Wilma Lam,

Host:

Welcome to Optimistic Design, a podcast where we take a practical, positive look at the future of design, ethical innovation, and technology. I'm your host Wilma Lam, Strategy Director here at Substantial.

Today I'm excited to be chatting with Dr. Ijeoma Azodo, who brings together service and systems design with her expertise in surgical care, health research, and patient-centered outcomes to build digital healthcare experiences. Dr. Azodo is the Associate Director of Service Design at NHS Education Scotland technology service, honorary clinical tutor with the Surgical Sciences at the University of Edinburgh, and council member in the Faculty of Clinical Informatics.

Dr. Azodo, welcome to Optimistic Design.

Dr. Ijeoma Azodo:

Hi, Wilma. Thanks for having me.

Wilma Lam,

Host:

Yeah, really excited to have you join us. I mean, obviously, healthcare, and especially design innovation in healthcare, has been a huge topic over the last few years. I'm especially interested in an understanding, at more of a global level, considering that you work with the NHS, of how this has evolved over the last few years. Maybe just start by grounding our conversation. You originally trained and practiced as a surgeon, which I think is a really unique background for coming into design innovation. What inspired you to shift your career focus from surgery to thinking about digital innovation and design for healthcare?

Dr. Ijeoma Azodo

For me, it's an extension, although a pivot, in my surgical practice and career. Quite a lot of what we do in surgical practice is work within a system. So we might see people at the point of care; there's trauma, there's cancer, there's a hernia, there's a condition. But we also work backwards to understand how the person got to our clinic. Have they gotten there in time for us to make a difference in their care and in their life? Also, what are the systems around them that, again, might prevent some people needing surgical care?

Again, we know that that's a limited resource, how many people you can operate on in a given year in a given system in a given day. So what we're really looking at is creating a system where people get surgical care when they need it. If there's something else where they might avoid surgery because it's not needed, how can we do that? So really, this idea of systems-based practice is really baked into surgery all the way through. I have this opportunity to work at the system's level, which is something that I've always wanted to do. So through a series of both fortunate and unfortunate events, I was able to make that pivot and make that shift.

Wilma Lam,

Host:

As you're going through that pivot, what shaped your learning and understanding of design innovation and technology and its role in healthcare?

Dr. Ijeoma Azodo

Yeah. I would say first and foremost, it's my surgical training. So I did my liver cancer and transplant fellowship at the Royal Infirmary of Edinburgh. The team there is very similar to where I trained in Mayo Clinic in the States, in that there's a real focus on applying an intervention where it's going to have the best effect. Then really looking at: what are our outcomes, is that the best treatment, how are we doing? So really, continuously looking at our practice. And for that you need data.

I think that that's where, in a very simple level, technology comes in. Because you're looking at what's the difference between different surgeons, different types of patients, people who live in different parts of the city, transfers. So you're looking at all of those to see where you can affect change. Are people in one part of the city doing worse than the other part of the city, and what is that? Is that the intervention? Or is it something having to do with the environment and other social determinants of health? So we look outside our scope of immediate care, meaning the person right in front of us, to see how is it that we can be better?

“We look outside our scope of immediate care, meaning the person right in front of us, to see how is it that we can be better?”

So between Edinburgh and Mayo Clinic, that was the same ethos of our work. That's why I say that working in this technology service is really an extension of my practice, working more at the system's level. How can we support and enable people with technology to understand what interventions are going to be helpful? Then I think particularly from surgery, we're used to working with tools, whether that's forceps, scissors, and stitches, or complex things like robots. We're really attuned to how do our tools support us in our work to provide care, the experience of care, and most of all, the outcomes for beneficial impact?

Wilma Lam,

Host:

I can actually definitely see now that you've laid it out that way. I hadn't thought about surgery as kind of being a systems design problem. But it's a really interesting lens that you're able to bring to that, I hadn't thought about that before. So you're currently Associate Director of Clinical and Health Service Design on NHS Education Scotland Technology Service. Being stateside, I'm not super familiar with how the NHS is organized. From an organizational level, can you explain where NES Technology Service sits within the broader healthcare ecosystem in Scotland?

