Friday, June 26, 2015

And they're off....

A person-directed medication education system.  After 11 weeks, many conversations, a phone conversation with a national leader in health and aging and a readmission summit it is clear we found the place where are story, experience and capacity makes the biggest impact.  As health care transitions to performance based care they will need to be patient-centered.  After hearing Cheri Lattimer speak at the readmission summit it was clear that it is deeper than a phrase and she talked about the future of health care being directed by the patient.  After all patients are people so we chose the words person-directed medication education system because every person is going to direct type of education, what will be delivered and even how it might be delivered.

Together with our community are building a system that will be simple, adaptable, personalized, hands-on and be in a language every person can understand.  Our definition of system in this case is the simple and familiar tools + the skill building hands-on experiential learning place where each person can build the skills, in a sustainable way, with the supportive tools to successfully manage their health at home by being knowledgeable, feeling confident and owning their independence.  It is also a place for the medical professional to share their experiences and express their individual abilities.

Together we looked at the roots of a successful, adaptable and sustainable system.  Like the roots of a oak tree these roots draw nutrients, keep the tree grounded and support its growth.

We looked at what tools, elements, guiding principles and goals or outcomes were needed for a successful, healthy, adaptable and sustainable system (below).

Each week we will focus on designing one of the elements or tools of the system.  Bleow is a list starting with 'Understanding A Person's Routine'.  Each week we will design one component of this system. 
  • Understanding Routine
  • Visual Med List
  • Pill Organizer
  • Medical History
  • Totem/Reminder
  • Identifying Skills and a Platform for hands-on learning
  • Awareness of personal goals
  • Understanding Context (Place)
  • Rewards 

 The one that we didn't record this week but I think is critical is; identifying the skills a person needs to learn to maintain their health and independence and having a place to learn hands-on with feedback from a coach to build long term capacity.

On July 10 we will bring our ideas, drafts, templates, mockups, prototypes for how to understand a person's routine and develop a detailed design.

See you on July 10.

Monday, June 15, 2015

Can You Teach An Old Dog New Tricks?

As a community we met for the last 12 weeks.  We shared our own personal experiences with health and medication and assisting with loved ones.  We brought together mothers, daughters, sons, husbands, grandmothers and grand fathers, caregivers, designers, occupational therapists, pharmacists, nurses.  Some of us dealt with chronic conditions or helped a loved one.  In the end we all benefit from design in community.  We were enrich by each other's experience, gifts and perspectives.  Our relationships were strengthen to each other and the challenge at hand.  We finished with an impassioned community who wants to do more.  The more is the detailed design...

Together these experiences, stories, gifts, passions and talents helped us see the world and the world for those taking medication in a much deeper and richer way.  We dug deep attempting to gather empathy and a better understanding of the challenges that people deal with on a daily basis.  We looked to the world that exists around our own personal health, the role of our own personal routine, how each of experienced adapting to change.  We looked at ways to solve different challenges that emerged all to stretch our perspective and understanding.

The primary themes that emerged were:
  • Routine - Discovered the importance of understanding routine and each routine is unique and without finding out how health fits into these routines the outcomes could not be sustainable
  • Unspoken Goals - the deepest sense was that the goal for each of us as individuals is freedom, independence, control and confidence.  Medication and health are barriers to achieving this. 
  • Personal Goals - Purpose/Interests/Goals it is personal goals that motive us to make health adaptions so we can continue to LIVE.
  • Education and Learning - Reaching these goals only comes through the right kind of education, skills transfer, coaching, teaching and learning.
  • Totem - Take or Not is an area that may help build confidence and control
  • Medical History - Medical history is an important and often redundant part of our personal health
  • Using the Senses - Visual, tactile and other senses are important to consider. 
Once we explored all these themes we looked at how they fit into the three primary relationships in an individuals health ecosystem (see diagram below).  What emerged at the center was education, skill building, learning, this is what enables a person and their family to feel in control, confident and have the freedom and independence to live their personal goals.  

