Case study

Cord Health

Cord Health was a digital health platform that enabled healthcare providers who relied on self-reported information and paper processes to deliver care outside of the clinical setting and capture patient data remotely. It was built using Apple’s CareKit, Researchkit, and Healthkit frameworks.

Team

Andrew Zallie
Nino Guba

Categories

Product Development
Product Design
Mobile & Web
iOS
CareKit, ResearchKit & HealthKit

Background

The idea behind Cord Health was born out of my families personal experience caring for my grandmother as she aged with Alzheimers and Dementia. Our difficulty coordinating care in the home opened my eyes to the challenges families face when finding caring for a loved one.

My initial goal with Cord Health was to equip home care and home health providers with an easy to use mobile and web app that would allow nurses, aids, and caregivers to document activity and collect health-related data at the point of care. Activity from each visit was shared with the family, patient and the provider in an effort to help with the coordination of care. All care activity was guided by a shareable care plan that formed the foundation of every patient’s journey toward improved outcomes.

The Customer

The Cord Health platform served both healthcare providers and patients. However, Cord was a B2B SaaS application. Platform adoption was driven by the healthcare provider.

Providers

  • Non-Medical In-Home Care
  • Home Health
  • Outpatient Rehabilitation
  • Post-Acute Care
  • Primary Care
  • Hospitals 

Patients

  • Seniors who were receiving in-home care or home health services
  • Patients with one or more chronic diseases
  • Patients who were recently discharged from the hospital
  • Medicare and Medicaid patients 
  • Patients who were part of a plan that paid for care management

The Problem

How are providers supposed to communicate and collaborate effectively with patients across multiple settings when a majority of care is planned using “technology” that was invented hundreds of years ago?

Providers

Due to manual and paper-based processes, most healthcare providers delivering care in the patient’s home work very hard to answer basic questions such as:

  • Did the caregiver or nurse arrive at the patient’s location on time?
  • Did any patients not receive care?
  • Did the caregiver or nurse deliver services according to the care plan?

Families

Families face challenges related to quality, trust, and transparency when searching for home healthcare services. As a family member of the loved one receiving care, how do I know:

  • Which caregiver or nurse showed up today and were they on time?
  • How my loved one’s day went? 
  • Is there any action I need to take regarding my loved one’s care?

Patients

As a patient receiving care, how do I stay involved in my care journey and:

  • What daily activities do I need to complete in order to adhere to my care plan?
  • What medication to take and when?
  • How do I inform my family of my health progress?
  • Did the caregiver or nurse arrive at the patient’s location on time?
  • Did any patients not receive care?
  • Did the caregiver or nurse deliver services according to the care plan?
  • Which caregiver or nurse showed up today and were they on time?
  • How my loved one’s day went? 
  • Is there any action I need to take regarding my loved one’s care?
  • What daily activities do I need to complete in order to adhere to my care plan?
  • What medication to take and when?
  • How do I inform my family of my health progress?

Goals

Product

  • Build strong on-boarding and self-service flows that allowed providers to pick up and start using the product immediately.
  • Build a platform that scales easily with the provider. Whether it was creating new teams or organizations, we wanted to grow with our customers.
  • Build an open platform that developers could connect to, build on top of, and extract data from.
  • Build a modular platform in which new features and functionality could be easily added to expand up or down the hierarchy of care services.

Design

  • Design a mobile app that was intuitive enough for patients and providers to pick up without the need for “implementation services” or training.
  • Design visual patterns that would allow the product to scale easily with new features and functionality.
  • Create a flexible information architecture that would easily scale.
  • Create strong brand recognition by including the logo throughout the app, often as an action button.
  • Focus on the details of color, typography, and spacing to create a friendly and engaging experience that would rival many social apps.
Cord Health’s main goal was to facilitate better care and positive health outcomes by connecting people with the right information at the right time.

Approach & Design Process

Research Immersion

We started our Cord Health journey by immersing ourselves in the in-home and long term care space. I met with nearly every local home care agency, home health agency and assisted living facility that was willing to give me time or that was interested in what we were doing. I shadowed caregivers, office managers, and owners as they ran their business and delivered care.

We took a collaborative approach to understand the real problems the providers in the industry faced. We also met with the families of aging loved ones to better understand their perspective and the patients on the receiving end of care.

Aside from the primary research and observation, I immersed myself deep into medical journals and peer-reviewed research related to our subject matter. Due to the trends of aging, chronic disease, and provider burnout, there is a lot of research on new care delivery models leveraging lower-cost providers such as home health and non-medical home care to help health systems reduce readmissions and deliver better outcomes by extending care services in the home. However, engaging providers in discussions around these topics proved to be challenging, especially as we were primarily working from the bottom up.

Throughout my research, I recognized a disconnect between the promise of technology to improve care and the reality of implementing technology on the ground in a healthcare environment.

For instance, basic assumptions such as caregiver access to a smartphone proved to be a challenge. Many providers did not want their caregivers and nurses accessing their phone while they were in the home of the patient for fear of distraction. The more forward-thinking providers recognized that it is next to impossible to limit the use of a smartphone in the home. These providers recommended that we work with them to purchase iPads or smartphones that their staff could use while providing care in the home. We also discovered that we couldn’t rely on a constant internet connection. We had to make sure that our solution offered an offline mode that would sync when connected to the Internet. 

Other than the purely technical challenges, we discovered that the majority of the challenges providers in this space face were related to getting the relevant information to their staff at the right time.