Dr. Ijeoma Azodo

Absolutely. So NES Technology Service, we sit in NHS Education for Scotland. NES, for short, is the special board of the NHS, so it has a national remit for education and training across all of Scotland. So coordination of training, placements, licensing, things like that. So that would be kind of like a licensing body for a state, except it covers all of Scotland in terms of training and education. There are other special boards, again, that have national remit. So we have Public Health Scotland, National Services Scotland that does a lot around data and technology as well, and the Scottish Ambulance Service. So all of those are special boards.

The rest of the NHS, there's 14 health boards that are divided into geographic areas that cover all of Scotland. So there's no area of Scotland that's not covered by a health board, and you have different city regions that are embedded within that so that you have a local authority or a city area, and that's covered by a health board. So regional versus national. You might think of some of the NHS health boards like some of the big regional systems, like Kaiser Permanente, even Mayo Clinic, or Intermountain. So those big health systems that cover areas of the country, if they were all knit together across the United States with no drops and complete coverage, that would be like the NHS.

Wilma Lam,

Host:

That's a really helpful explanation. So then I'm wondering, the NES Technology Service, in particular, was set up by the Scottish Government in 2018, following the publication of the Digital Health & Care Strategy for Scotland. Can you talk a little bit about what the Digital Health & Care Strategy for Scotland is, and the mission of NES Technology Service?

Dr. Ijeoma Azodo

Yeah. So what came out across Scotland in 2018 was a plan to provide the right information at the right time to the right people. Out of that, the NES Technology Service—we've gone through a name change—we're an organization that's one of many across Scotland, charged with building the national digital platform. That's going to be a conglomerate of products, services, and capabilities, to really help support people all through life, using digital services, understanding that digital is going to be core to the way we deliver healthcare and social services. But in the 2021 iteration, the Digital Health & Care Strategy, again, just builds on the 2018 Strategy, and that focuses around the right care at the right place and the right time.

“What came out across Scotland in 2018 was a plan to provide the right information at the right time to the right people.”

Wilma Lam,

Host:

That's a really good model. I think one thing I was curious about when we had first connected and I had learned a little bit more about your team is, with this mission to enable excellent care by creating tools, services, and digital infrastructure for the right care at the right time, as you mentioned, usually people think of a healthcare system as being all basically healthcare providers. But the Technology Service team is a multidisciplinary team. Can you talk about how this team has been assembled, and in particular, your role within NES Technology Service?

Dr. Ijeoma Azodo

I came onto the team when it was almost two years old. And what we are is a team of designers, clinicians, engineers, product managers, and then core expertise around health and care. So whether that's clinicians, knowledge management and discovery, so education and learning, and elements of the workforce. And wherever that sort of insight or foresight came from, I don't know. But it brings together all that's excellent about the NHS, knowing deep, deep knowledge of the NHS, but with the idea around design and technology of being able to build and iterate. We have in-house development capability so that there's things that we can build and stand up within our expertise. That's just part of our day job.

So bringing that whole team together, again, is that idea of having engineering and technology and products kind of at the elbow, as I've heard a couple people say, while care and health and social services are going on. It's almost to try and offload the problems, the things that people need, onto the service for us to support and build and bring that back to people. But also focusing on the infrastructure, what's the infrastructure for that to be used, I suppose across Scotland or across large regions, and continue to support existing health boards and services and communities that are already there.

“It’s that idea of having engineering and technology and products kind of at the elbow, as I've heard a couple people say, while care and health and social services are going on. It's almost to try and offload the problems, the things that people need, onto the service for us to support and build and bring that back to people.”

Wilma Lam,

Host:

I mean, I think it's a really innovative collaborative model to bring all of these disciplines in house, I think especially in a government healthcare organization. I'm curious, so your role specifically, as I understand it, involves end-to-end care and partnership between patients, health and social care professionals, working towards creating a more kind of holistic ecosystem, as you mentioned, for better health, better care, and improved well-being. One of the important concepts that you've kind of mentioned before when we've caught up is this idea of care as a core business. Can you talk about what that means, and in your role, how you think about that?

