Using Design to Make Healthcare Better

[Music] thank you for coming for our second talk of our innovation series it's my pleasure to introduce to you dr. Amanda salmon she's as you can see an assistant professor in residence and Department of Surgery here at UC San Francisco and is a trauma surgeon and we're very pleased to have her she in fact ran over here from the O R and barely made it so thank you dr. salmon dr. salmon has a lot of experience in innovation and I'm really excited to hear this talk one of the things that she did I think in between her fellowship at Oregon Health Sciences University was a two-year stint at IDEO and for those of you know I do is a world-renowned innovation firm and so we're very pleased to have her please welcome dr. salmon so I'm gonna apologize because I have a little bit of a cold and I'm still sort of out of breath from running from the or so um so Georgia and Toth asked me to come and speak about design and the role that it can play and innovation in healthcare so I'm gonna talk a little bit about healthcare but mostly for the focus of design and I'll take you through sort of one example of how we've applied design and through a few other short examples to try to show you the breadth of how design can be used so as as dr. sue said I am a trauma surgeon at San Francisco General so I do trauma surgery emergency general surgery general surgery and surgical critical care and I run a research lab called the better lab in the Vetter lab the purpose of the better lab was to bring human centered design so design methodologies in-house into into a healthcare setting and then to study the process rigorously using public health methodologies now if you know anything about does how many of you know I do or have heard of human centered design all right so some of so a lot of design human centered design gets done in sort of a consulting way and so consultants do it in the outside in the hand you a pretty deck and then and then you take it back to your entity and you try to apply it and I spent two years at I I do is to the best professional years of my life learning this methodology and really wanted to bring it into healthcare because I wanted to see what happens when you actually took those ideas and tried to implement them as you can imagine in healthcare it's really challenging and then I felt like well this is a really good methodology to get to better to understand what it is you're supposed to implement to get to the P in the PDSA cycle and and so this information should be shared and when it happens in a consulting format or if it's not published no one really knows about it and so the purpose was twofold one to show that design and human center can be done and design can be done in a healthcare context and the other was to study it and publish on it with rigor so we have a team of I think we're up to like eight or nine people now half of us have some sort of medical background I have a couple medical students and residents and the other half are purely designers and I have a few unicorns who are both healthcare for people and designers and so we spend a lot of time either seeking out our own projects are working with other teams to try to bring a design lens to to a healthcare challenge so what exactly is human centered design some of you are familiar with it this is a great quote by one of the founding fathers this human centered design is a philosophy it's not a precise set of methods but one that assumes that innovation should be start by getting close to users and observing their activities and that's the real core of human centered design in that the purpose of human centered design is to really understand users and understand their unmet needs and maybe even understand their unmet needs better than they could articulate them so human centered design provides a very rigorous structure and a framework in order to sort of think about how to tackle any challenge and it's great for those sort of very messy hairy wicked challenges like we have in healthcare for which there is no clear right answer there is no empiric evidence it prioritizes people so unlike other methodologies maybe something like mean that looks at the system or efficiency this really prioritizes trying to understand humans innate behaviors their unmet their fears their passions into design for that to help to design an environment to make those humans successful it's very expansive which can be very comfortable uncomfortable in healthcare to think very big and then have to rein it back in and it is built on this sense of iterative prototyping and we do see this in healthcare in lean in PDSA cycles of you know in design they'll say fail early and fail often we don't say that in healthcare because if you fail in healthcare that's human lives but it is too it is too low risk try something early and then just and then to study the outcomes so it can really build anything and these are some really great examples the first is a community market in Oakland and that was a solution to try to address preterm birth and poor maternal fetal outcomes of under from underserved communities the solution they found was a market the other one is a medical device this is a novel breast pump it actually won one of the best April one best in tech at CES which is the big tech conference in this small little breast pump that was put in the corner and the last is from a colleague of mine at UT Austin clay Johnston who used to be here at CTS is now the Dean of the medical school at UT Austin and they used design to redesign an entire building of outpatient clinics in this entire building has no waiting rooms so you check yourself I know right you check yourself in to your exam room so this is we um you know if you google human Center design or design thinking there's a number of different methodologies you know I do is probably the the gold standard of human centered design the founders of IDEO then went on to found the D school at Stanford which is a multi multi disciplinary school that teaches students design and design methodologies and you know founded by the same people one uses three stops one uses five steps so this is the process we use and we break it down into sort of three core steps which are very similar to idea which is inspiration ideation and implementation those are the ones in the middle if we were doing pure design this would probably be fine but because we're trying to study this and we're trying to do it academic context we we we've have created barriers in the front in the back one of which is preparation which is all those painful things you have to do like do getting your IRB and all your research set up and at the end of the evaluation of actually going back and studying did whatever we end up with actually work and we think of this when we think about design design in and of itself in human centered design as you're implementing and iterating your learning as you go and so we have a red bar on the bottom which is data collection and so we try to be very rigorous about these learnings and to do them in an academic way so that we can publish on them so that we can share these learnings with other people so the overview the design process so any of you do qualitative research some of you and you use Excel spreadsheets I'm sure so design one of the things I learned from design which has changed my life it's the post-it note so and I was underappreciated I didn't actually appreciate how expensive they were but I also didn't appreciate how useful they were and so we the design process often uses post-it notes to download key themes and so we go about interviews and our interviews are very unstructured we don't use we don't really use interview guys they're very unstructured and then we download and post-it notes and put them on a wall and then as we aggregate interviews it allows us to sort of live if you will in our Excel spreadsheet and start bringing some of these themes together so that's the next step which is synthesis so we start taking all these interviews and start saying you know I heard this from this person and then we heard it from this person and we're we're starting to hear in qualitative research would be thematic convergence and then we start identifying well here's an insight in an insight and I'll show some examples in the example I'm gonna give you in a minute an insight is one of those things one of those aha moments something that's either like I can't believe that is linked to that or wow I can't believe all of those individuals feel this way that for us is a design opportunity because it is either a surprising finding or an unmet need that you can address then we sort of formulate these into brainstorming topics and few Google brainstorming you will see dichotomous opinions on whether it's useful or not I do it uses a in the d.school use a very rigorous form of brainstorming and so I find it to be very useful and then we prototype and we have I have a rule it's 110 and 100 which is any one idea can't can't cost more than 10 hours of time over the course of a month and can't cost more than $100 so these things have to be they have to be low fidelity