Adaptive Path Blog

As our primary goal with Charmr was to generate enthusiasm for human-centered thinking and thus inspire broader change throughout the medical device and design industry, we’ve been glad to see the project getting some press.

Most recently, Charmr appeared in the NY Times online (1/14/08):

New York Times: Function Dysfunction

In her discussion of dysfunctional and unsustainable product design trends, Allison Arieff cites Charmr as an example of designers’ growing sense of conscience. Her article provoked over a hundred comments suggesting other products due for a rethink — rich fodder for innovation.

http://arieff.blogs.nytimes.com/2008/01/14/function-dysfunction/

“Consumers are also getting into the act, pushing companies to tackle the products, improvements and functions that we truly need as opposed to those they think we’ll desire…. The sort of design innovation that [Amy] Tenderich is after is about much more than aesthetics or styling; it is really about improving quality of life. No one needs much convincing that this is a huge potential growth area for the health and medical care industries. Certainly Adaptive Path didn’t. The San Francisco-based design consultancy contacted Tenderich and agreed to accept her challenge; their prototype, called the Charmr (below), is not in production but may help guide future design improvements (and it fits on a keychain!).”

Business Week: Designing for Diabetics

The concept also appeared in the web version of a BusinessWeek article on Designing for Diabetics (09/21/07).

http://www.businessweek.com/innovate/content/sep2007/id20070921_545251_page_3.htm

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We’ve been overwhelmed by the (mostly positive) feedback for the Charmr concept, and we thank you for it. Comments like this one:

I am not a techie, just a Mom with a social work degree who has a 17 year old daughter with diabetes. My husband sent me this link and I am so excited that some real interest is being shown in developing an insulin pump with current technology. If I could get my daughter Caitlyn to download her pump record, when she is charging her IPOD and downloading music that would be a miracle. Currently the pump she has can’t download on our mac so we end up doing records by hand right before the next Doctors appt, not ideal. The charmr sounds really cool, she would wear it better than she wears her med alert necklace and it could take the place of that also. From a Mom’s heart Thanks for the real interest.

really got to us. It was a scramble to get the project completed in the very short timeframe we had (9 weeks) to research, design, and create the concept movie in.

Obviously in that time frame, we had very little time and no mechanical engineering resources with which to explore fully some of the engineering challenges that the Charmr requires. It is a concept, and a concept is only the starting point for any product. Around such topics as battery life, the size of the insulin reservoir, the exact size of the pump/monitor patch, and the different types of wireless technology to tie the system together, we simply had to make our best professional judgement as to what would be reasonably available in several years’ time. And, even after some of the critiques of the concept, I’m still convinced of its feasibility in the near future.

Some have asked why we didn’t solve the problems of diabetics right now. The reason is that while there could be some incremental changes to the pump/monitor system currently in place, those changes would make only a minor difference to diabetics. They wouldn’t address the range of issues we found in our research nor would they easily fit all the design principles we derived from the research. One might easily ask why it took Apple several years to design and develop the iPhone: because sometimes you have to wait for (or arrange) the technology and business opportunities to create a product that will disrupt the marketplace. Technology sometimes has to mature, and as many have rightly pointed out, the process for getting a medical device on the market takes much political and financial will. Additionally, we simply wanted to change the way people thought about these devices and how they could be designed, and that kind of demonstration isn’t accomplished by mincing steps. Bold strides were required.

So it might take several years for the technology to mature and for all the design decisions to be made and the product to be manufactured. But, based on comments like the one above, it might just be worth the wait.

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I’ll have to admit that I struggled with some skepticism of the Charmr project when it first began.

How could we take a complex subject that others have studied and researched for years and make a meaningful contribution to the field in a matter of weeks? With all of the engineering problems that remain unsolved, what could we, as user experience researchers and designers, bring to the table?

As I worked on the project, however, I realized what we could introduce by taking an “engineering problem” and approaching it from a user experience perspective: An experience-centered vision of the future and a more human approach to medical device design.