Each of these relationships 1) individual 2)family and 3) healthcare have a different language but the outcome seemed to be the same and the path, through the right, personalize and individualized education was the path to achieving a shared outcome.  Because each person has their own system the education needs to build real skills, in an accessible way (language for a layperson) and must work with each unique person.  

The only way to design an adaptive education system that works with each unique situation, person, learning style, skill level is to design a system:
  1. based on guiding principles 
  2. Includes simple tools
  3. Hands-on education that can be adapted to every learning style with a feedback loop to continuously improve
  4. starts with discovery of each person's unique routine, personal goals and feelings
  5. the appropriate language that the lay person understands

Getting the language right is going to be important and there is at least three primary audiences.  For the person like my grandma Stella who was in her late 80s she would never want to be "educated".  She would probably say something like you "can't teach an old dog new tricks". So the language must be appropriate.  Language she might relate, "daily independence recipe".  Or the "at home health living guide".  For the caregiver they want peace of mind and stress relief.  For them the system might be called "information is power" or "what I need to know system" or the "help my parents adapt to changes" or the "healthy parent peace of mind".  And then for the health system the language might be something like "patient directed education system" or "patient safety through patient self management" or "lay education system".

All of these are saying the same thing but the language that is a bridge to each primary relationship.  As we move into detailed design.  The design will be rooted in the simplicity and familiarity of the original Pill Pouch and will go deeper in designing a personal education system with familiar tools that grows confidence, control, freedom and independence while strengthen relationships between these three groups and improving outcomes.  

We will start by designing system that addresses one of the barriers to freedom and independence for elders or peace of mind and knowledge for caregivers or to patient safety and improving transitions for the healthcare industry....medication.  We will enter detailed design with the goal of designing a medication education system in the spirit of the above and modeled after some of the successful hands-on, personalized educations systems we identified last week including:
  • Teach back
  • Watch one, do one, teach one
  • Hands-on with feedback loops
  • Coaching model
  • "Tell me and I forget. Teach me and I remember.  Involve me and I learn." ~ Ben Franklin
  • Cabinet learning (my learning that included youtube, google, experts and prototyping)
The journey has just begun....Here is a link to our presentation of the structure of our system design.

Tuesday, June 9, 2015


High temp, racing heart, out of breath, cold and clammy, kankles...what do they have in common.  These are some of the signs of Sepsis.

Elderberry was asked to facilitate 'active research' during the STARForUM monthly community meeting at St. Mary Mercy Hospital.  STARForUM is "Safe Transition of All Residents For yoU and Me" – a grassroots organization with primary goal of improving transitions of care between senior facilities and the Emergency Department (ED) in both directions.

Our process engages community in an energizing way to co-create, with members of a community, company or organization, transformative outcomes that bring these closer to their goals, identify opportunities or create innovations. 

We were asked by Michelle, the Director of the Senior ER at St. Mary Mercy, to get the STARForUM community excited and inspire their creativity to identify ideas that will tackle Sepsis.  Sepsis, as we learned, is more common than heart attacks, and claims more lives than any cancer.  Yet less than half of Americans have heard of it, prevention can be as simple as washing hands and early recognition is critical to treatment.

In our process we use energizing and creative activities to harness the excitement of the community to generate unique ideas.  For the STARForUM we used an activity called 'How To Draw Toast?'.  This is a great activty to harness the power of community developed by Tom Wujec and shared here in his TEDx talk.

The patterns that emerged:

  1. There are many faces of Sepsis
  2. Prevention is just as critical as recognition (could be as simple as washing hands and saying your ABCs)
  3. There were a number of creative ways to build awareness that are in the spirit of the STARForUM 
The next step is choosing a way that best fits the spirit of the community.  The launching pad has been its time to #KissSepsisGoodBye!

Stay tuned for the final outcome!

Monday, June 8, 2015

What is the best way to learn?

There is so much debate around education and learning.  Direct instruct is the industrial model that has been around for a century.  Now there are new terms for new ways of learning decentralized learning, practical learning, unschooling, project based learning, simulated etc.

