InForm
Winner of the IDEA Health Design Award 2018
As part of a project to support clinical operations, quality improvement and evaluation, and integrated clinical research, my colleague Kelin Kaardal and I began working with BC Children’s Hospital (BCCH) Child, Youth and Reproductive Mental Health Programs (MH) to establish a program-wide data registry. The hospital had ambitions of strengthening its research capacity and contribution by developing a central database of patient reported data obtained during the intake process. Unfortunately, these plans did not include the family and patient experience. In some clinics 50% of families did not complete initial intake forms. This is a figure we found to be surprisingly high given the barriers to success families were faced with when sent this package. Our goal, early on, was to ensure the repercussions on families and patients were understood, considered and improved.
“Since having a baby I can only do things with one eye and one hand. There is no way I could complete forms like that now.”
- Quote from a patient of the reproductive clinic
Barriers for patients and families
Not only are there physical and time constraints preventing individuals from completing these forms, but also the complications of daily life, which for many families is immensely stressful. A parent with a child in need or a youth in need of mental health treatment is something that we found to be a neglected contextual element to the existing system. We found that the sensitive nature of questions within a complicated form filling format, increased the cognitive load on the average user, not to mention those with lower comprehension levels, those who speak English as a second, third or even fourth language, or those simply under extreme stress. These factors were strong motivators in our desire to improve this system. Intake forms should not be a barrier to health care for the youth, children and families of BC.
Innovation & public healthcare
Although there were many different paths to take in the approach of this project, we prioritized having a low cost, low resource implementation plan. Being innovative within public healthcare means producing a product that is current and creative but with a holistic understanding of the realities of implementation for these complex services. A virtual reality app that the user could act out their answers to might be an inventive approach, but as this would be extremely difficult to implement and completely impractical for patient families, it would be a failure before ever starting. Innovation with out implementation has its place, however innovation with implementation is what was desperately needed for BC Children’s Hospital.
Within this project, being innovative meant building a system through which physicians could reduce the glut of questions being asked to patients while still getting the information needed for a productive first appointment. Our product is one that can be implemented in stages. This allows the product to be integrated as soon as possible to meet the urgent needs of patients and families and be less dependent on institutional funding rounds. As our design was built into a higher level service, no portion of the product is ‘wasted’ and can be integrated according to the organizations needs budgets and time-lines.
Process
Laying a foundation for teamwork
While presenting our research and concept to the board of stakeholders we were sure to make it clear that everyone’s knowledge and experience were of utmost importance to us and would be utilized throughout our design process.
User testing 1
Our initial round of testing focused on three prototype variations. Three paper screener questionnaires (a control, very simplified version and mid-level version),
User testing 2
We tested a two prototypes (the simplified and mid-level versions). Despite wanting varied resources called out, all users unanimously requested examples to accompany each question in order to provide further context and clarification
User testing 3
After re-iterating these two versions we tested them again. We confirmed our hypothesis that the single question format, although longer, was far easier to understand and complete.
User testing 4
We made our case for a simplified form design offering quotes and direct references to research that we had done. It was very exciting to see all of our recommendations being worked into the clinics establishing the screener.
Discover
To understand the problem we learned quickly that we needed to piece together information from experts in disparate areas of the system. Through this process we learned that the patient intake forms we were asked to redesign were situated within a complex network of interactions. One of our early decisions was to move forward with a service design model in mind.
Opportunity
Patients and families were being sent up to 4-hours of paper forms to fill out. After assessing the needs of the various clinics and understanding the expectations of our role in the project, we put together a few ideas for patient centered project directions. These ranged from the lowest cost service models using an existing email link system up to total system redesigns consisting of an integrated web platform.
Prototype
The questionnaire which we focused our primary efforts was meant to replace the different forms being used by the 13 clinics. This updated form would act as a single screener that could indicate if additional data was needed by the specific clinics. This means that patients would only be filling the forms that were absolutely necessary before their first assessment. The initial prototype we developed focused on the needs of patients before their first appointment. We had theories and assumptions about appropriate hierarchies and density of information for these forms based on secondary research. These initial theories were tested with patients and families from all ends of the programs. We conducted three cycles of testing and prototyping before our design freeze.
Communicate
We had done the work of prototyping and had formed clear solutions and recommendations for implementation. And once again we were invited into the room and meeting of stakeholders to communicate our findings. The ensuing conversation between the stakeholders included 100% of our recommendations and the implementation planning of our design propositions for the updated online form system.
Story boarding
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Step 1
Once the parent receives thier referral they are sent a secure code to log in to the InForm portal. The portal will be located on the new hospital website. It’s easy to find the log into.