A Vision of the Future

The result of this project was not a polished product, but a vision — a vision of what the diabetic experience could look like in a few years if considered from a user-centered perspective.

People generally agree about what technology is desirable, but we wanted to go a step further and paint a more concrete picture of what it might look when these technologies are brought together to create a coherent experience. Beginning with the assumption that technologies under development will become reality in the next 2-3 years, we asked, what could the end result look like?

The idea was to give diabetic device companies a more concrete goal to aim for and to promote a user-centered approach for getting there.

A Human Approach to Medical Device Design

The technologies used in the Charmr are not new ideas: The Omnipod (with its remote controlled pump and insulin reservoir that’s kept close to the body) and the Minimed Paradigm Real-Time (continuous glucose monitor that communicates with the pump) have already been introduced; other technologies are under development.

Our focus was not on the technology itself, but on humanizing it. As Amy’s original call to action read:

“We’re people first and patients second…. If insulin pumps or continuous monitors had the form of an iPod Nano, people wouldn’t have to wonder why we wear our “pagers” to our own weddings… In short, medical device manufacturers are stuck in a bygone era; they continue to design these products in an engineering-driven, physician-centered bubble. They have not yet grasped the concept that medical devices are also life devices, and therefore need to feel good and look good for the patients using them 24/7, in addition to keeping us alive.”

These devices are not just medical necessities… they’re part of millions of people’s lifestyles. Understanding the complete experience surrounding these devices — the emotional struggles, the everyday hassles, the social scenarios — is critical to creating a device that looks and feels like it was designed with people in mind.

Our primary hope is that device companies will see the enthusiasm that a vision created from this perspective can generate and might embrace a more human-centered approach in their work. And we hope to inspire others to answer Amy’s call to take action now.

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As experience design consultants, we love having the opportunity to tackle lots of different kinds of problems. But we don’t always get to try out all the problems that interest us the most — after all, we can only solve those problems somebody has seen fit to devote some money to solving, and then shown the good judgment to hire us to take them on. So we decided to go hunting for problems nobody’s asked us to solve yet.

Then blogger Amy Tenderich posted her “Open Letter to Steve Jobs” in April, pleading with the Apple CEO to apply some of that company’s design expertise to improving the lives of the 20 million American diabetics who rely on technology to manage their condition every day. Amy’s blog post got a lot of attention, even making its way to TechCrunch. Amy asked for better products for diabetics, but we recognized that those products had to add up to an experience that would satisfy their emotional and psychological needs. So we set out to develop an experience design concept that addressed user behavior and psychology as well as current technological trends to project how insulin pumps and glucose meters might work five years from now.

We spent time with diabetics, who showed us their routines and talked about how hard it can be to stay motivated to keep themselves healthy. They shared their experiences with the technology products that they literally depend on for their lives. With their insights, we were able to formulate a set of design goals we’d have to meet in order to transform the experience of managing diabetes. We came up with dozens and dozens of possible design concepts, sketching out different approaches to achieving those goals. Out of those concepts, a few key elements started to fall into place. We looked at the solutions out on the market and talked to diabetes educators about what works for people and what doesn’t.

We built on those concepts by fleshing out the interaction design of the product, mapping out how the users would monitor their condition and give themselves insulin. At this point, it became clear that a bunch of interface mockups wouldn’t be enough to convey our ideas. That’s when we started producing this video.

The video doesn’t stand alone. We’ve provided all the background on the thinking behind the Charmr concept, including our research findings, as part of our case study. It’s been an exciting project that has pushed us in unexpected ways — in other words, just the kind of project we had hoped for. We look forward to doing more of them!