We can simplify it even further.  Think about how we learned the English language or how to walk or ride a bike.  Have you ever wanted to learn a new language?  There are many ways available but the consensus is get a girlfriend or boyfriend who speaks the language you want to learn.  There is a theme that exists in learning as a child or the best way to learn a new language as an adult....hands-on!  In the trenches.  With real-time feedback loops.  

When we learn something we become confident.  I recently built my own kitchen cabinets.  Before attempting to build cabinets I could barely operate a circular saw.  I was intimidated, scared, worried about spending too much money, waste material or the cabinets just not working.   So I built a small test cabinet with some scrap wood.  It wasn't perfect but I learned.  I was no longer intimidated because I built a rough yet functional cabinet.  I was now confident.  With that confidence and what I learned about building the test cabinet sprinkle in a touch of patience I build an entire set of kitchen cabinets.  This was hands-on learning.

This is just proof I am not lying and hands-on learning works
To bring this idea of hands-on learning to our work, somewhere near the core of my mom and grandma's story is to facilitate learning and skill building. The results are the development skills and confidence.  This week we are going to define whats at the core.  Attached are the themes that emerged from the summary of the series of community design sessions.  

Bring your examples of the best way to learn....

Thursday, June 4, 2015


I believe...That every person has a gift

I believe...That every person has a personal goal

I believe...That every person wants to achieve those goals

I believe...That every person can build the skills to achieve these goals

I believe...That I have the ability to coach any person to build these skills

I believe...That I can nurture sustainable change in that person

I believe

This came to me while at a health care conference after hearing Dr. Eric Coleman speak and share his vision for health care professionals or laymen is to create coaches and the gauge of a successful coach is the transferring of skills.  It is the teaching to fish rather than the giving of a fish that Dr. Coleman says makes the sustainable change that can improve outcomes. 

Monday, June 1, 2015

Do you have any______?

"Do you have any allergies?"  How many times have we had to answer this question?

Don brought up this question "why am I asked this question every time I go to the doctor even though I keep answering it the same way?"

I am sure we have all experienced this anytime we go to a doctor visit, urgent care, the dentist or emergency room.  We're handed a clip board to fill out all the same information; surgeries, conditions, allergies, medications, emergency contact etc.  This information floats around in stacks of papers that are called my medical records.  My stack is probably the size of a small monument at this point and I can't even imagine what my grandma's stack of health records looked like.  And most of it is the answer to these same questions.  

So what if I had control of this information in an accessible place that was easy to update?  Then the question might be how and what information is relevant?  Should I include any procedure including a ear flushing or stitches? What do they mean by conditions?  I get dry mouth at night...does that count?

But this is really my information and I should actually be in control of it, right?  Now full disclosure, I am horrible in keeping my immunization diary and remembering my vitals (cholesterol and blood pressure).  Shouldn't I know this information? It just isn't easy for me to remember to record this information and if I do remember to record it...where the heck did I put it?

The two questions we discussed; how do we create an easy place to record and keep my personal health information and how do I get the right guidance about what information is relevant?  File of Life and Plan In A Can both provide an avenue to do this.  Google also tried and failed to create a digital Personal Health Record (PHR) that would widely be accepted.  Is there a simple way to capture, safely store and access this information?  Why did Google Health fail?

NOTE: I like how St. Mary Mercy's Plan In A Can form is called the "Just In Case Card".  Language is important and powerful to create the appropriate association with something that can become associated with something negative, emergency, pain, suffering or even death.  

We decided to create some requirements for our version of this "Just In Case Card" or "File of Life".  We post our draft requirements here.  It also might make more sense to partner with either of these two organizations who have already developed the requirements, designed a form, vetted the form and have channels for communicating and sharing this tool.  

