Ethnographic Research

Why Health IT Benefits from Engaging Diverse Communities


Telemedicine--the ability to conduct remote clinical visits through videoconference--is a rapidly growing industry.  HealthcareITNews reported that, “The global market for telemedicine is expected to be worth more than $34 billion by the end of 2020.”  

One of my clients, the non-profit health insurance fund UniteHere! Health, contracted with a telemedicine provider to help keep their ten thousand New York and New Jersey members away from unnecessary emergency room visits and hospitalizations.  The problem was that very few members were taking advantage of the service.  With low utilization, UniteHere! Health would end up with little return on their investment.  

I got called in to help UniteHere! Health increase utilization of telemedicine among its members because I had worked with them on a project to drive down costs by connecting their membership to primary care doctors and chronic conditions management.

I went straight into the field to test the mobile app, focusing on UniteHere! leaders who I knew would spread the word about telemedicine across the organization--that is, if they liked it.  I sat down 1-1 with each member and watched him or her navigate the service on their phones, from downloading the app all the way to having a videoconference with a doctor.

Here are my two major findings that I think will be valuable to all telemedicine or health IT providers who want to get more people engaged with their technology.

1.    Language
To reach the broadest base of potential clients possible, cater to language.

The majority of UniteHere! Health members that I tested the telemedicine technology with did not speak English as a first language.  To navigate a website or a mobile app that is written entirely in English is a barrier for immigrant communities.  It’s a high hurdle to jump.  Equally important, there have to be doctors available who speak the same language as the patients.  UniteHere! members who speak Chinese or Haitain Creole would have to be comfortable enough in English to navigate to the menu option that allows them to choose a doctor that speaks their language.  And then, radio silence.  There wouldn’t be any doctors available. 

 If telemedicine wants to serve a global population, it can’t be shortsighted about language. Language is essential. In New York City, half of the population does not speak English as home.

2.    Scaling the Digital Divide
Invest resources/staff into underserved communities and reap the rewards.

About 50 percent of the UniteHere! members I tested the telemedicine app with were confident tech users.  These were the type of people to whom you could say, “Download this app and let me know what you think.”  Typically, this is the person that tech developers are designing for.  The other 50 percent of UniteHere! members I tested the technology with had never downloaded an application on their smartphones. They needed step-by-step assistance to help them learn how to use it.  Once they learned however, they were up and running.  

A lot has been written lately about the lack of gender and racial diversity in tech.  As CNN Money writes, “After all, engineers build gadgets and software for men, women and people of every color—and a diverse workforce means a more expansive understanding of what customers want.”  In this instance, increased diversity would contribute to designing better gadgets and software, and work to get that technology into the hands of “unlikely” customers.  

The Opportunity:  How might we bring the benefits of telemedicine to underserved communities?  

Here is the good news:  The UniteHere! members I tested the telemedicine app with uniformly LOVED the service.  They loved that if their child got sick in the middle of the night they could see a doctor from home for the cost of a primary care visit, instead of going to the emergency room and paying a much bigger bill.  They loved that telemedicine gave them the option of getting a doctor’s opinion on that pesky rash, and even receive a needed prescription, without having to miss a day of work.  One UniteHere! member who suffers with chronic conditions said, “I’m a fan of this, and I’m not a fan of ANYTHING.”  Another said, “This is like having a doctor in your pocket.”  

On top of that, the UniteHere! members who struggled with the technology were completely undeterred from trying to learn it, and were still very enthusiastic about what it could do for them. Some members sat with me for over an hour working to set their mobile accounts up.  What should have been a 5-minute registration process took longer.  They didn’t have an email address.  Or they couldn’t remember the password to their email address.  Or they were confused about how to enter their insurance information.  At no point did they say, “This app is not worth it.  I’m out of here.”  They wanted what the technology could provide for them.

The Value of Community Engagement

Telemedicine, health IT, and the tech world in general, would benefit from a strong investment in community engagement. And underserved communities will benefit from technology that they are currently being overlooked for.  