they have to be quick and easy and they can't be precious because what happens in health care is we invest a lot of time in these ideas and then when you go to implement them it's like your baby and no one wants to tell your baby's ugly right and so you end up with something that just sorta doesn't work and at the end of the day whatever your first design is is probably not gonna work you know the clocks the clock is Right twice if you have a broken clock it's right it's right twice a day or yes that's correct so in this and that's the context with design right you may get lucky but for the most part what you really thought was gonna be a great idea probably doesn't need to be iterated on so we iterate and then eventually we implement and study so this is my one of my favorite quotes and it's sort of attributed to Henry Ford although I don't think he actually said this and he said if I'd asked my customers what they wanted they would have said a faster horse so if I had asked you 10 years ago what you hated about public transportation or we hated about taxis you could have told me a long list but you probably couldn't have told me you needed Buber or lyft you could have said I don't like not knowing when they're gonna come I don't like standing on a street it's shift change in New York City in the rain I want to use this thing that comes out of my pocket and also can make phone calls and I want to be able to see where this thing where this car is I want to know how many are around me I want to know that I I want to be able to refine down to the absolute minute of when I need this car so you could have told me the things that you wanted but you probably couldn't have said I need over a lift you couldn't have described it or articulated it and that's where design is really useful is to try to understand those unmet needs those frustrations those challenges and to design that thing to take you from the horse to the Model T Ford to take you from taxis at shift change in New York City to BRR so why does human centeredness matter and I think in health care a lot of the time we talk about being human centered but we're really not because the pressures don't really come from the humans they come from regulation and they come from throughput and they come from the system and they don't really come from the human so why does human sin or this matter so if you think about innovation innovation requires three things it needs to be desirable by humans right it needs to be financially viable you have to be able to pay for it and it has to be technically feasible right so how many of you can think about something where we spend a lot of money on and it just didn't work what do you have the example right EHRs in some cases right so what about things that hadn't really switched technology and just no one really wanted them like 90% of the apps on your phone right right Oh amazing they're gonna make me so organized in like a narwhal flies across my to-do list but if you don't want it if people don't want it if it doesn't meet an unmet need it doesn't matter how much money you have and it doesn't matter how swish your technology is no one's gonna adopt it and so the key is to really start with humans the other thing and I sort of spoke about this earlier is this sense of the 110 100 so fail early fail often in health care try early iterate often so don't wait until you have that beautiful packaged thing that you're gonna try to shove down everyone's throat that really not gonna work so we fund spend a lot of time when we're trying to implement something telling people this is just a prototype if you like it that's wonderful if you hate it even better because we can learn from what you don't like so I'm going to talk about a couple examples I'm gonna spend a lot of time on one that we're working on right now and I have some prototypes here the room is not really conducive to prototypes but I'll leave them in front that we were working with a pulmonary critical care doctor here who has a ton of NIH funding to try to improve adherence to tuberculosis medications in Uganda and human Center design is essential for this one because I'm not Uganda and I don't have to and I can't even begin to understand the challenges they face and being inherent with our medications so I'd like to start with that example because it really we learned a lot of things and we made a lot of mistakes early on and I think it shows you the power of human centered design and then I'll tell you about a couple spent a little less time about a couple designs we're working on there near and dear to my heart and around trauma care so a little bit about TB in Uganda so it's the leading infectious cause of death worldwide in Uganda and the World Health Organization has set a goal of successful adherence rates to medication of 90% in Uganda it's about 60 to 75 percent sixty percent of people are co-infected with HIV and there's an estimated burden about 83,000 cases in the country the gold standard so tuberculosis is curable and it requires six months of medications the only challenges you have to take them for every single day and so the gold standard is what we call dot therapy or directly observed therapy so you traditionally you show up to clinic every day and the the you know medical officer or the nurse hands you know medications you take it they confirm you took it and you leave that's great right that is you directly observed therapy you can guarantee they took their medications does that seem like it is feasible for people living in Uganda no it's not so so Adithya cada machi and a number of other people are trying to think about innovative ways that they can try to do and document the adherence sort of do directly observed therapy in novel ways so some of the ways they've thought about our community-based so there's a person in your community a village a village health worker maybe a colleague or a friend who partners with you and says okay I'm gonna be there to take you I'm gonna confirm that you take your meds every day in some cases this works really well in some cases it's an epic fail and then there's some novel things coming your honor on technology and so we were tasked with a challenge of trying to apply technology to Uganda and I'll tell you a little bit about this technology so this is 99 dots so it's um it's based out of India and it's been used in India and Myanmar and it is a pill pack and I have a couple here that I'm happy to pass around so it's a pill pack that you slip the pills in blister packs and when you pop it open there's a number there so you have sort of a full number and then if you see up here a full number and then empty numbers and when when you get to the pill depending on how many pills you take that has a phone you type in that full number including the number at the phone and so that then documents that you've taken your medication you get a beep you hang up now this seems like a great idea right but not everyone in Uganda has telephones and not everyone in Uganda wants to take their medications so our challenge was to take this project which is to use this technology and figure out how to make it work for the Ghana Ugandan community so how might we design ninety nine dots to deliver meaningful value to TB patients in Uganda and that was where we started so we have structured this in our three phases of inspiration ideation implementation I took out the evaluation component it will be lengthy and we are about we're moving from green to blue so we have just finished our last Rev of what this design will look like and I'll take you along our journey so phase 1 was basically inspiration so trying to understand what makes Ugandan ticks what makes you Gandhian stick what the challenges are around tuberculosis adherence and how we might address them so to start so we were going to go to Uganda and we didn't want to go in unprepared so there's an entire ground team there researchers who are well versed in TB adherence in Uganda and so we interviewed three of them and the purpose of this was sort of to understand what makes Ugandan to tick what are their cultures what are their values what are their interests what do they like they like soccer they like a musician slash politician called Bobby vine they love their family they're religious they or they some speak English and some speak other dialects we then went through a literature search we then did some cultural research so we listened to some popular music we watched some TV we read some news and then we came in and this is a tool that I think is incredibly powerful which we don't use in academics but we use in design which is sacrificial prototypes some column provo types but basically we came in with some solutions they were not these solutions the purpose was to give people something to give feedback on right a provocation because if you can tell them if you if you ask them what are your challenges they'll give you something superficial but the provocation allows them to give you feedback to tell you what they don't like and then you start getting a little bit deeper you get beyond what they just say and what they do but what how they really