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<h2 class="hd hd-2 unit-title">Why Design Thinking?</h2>
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<h4>Philanthropic Colonialism</h4>
<p>Although the convergence of interest and improved communication has lead to increased attention and action surrounding innovation in global health settings, there are several flaws with the current approach. First, too often “global health work” consists of teams from high-income countries (HIC) travelling to low-and-middle-income countries (LMIC) for short periods of time, leading to inconsistent and lackluster results. These teams, while well intentioned, attempt to roll out new technology or provide care without developing sustainable models for moving forward with innovations and worse, often without understanding the true urgent needs of the local communities. A recent article by Jane Cockerell highlighted that “at least 40% of medical equipment in developing countries is out of service (some studies cite 50-80%) and that doesn’t account for what equipment should be present and isn’t. By comparison, less than 1% of medical equipment is out of service in high-income countries”. In cases of novel technology, the ground-level stakeholders often do not know how to resolve issues when the new equipment malfunctions or requires a replacement part. This leads to “graveyards of technology” taking up space or left to age without providing value in these resource-constrained settings. Additionally, the sporadic status quo efforts often fail to understand the unique cultural, societal, and political needs of the LMIC settings, with a spectrum of consequences. As stated by Howitt et all, “technologies from high-income countries are often deployed in these [low and middle income country] settings without enough thought of the consequences, and such technologies might rapidly become useless… donations can place a burden on recipients; oxygen concentrators donated to a Gambian tertiary hospital required a voltage incompatible with the electricity supply in that country”. Users are inadequately trained or there is insufficient infrastructure to support the often sensitive medical equipment. At best, this approach wastes or displaces needed time and resources; at worst, it may create what Peter Buffett has (controversially) labeled “philanthropic colonialism” leaving negative impressions to disincentivise potential future efforts.</p>
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<h4>The Birth of Pilotitis</h4>
<p>Secondly, innovations utilizing mobile health or ‘mHealth” have often failed to integrate into the existing social, cultural, and organizational fabric and infrastructure in global health settings. They have stayed as isolated projects outside of traditional care pathways with limited incorporation to the existing system or current improvement efforts. Mobile health innovations are often attractive to teams or individuals with entrepreneurial mindsets because they present lower barriers to initially deploy these technologies. However, many of these initiatives suffer from “pilot-itis” where they do not move forward into integration with existing systems. Often the end result of these pilots may be a published paper at best, without focusing on sustainability beyond the research phase. Furthermore, negative results are rarely reported, so many pilots are reinventing broken wheels that are doomed to failure. The speakers at the 2012 GSMA (Groupe Speciale Mobile Association) mHealth Summit in South Africa “bemoaned that 'Pilot-itis’ - the inability to break out of pilot stage - is holding back mobile health in developing countries”. The failure to get out of the pilot stage can take away resources and supplies in already constrained settings leading to fragmentation and little improvements in health outcomes. In many cases, these efforts remain isolated, insignificant projects taking away valuable time from local stakeholders.Thirdly, this wave of interest in global health settings has attracted diverse groups of stakeholders, including involvement from engineers, public health workers, medical professionals, and computer scientists. However, the formation of projects from various disciplines in parallel has often led to fragmented and redundant work in global health settings. With little coordination taking placing across these stakeholder groups, segregated fiefdoms are formed, negatively impacting health outcomes. For instance, an mHealth program for obstetric care, diabetes care, HIV care, or another specialized disease process that does not integrate into the existing public health and governmental infrastructure will ultimately create fragmentation and redundancy.</p>
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<h2 class="hd hd-2 unit-title">The Design Thinking Process</h2>
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<h4>Focus on Quality Improvement</h4>
<p>Before any technology development begins, we must first determine the required components through an intensive design process. This section is not a detailed process manual to be followed step-by-step, nor is it an explicit implementation of the various “design thinking/human centered design/integrative thinking” processes that are excellent tools to follow. Instead, we present here the crucial elements to consider when integrating an informatics solution in a global health environment. The primary focus on quality improvement brings attention to capturing and communicating the right information, while also connecting to the workflow loop for appropriate clinical intervention. Equally important, we must focus on making it easy to use, in order to encourage adoption and sustainability.</p>
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<h4>Radical Collaboration</h4>
<p>One of the recurring themes in global health is the failure for programs to develop sustainable plans and models to ensure they both fits into the existing system of care and is maintainable and adaptable to meet local needs.</p>
<p>Medicine and health systems are immensely complicated, as we will repeatedly emphasize in this course. With so many interacting fields along the entire healthcare vertical, it is a given that no group can solely control quality outcomes; even front line clinicians directly treating patients are impacted by government regulations, medical supplies, and market forces. This is why the principle calls for collaboration across fields, purposefully pulling together multidisciplinary teams. Innovators need to pursue new modes of collaboration in global health settings.</p>