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Step 2
Once logged in the parent can see the form ‘call to action’ clearly. It looks like it will take approximately 30 minutes and can all be done online in as many sessions as needed. The parent clicks on the form and is pleasantly surprised to see a how straight forward the questions are. They are used to answering these questions through the old paper system which used a lot of complex wording. On the new online version, they could see that not only was the question straight forward but there was also an example available for clarification on the topic if needed.
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Step 3
The parent hears their child crying and goes into the other room. They come back to the computer and realize that the internet has dropped in and out. They log back in and are pleased to find that their progress on the form has been saved. They resume the form exactly where they left off.
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Step 4
After completing the form they are directed to information about their first appointment. They take a good look at the map, they can tell it would have been hard to find the building and are glad they have this information readily available to refer back to. They can also see in the FAQ’s section that there is even free Valet! This is a huge relief, getting settled in and out of the car is a always a challenge with a newborn and not having to worry about getting inside with the baby from the parking lot is a big time saver. They are feeling really confident in BC Children’s Hospital, and are able to get back to their family for the night with one less thing on their plate.
Screener re-design
The design of the question interface was at the core of our project. These questions made up the new intake screener. The development of this component of the intake process ensures families are only completing forms that are necessary before the first appointment. Rather than completing 30 pages of questions, families and patients would only be answering questions about areas they are very concerned about, and never more than 3 clinics worth.
This is a challenge in that developing an accurate self diagnosis is not a reasonable expectation for families and patients. To make matters more complex the desire of families to avoid or obtain diagnosis must also be navigated.
The question architecture and design of how best to ask these questions was something we were given a great deal of free reign on. Our recommendations were to keep each question to one idea. This was a large departure from the original format in which 4-11 points were being asked about within one question. By reducing the bulk in each question we created simple yes or no questions for users. This, however, was not yet optimal for users.
Homepage
Our initial interviews with clinic operational staff revealed that many patients had trouble with appointment expectations. In exploring how one might find the answers to these questions ( “What do I need to bring to my appointment?”, “Is there any accommodation support for me and my child if we have to travel?” and “Where is the appointment?”) we found it very difficult, even for two tech-minded designers, to locate on the hospital’s website. Within the portal, appointment details are located on the homepage or dashboard (as opposed to having this information hidden within the body of an email with a link to an online questionnaire).The user can also see their current progress on their forms, and easily navigate to personalized Resources and Patient Feedback. This makes it easy for families and patients to keep track of appointment times, and be prepared for a successful first meeting.
Feedback
The feedback mechanism was inspired by a published medical case study looking at patient reported outcomes for youth and children participating in mental health treatment. It was discovered that providing short feedback on the effectiveness of the therapy after sessions is helpful in determining the appropriateness of the therapy. This may seem self-evident, but the study also found that 90% of clinicians believed they were within the top 25% of their field. The study found clinicians were not able to accurately determine their effectiveness and that if a patient feels a therapy or course of treatment is not working for over 5 sessions the therapy will not work. Worse still, if the patient believes the treatment is not working it is possible that to remain with the same therapy will have serious negative implications on that individual’s mental health leading to a regression of any progress made or even a worsening their symptoms. Our feedback mechanism is not intended to antagonize clinicians and is simply a tool to increase communication between patients and clinicians and improve the overall experience for patients attending sessions at the mental health programs.
Resources
One of the key insights we heard from families and patients was that they were not aware of the resources available to them until after their first appointment. Given the long wait times before one’s first appointment we wanted to create a space for clinic endorsed resources. Some of these websites are made specifically for mental health patients and families in BC and even specifically for those attending mental health programs at BC Children’s Hospital. Rather then expecting families to know what to look for we put together some of the top resources recommended by the hospital and provincial health services.
Outcomes
BC Children’s Hospital plans to rolled out the basic version of our system in August 2018. Based on our recommendations the physicians finalized the structure of the intake forms. The design of the forms is being implemented as an email link with information that patients have requested within it. The question and form redesign can then be re-homed into a new website that began development in 2019. This means that the hospital won’t be duplicating efforts in producing the screener but instead able to seamlessly integrate the questionnaire into their new web page. Although email links are not our primary recommendation for the product and system it is what is possible to be implemented right now. This upgrade allows patients and families access to the updated digital service and online form process sooner than a full web implementation would permit. Given the urgency and need for this update, we have helped create a design that works within this constraint. In addition to the hospital’s implementation plan, we have had interest from parties at TELUS Health. TELUS Health is the primary telehealth facilitator in BC. Our digital intake system is something that they have expressed interest in and that we believe would be a positive supplemental service to their existing programs. We will continue to advise BC Children’s Hospital as neither of us were able to accept their employment offers for the continuation of this work.
Our work on this project was entered into the IDEA health design award. For this application we needed to create an interactive installation. We are pleased to share we won this award.