High quality video of Charmr (18 MB)

Movie Credits:

Sushi: http://www.flickr.com/photos/purpleslog/233433951/
Doctor’s Office: http://flickr.com/photos/sbconsci/361586238/
College: http://flickr.com/photos/genvessel/110114471/
Background of Charmr: http://flickr.com/photos/post/19350897/

Voiceover by: Laura Kirkwood-Datta
Music: Andrew Crow

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It started with an Open Letter to Steve Jobs. Dear Steve Jobs, Amy Tenderich wrote,

I’m writing to you on behalf of millions of people who walk around wired to little tech devices and won’t leave the house without them. No, I’m not talking about the iPod — and that’s the point. While your brilliant product line enhances the lifestyle of (100) millions, I’m talking about the little devices that keep us alive, the people with chronic conditions.

Let’s talk about diabetes, the disease that affects 20 million Americans, and I’m one of them.

…

Whether blood glucose monitor or insulin pump, thanks to the achievements of medical device companies, we can now live a normal life by constantly monitoring and adjusting our blood sugar levels.

But have you seen these things? They make a Philips GoGear Jukebox HDD1630 MP3 Player look pretty! And it’s not only that: most of these devices are clunky, make weird alarm sounds, are more or less hard to use, and burn quickly through batteries. In other words: their design doesn’t hold a candle to the iPod.

…

This is where the world needs your help, Steve. We’re people first and patients second. We’re children, we’re adults, we’re elderly. We’re women, we’re men. We’re athletes, we’re lovers.

If insulin pumps or continuous monitors had the form of an iPod Nano, people wouldn’t have to wonder why we wear our “pagers” to our own weddings, or puzzle over that strange bulge under our clothes. If these devices wouldn’t start suddenly and incessantly beeping, strangers wouldn’t lecture us to turn off our “cell phones” at the movie theater.

In short, medical device manufacturers are stuck in a bygone era; they continue to design these products in an engineering-driven, physician-centered bubble. They have not yet grasped the concept that medical devices are also life devices, and therefore need to feel good and look good for the patients using them 24/7, in addition to keeping us alive.

Clearly, we need a visionary to champion this disconnect. We need an organization on the cutting edge of consumer design to get vocal about this issue. Ideally, we need a “gadget guru” like Jonathan Ive to show the medical device industry what is possible.

What we need here is a sweeping change in industry-wide mentality — achievable only if some respected Thought Leader tackles the medical device design topic in a public forum. We therefore implore you, Mr. Jobs, to be that Thought Leader.

I read this plea and thought, wait, it’s not just Steve and Jonny who can do this stuff. Don’t I work at a design firm? Don’t we have the experience design tools to tackle this challenge? Why, yes. Yes, we did.

I sent around an email to our staff. Would we be interested in working on this as a Research & Development project? People got excited. Adaptive Path staffers had family who had diabetes. It was important; it would make a difference in people’s lives, and it affected us personally. We were onboard.

We carved out a chunk of time between projects — nine weeks, as it turned out — to do this project. With the complicated subject area and issues we uncovered during research, we easily could have taken nine months, but we were on our own dime here, so time was a constraint. We put together a small team consisting of me, Rachel Hinman, Alexa Andrzejewski, Rae Brune, Sebastian Heyke, and Jamin Hegemin. Jesse James Garrett and Julia Houck-Whitaker were our project sponsors and de facto “clients” for the project.

We spent three weeks just learning about diabetes and talking to patients and experts, then another week analyzing and taking in all the data we gathered. We spent another two weeks concepting; creating as many ideas as we could around the design principles we’d come up with. My next post will talk about this process. Once we narrowed down to an idea, we created the visual and interaction design to really flesh out that concept, then a movie to explain the vision.

I hope our solution delights you. I think it solves the problem of diabetics carrying around clunky, ugly objects that work somewhat well, but certainly aren’t easy or pleasurable to use and own. And Amy, I hope this answers your challenge. But more than that, I hope our process is adopted by more medical device manufacturers and their design partners (call us!), as I think it will improve their products, making them fit the lives of their customers more comfortably and more naturally.