Dr. Ijeoma Azodo

Yeah. I think that's my framing of what we do, is that the technology and the business and design are in service of care. So if I were to take an example from me being a surgeon, if I operate on 100 people with appendicitis and none of them go home, then it doesn't matter that I've done 100 operations. The end-to-end service is that a person comes in, say, with appendicitis, and I want them to get back home, or I want them to get back to work, or I want them to get back to school, or I want them to get back to retirement. So that's actually the outcome that I'm looking for is how many people came through the system that got to that end outcome that they care about? Then if you go backwards, then you look at all the systems aspects of that, that let you know that you're on the right track.

“I think that's my framing of what we do, is that the technology and the business and design are in service of care. So if I were to take an example from me being a surgeon, if I operate on 100 people with appendicitis and none of them go home, then it doesn't matter that I've done 100 operations.”

So appendicitis is maybe a short stay in the hospital, one or two days, and then people are back home. So you can close that cycle quite quickly. But a lot of the things that we're doing in health and care and social services have a long tail on them. We want to look at some of the progress markers to know that we're in the right direction, that people go home, that people aren't spending a lot of time in intensive care.

So as part of that, it's that you provide a digital service that supports health and care, but what are the steps in between that let you know that you're going in the right direction? Some of it is people's experience of the whole thing. So there's a lot around digital experience: that people feel looked after, that people feel supported, and then your final outcomes. Were they actually supported? Did they make it back home? Did they have no complications? Were they able to receive their benefits? Was there a lot of hassle with getting their benefits? Did they have to reapply four or five times?

So I think the core metrics around what we're doing are not different because we're digital. It's about have we provided a service, and have we provided that service with care? One of the metrics that can be helpful in terms of looking at this is the Institute for Health Improvement (IHI), things like effectiveness, timeliness, equity, safety. Those are all the things that I want us to look at when we're looking at a service, is are we doing those six primary things that are needed in care services, including experience, not just applying a technology.

Wilma Lam,

Host:

That makes a lot of sense. I mean, what it sounds like to me is starting to bring some of these frameworks and techniques which might have been originally created for digital product and service design, and applying it to healthcare, which is a very large, complex system; thinking about patient journeys, end-to-end. But I think also with what you just mentioned, starting to think about this idea of experience and principles at a healthcare system level, which I think is extremely unique. So then when you think about what you're working on more day-to-day, what are the skill sets that you feel are most important in the work that you're currently doing?

Dr. Ijeoma Azodo

I find this one a challenging one, only because it's reading, writing, and analysis. I spend a lot of time speaking with people, looking for patterns and connections across their needs, their tools, the gaps. Because we're thinking about systems and infrastructure, we're looking to build something that works for a lot of people. And when we do that, we want to make sure that we're applying an equitable lens to it. Is the infrastructure accessible to everyone? Is that accessible across the whole geography? What are some of the barriers? So again, that we're building something that scales, but is also useful.

“I spend a lot of time speaking with people, looking for patterns and connections across their needs, their tools, the gaps. Because we're thinking about systems and infrastructure, we're looking to build something that works for a lot of people. And when we do that, we want to make sure that we're applying an equitable lens to it.”

Wilma Lam,

Host:

Yeah. So with this idea of scale, I think it is unique to be on a team that's embedded within NHS Scotland. I imagine that their team's ability to drive innovation is different because of that level of collaboration and being embedded. Could you talk a little bit now about how your team is uniquely positioned, kind of partner, in order to prototype and test new ideas?

Dr. Ijeoma Azodo

Yeah, I think that's one of the huge benefits is that we are within the NHS. So things around confidentiality, privacy, procurement—a lot of the strict processes that the NHS has in place in order to use our position well, use our information well—because we're in the NHS, we know those things, and we follow them. Again, because the work we do is part of our normal working day, there are small experiments and small tests that we can do with our partners across the NHS. That would be difficult, if not impossible, if we were outside. So again, it's that being within the system and knowing what the system wants, we're all working towards the same thing. So really, it's focusing on the coordination of all of our collaboration in order to do that.

“Again, it's that being within the system and knowing what the system wants, we're all working towards the same thing. So really, it's focusing on the coordination of all of our collaboration in order to do that.”