A commitment to community engagement would mean that tech companies equip skilled cultural workers to introduce technology in neighborhoods and regions beyond the middle-class tech-savvy markets. This engagement is an excellent opportunity to get product feedback from a diverse range of potential users and get new people onto platforms that they would never know about otherwise.  Many community leaders simply need the initial training about the technology and then they are up and running and ready to tell their family, their neighbors, their co-workers, the people they go to church with, the people at the YMCA, and the people who hang out at the local bar or coffeeshop.  That is how an intensive community engagement practice becomes scalable.  

Something as valuable as telemedicine should be accessible to everyone.  Catering to a more diverse clientele is a great way for the health IT industry to bring in more valuable business.  It’s a win-win.  And I would love to work to make it happen.  

Contact me if you are interested in learning more.  

On the Frontiers of Human-Centered Design

This summer I’ve been exploring the whole wide world of social innovation and human-centered design and talking with studios that are leading this work —like Ideo.org, Greater Good Studio, Public Policy Lab, and Design Impact.  When I tell my friends and colleagues that I’m interested in social innovation, they usually respond with, “what does that mean?”  When I mention human-centered design their reaction is something like, “huh?”

Let me explain. The way I understand it, big global design firms like Ideo popularized human-centered design as a core method to create innovative products and services for clients like Apple and Nike.  The principle is that the best way to design stuff that is really transformative for people’s daily lives is to deeply understand the person you are designing for. You need to watch that person go about their day, understand what they are motivated by, see their biggest frustrations first-hand. Then you can prototype a product or service directly based on their needs, and even better, involve that person in helping to improve your prototype by getting their feedback and watching them use it.  What you end up with is a product or service that directly caters to the person you are designing for.  And as a result, what you design is not just more effective, but can actually be transformative in a person’s life.  Human-centered design is definitely not rocket science.  It’s a common sense approach.  But in the design industry, it seems like it was fairly revolutionary to move away from thinking about consumers as “users” and designing for them from a distance.  

THEN (this is the part that’s exciting for me) a number of people from the design industry who had been using this human-centered practice with corporate clients started to say, “Hey, this technique is super effective for coming up with incredibly innovative and powerful solutions that change people’s lives.  What if we applied this design approach to social issues?  What if we used design to create transformative products or services or systems for vulnerable communities?”  And that’s how you get solutions like Greater Good’s work to empower Chicago citizens to help design a better public transportation app that encourages more people to get out of their cars.  Or Ideo.org’s work designing a high quality and affordable solar light for families in Kenya and India living on less than $1.25 a day.  Or Design Impact’s work to strengthen programs helping low-income women in Northern Kentucky get and maintain good paying jobs in advanced manufacturing.  

Now, I LOVE this stuff.  My entire career has been focused on working with local communities to find innovative solutions to complex problems.  Like fundamentally changing the way police and social services were interacting with the community in Oakland, California, so those systems could proactively prevent the homicide and gun violence that was devastating the city.  Or working with the Center for Medicare and Medicaid Innovation in Washington DC to pilot new healthcare delivery systems across the United States that would better serve high need patients.  I’ve been practicing human-centered design my whole professional life!

And I’m really excited to learn even better ways of doing it. That’s why I’m currently participating in Ideo.org’s Design Kit: The Course for Human-Centered Design.  As a change agent and practitioner, as someone who loves to connect with people, create new systems, design new experiences, find interesting solutions and take action to implement them, human-centered design is an awesome addition to my toolkit.  It’s a super systematic and fun way of collecting insights, discovering design opportunities, brainstorming and testing innovative solutions, and implementing new ideas.  It’s a powerful approach for staying true to the community you are creating with.  And ultimately, human-centered design is a method that allows truly transformative and revolutionary ideas to break through, come to life, and have incredible impact in the lives of the people I care about.  This motivates me more than anything.

I can’t wait to share the solution I’ve been working on with my ideo.org team this last month.  My next addition on human-centered design: coming soon!

Lifelines: Culture Change in Oakland

In 2006, I started working as a community organizer in Oakland, California. I spent the first few weeks on the job driving around West Oakland, meeting with church pastors, families who lived in the neighborhood, teenagers at the district high school, and people who ran local service programs. Everyone was talking about the same thing: gun violence and homicides in Oakland. 145 people were murdered in the city that year. Mostly men, these were the lives of sons, brothers, nephews, fathers, cousins. The community was devastated. And angry.  And wanted to do something about it. 