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At the onset of the diabetes management project, our team had a textbook understanding of diabetes, but we had no insight into the experience of living with a chronic condition like diabetes on a daily basis. We had a hunch that, like most products and services developed today, the current products diabetics use to manage their condition are designed to accommodate technology and business constraints — with very little understanding or empathy towards the human experience.

The objective of our research was to gain that perspective, to understand and empathize with the daily experience of living with diabetes, and then design a product that met their needs and could improve their lives. Who better to talk to than diabetics themselves? We spoke with a total of ten people; a combination of diabetics living with type 1 or type 2 diabetes as well as two diabetic educators. We conducted in-depth, 2-3 hour interviews — some in-home ethnographies, some in-person interviews at local restaurants or our office. At the end of two weeks, we compiled our findings in this presentation. Three of the key findings are below.

The Emotional Impact of Numbers
We knew diet was a key concern for diabetics, but meeting with our research participants helped us understand the additional issues diabetics must consider with regards to food. When I look at an ice cream cone or a cookie, I think about how good it will taste or how I deserve it because I walked a couple blocks. Diabetics have a host of additional concerns: they must calculate the number of carbohydrates a given food contains, translate how much insulin their body will need to process the sugar, anticipate the amount of exercise they may do and adjust insulin doses accordingly. They also have to worry about how eating that ice cream cone or cookie could impact their blood sugar levels for the next 2-48 hours and consider if it’s really worth it.

In addition to carbohydrate counting, diabetics have to monitor their glucose levels. Six to 10 times a day, diabetics must test their glucose level with the goal of keeping it between 80 and 140. The emotional impact of these numbers is significant. One participant, Eileen, shared that high or low numbers can ruin her day. “I watch my diet like a hawk, I exercise, so when my numbers are high or low I get really pissed. I feel like I am doing everything I am supposed to do, so why is this happening. It can be really frustrating.” For many, the numbers can feel like a judgment: almost like a letter grade. While the numbers are a good guide, they aren’t always a reflection of how well a person is doing. Sometimes, diabetics have a bad day, despite great efforts, their body just goes high or low. Unfortunately, the emotional impact of the numbers can be enormously discouraging.

All diabetics really have to guide them is numbers — and numbers can lie. The reading from a glucose meter is the result from a single moment in time. Amy Tenderich, the woman who inspired this project, described the process of testing glucose levels in her book Know Your Numbers, Outlive Your Diabetes. Amy describes the process as being akin to driving a car blindfolded and only being allowed to remove it for a few seconds every few minutes. You have a sense of where you are going, but you could get far down the wrong path and not know it. A diabetic could be crashing, but their monitor could give a ‘normal’ reading because current glucose monitors do not provide data over time.

So Much Stuff… and So Many Needles
In addition to the typical “essential stuff” that people carry around like a wallet, a cell phone and keys, diabetics have a host of additional items. Some diabetics carry around: Glucose monitor, test strips, lancet, extra lancet needles, extra insulin, back-up syringes, and glucose tablets. One participant, Alice, pointed to her big black bag and said, “Sometimes I think it would be nice to carry around a tiny stylish purse, but that just isn’t possible for me.”

Needles are also an issue. Our team was blown away by the number of times a type 1 diabetic has to contend with needles in a given day. Between monitoring blood glucose levels and injecting insulin, most type 1 diabetics have to poke themselves with a needle 10-14 times a day. When asked, all participants had a similar response: “You get used to it.” Perhaps. I couldn’t help but think that response is just something diabetics say to deal with something that is really difficult to explain to someone who isn’t diabetic. I imagine that poking yourself with a needle isn’t something you get used to, but something you adapt to in order to stay alive.

Several of the type 1 diabetics we spoke with used insulin pumps. These “pumpers” love the functionality of their pumps: the control they provide and the positive impact the devices have on managing their condition. While people love what their pumps do, they don’t love the pumps themselves. Pumps are an awkward size and people don’t always know where to put them. Most people use a pocket — which requires whatever they wear to have a pocket. Women sometimes put them in their bra but that makes it difficult to read and control discreetly. Tubing on pumps often gets caught on door handles and are awkward in social situations when the tubing is visible. Most pumps are not waterproof, which makes exercise and showering a challenge.