For a caregiver, getting access to basic patient information or a care plan while at the patient’s home was not possible or completely manual. Patient notes are kept in logbooks at the home, and these books often get misplaced. 

Communication and collaboration between caregivers in the field also came up often. Many of these nurses and caregivers are using unsecured methods such as texting to discuss patient information which is a HIPAA violation.

Additional problems discovered:

  • Intake and the creation of custom care plans for each patient
  • Clocking in and out at the patients home
  • Viewing and modifying schedules
  • Collecting patient information at the point of care for reimbursement purposes
  • Real-time access to caregivers and nurses
  • Training and education of staff

Requirements

Thinking Big, Starting Small

Initially, our biggest challenge to overcome was figuring out where to start. With a list of problems and a myriad of solutions in the marketplace, it was hard to filter out the noise. Which is why for us, it was most important to listen to our customer and observe what they were actually trying to accomplish (what were the “jobs to be done”).

By listening to and observing our customers, we determined that the process of documenting care activity in the home to be the place to start. Fundamental to delivering in-home care or home health services is the use of a care plan. Determining that the care being provided in the home matches what is in the care plan proved to be very challenging for many providers. For obvious reasons, families were also very interested to know what was taking place while their loved one received care.

Our vision was to create a solution that would be the foundation for any care team delivering care outside the four walls of the hospital, regardless of the context.

For our MVP, we sharpened our focus to assist in-home care providers:

  • Create a shareable care-plans for their patients that could be accessed at any point during the point-of-care
  • Complete activities and assessments that were a part of the care plan at the point-of-care
  • Take notes at each patient visit

Other areas that we considered, but moved to the product roadmap were:

  • Clocking-in and out using GPS visit verification
  • Viewing and managing patient scheduling
  • Communicating and collaborating with the care team in the field

Synthesis

Before starting any design, I spent time making sense of the workflows and existing processes. I did this by reviewing user journeys, documenting additional user stories and task flows, creating a sitemap, and designing initial wireframes.

User Journey Mapping

From our research, interviews, and shadowing I documented a journey map which helped identify the various actions and pain points for both the patient and the provider during care. This was the first step to determine how we could improve the current care processes with a digital solution.

User Stories and Task Flows

After reviewing our research and list of pain points, I documented user stories and jobs to be done. I prioritized and bucketed these stories into themes or epics which we then considered for our MVP. Additionally, I sketched out task flows which outlined the steps a user takes to achieve a goal. Starting with the user, I was able to identify the core issues that we would address with the MVP.

Information Architecture

I created a sitemap to visually document the structure of the entire application. Because mobile access would be driven by providers who signed up via the web, I started by documenting the sitemap for the administrative web application. In the sitemap, I addressed the main buckets of functionality that we agreed on for the MVP.

Wireframes

From the information documented in the task flows and sitemap, I designed simple wireframes using pen and paper. From pen and paper, I moved to Keynote which allowed me to quickly spin up wireframes and solicit feedback. Ultimately, nothing beats pen and paper when getting initial ideas down, but Keynote kept me organized.

Design

Mockups

For the mobile visual design, I followed Apple’s iOS design guidelines very closely. CareKit and ResearchKit came with pre-built screens for various functions in the care delivery and management processes. We leveraged Apple’s screens for task and assessment completion as well as insights and patient management. I made the decision to build leveraging Apple’s UI so that we could quickly spin up an MVP. We had plans to later re-work the mobile UI for engagement on both the provider and the patient side of the mobile app.

For our web visual design, I exerted more creative muscle. I had previous experience working with and building designs systems. With Cord Health, I wanted to create a simple, consistent visual pattern that would allow me to move quickly in my design and be agile enough to incorporate feedback. Before I designed a single screen, I started designing the most basic building blocks of our application by following the Atomic Design Methodology. By following this methodology, I was able to build a design system in Sketch that accelerated our mockup creation and made it easier to translate the design to development.

I also developed my own color palette and chose a typography and icon set that aligned with our brand’s aspirations and standards. Simplicity and ease of use were our guiding principles. With our users, we had to keep distractions to a minimum. 

Prototypes & Testing

Using InVision, I created multiple prototypes to test the experience of both the provider and the patient. The provider had a web prototype that was used to test the functionality of setting up a care team, adding patients, creating a care plan, and managing a patients care. In addition to the web app, the provider tested our iPad app that was built for the caregiver to use at the point of care. The iPad prototype handled clocking in and out, completing care activities, delivering assessments, and viewing patient information. Providers responses validated many of our design decisions and gave us direction regarding how to improve the app.

For the patient app, we didn’t solicit as much feedback due to the priority of the provider app as our MVP. Since we followed Apple’s Design Guidelines leveraging CareKit and ResearchKit, we were able to follow the experience of a number of other apps who had released patient engagement apps leveraging the same UI. Ultimately, we did create a patient app prototype in InVision that we used to demonstrate the platform end-to-end. 

Output

At Cord Health, we were extremely proud of the progress we made with such a small team. Ultimately, we made the tough decision to not launch the product. If you are interested in learning more about Cord Health and the decision to shut down, you can read our post-mortem. In summary, we were too early. Healthcare is the only industry in which technology is used as an excuse for its rising costs. There are many hurdles entrepreneurs face in this industry. However, I’m still optimistic about digital’s ability to transform how we provide and consume care.

©2020, Andrew Zallie, All Rights Reserved