<p>While skills often overlap across fields for any individual, the following generalizes some simplified stereotypes for illustration. Clinicians should be abreast of the latest developments in medical practice via continuous medical education, but generally are only aware of the latest well-marketed technology development. Therefore, clinicians should collaborate with the technologists who are aware of the limitations and constraints for what is feasible on a platform. Conversely, for the engineers who think their technology can solve every problem, they are usually unaware of the complexities and complications of delivering medical care, especially when focused on quality improvement. Only when clinicians and engineers work together can a team implement an intelligently designed and impactful innovation.</p>
<p>By definition, entrepreneurs are risk-takers and often drive towards the path of least resistance. They are incentivized to build barriers around their intellectual property to protect themselves against competitors and ensure that their venture is a profitable, sustainable entity. However, when engaging in global health settings, taking time upfront to involve local stakeholders to build entrepreneurial teams results in superior outcomes. Although engaging community members early in the innovation effort may initially feel like an “obstruction”, it will ultimately lead to more productive, collaborative efforts and in the long run will create a more sustainable innovation. Interdisciplinary teams create a learning environment where stakeholders are free to share ideas to develop best practices surrounding the newly proposed innovations.</p>
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<h4>Co-Creation</h4>
<p>Co-creation in the context of global health innovation is making sure to partner with collaborators from the local environment. For foreign innovators, it is crucial to retain a cultural sensitivity to what makes the locale unique. This includes knowing which problems are most urgent for the local community, accounting for wide differences in disease prevalence across borders and socioeconomic status. Co-creation is also required since, what works in one locale won’t necessary translate to a global location. Often there are local resource limitations, such as poor roads, limited power infrastructure, or lack of Internet access. More difficult to navigate are the often undocumented cultural differences, such as understanding who the primary decision maker is for a family. In the US, it is biased towards the individual or spouse, but in many cultures outside the US, there is a much more extended familial influences where parents or other relatives have a significant influence over the medical decisions of even other adults. Rather than having the design driven by researchers from HIC applying their tools and processes to familiar problems, it is crucial to have core members of the team that are integrated with the target community and is familiar with the specific local characteristics.</p>
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<h2 class="hd hd-2 unit-title">Closing the Loop</h2>
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<h4>Workflow Integration</h4>
<p>Any technical innovation needs to be thoughtfully integrated within the clinical workflow. Rather than designing around a novel technology, it is often constructive to begin with the clinical intervention and analyze where technology can play a role and improve processes. At the outset, it is helpful to investigate any significant barriers to implementations, such as pre-existing systems, user hesitance, immutable processes, or insufficient human resources.</p>
<p>An aspect of workflow integration is a strong emphasis on workflow efficiency. Clinicians are notoriously overworked, with limited time and significant amounts spent on documentation already. As much as possible, any innovation needs to avoid adding work, else the solution won’t be adopted by the clinician user-base, nearly regardless of the potential benefit. Therefore, it is imperative to design efficient clinical interfaces that minimize the amount of additional work, with improving efficiency an ideal objective. An important caveat comes from including the previous recommendation of end-user analysis, where the clinician users will likely have different biases towards what interface improves efficiency from the implementing engineers, so it is prudent to include clinicians in the design process.</p>
<p>Most importantly, for any mHealth solution to yield a lasting impact, it must be directly tied to quality improvement. This requires 'closing the loop' with a clinical intervention, so it is strongly recommended that a holistically designed intervention connect the informatics innovation with the clinical process. This is a challenging proposition and requires clinicians to collaborate closely with the technologists to push the envelope of what is technically feasible with what can make a clinical impact.</p>
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<h4>Prototype Validation and Rapid Iteration</h4>
<p>The final recommendation is to learn during the design process and to adjust accordingly throughout development to adapt in order to lead to the best outcomes. This can be built into the process through prototype validation and rapid iteration. For prototype validation, this might include planned 'Proof of concepts', which are small prototypes that attempts to answer any significant questions from the design stage. These can be as varied as a questionnaire to determine the target users' need or acceptance, to a technical prototype validating an exchange protocol. Another possibility includes mockups/screenshots to test usability for a target audience. These prototypes should test and validate or disprove the questions so you can adjust your plan early enough rather than be caught delivering an ineffective project.</p>
<p>Even after the design stage, if possible it is recommended to implement a process of rapid iteration during the development phase. This entails getting feedback quickly from stakeholders in order to quickly adjust the solution. This entails not locking into what is in the technical specifications and keeping an open mind to what the feedback is telling you. The quicker the development team learns what will actually work, the likely lesser the impact on the ultimate development timeline or cost.</p>
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