feel so I'll take you through the first sacrificial prototypes so I'm gonna admit that I was completely out to lunch when we started this I came from the context of being an American living in America and with all the luxuries that that affords me despite knowing better and so we had said you know where how might we make this improve the experience of taking medications for Ugandan but we also are sort of a sub challenges how might we make this the best part of their day which i think is an amazing goal it was completely framed wrong and I'll tell you why but I was really excited about that so here's what we started and so we said okay things we knew about Ugandan is that they're really nationalistic they're proud of their country and so we started playing with imagery on the pill pack of the Ugandan flag we also heard that TB is incredibly stigmatized and that people sort of hide their pill packs or don't want individuals to know so we played with sort of carrying cases even things that might be worn on a garter so you could take it to work and no one would know it was discrete and then we played with how do we help people motivate through their treatment so tuberculosis treatment is six months long people feel horrible when they're diagnosed with TB they're weak they're frail and they feel miserable so the initiation phases the first two months they feel terrible by the time they get to the end of their two months they start to feel better but they still have four months left and so how do we get them through that four months I actually think the ultimate design is to make them feel terrible for the six months and then they feel better on month six but that's that's an ethical but that would actually be a solution would it not right because everyone finishes the first two months if they believe they have TB so we started playing with color gradients how can we move them pull them through and does it change from like in the beginning it's red and then you get to yellow and then eventually your goal is to get to green and do these colors mean the same things to them in Uganda so this is how we started so we went into Uganda and we had these prototypes um in addition to probably twenty more we had inserts with football sports players we had little religious cards and then we had okay so we could design the pill pack and then we designed what that experience was when you actually typed in the number cuz right now you just typed them on number you hear a beeping you hang up but that's a golden opportunity that's a teachable moment that's an opportunity to entertain right and I was thinking hey how do we make this the best part of their day so I'm gonna embarrass myself right now we did some does it complete a knock-knock joke right these obviously would have been translated in the local dialect you know a quote of inspiration do you get enrolled in a lottery do you and then do you get assigned to a team and you two as a team compete to see who can be more adherent we had all these brilliant ideas we had them and I can pass them around we had him on like cutout cardboard cards of phones so that people could physically feel them almost every single one of these bond Bobby wine football how might a entertain you completely bombed it was shocking it was amazing it was perfect right because we realized we were completely out to lunch so we went to Uganda and this is how we learned this we had two teams of two people so one person sort of primarily interviews and the other person takes notes and we went to Jinja and Kampala and it this was this was a world wind so we did four days of interviewing we would go out we went a different clinic each day so we had we went to eight different clinics they put us in a room and we would interview for like 10 hours straight hour each I mean it was exhausting but we we got to cover a lot of people and we went the goal was 360 degrees so in Uganda there's the usual sort of provider or the TB focal who's a person who runs the TB clinic and then there's no nursing officers and there's a clinic staff and of course there's the patients and then there's all these community health workers so there's VHT CHWs all these people who are sort of their delays with the community and if they hear from the the local clinic that you know Johnny's not showing up they will go out and actually hunt him down and bring him in we spoke to family members we went and visited them in their homes we spoke to bacteriologist and we spoke to spoke to government workers we really tried to get 360 of what is the experience of having to be what is the experience of caring for people with TB in Uganda so um unlike most Sophie's if you know I was going working with an implementation scientist and so when we were putting together his semi-structured interview guide and our completely unstructured interview guide which is a little bit structured you know his first questions were do you understand what the rules and regulations are around TV adherence and you know some of those questions and and we we started with what's your average day like I had because that's that's gonna tell you a lot about how they take their medications what's your average day like what do you like what do you look forward to in your day what do you dread during your day do you have a phone oh you do how do you use it can you show me do you take medications what do you take medications for what does that disease mean to you so we really tried to understand and we learned some pretty amazing things we then spoke with a clinic staff and our purpose there I mean TV is sort of a stigmatized disease there and you'll hear a little bit about that in the next few slides so it's it's a labor of love to work with TB patients so you know we started with why do you do the job that you do what's your average day like what do you like about your job what is the worst part about your job what makes your job easier and interestingly we saw thematic convergence across all these individuals with these sort of coming up these people from different angles so these are the insights that blew our mind so in public health education is almost never the answer right education was the 90s this is your brain this is your brain on drugs any question like it's almost never the answer it's almost not that people don't know they need to take their medications or understand the disease but in Uganda people really did not understand tuberculosis they didn't understand how they got it they didn't understand how it was spread they didn't understand that it does not inherently mean that you have HIV the other thing which we were fascinated by is that the health workers are incredibly trusted individuals not only they trusted but their people desire patients desire their feedback they desire their accolades and that was surprising to me that's I didn't I think in the literature you might find some of that but that I didn't assume that to be true the other thing is that the gamification and entertainment wasn't was an insulting luxury and when you are just trying to survive game of I mean knock knock jokes almost trivializes the struggle so shame on me but it was a great to learn early on the other is that celebrities Dobby vine politicians nationalism in the sense of your public health Minister wants you to take your medications does not work they're not motivators but modeling does people and what we found is people patients were motivated by other patients at the clinic when they showed up with a new diagnosis of TB and they saw someone else walking out who looked healthy who said you know take your medications they are motivated by that but if that person were to be on an advertisement was not physically in front of them or was to send you a message on your phone it felt fake they assumed they were paid very very distinct modeling only worked in person the other thing is if you look at the pill packs every pixel of ink matters everything on that pill pack mattered every word every color if it was too busy it was overwhelming if you said take it with food they would take it with food so guess what if they don't have food they don't take their medications can you imagine so this is how we learn this we ask this gentleman who's come back he's had a relapse of his T V and we heard this a couple of times and we said so why do you think this happened he though I don't know I took all my medications we somehow did take your medications well I take him at night and I take him with food and either ever times that you might not take him well sometimes I don't have food sometimes the only food I have I give to my children how often does that happen about three times a week so when you don't have food you don't take your medications no so you're not taking your medications three times a week I mean does that not break your heart because you know what on the pack it says take with food and they're following the instructions some other insights language things when we translate and when we speak them in English they don't call them medications they call them tablets but TB is a physical disease people describe TB as being weak and when they're better