The information we thought might be relevant included:
  • Advanced Directives
  • Chronological surgeries, incidents and/or conditions
  • immunizations 
  • Prosthesis and implants 
  • Doctor names, phone numbers and their specialty
  • Insurance information
  • Medication history - medications taken before that were; change, replaced or discontinued
  • List of current medications
  • Pharmacy contact 
  • And of courses........Allergies
We also discussed some design principles for this diary/form/repository:
  • Simple
  • Not pages and pages (that would be daunting)
  • Simple to update one portion and update other portions easily 
  • Doable
  • Feeling of accomplishment 
  • Easy to keep and accessible for routine doctor visits, to update and in case of an emergency
  • How does digital fit in?
  • Builds knowledge and confidence 
1st Half of the Discussion Routine and Purpose

The first half of our design session was recapping the previous weeks conversation about a totem and the recurring theme about the importance of routine and purpose when integrating medication into our lives.  This week I was at a conference and heard two of the speakers refer to this purpose/motives as personal goals. 

Don said "each person's routine is their own system and everyone's system is unique."  We can't expect every person to be given the same orders and directions in the same way and expect every person to understand, comprehend, and fit this into their vastly different person routines.  Example; a doctor may tell every patient who she prescribes Metoprolol to take it after breakfast in the morning by 9am.  If the patient doesn't wake up until after 9am or doesn't eat breakfast it is now implied they need to either change their routine to do what the doctor ordered or decide for themselves if or how they will take it.  Changing a person's personal routine is drastic and not sustainable.  Have you ever decided you are going on a diet; going to eat vegetarian, eliminate coffee and eliminate alcohol? This may last a whole day because these are huge changes to our personal routine and once we fail one of these things we quickly revert back to the routine, diet and habits we developed over time.

We decided it was necessary to have a set of questions that allows the medical professional, family or patient to understand their own routines, learning style, feelings and motives.  Knowing these allows us to develop our own sequence and learn how to fit doctor prescriptions into our existing routine so daily activities can reinforce this new sequence.  We created a rough draft here of the questions that might guide individuals, families, friends, caregivers, doctors, nurses or pharmacists to understand a person's routine, motives, and learning style to successfully involve, teach and integrate this sequence of health prescriptions.

NOTE: we found the concept of sequence to be more important and more fitting when talking about performing prescriptions at specific times of the day.  The exact time of day was not helpful as it implied that every patient has the same routine.

Also to further enrich our discussion I heard Dr. Eric Coleman who developed a program to train what is called Transition Coaches.  He had a few points that added to this discussion:

  • We need to understand a patient's personal goals not assume we understand their goals or even health goals.  Personal goals are bigger and more motivating.
  • Learning/Coaching is transferring Skills
  • Transferring skills happens through simulation (patient being involved in hands-on learning)
  • A feedback loop is important to gauge whether or not a patient has obtained the necessary skills
  • We also need to be aware of medical professional's need for personal fulfillment when treating patients
Dr. Coleman used the analogy of giving a man a fish, which is fulfilling in the near term but not sustainable in the long term and teaching a man to fish which is more time consuming in the near term but more fulfilling and sustainable over time.  He used the quote from Ben Franklin to outline his method for transferring skills: 
"Tell me and I forget. Teach me and I remember. Involve me and I learn." ~ Ben Franklin

In addition to all this conversation about routine we discussed tying medications to activities in an existing routine.  See example below:

           Name|Dose|Use|When (the activity int he daily routine that the medication is tied to)

           Metoprolol|25mg|Lower  Blood Pressure|After eating breakfast in the morning

Finally, as another data point, I read the headline in Rock Health's weekly update

What takes up 50% more of a doctor's time than caring for patients, was supposed to save $77B for healthcare, just got a funding boost from CMS, and had sweeping changes proposed from AMIA last week? The EHR. A valuable tool or a total disaster? 
Then I read the twitter responses, mostly from doctors, who the EHR seemed to be their arch nemesis and a Washington Post article by Charles Krauthammer where he shared a quote from a doctor "the introduction of the electronic medical record into our office has created so much more need for documentation that I can only see about three-quarters of the patients I could before, and has prompted me to seriously consider leaving for the first time.”

Are we moving to a more decentralized and patient owned and directed health care model?  How important is this documentation?  And is it the doctor's responsibility?  Where does our community design fit in the current world and in the future?

Big questions....