Wilma Lam,

Host:

So I imagine over the last few years, there's been a change in the global acceleration of healthcare innovation due to the pandemic and the needs of managing care during the pandemic. You mentioned the earlier mandate of setting up the Technology Service, I'm guessing that that's really accelerated in terms of pace and focus over the last few years, as there's a shift now in thinking about how healthcare is delivered—the rise in need of telehealth, mobile clinics, and new digital touch points of care, over the last few years. Have there been fundamental shifts in relationships between patients and healthcare providers from what you've seen?

Dr. Ijeoma Azodo

I'm not directly in clinics and in the hospitals, and that's one of the things that we've all noticed as a shift. Part of what we anticipated our working with be is working right next to people, observing them, working with patients in their back processes. All of that has changed. So as some of our legal regulations around COVID have now been released, we're starting to go back into the health and care spaces and see how people are working. But also, the healthcare workforce is now sort of readjusting how they're delivering care. So it's in the space that's in a bit of transition, and it's hard to know what the new set state is going to be.

To some extent, it has been easier to connect with people, both for research and working with partners, because we can do that virtually. So people that live outside of Edinburgh where I'm based, I can reach them over a phone call over and over virtual teams. So that has made it easier to make connections with people. You'll know with a lot of the design, there's things that people say they do that are different to how they actually use things. So it's being able to disconfirm and triangulate what you're learning to how it actually is in practice, where I'm not sure what's going to happen and how it's going to unfold.

Wilma Lam,

Host:

So in addition to core shifts in healthcare, which I think has impacted the way in which you and your team are doing research and thinking about innovation, there's also been core technological innovation outside of the healthcare industry that may be disrupting it. I'm thinking of everything from NFTs to all this conversation about the metaverse now. What are your thoughts on what comes next for digital innovation in the healthcare sphere?

Dr. Ijeoma Azodo

That's a great question. I suppose I'm looking at all of those references as well, to see what's going to land. I really do think that we're in this transition state. One of the things that I'm watching quite closely are things that are happening in intensive care or acute care and critical care. The reason for that, for me, is that a cycle of applying a change to seeing an outcome is much quicker than a community. As I mentioned before, you just have smaller time cycles to see an effect.

So looking at some of the innovations I've seen in intensive care, mostly around COVID care and predicting outcomes, is looking at their challenges with sustaining the innovation and changes that they've made, funding for the innovation and changes that they've made around watching COVID wards and capacity and managing flows of patients. So now that some of the main excitement around COVID has kind of slowed, what needs to keep going and how's that going to be funded? So I think that that's something that'll cascade out to the broader community.

I'm looking at communications and communication approaches. So we've done a lot of stuff virtually over the last two years, around learning internally and externally, and education. So where's that going to land now? I made a conscious effort in terms of growing a network and maintaining a network, because it's something I understood I needed when I started working outside of the hospital environment. Because when you're in the hospital environment, you have your colleagues you learn from, you have your regular meetings around practice development, M&M, all of those things. If you just go through your normal day, you'll be up-to-date, you'll understand what's new, and you'll understand what your challenges are. So how do you do that when we're in this hybrid world, when you're not in an office? How do younger people learn how to work, how to develop, how to be mentored? So all of those things, again, I think, are a small microcosm, if I look at that.

“I made a conscious effort in terms of growing a network and maintaining a network, because it's something I understood I needed when I started working outside of the hospital environment.”

I'm looking at some of the things to keep. So some of the things that are anchors to people are material things. We had a bit of conversation around the book, Reimagining Design, Kevin Bethune's book that's just come out about materiality and physicality. He has a background in engineering, design, and sneakers, and the meaning of material objects in a virtual world. So I think it's going to be interesting.

One of the things that's always struck me about patients I've cared for, and even now, is the paper. So whether that's a letter from your general practitioner, whether that's your vaccine certificate, whether that's your prescription, those artefacts of care that have always been really important to people, what's happening to those now? Because they were all things that gave people a sense of control over what happened to me, what to do next, who to call, etc. So when that's virtual, what does that do, or does that need to stay physical?

Then really, around a lot of the shifts, again, out of the traditional institutions. I remember when a lot of surgical practice went to day surgery, and one of the things that we realized was the sequence of care. So you might come in the night before, or in like the olden days, the week before, and get prepped for surgery. Some of that was you learning how to look after yourself when you left the hospital; how to get up, when to take your pain medicine, when to eat, when to lie down. You had support from the nurses and the team, to see if you could do it yourself.