they feel strong and so when they're strong they're better which is about it month two but we've got to get them to month six the other thing is that TB is not just stigmatized as an infectious disease it's associated with certain death HIV in witchcraft and we heard stories where women divorced their husbands because they were diagnosed with TB and they were convinced that they also had HIV and that everyone was lying to them because t v-- and HIV always happened together the other thing we learned is that this pill pack is great right people who have phones are gonna they're gonna they might text in but what about the people who don't have phones and what about the people get lost to follow up because what happens is when people feel better they're in survival mode so if they feel better and stronger and want to work they go back to work why because they need to put food on the table for their children and if they happen to work in a job that is transient they're policemen they're taxi drivers they drive trucks they're sex workers they disappear so they can't be followed so this pill pack was not gonna change the fact that the unreachable are still gonna be unreachable and lastly that this 99 dots is not I'm Garrett's guarantee it's not gonna guarantee they take their medications right they can open the pack gate play the game toss the pills out because it makes them feel crummy it turns their pee orange it makes their skin itch or whatever it is right and and call them the number and that's true it's not a guarantee but we saw it as an opportunity to connect every single day you through the pack and through the phone call it is an opportunity as a teach woman his opportunity connect every day that you didn't have before so where do we go so phase two and we're just float closing phase two is brainstorming so we filled the entire TB reach office building in Kampala Uganda with post-it notes we downloaded it was exhausting we downloaded 30-something interviews with a local team and with our team and then we started identifying some of these insights some of which I've shared with you and then we started brainstorming so things around how might we make how might we make the pillpack educational how might we make the experience in educational moment a teachable moment how might we make pill packs customizable so they feel personal we went through a number of these and we got came up with some other prototypes some of these are derivation zhan the early runs and some of them completely new the first is a derivation a cheaper version but also more effective of this cute little carrying case the garter carrying case the high dat carrying case is it if you saw the pill pack so just one sheet and it says something like TB on it so what if you just put a cover on it that give that gives it a little bit of anonymity it also makes it so that you have some more real estate an opportunity to connect with them so then for the front cover options what were we gonna do we couldn't very well say TB medication we played with something of daily vitamins strength medications people did not like that they felt like it was a lie it was a lie we played with nationalism right we took a derivation of the garden colors made a sort of a traditional Ugandan textile Lake Victoria which people really were proud of and liked but even better a map of Uganda why is that better it filled two purposes the first was that it was Uganda it had some some pride but it also could be used as an opportunity for people to customize Ojo oh you work as a a bus driver well here is your clinic and here are all other clinics along your route as a reminder system is a way to orient them as a reminder that there are other clinics out there if they need to seek care the other thing we said is you know this pill pack functions basically as a calendar when they get to the end of their pill pack if they're taking every day it's at the end of a month if they're not who knows then they know they have to go back to the clinic so what if we just honored the fact that this functions as a calendar and made the front of calendar they could put personal information in there they could put the reminders and when they needed to go back and give a sputum sample or when they needed to refill their pills then we said well so that's the front of the pack so what about the inside so one side is just gonna have the numbers and we realized with the real estate it's got to be simple so it's just gonna have these numbers and we did some redesign of this but when you open the inside what's that gonna do and what we realized is what they really needed was education so we played with a couple versions so these are in English but the first one is just TB is an infectious disease make sure to protect your family and others by covering your cough and coming to clinic and that was a big public health thing is if you have children under five in the house bring them in if you have see other people coughing bring them in they might also be infected with TV and then make sure to take your tablets daily and then there are two lines and this is in the left upper corner so that the focal the TV local person could customize it Joe you're gonna be great you can do this if you need me call me so they can make it feel personal to honor the fact that people really respect and wanted accolades and wanted connection with their with their local health workers the other and this is the most elegant and I loved but was not possible which is the far top left which is hello my name is Sally and I am your local health worker very personal so we had this whole system where we were going to take photographs of them and print out stickers and it turns out there were like hundreds and hundreds of TV health workers from so that was not gonna be possible but I'm so hopeful I'm holding out down here was to say you know what let's take this out of the realm of like medication and let's just tell them what these tablets do but they help you fight your medication they help you fight TB and you need to give your body the drugs that needs to be cured to sort of make Dee medicalize it make it a little cartoon and so that was idea number three and the fourth was something we heard multiple times which I was surprised by which is a before and after photo so the before the after photo if you're in the initiation phase you've recently diagnosed and you've lost a lot of weight seeing someone who went from skinny and emaciated to robust and healthy and strong which is important to them was motivating if you are now the strong person remembering what you looked like when you had TB as a reminder that you needed to make it for the complete treatment was was sort of a motivator a little bit of a fear factor so this is where we started the other one was to take all the stuff if you look at these it says take your pills and take with meds and take the food and all these numbers down here so we said let's take all the instructions off the real estate let's just make it very simple and let's put them down here and let's put iconography because people don't all speak the same language and some of them are illiterate so the first was take this many number of tablets and then we said you know what there told us take him in the morning or take him in the night and so if something happens in the morning if they don't have food they won't take him at night because they follow the rules so he said let's play with some sort of icon that helps orient them and they can choose either morning or night and then let's show them what taking their tablets means right we're not going to right we're gonna illustrate it so put the pill in your mouth and then the third is let's the food thing you don't have food you don't take your meds that's horrible now you might get sick if you don't have food so we'd prefer you take it with food but we put take it with water so there's water and then the local plantain is sort of the most common food there so water or plantain so you know that it's okay to take it with one or the other and then lastly which is we kept airing as well people are gonna be worried that if they make this call that it's gonna cost the money so the last one is make the call it shows zero basically zero dollars it's not gonna cost you anything so that was round two so we're heading into the implementation phase in Uganda the way these studies are run it's being disseminated across eighteen clinics and what they do is they bring all the clinics together as sort of a randomization ceremony so it brings everyone together so they don't feel like those who are getting enrolled first and those are getting World last the people are getting rolled last don't feel like they've been left out or they were a second choice it gets done randomly in front of their eyes and so they understand and they all feel part of it and it's fun and you pull balls out of a bag so we use this as a golden opportunity and our purpose our goals were to design two things to design the pill pack and then design the experience of what happens when you make that phone call so we held focus groups with members of each of the clinics and