The most notable research finding regarding pumps was that they are just plain ugly. Pumps are big, and clunky and the form factor is not terribly human. When you think about the beautiful product design of portable consumer electronics such as mobile phones and MP3 players, it’s truly sad that diabetics have nothing more to choose from than hardware design that is reminiscent of an 80’s pager. Pumps could be better… a lot better.

Motivation and Sheer Determination
We soon realized that quite possibly the most frustrating part of living with diabetes is that there is no break from it, especially for type 1 diabetics. The analogy we came up with was that living with diabetes is like having a newborn infant for your entire life. It requires constant attention and vigilance. Keeping motivated is an essential part of living with diabetes. Nancy, a diabetic educator we spoke with wears a yellow bracelet that could easily be mistaken for a Lance Armstrong “Live Strong” bracelet. Instead it says, “Be Your Own Cause.” Nancy has worked with thousands of diabetics in the 25 years she’s been an educator and believes that motivation and sheer determination are the main things that keeps diabetics alive and healthy. “It’s very difficult for someone who doesn’t have diabetes to understand. There’s no vacation from it, it never stops.”

Admittedly, this was emotionally challenging research for the team to conduct. At the onset, we had an understanding of diabetes, but we had no understanding of the daily experience of living with the condition. Meeting with people and hearing their stories humanized diabetes for us — it helped us understand the profound impact diabetes has on people’s daily lives and how the experience could be improved. It forced us to realize aspects of our own health that we simply take for granted. More importantly, meeting these ten diabetics and diabetic educators inspired us. The folks we met wake up everyday and deal with a condition that is frankly not very fun to live with. They do it so they can live a life with the same dreams and aspirations any person has: run a marathon, work at a job they enjoy, have a baby, see their kids grow up, or grow old with the person they love. The only difference is that diabetics take on the added responsibility of keeping themselves alive every day. Our key research finding is that diabetics are some of the bravest people out there and they deserve better tools than what they have now.

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After research, it was time to begin coming up with concepts for what it was we were actually going to design. From the research, we came up with six primary design principles:

• Wear it during sex. Make the product elegant, discreet, and comfortable.
• Make better use of data. Have the product use the data that is generated (blood glucose levels, amount of insulin dosed, trends) in smarter ways.
• Easy to learn and teach/No numbers. A broad cross-section of diabetics will use this product, so it cannot be overly complicated, nor difficult to teach. And while numbers are important, we didn’t want to solely rely on those for indicating status and trending.
• Less stuff. Diabetics have to carry around a lot of stuff. We wanted to be sure that whatever we created wasn’t just one more thing to carry around.
• Keep diabetics in control. The people we spoke to weren’t interested in automatic pumps for the most part. They wanted to retain control of their insulin dosing.
• Keep diabetics motivated. Diabetes is a difficult disease to have. Diabetics, in the words of someone we talked to, “never get a day off,” so keeping motivated is a challenge. We wanted our product to help diabetics set goals and be so easy to use it helped keep them on track.

We also observed five major activities that all diabetics have to perform: maintaining equipment, checking blood glucose levels, interpreting those results, adjusting their blood glucose, and keeping motivated. (See our Diabetes Alignment Diagram [48k pdf]).

We started brainstorming around these core sets of principles and activities, first with just our small team, then in an open design session with about half of Adaptive Path participating.

After several brainstorming sessions, we had about 100 different concepts, all pasted up in our project space.

We had to make some hard decisions: would what we were going to design work with people who used syringes? (No.) How far into the future did we want to design for? (Two-three years.) What part of diabetes management could we reasonably affect? (We focused primarily on the day-to-day diabetes management, not on things like long-term care and diabetics’ relationship to doctors and to the health care system.) Was it going to be one object? Two? Three? (Two, as it turned out: a pump/monitor and a controller.)