Now that we don't have that at all, it's just in and out—you don't have that learning period, even though it's not called learning—how do we do that now when there's an expectation for people to manage everything at home or outside of the hospital, without a lot of expert guidance? But there hasn't been that deliberate bridge to say, this is how you do it, this is what to expect. So those are the kinds of things I'm looking at to see how we make that transition.

Wilma Lam,

Host:

I think, definitely, these are all big topics in healthcare. I think when we first met, I was working doing healthcare design as well. So I think these are core principles around behavior change in healthcare; understanding how to meet patients, where they are at this point in time. You've also mentioned a few times in this conversation so far, a focus on healthcare equity, and making sure that things are equitable for all patients, no matter where they come from or what background they may have. I'm curious, I think especially because the conversation on equity has really evolved over the last few years. How do you think about building in principles for design and technology, around behavior change and around equity, for all patients?

Dr. Ijeoma Azodo

I think part of what you mentioned briefly is, meet people where they are. That's what you would do one-to-one, is understand what people understood about their condition or their care and their role in it, and bring them up to a level, and offer them as much support as you can. Some people are quite independent; want to read it or know it, have had it before. So it's really about how do you look at your systems and your infrastructure to assure that you have a baseline level for everyone? Part of that, again, I think, for me goes back to care as core business is how do you care for everybody?

But if you look from the design perspective, it's really paying attention to who your users are, and then also the intersections of your different users. So some of the things that I'm looking at are age and gender, some of the traditional social determinants of health. But I think one of the things that's coming to the fore a lot more now is digital as a social determinant of health. If you look at that, from the very macro level, around infrastructure and access, all the way down to the product or the experience level of experience and accessibility, again, it's knowing who you're designing for, and within your design process, attending to all of those things. I think there's something about designing for multiple intersections that allows you to really do so with high fidelity and design something that's equitable. But it's understanding who your users are, the scope and the spread of your users, and then where are they, to do your testing and prototyping and iterating.

“It's understanding who your users are, the scope and the spread of your users, and then where are they, to do your testing and prototyping and iterating.”

Wilma Lam,

Host:

As we've talked through these ways of working, you shared a lot of deep insight into how to approach design in healthcare, and the kind of research you've done, as well as being part of the Technology Service team. In your view, what do you feel the relationship is between design, research, and technology when it comes to healthcare?

Dr. Ijeoma Azodo

So the design is in service of the care that you're offering. I think research is the thread that runs through the design all the way through. At each of the process, you're going to have your ultimate outcome or your impact: that the person gets home, the person lives well. Then you'll have your intermediate outcomes: how do you know that they're going there? So they've left the hospital in the right amount of time, they've had a good experience of being in the hospital.

Technology is the thing that allows you to measure what's going on, whether that's using data to look at your outcomes, or to visualize who's using the product; where are they using the product and where are they not using the product? Is that because their passwords don't work and everyone is locked out? Is that because a system is down? Then you're looking at what's the distribution? So if you were looking at competency, everybody that's competent to give a certain procedure, are they doing it? What is the variation in the gaps? Is it all senior people that are using that particular skill, or is it all junior people? So that's where technology I think helps you understand, are you headed in the right direction? But technology can also be part of your intervention. How are you building your infrastructure? What are you using? Do people know how to use it? So that's the two levels that I think come from surgical practices. It's both about how well are we doing, and what tools are we using to do it?

I don't think the research is separate to it. I think one of the things I would advocate is that there is a stream of pragmatic research through health services, health products, health interventions. It's that stream that allows you to understand, are we making progress towards their intended outcome and impact before it's 10 years or 15 years down the line? There's a lot you can learn and adjust. And that really goes into the engineering and product idea around agile design, iteration and prototyping; you need feedback to understand what to iterate to.

Wilma Lam,

Host:

We had touched upon earlier that working with the NHS, obviously there's scale of the work that you're doing, but it's also an environment where there's a high level of regulation as you're thinking about scale. Could you talk about how you maybe consider both of those things, both large scale and the need for regulation?