then we went back out to the clinics and we tested these prototypes and we tested the language of what happens when you make the call and we iterate it again and so I'm going to show you what the final version is and as you'll see with this illustration we're enrolling in tranches so we're gonna enroll three clinics a month so we'll have a tranche January through April and then March through July and then August in November so we are gonna have three opportunities to iterate in context so we're gonna implement what we have now and then we're gonna go back and get feedback and iterate again with the purpose by the time we get to the end of this we have been through six seven eight iterations and we will have gotten to something that's better that works better that improves adherence hopefully so what's the final version so this is the final version and this is not an English so I apologize so we realized as the focus and the people who work on the clinic liked the idea of being the expert and being able to customize and customizing to the individual so when you open the inside flap which is what you see here on the left it says hello TV is an infectious disease or no it says hello I am your foot local health person and this is where I had to sacrifice the personal photo which I'm still devastated about we put in the name and then this is the number you call people loved that if I have a problem this is my person this is who I call this is what they were looking for on the right is the opportunity to put a picture a sticker and we have a couple versions of what that sticker might be and it's going to be customized between the patient and the provider or clinic staff and then down below we iterated again on the illustrations and it seems silly to be like playing with iconography and illustrations but these things really mattered so it says down there take this many pills and then we have we had two separate day and night because people got confused when it was in one box so you Circle one but this also created an opportunity for the health worker to engage with the patient so when would you take it okay we're gonna circle the day but if you can't take it in the day it's important you take it in anytime so you can also take it at night so gave an opportunity for them to engage make the make the patient feel like they were getting something personal and make the health worker feel like they were the expert then we show them you take your medication and then we you know what the food thing they just kept saying just take it off because it will be a barrier people will be confused so we're saying take it with water and when they're if they're savvy they will and if we we will tell them if you can't take with food to get the food but the instructions say take it with water there'll be no confusion and then lastly is again the I confer to call in the number it's not gonna cost you any money and then we played with the color gradations because this requires that you actually follow some sort of pattern and what the ugandan do is what they tell us is they take the pill wherever their finger lands it's a direct quote they might take one here one here one here there's a very good chance they could take pills in a day that didn't have a phone and so the way the Indian pills were structured is to go right like you read but that's not how they take pills in Uganda they go down so then we played with well let's go through the colors and let's take them down let's make it very clear let's have area arrows that take them back so that they it follows what their natural process would be and prevents them from sort of taking whatever pill wherever their finger landed we took everything out off of the pill pack there is no take with food there is no instructions it's just the number you call and these are the stickers that allow you to customize the first was the before and after now when you if you notice before it was a circle which made it feel like a cycle which made it feel like you could fall back in to it that didn't work so then we changed the arrow so it was very clear if you take your pills you get stronger and if you don't take your pills you get weaker and the other one and this seems so simple the other most important thing was to teach people how to call and we'd have language from our first iteration illustrating it but or describing it but we needed to illustrate it so coughing your elbow don't coffins your hand don't coffin to space don't coffin to the face of your five-year-old child so these are the two options that they're going to start with there's the customization on the left of this is your local health worker and this is the number you're gonna call and that on the right is either this is how you call for appropriately or this is what happens if you take your pills or this is what happens if he doesn't don't take your pills it actually works both for people in the initiation phase and for people who are trying to continue in the continuation phase and lastly the front cover so we landed on the map in the calendar and we're giving also stickers people options and one of the things we're looking for it if learning is which they choose and why does the map option get chosen more for people who might be more transient does the calendar option get chosen for people who want to customize it do the nurses or the clinic staff influence what gets chosen we're hoping the patient chooses but it'll be really interesting to see how this unfolds so that's the pill pack it we have been through seven eight iterations of this over months silly things changing iconography changing words but it really has gotten it to us something that's much better and I think I'm hoping we'll make an impact and the last bit is so when they call in what are they gonna hear so before was gonna be a knock-knock joke or something ridiculous that was just demonstrated that we didn't really quite understand our population so what we heard is people wanted to people wanted to be thanked for taking their medications they wanted to make a connection they wanted for those who are early diagnosis in the activation phase they wanted to know that they could be cured it's not witchcraft it doesn't mean you have HIV although 60% do it doesn't mean you're gonna die if you take your medications you will be cured it also has a lot of messages around protect your friends and family coffee properly bringing children under the age of five if you see someone else coughing bring them in and for those in the continuation phase the messaging is a little bit different we're still thanking them gratitude and reminding them by taking your medication every day you'll be you can be cured at the end of six months you may not feel sick but you still have TV it needs to be treated for six months so I have about 10 or 15 minutes that's an example of I really wanted to go into detail because I thought it was important to really show the iteration and how you know there's a very good chance if design wasn't involved that pill pack like this would have gone to Uganda and it might have worked but I think we uncovered so many opportunities and so many opportunities to treat these as educational opportunities teachable moments adherence tools to help make people's lives a little bit easier to make them feel more cared about and so I'm looking forward to seeing what comes out of this so now I'm gonna talk a little bit about trauma care and then I'll take questions and this is gonna be pretty quick so I'm a trauma surgeon I work at San Francisco General we're the only level 1 trauma center in the Bay in the Bay Area in San Francisco Bay Area so anywhere from halfway across the Golden Gate Bridge to ninety two we have we are a well-oiled machine we would have a really hard time improving on our outcomes but we can certainly improve on experience trauma in and of itself is a little bit like a snowflake no trauma is ever the same seriously it is an ad-hoc group of people depending on who's on shift residents attendings nurses respiratory therapists pharmacists radiology technicians and then throw in the patient this patients dying from a head injury this patients been shot this is a kid who's fallen out of a window it's never the same and so you bring an ad-hoc group together in unknown circumstances and then expect them to perform and make decisions in seconds if you imagine doing that in your professional life it's sort of bananas and so we came in and saying you know we can't really improve upon outcomes I mean I'm sure you can always improve on outcomes but you have really good outcomes but we want to improve upon the experience and so we said we're just gonna take where as Uganda was we have a technology that we're gonna sort of you take a design lens - it was a very constrained challenge we came in and saying we're gonna just try to understand what's going on in the trauma Bay how our trauma care is administered and see what we think we might be able to do make the experience better so we did 35 in-depth interviews these are sort of our long unstructured semi-structured interviews we did 50 hours of live observations in the trauma Bay and