That’s when I learned about Ceasefire. Ceasefire is a national violence prevention model that grew out of Boston and was gaining traction in other cities, like Chicago.  My community organizing network flew the Boston Ceasefire leaders out to Oakland to tell us what they did to dramatically reduce homicide in their city. What I heard hooked me.

Ceasefire is based on the premise that building strong relationships between local community, social services, and police can fundamentally alter patterns of gang and drug violence.

Violence isn’t random. The goal of Ceasefire is to focus on people actively involved in violent circles, in order to interrupt shootings before they happen. What’s innovative is that the Ceasefire model doesn’t target violent offenders in order to to arrest them. The goal instead was to CONNECT them. To connect young people to real job opportunities beyond drug dealing, to connect young people to supportive social services that could help them make different choices, to connect young people to community members who cared about them, and to connect young people to former violent offenders who had changed their lives and who could help mediate conflicts and disputes. 

This was different! It was a strategy that wove new relationships between community, social services, and police, to take a stand together, in order to protect and support a group of young men who have been marginalized.

It was hard work to get this new strategy off the ground in Oakland. A lot of people said it couldn’t be done. But my team of community leaders and I met with the police chief, we met with the department of social services, we met with job-training programs, we met with church leaders and community-based programs, and we got them to commit to work together for the Ceasefire violence prevention model. We mobilized thousands of people to stand before the mayor and police in support of Ceasefire. We declared: “This is the new way to handle violence in our city. This is what Oakland should invest in.”

And we won!  Oakland hired street outreach workers to build relationships with young people involved in violent circles to interrupt conflicts. The police started partnering with community and social services to connect potential offenders with help. We built an alliance between community, faith leaders, social services and police that hadn’t existed before. 

It was an uphill battle, but we slogged along because we knew that Ceasefire was a new chance for Oakland, a new chance for the next generation of Oakland youth.  We were saving lives, and we were radically changing the culture of Oakland. 

Oakland is still changed. This week, eight years since we started our campaign in Oakland, the East Bay Times ran the headline: "Steps Towards Peace: Ceasefire seen as a cultural shift in Oakland," reporting that Oakland has a 30 percent decrease in homicides. The article states that Oakland has undergone a transformation, that the city is different because of its commitment to build new relationships and persevere to achieve new outcomes for the people who need it most.

I’m proud to have worked, with community leaders, to catalyze this change. I’m proud that over time (which is how culture change works!), we moved Oakland towards more peace and justice for the families and communities who deserve it. Bravo, Oakland!

Photos:Oakland Community Organizations

Photos:Oakland Community Organizations

Better Living

For the last four years, I have been organizing to help communities overcome injustice in the food and healthcare systems (see my recent post Sugar and Social Justice).  When I was in Washington DC, the work focused on making sure that low-income people with diabetes, high blood pressure and high cholesterol have access to doctors, so they can better manage these chronic conditions and stay out of hospitals and emergency rooms. 

But what if we could actually support people to become healthier?

At UniteHere!, I’ve organized a committee of low-income union members who are focused on making sure that their co-workers stay healthy.  This summer, we launched a program called Better Living.  It’s a six week workshop where people with diabetes, high blood pressure, high cholesterol and other chronic conditions learn together about taking better care of themselves through nutrition, exercise, and stress-management.  Together, the group sets goals to make concrete changes in their daily lives that support health.  Eating more vegetables, laying off the sugar.  Regular exercise.  Meditation. 

This week, 28 people graduated from our first workshop.  These union workers are from all over NYC, from the Bronx, Brooklyn, Queens, Harlem and Washington Heights.  And they are taking what they learned back to their workplaces, back to their families, and back to their religious communities.

Carlos is one of the first graduates of our Better Living workshop.  He works in the cafeteria at the American Museum of Natural History. 

Carlos: “I’ve had diabetes for 27 years.  Before this workshop, my doctor told me to change my diet but I didn’t know how to do it.  I felt really alone.  It was hard to stick to a program when I was trying to do it by myself.  Better Living gave me a lot of support.  Now I am starting to stick to my goals.  I didn’t even realize before that I was feeling depressed.  But by working with others and taking better care of myself, I feel so much happier!

The Unite Here healthcare committee is all set to get another 30 people through the program in October. Together, we are working to transform the health of our families and communities.