Designing for Health: The Human-Centered Approach
Jerome Pagani and I wrote this book for the people who run health systems and the clinicians who work inside them. Its claim is simple: almost nothing in American healthcare was deliberately designed for the humans who give and receive care, and that is a fixable problem if you work on it one system at a time.
Who is the book for?
It is written for health system executives, clinician leaders, and the informaticists and operations teams who have to make decisions work on the floor. It is deliberately not an academic text. It borrows what is useful from design thinking and behavioral economics, and it is written to be easy to use, since anything else would be a little hypocritical.
What is Designing for Health all about?
Healthcare is difficult to use because nobody designed it to be easy. The system accreted, one reasonable-looking decision at a time, with each piece optimized for cost, throughput, or survival until next quarter rather than for the experience of the patient or the nurse. We don't expect a national redesign any time soon, so the book argues for building better from the bottom up: inside your own organization, with your own workflows, using a shared set of design principles.
We also make the case that this is a strategic necessity, not a kindness. Retail and technology companies that are very good at consumer experience are taking the profitable, routine parts of care. Traditional health systems still hold the expertise for everything that stops being routine, and they fund much of it with margin from the services now under attack. Systems that don't make themselves easier to use will lose that margin, and with it the ability to deliver on their mission.
If healthcare is already about people, what does "human-centered" add?
Being about humans is not the same as being designed for them. A process can exist to help patients, be run by people who care deeply, and still be miserable to use. We use the familiar example of the door with a handle on both sides: built by humans, for humans, and still requiring a small puzzle every time someone walks up to it.
The book holds designs to two tests at once. The first is usability: does the system fit how people actually think and work? The second is outcome: does it lead them somewhere good? A frictionless path to a bad result is worse than a clumsy path to a good one, so neither test is enough alone.
What are the six principles?
The core of the book is six principles. We call the list important but not complete, and we mean it.
- Make it easy to do the right thing: Arrange choices so the good option is the path of least resistance and the bad one takes a little more effort, without removing anyone's freedom to choose.
- Get rid of stupid stuff: Ask the people doing the work what is pointless, then fix it quickly or explain why it has to stay.
- Start with the end users and their context: Figure out which humans a design serves, recognizing that there is almost always more than one, and weigh their competing needs before settling on a solution.
- Be transparent and predictable: Build systems that behave the way people expect, and when that isn't possible, make it obvious how they work and why.
- Listen to your real experts: Users are the authority on their own experience but not always on what is best for them, so design draws on several kinds of expertise and has to reconcile them.
- Improve continuously: Treat every workflow as something that will drift out of date, and plan from the start for maintenance, feedback and retirement.
The last two chapters apply those principles to technology and to the wider health ecosystem.
Why start with how people actually think?
Because you have to design for the humans you have, not the rational ones economists like to model. People lean heavily on fast, automatic judgment and on biases shaped by evolution. The useful news is that we are predictable in those habits, which is what makes design possible at all. That applies to clinicians as much as patients: the memorable save that makes a physician keep ordering a test the guidelines have retired is the same machinery that makes a patient skip a screening.
That is where choice architecture comes in, and where the book draws its lines. A nudge that fires too often becomes what MIT's Joe Coughlin calls a "noodge," and an environment saturated with them trains everyone to ignore all of them, which is a familiar story to anyone who has counted clinical decision alerts. Nudges that outlive their purpose turn into sludge. And deliberately obstructive designs, the dark patterns that make cancelling a subscription a quest, are off the table even in service of a good outcome. Once the cost you impose is high enough to compel rather than encourage, you have stopped designing for people and started deciding for them.
What is GROSS, and why does it get a chapter of its own?
GROSS stands for Getting Rid of Stupid Stuff. Melinda Ashton and her colleagues at Hawai'i Pacific Health developed the approach, and it is the most immediately usable idea in the book. You ask staff to name what they find poorly designed, unnecessary or plain stupid, and then you commit to acting on what they tell you.
Ashton's team found that the submissions fell into three groups. Some requirements nobody had ever meant to impose, like a neonatal umbilical-cord checkbox that survived into the adolescent nursing form. Some were needed but could be done more efficiently. The rest were legitimate but looked absurd because nobody had explained their purpose. One redundant hourly-rounding attestation, which took each nurse under thirty seconds, added up to an estimated 1,700 nursing hours a month across four hospitals once it was removed.
The chapter's practical advice is about scope. Keep the program focused on fixes small enough to deliver quickly; we suggest a rough ceiling of about twenty hours of work each. Move anything bigger to another process, so the program's reputation depends on visible wins and not on the slowest item in the queue.
Where does technology fit?
Technology gets its own chapter because it is capable of both extremes in healthcare: breakthroughs that save lives, and the EHR-era friction clinicians know too well. The book's position is that the useful question is not what a tool can do but what it does for the people whose work and lives it touches.
Most technology either automates a routine task or extends what people can do. Even obvious wins need a second look. When results stop being printed and hand-carried, what informal conversation disappeared along with the paper? And sometimes a feature that looks like a weakness in one setting helps in another. The distance that makes telehealth feel impersonal for chronic care may be exactly what lets someone in a mental health crisis start talking.
Why does the book end with ecosystems?
No single organization delivers anyone's lifelong health, so human-centered design eventually has to reach past your own walls. As care spreads into retail clinics, ambulatory surgery centers, apps and the home, patients gain convenience. They also risk more fragmented data and an unbundling of care into narrow, efficient services that nobody coordinates.
The book argues that traditional systems will either redefine their role in that ecosystem or have competitors redefine it for them. The better path is to decide deliberately which niches to own, compete on experience as well as outcomes, and connect with partners in ways that keep the patient's journey coherent. It does not require winning every service line.
What can a leader do next Monday?
The epilogue offers three starting moves.
- Take an innovation safari: Bring a team to watch a well-designed organization outside healthcare at work, less to copy its ideas than to make change feel normal.
- Build a Mr. Wolf team: Create a small group of human-centered fixers, named for the problem solver in Pulp Fiction, whose job is to arrive, solve a defined problem and leave.
- Go piecemeal: Accept that you will not redesign everything at once, and treat steady, visible improvement as the goal.
Book details
Designing for Health: The Human-Centered Approach
Craig Joseph, MD, and Jerome Pagani, PhD
One Louder Productions, 2023
ISBN 978-0-9601205-0-5