then we also videotape our traumas for quality improvement and they last for about 14 days so we observe some of our most acute traumas about 15 of them and we identified two things one is PPE which is personal protective equipment the masks that gowns the gloves but it needed a redesign and that our adherence rates were deplorable the second was is that people because it is ad-hoc people didn't really understand each other like people didn't know each other which is fine because that's how it's gonna be but they didn't understand each other and we identified an opportunity to add technology to try to solve this and so I'll talk through these two examples pretty quickly oh yeah and I have actually the technologies VR virtual reality so I have a VR headset for anyone who wants to play with it after after the talk so PPE so we did the 50 hours of unstructured observations of 900 which is our highest level trauma so though our lights and whistles someone's acutely gravely injured and everyone reports that we did structured observations of the 900s which is the the video we did the in-depth interviews and then we did usability testing because what we realized is about 25% of the people in the trauma Bay actually had appropriate personal protective equipment on and the other 75% did not and if you think about any context in healthcare short of an infectious disease like TB trauma care as put you are probably the most likely to get contaminated and so why is that is it that they don't understand I told you before it's almost never education and I can tell you this case it was not education so we tested usability tested the PPE so we asked people we said please put on the PPE you please put on the personal protective equipment as if this were 900 trauma and I I don't have a photo here but the way our PPE is stored is it comes in you know those um the carts that like you'd see in an auto shop and you pull them out and they almost have a you when you pull them out you get a little bit click so they come and like one level has the masks and one level has gloves and some other booties and the other one has the the gowns and so so we said ok we have a complaints rate percentage of 25% and what we've heard from our interviews is that it's really painful to put on PPE it's time-consuming and in a time compressed environment people sacrifice themselves to keep their patients alive and so here's what we found it takes 83 seconds to Don PPE appropriately in our trauma Bay that's 83 seconds we make decisions about whether we're gonna open someone's chest if they've had CPR for five minutes are you gonna allocate a minute and a half of that to put your PPE on probably not the other thing is if you if you want to put on shoe covers it's an additional 30 seconds so you're up to two minutes just to get your appropriate stuff on there are 19 steps to donning PPE and that includes both physical steps of putting stuff on and decisions you have to make pull out the cart decide which one I want okay I want that one shut the cart pull the next door okay I want this one I'm gonna put this on but I got to put this one on first I'm gonna put this one under my arm because that was it just doesn't make any sense and so what we realized is the personal protective equipment we're wearing and using was never designed for macare it was not designed to be rapidly used and put on by an individual we are using personal protective equipment that is either for infection control which sits outside of a patient's room who may have TB and you have the luxury of time of putting it on or it was designed to be donned for you in the operating room no one's designed rapid use personal protective equipment so the storage is inconvenient it's fragmented you have to literally open a package to pull out a package to open a package to put on a gown I kid you not um there's overwhelming choices like if you have to stop and think do I want this one or that one you've wasted seconds there's no clear protocol so if you ask people what they put on first they don't tell you but people aren't even sure what the appropriate PPE is does it have to have a hat on doesn't include booties I'm actually still not sure I can't find it in the literature there's multiple steps and it's unavailable to many so when you go to the cart one person can use it do you know how many people we have in our traumas that are high level 20 so 83 seconds times 20 people pushing people out of the way to try to get to it if you were more important I mean it's a little bit it's a little bit of chaos and one of the problems is in our trauma Bay we sometimes have short ring downs so the trauma pager goes off and when you get there the patient's there or we get a walk-up shooting or stabbing patients is already there and you have to get there and so it's inefficient the storage is the storage is challenging and it oftentimes does not adequately cover you the PPE stands in the way in patient care so if you ask providers they will tell you yes I want to wear PPE but when I get to the trauma Bay I'm gonna walk in the room and assess the patient figure out how they're dying and I'm gonna stand there until I either need it for a procedure and that's when we see people put it on or the patient's stabilized in some format and then they go put it on people are putting on PPE to protect the patient not to protect themselves because they've already decided that the patient's life is more important than their own protection it is exactly what you want your doctor right you want them to like run into a burning building for you but I think we could probably design this to make this better so we actually to brainstorm today but we've been working on this for last couple months so we've played with things from on the left side is taking a cue from the firehouse so how do they get into gear quickly they line it up so let's not make a bottleneck at the annoying pulley you know pulley drawers line it up against the wall you can grab your PPE as you're walking into the trauma Bay or what if it was all in one what if you like skis you like clicked into it and you just pulled it up another thing we've played is what if it's the belt and you always have it on you and you roll it up rolling down and you're ready to go and you just Reese insert cartridges I think there's a lot of opportunities and that's one of the things we're currently working on right now so to round this out the last is virtual reality so I know nothing I knew nothing about virtual reality I had no interest I'm not like someone who is trying to bring technology to healthcare I have a hard enough time just working the technology I have in healthcare already so adding additional technology was not the goal but we found an opportunity and I think this is the best way to add technology is to find an unmet need and then to realize that there's technology to meet that need and that is virtual reality and so it all started from realizing that traumas are snowflakes there's no way you're gonna know everyone in the room you're not gonna know everybody you're not gonna be sometimes you know the you know sometimes you know the other attending or the other resident that's not the way this works sometimes you know the nurses name but that's not the way it works so the goal is not to know the person the goal is to know their role and to understand who they are and to understand how the room works and one of the trainees said you know I I spent my entire training learning how to do the ABCs which is the care of a trauma patient airway breathing circulation but no one taught me how to run a room you want to know why because they've always trained from the perspective of themselves I trained as a trauma surgeon I have never stood in the shoes of an anesthesiologist I've never stood in the shoes or actually been in the role of an emergency medicine doctor never been in the role of a respiratory therapist or a nurse or charting nurse so I don't actually I am an individual athlete trying to play a team sport it would be like having a quarterback who knew what he wanted to pass the ball but not having a clear plan of where the running back was supposed to go right totally broken so there's an opportunity for us to cross tain we sort of learned you you sort of Intuit into what people's roles are but no one actually teaches you the cross train in this in the land of snowflakes and ad-hoc teams we need to know each other so 360 video so to simulate a trauma there's virtual reality as multiple sort of format there's virtual reality in its purest form as computer-generated but a computer-generated trauma does not have the fidelity you're looking for right you can't you can't simulate trauma you can't simulate someone coming in with a bullet in the chest and actively dying in the stress in the room you need it to be authentic which is where 360 video comes in so you can mount 360 degrees cameras and actually allow people to put on virtual reality goggles and be in that space it also allows you to perspective take because you can cross train if you have 360 cameras set up in different spaces in the room you can stand in those different spaces and