We spent a lot of time discussing how the best of these ideas (because, frankly, some were unworkable or loony or had been done before) could fit together into one system that would really address the needs of diabetics as we’d heard them. It was Rachel Hinman who finally came up with the idea of what we’d eventually call The Charmr. “There should be just this little thing you can carry around that controls the pump/monitor and it should be like a piece of jewelry or something,” she said one afternoon when we were all exhausted from thinking about this problem for weeks on end.

The moment she said it, the room came alive. “A piece of jewelry with a touchscreen!” “Get a piece of foamcore!” “How big could it be?” “How much would it weigh?” “Anyone have an iPod Shuffle to compare?” And on it went until we had a concept we all loved, and the more we thought of it, the more we loved it. “It’s like a mood ring for your condition,” Rachel said. We wore the physical prototype around and started to call it Charmr (dropping the E in a joking homage to Web 2.0 companies) because it was like a charm bracelet and it worked like a charm (we hoped).

Several days later, Alexa Andrzejewski and I sat down with a blank whiteboard and said, “Ok, now that we’ve picked this concept, how does the Charmr really work?” That’s the next story to tell.

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The next challenge after concepting was to prove that this concept could actually work by fleshing out the essential screen flows.

The displays on leading insulin pumps today are the size of PDA screens and use a number of hard keys for navigation. Was it even realistic to create an adequate, easy-to-understand interface using a 2 x .75 inch touch-screen half the size of my Nokia N73’s screen?

Dan Saffer and I began the interaction design process by examining the options and screen content in existing devices. Identifying what our participants actually used, we sought out the “essence” of the insulin pump.

The “Ah-ha!” moment for me was recognizing that the interface that most type 1 diabetics today are interacting with is nothing more than a simple syringe.

All there is to this “interface” is:

1. A way to select the amount of insulin you need (either by dialing it in or by withdrawing the appropriate amount from a vial), and
2. A way to deliver the insulin (which provides clear feedback that it’s working: seeing the insulin disappearing into your body and the feeling of pressing the plunger makes you feel in control).

The rest of the details are dealt with in the mind.

As one of the barriers to adopting pumps today is perceived complexity, our goal became to create an interface that is no more intimidating than dialing in your insulin needs on a pen. Additionally, the device needed to provide just enough “smarts” to take away true mental burdens (like calculating your insulin dosage using your carb-insulin ratio), while keeping the user in control.

With these principles guiding us, we delved into the interaction design details: What features should the Charmr have? What feature will be used the most (dosing)? Which buttons would be soft (most of them) and which hard buttons we would need (a back button)? What is the minimum button size for a hand-held touch-screen device (many kiosks use 16mm square, whereas the iPhone uses considerably smaller, 9mm square buttons)? Which information should be shown on which screens to support particular tasks?

We also spent a bit of time discussing what kind of imagery would make the best ambient display of status (the mood ring screen). Amy Tenderich told us that one of diabetics’ greatest struggles is with guilt. They look at the numbers and feel guilty all the time. Thus, the ambient display needs to visually represent your status without assigning “moral value” to high or low blood sugar — the way a thermometer might show blue or red; neither is inherently bad.

We considered virtual pets, lava lamps, color abstracts, weather, and simply a personal/family photos theme (because it’s family or a particular goal that often motivates people), and finally concluded that the device should offer multiple themes and allow the user to choose what motivates them.

Finally, I developed a skin for the interaction design, striving to make it compelling and modern, while avoiding both “medical device blue” and the iPhone look and feel. The user could customize both the themes and the skins to their tastes, and perhaps even download more skins and themes online.

With the screen designs as well as a rudimentary industrial design concept completed, we put together an Experience Blueprint (4mb pdf), then it was time to tell the story of the product.

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