Dr. Ijeoma Azodo

Yeah, I think the regulation is a benefit or a bonus. It gives you the constraint to work through or work around. So there are a lot of statutory obligations around information governance, software as a medical device, clinical safety, so things that are things we must do. I think that that scopes down the imagination to what is needed, what is safe, what is beneficial, what protects confidentiality, what sets out the use for data. So I've always thought that that's a good thing. It forces you to be creative. One can't just do anything with the information and the products and services, and I think that that's very much a good thing.

“The regulation is a benefit or a bonus. It gives you the constraint to work through or work around.”

I think it also brings whatever you're building that to the idea that it's a service within a particular discipline, and that discipline has practice standards, governance, and regulations. So if you flip it on its head, I think the regulations are to enforce the standards of care, the standards of practice, and the governance, rather than the other way; they're not arbitrary.

Wilma Lam,

Host:

That makes a lot of sense. I think often, in the field of design, people talk about the importance of having good constraints. I think in helping drive creativity, and I definitely feel like in healthcare, that certainly the constraints are important and invaluable. I'm also curious that you've changed careers quite a few times, a number of pivots, as we talked about earlier in our conversation. So you've had the opportunity to see healthcare as a surgeon, as an educator, as a healthcare entrepreneur, and now in kind of a service design and systems design role. How have you seen healthcare evolve in terms of innovation over the course of your career?

Dr. Ijeoma Azodo

It's definitely gotten faster in terms of the applications, not necessarily the innovation. So there's things that we're working on bringing into practice now that I've used during my training. I think, in healthcare, the lore or the legend is it takes about 15 years for an innovation to come into practice. Some of that is because it's highly regulated, because these have an effect directly on people. Practitioners are perhaps relatively slow to change because of the potential for adverse outcomes or people to be harmed. So you practice the way you know until you learn and know better. So I think that that opportunity for sharing techniques and innovation and knowledge has gotten easier, so things are changing over a bit faster.

“In healthcare, the lore or the legend is it takes about 15 years for an innovation to come into practice. Some of that is because it's highly regulated, because these have an effect directly on people. Practitioners are perhaps relatively slow to change because of the potential for adverse outcomes or people to be harmed. So you practice the way you know until you learn and know better.”

It's a space that I think is really exciting, because you can see a lot of benefits a lot quicker. I think that in a way, I've been able to practice as a clinician, being able to see my practice and the process and the outcomes and make changes a lot quicker—and it's always beneficial for patients—and knowing that things aren't working. But I think it definitely takes this introduction of people to what's new; people need to be part of it, whether that's from the public side or the professional side. It has to be clear how it's going to support their practice or their life, and how do they troubleshoot what's going on when it doesn't go to plan the first time? But really, how do you involve people in design from the outset?

Wilma Lam,

Host:

So maybe building off this idea of where healthcare innovation is evolving, I'm curious, primarily from your position now and having seen the evolution of this over your career, what is top of mind now as you think about the future of design and innovation in healthcare? What are you optimistic about?

Dr. Ijeoma Azodo

What I'm optimistic about is the environment so that there's this concerted focus on place. The place people are being cared for is shifting out of the traditional general practitioners or the hospital for the most part, and that's been a push by COVID. But I'm really excited about this opportunity and this growing belief that people should be supported to live their life well and work well, and use technology to do that. So again, what are the environments and structures that are needed for people to be how they are, and thrive and do well. So I think that that being the environment, and that being captured in policy and strategy, for me, is a very good place to be in.

Wilma Lam,

Host:

Thank you so much, Dr. Azodo, for joining me today. It was a really informative conversation.

Dr. Ijeoma Azodo

Yeah, thank you very much for having me.

Wilma Lam,

Host:

Thank you everyone out there for listening.

To learn more about the NES Technology Service, you can click on links that will be posted on our show notes, which will go to the Digital Health & Care Strategy Plan and the NHS Recovery Plan, along with other links which Dr. Azodo has mentioned in our conversation today. To follow along and hear the most recent releases of our podcast, please head to Substantial.com/OptimisticDesign.

If you enjoyed today's episode, please subscribe to Optimistic Design and leave a comment. Join us next time as we continue to take a future-focused look at design, ethical innovation, and technology.

I'm Wilma Lam, I look forward to talking with you again soon.