play that different role it's authentic it's it gives you the Grouse sort of feel of what it is like and it allows you to take reps and when you're dealing with snowflakes you can't redo something so you do a trauma decent you know I think I could have caught that hypotension earlier or I think I could have done this better you don't get a redo and oftentimes you don't get a debrief because we move on to the next trauma and so this gives you an opportunity to take reps and take reps from different perspectives and take as many reps as you want so you can get a you can get better football teams are using this quarterbacks are using this kickers are using this they're using this in at Walmart to help customer service people respond to customers better and it just makes sense that we'd be using this as well so we set up cameras in the trauma Bay and I'll just take you to our trauma base so we did this in recess two and we filmed about 15 real sort of high-fidelity simulations with moulage so making actors look like they've been injured and then we filmed for four evenings and then for 24 hours straight over a week and filled every trauma that rolled in the door and as you could imagine the logistics and the consent and the legal was astronomical but we had to consent every single person who came into the room so that's 20 providers and staff plus Tech's and paramedics and patients and family and so we have about a library of 25 videos so this is what it looked like this is four weig gaff taped it so we've taped it all up white so it didn't seem so sort of intrusive but we had a tripod above sort above the head so from the from the perspective of the anesthesiologist standing at the head or the person who intimated standing at the head of the patient the person perspective over the left side of the patient which is usually the trauma junior provider either a trauma surgeon or emergency medicine resident from the right side of the provider the patient which is usually either a nurse or a respiratory therapist from the foot of the bed which is sort of the senior attending role and then from the door which is where the charting nurse stands because she can never see or hear and yet she's expected to document so so we're currently in the process of editing all the videos in creating a curriculum and the goal will be that that we will be taking residents in multidisciplinary teams so anesthesia emergency medicine and trauma surgery through these different positions and they will watch an Augmented video and they will sort of document what they think the perspectives and goals were of the of that provider and then they will experience the same video with graphic overlays and audit audio cues around three or four key teaching points from the perspective of that provider and you might think well how different could that be incredibly different so and I'll give you an example so when I look at the chest of a trauma patient and I see ek liji leads there I'm a trauma surgeon an anesthesiologist may look at the chest and look at the EEG leads and say you know I wonder if they're in the right place to reflect the rhythm when I look at the EKG leads I think I wonder if they're in the way of my knife I kid you not it is a constant thing they're putting the EKG leads in the optimal position and we're moving out of the way of our knife you know it's like a trauma provider looking at a face in an anesthesia provider looking at the face they're looking completely different things and we into it our way and sort of discover our way into that but no one really trains us and virtual reality allows a really interesting opportunity to do that some other things that were interested in once we can sort of help people perspective take I think it allows us also to improve performance and there's technology coming out every year and some of it is eye tracking so a trauma Bay you learn ABCs every breathing circulation so Airways intact if they're there making words they have breath sounds they have a pulse and then you move on but no one teaches you going back to that quote how to run the room so if you look at a junior resident if someone comes in with a traumatic amputation everyone's eyes goes to the traumatic amputation if you're a senior trauma provider you look at the traumatic amputation you figure out if it's of still bleeding and then you move on you spend most of your time I spend most of my time looking at the monitor watching the nurses looking at the IV poles to see if bloods hanging and watching the room I spend less time looking at the patient I don't know what the best practice is but I think we can determine that with eye tracking with gaze tracking we can see how senior trauma providers work a room and then we can train residents and people to perform like that like you train a quarterback to catch a read a couple seconds earlier and the last thing about virtual reality is you know for us again its refining on the margins I mean we do trauma care all the time but unfortunately mass shootings aren't just happening in cities anymore they're happening in places that don't have the exposure don't have the access places where they feel unprepared end up with acute stress disorder PTSD after the fact so something like virtual reality particularly with the cost of these this is $200 now it democratizes experience an exposure you can deploy these each level-2 level-3 small town hospital can have one of these where people can take reps they can see what trauma care looks like feels like so that if it ever happens god forbid in their hospital that they are prepared and we're working on putting together a proposal now for the military one of the big challenges is attrition of knowledge skills and abilities during peacetime so all of a sudden you take a guy who's doing you know appendectomy zhan healthy twenty something year olds it you know a military base and you deploy them to the forward lines in a war zone they're not taking the appendix out of young men they're dealing with mangled individuals mass casualties and they don't they didn't have the opportunity to train so you can actually use this to maintain skills you can train and again take reps so I have this here Delica who is one of my designers in the back and is an amazing may be the motivating force behind a lot of this consider to set this up a few guys some people want to ask questions and some want to put the headset on - just take a feel we have a three-minute video and it's it's a simulation obviously because we can't share a real patient we can't share a real patient scenarios but it gives you an opportunity to see what it's like in virtual reality to be in a trauma Bay from multiple different perspectives and lastly this is the perspective of the patient so very few of us actually sit in the patient's shoes to see what it's like and so one of the things we can do besides perspective taking is empathy and allow people to providers to experience what it's like to be a patient in the hope that we can provide a little bit more humanistic care for our trauma patients so I think we have about 20 minutes for questions dev I'm gonna if anyone does I'll just give this to you and then we have some of the prototypes and if you physically want to look at the prototypes of the pillbox I'll just put them up here [Applause] yes oh yeah so that that was actually one of my early ideas is to pay them yes so the patient the question was what happens in Uganda if he just paid people to come and take their medications and then I said that was one of my early ideas why don't we just pay them and that was people had vehement vehement dislike for that surprising one of them was this is their personal responsibility they need to they need to they need to be make it a priority this is their health the second is what happens when you leave nice research program and you leave with your money then what that's not a sustainable solution the things we did here is paying or compensating for transportation was the one way that payment seemed just but otherwise yes I mean I said what if we just paid them I mean I play with paying our patients to come to clinic at San Francisco General or come to their operative appointment it's cheaper but yeah it was really it was met with a lot of cultural disdain which I which I was surprised by but it makes sense when research money leaves then what they're no better it's not a sustainable solution yes yeah I personally went to Uganda yes it sounds like I personally went to Uganda yes I person what do you got yeah yeah so the question is as a trauma surgeon what what got me from going leaving trauma care which is something I know a lot about into tuberculosis in Uganda if I told you I was also working on redesigning perinatal care for vulnerable patients in San Francisco in designing early family care and mobile app for victims of violence and a couple other things I'll tell you that we're a design shop I mean and I see our expertise as doing design work in healthcare and then we say we are challenge agnostic but design focused and I think it's really fun to design things from my own department in my own discipline but it's