message rang clear. I was never going to make the best design decisions if I didn’t get a chance to observe the messy, real world environment of the ICU. It was an easier said than done solution, since most hospitals prefer that some random guy does not just walk into an ICU.  

My opportunity finally came through the unfortunate admission of my grandmother into the ICU. 50 plus years of smoking, high cholesterol, and COPD will usually require the need to be placed on a ventilator. It was an emotionally difficult time, filled with potential end of life care discussions. Since she was expectedly anxious, I decided to help the family out by spending a couple nights in the room with my grandmother. 

It ended up being a learning experience as I was immersed into the day to day life in the critical care environment. I was able to observe clinician interactions with my grandmother and the equipment in her room. Some things I noticed included:

• Her ventilator was tucked into a corner, behind a lot of other equipment. I think I saw it touched once in 2 days. 
• The nurses usually came in the room, checked my grandmother, checked her vitals, and looked at the IV pumps before leaving the room. They usually didn’t glance at the ventilator.  
• If my grandmother coughed and trigged the high pressure alarm, no one came running in a panic…in fact usually no one came in. Alert fatigue is a real thing. 
• A Respiratory Therapist would come in every few hours for a nebulizer treatment. They would check the ventilator, but hardly needed to adjust anything. 

Before this, I was designing under the assumption that the ventilator was under constant supervision, like an anesthesia machine. This was hardly the case. The ventilator was a life support tool that rarely needed to be adjusted compared to the IV pumps, catheters, and other equipment keeping my grandmother alive. You set it up, might make an occasional adjustment, and you just expected it to work. 

After that experience, I remember coming back to work and saying “I get it now, I really get it” to Terri. I understood the environment and each clinicians interactions within that environment. I saw how busy and overwhelmed the clinical staff was. I finally realized that what I was designing was a piece of a much bigger clinical puzzle to care for a patient. 

In the product development world, it is easy to have such a strong focus on the product that it is designed as if it is the most important part of someone’s day. The reality is, most of us are designing products that are just a tool…and may not be looked at for more than a few minutes over the course of the day. In healthcare, the patients really are the most important piece of that puzzle, not the technology. This is just one reason why User Research is so important in the development lifestyle. Good User Research shows the reality of the problems in a work environment allowing for smarter, more informed design solutions. 

I have had a few of these reality checks in my career (here’s another great exmaple). I would like to think these experiences have made me a much better UX designer as a result.

Just remember: “If you don’t spend time in their environment, how will you know how users really use your product?”

My old blog

If you're interested, check out my old blog "A Healthy Dose of Reality" from 2010-2011:  Read →