I Am Not a Transaction

I filled a prescription today at the drugstore; my receipt -- for that one item, paid in cash -- was five feet long.  I know; I measured it.  You can probably guess what chain that drugstore was part of.  This issue has been covered extensively before, such as Rachel Sugar's Vox investigation last fall.

Now, I know that, in this case, there are digital options, and that the company claims they cut the length of their receipts by up to 25% years ago, but, honestly, if this was the only issue, I'd just keep throwing them away (after letting my wife peruse the coupons, of course).  The trouble is, I also know from experience that I'm going to get a 4-6 page explanation of benefits (EOB) from my health plan just for this prescription. 

It's not the wasted paper, it's not even the volume in itself.  It's how healthcare organizations keep treating me not as a person, not even as a patient, but as a transaction. 

Credit: Lauren Giordano/The Atlantic

In the drugstore case, the receipt is less about explaining the transaction I just had with them and more about enticing me to buy more from them, with coupons galore (no matter that they're really targeted at my wife, not me, nor that they often are for products we never buy).  In the EOB case, well, I worked for health plans for many years yet still usually struggle to understand what they've covered and why. 

Annotated hospital bill
Credit: Patrick Slawinski, US News & World Report

Similarly, my bills from my other healthcare professionals are more focused on ensuring my account with them is fully paid up than in explaining why they are billing me what they are.  It takes some detective work using the EOB and their bills to form a hypothesis about why I'm supposed to be paying what I'm being asked to. 

Many in the healthcare system assert that EHRs are not more user-friendly because they were built more to facilitate billing than to support clinical work.  I can't attest to that, but it would surprise me if it wasn't true, because almost everything in our healthcare system revolves around billing. 

I.e., is our universe of diagnostic and procedure codes expanding as rapidly as it is because we need that level of precision to understand our health, or to ensure that the people coding them can squeeze every possible dollar from whomever is paying?  Why do hospitals still use chargemasters that rarely are anywhere near the actual cost or negotiated prices?  Why did so many healthcare professionals and organizations need federal incentives to acquire EHRs, but not to move to electronic billing or scheduling systems (which most did decades ago)? 

It's all about the transactions. 

There probably are examples of things happening with our health that can be considered a transaction, a one-and-done event that has no relation to any other health issues -- past, present, or future.  But I suspect that is rare.  Our health is holistic, a function of everything that is happening, has happened, or will happen to us.  When it comes to our health, transactions are part of the story, but they aren't the story. 

You just can't tell that from most of the communications we receive about our encounters with the healthcare system.  Too often, they are about the money: how much who is going to get paid by whom.

We should be doing better.  Each touch with a person using the healthcare system is an opportunity to educate, to explain, to try to make things simpler.  Bills, receipts, EOBs can and should be part of that.  If a healthcare organization gets negative feedback about those kinds of transaction-driven touches -- as most probably do -- then maybe it's time for them to stop thinking so much about what that organization will get from that transaction and more about what that person is going through that caused the transaction.

I was excited to read a Fast Company article about receipts getting an extreme makeover.  Susie Lu, a Netflix senior data visualization designer, put her skills to use:

I was compelled to think of ways that data visualization could be used to redesign everyday experiences.  Of the use cases I had brainstormed, the receipt was the idea I was most excited to play with first.

Credit: Susie Lu

Her redesign updates receipts by showing a bubble chart at the top categorizing spending, following by the standard itemizing, but with each item accompanied by a bar indicating how expensive it was relative to other items in the same category. 

Ms. Lu was operating under several constraints.  She used a low-resolution thermal printer, the kind used in most retail stores.  As Fast Company noted, the printer couldn't even draw horizontal lines, hampering the images it could be coaxed into producing, and the receipt paper doesn't allow for great resolution. 

Despite those constraints, Fast Company raves:

But the final result is fantastic. It’s clear, helpful, and a bit quirky–a perfect trio that would make it a valuable design for any big grocer trying to humanize its customer service a bit

For "big grocer," substitute "healthcare organization."  Think of what my drugstore receipt, with its five feet of available paper, could have shown me.  Think about what Ms. Lu could have done under fewer constraints.

Ms. Lu didn't start with healthcare in her attempt to redesign everyday experiences, but I wish she would have.  More to the point, I wish others would.  As she has demonstrated, data visualization is sorely underused in everyday experiences, and, as I've previously discussed, perhaps nowhere is it as badly needed as in healthcare.  Healthcare is confusing, full of data, and all-too-often designed around the people providing the care than the people receiving it.  It needs all the data visualization it can get.

Design in healthcare has gotten much more attention in recent years, such as from Dr. Joyce Lee, Dr. Bon Ku, or Stacey Chang.  Indeed, Dr. Ku's great quote is: "Everything in healthcare is design."   Design isn't about making things prettier -- well, it's not just about that -- but about making things easier to use and easier to understand. 

Even receipts.

When designing anything for healthcare, we should start with this: healthcare may be full of transactions, but we are not those transactions, and they shouldn't define us or our interactions with the healthcare system.