even more fun to design things for other for other disciplines because it gives almost as a designer it gives you a license I don't have a dog in the fight you know I go to these meetings and I say I don't I I don't I don't care one way or the other I want to design the right thing I have no agenda here I'm not in the Department of OB kind I'm not a patient I am just an unbiased designer who wants to do right by our patients at San Francisco General or you know in Uganda and so um we are very focused on doing projects in our discipline but always every year having one or two projects outside of our discipline and also we're building sort of a knowledge base of institution insights and truths and design principles of working for with vulnerable patients working with San Francisco General von applications and then you can layer on substance abusing or victims of violence or pregnant and so with each experience we sort of build upon what we already know and and it it broadened us but it also helps us come with a broader perspective if you will yes yes so the question is in Broadway shows and runways runway modeling fashion shows they have dressers and that's ostensibly what we have in the operating room and we did think about that and it is it's a possibility but sometimes we have three traumas at the same time sometimes we have a mass casualty and so we were thinking when we think about sustainability it's it is a great idea one of the things I started we started wooden bar Diaz was dresser and then we moved to well what if it was like the iron dresser like we called them we call the retractor the iron in turn because interns used to be the ones who hold the retractor so what if it was an iron dresser so it was stayed outside each room and you walked into it and it refilled or it had a cartridges and you walked into it and it was because you really just need to sort of dive in if you will so yes I think there is that from a storage perspective certainly having it displayed in that way having it set up as if someone was going to dress you is a way better design yes so the question is how how do how does the funding work at UCSF for innovation um and how do you get funding to move things forward um I don't know funding is challenging and the traditional funding is traditional researchers get NH government grants or foundational grants and so some of and and then now there's opportunities within UCSF and UCSF health or San Francisco general to do quality improvement grants so everything in everything gets funded from a research perspective from my perspective through some sort of grant now I have funds from my department to sort of start this entity that will run out in the future so that's I have that but then we also have grants so like we were written into this NIH grant in Uganda we have internal quality improvement grants most of this is grant funded and you know we if you were to hire a real design shop we've charged pennies on the dollar we gotta stop doing that but we definitely charge pennies on the dollar when it comes to implementing so I guess the question is let's say I designed the I earned the iron PPE sort of device and I could patent that and let's say I did that with the surgical innovations lab there's two labs so the way UCSF works in terms of owning your IP is that 30% goes to the investigator 15% goes back to the investigators lab of any world tease and then everything else goes to UCSF because it was designed on site so if it is my lab in another lab it would be between us to sort of decide who how we allocate those funds so you know we're working on a project with the surgical innovations lab and we're less focused on devices and patentable things although that may change in the future and you know they said we'll just put a 50/50 and like the P I and and the lab will decide how it among his people and you'll decide how it goes among your people and so but really and that's the challenge with design because I frankly think everything we do in healthcare should have a design component we should at least be pausing and saying are we implementing the right thing is this the right study am i writing the grant a grant just because I have a null hypothesis just because I can have a I have an assumption I really think everything the design is what you do before you write the grant like you you need to know what you're implementing is the right thing don't just grab something and implement it and so but there is no real true traditional funding for that I think human centered design is getting more popular but I that is that is a real challenge is how do you get that work funded because it's labor intensive I mean 50 hours of interviews you know a team of four deployed to Uganda we probably did collectively did I don't know ten hours of interviews in two teams that's twenty over four days you know I mean that's 80 hours of work it's very time intensive yes in the back yeah has anybody ever tried to talk to designers about how and let there's so many barriers right now people searching I I'm sure there have I'll be honest when I was at IDEO I think they did something around clinical trials designing clinical trials but that is getting people enrolled in clinical trials is a perfect design challenge it is messy and it is complex and there's a profound and equity of who gets from rolled and who doesn't and who has access and who doesn't and googling on the Internet is overwhelming for a provider not to mention a patient so yeah that is a perfect design challenge I'd love to tackle that let's put that in last [Music] it's a financial incentive for the insurance I think that's that's one of it that is a solution I have a colleague at UCSF who sort of does that through the the CIC which is the clinical Innovation Center he picks off challenges and does some design work around that for the hospital and you know you can decrease length of stay by decreasing delirium and then there's sort of you can take whatever the the revenue was from that and get takes a percentage of that revenue share if you will we that would be a great model for us we tend to take on vulnerable populations wonderful patients and so there's not going to be much of a revenue sharing from the Uganda work or even like developing an app for victims of violence it's it's sort of an orphaned process but it is it that is a way that some people have have financed their work and and that's you know some of the things we've done redesigning workflow we've you know improved discharge order times by an hour and got interns out an hour and a half early and you know done things that that have clearly clear financial rewards and I'm sure we could figure out how to monetize that at some point some of our work maybe but yes some some people are doing that any other questions yes just patience reporting their symptoms it'd be really cool you know yeah that I mean I know there's a lot of data around you know check-ins with patients with chronic disease like you know COPD or there was a woman a psychiatrist here who'd built an app for schizophrenic sand she can actually sort of to try to identify when schizophrenic break was gonna happen and intervene early on and so I think there's definitely social media I mean you can actually identify ask it's um a manic episode weeks before based on people's social media you know footprint so I think there is given how sort of quantified Arco the quantified self and how interconnected we are and we have our smartphones our smartwatches I think that probably makes a lot of sense it just would take a designer to do it yes I mean with actual work we are not and mostly because the interviewing the the skill of the quality of the interview is I think that's the most important thing and so we are pretty we're pretty strict about the criteria of who does our interviews and we really basically take people who are trained like we were so d.school or I do trained and so and we've we've fortunately had an endless supply of either masters and design students from Stanford who worked for Boeing and now want to get into healthcare or Berkeley students who are doing design and public health or resonance or medical students who want to learn the process so we have a fair number of bodies who help us do that work that is great we there's an endless supply people who are excited about sort of bringing design to healthcare and Brill I mean this is one of the reasons I I mean besides the fact that my family's here and I love the Bay Area and I love love San Francisco general but to build a design shop in the Bay Area they're the design talent here the quality that the quality of the ability of these individuals to to do the ethnographic interviews is really spectacular and so we have no shortage of like incredibly talented people the but health hub if they had funding hey that would be great thank you for the opportunity to speak and have a great night and thank you [Music] you

Channel: University of California Television (UCTV)

Views: 1,212

Rating: 5 out of 5

Keywords: healthcare, design, The Better Lab, innovation

Id: P_NPKt9WvMk

Length: 77min 17sec (4637 seconds)

Published: Thu Feb 07 2019