Breezely: service design for childhood asthma
Philips Healthcare has traditionally engaged with asthma through devices in doctors offices, but was interested in diversifying their business and and exploring opportunities for providing services around childhood asthma. About 10% of children in the US suffer from asthma, and that number is expected to grow until 2025. Having little experience in childhood asthma and a nascent in-house service design team, the Philips team engaged the School of Design to help generate ideas for how they could approach the space.
- Design prompt: Design a service that helps support the transition of children (4–10 years) from parental management to self-management in their asthma care.
- Client: Philips Healthcare
- Team: Nurie Agnes Jeong, Michelle Tai, and Chengcheng Zhao
- Tools & Techniques used: Service blueprinting, value flow diagrams, service experiments, design research, storyboarding
- Produced for: Service Design Studio, Carnegie Mellon School of Design, Professor Molly Wright Steenson
- Project length: 6 weeks, April - May 2017
Breezely is a service that helps doctors, parents, and young asthma patients better communicate and exchange information during the initial asthma diagnosis process. From the perspective of a 5 year old, it looks like this:
Introduce asthma with a storybook
The Breezely service is introduced through a storybook read in the doctor’s office during an initial diagnostic appointment. Asthma can be a confusing concept, even for adults, and we heard from parents and physicians that kids feel more empowered when they know what is going on. The Breezely storybook explains asthma in a language kids can understand and includes educational elements, such as how to properly take an inhaler. Read the full storybook.
Children also receive their own Breezely Bear to take home. It is the hope that by providing a physical version of the storybook character, children will stay engaged with the story through play and use the bear as a source of comfort during an attack.
Track Symptoms with an interactive journal
Tracking a child's asthma symptoms and medication compliance is one of the biggest challenges for physicians. Parents often have a hard time recalling symptoms beyond a 48 hour window, but longitudinal information is needed create an effective asthma management plan. The Breezely Journal is a nightly interactive journal that brings the character from the storybook home, and establishes a playful routine of recording the information doctors need to best manage a child's care.
Breezely prompts kids with questions about their day, any symptoms they may have experienced, and whether they took their prescribed medications. While a young child's sense of time can be warped, we learned through a service experiment that young children really delight in recalling events from their day and calling out specific events helps trigger more detailed information.
The interface uses simple drag and drop gestures suitable for s 4-6 year olds and features instant playful feedback, similar to many app-based educational games.
Asthma is a condition that can be controlled, but compliance with medications often low, so we embedded motivation within the Breezely Journal to reward positive behaviors. Kids earn stars for taking their daily medications and completing their symptom tracking. The tracking can serve as a gentle reminder for parents too.
Support during an attack with a Visualization
Asthma attacks can be scary, and inhalers and nebulizers for small children often require masks, which kids often find uncomfortable and try to fight off. Inspired by mindfulness and meditation apps that help slow down breathing, the Breezely Breathing Buddy helps children visualize controlled breathing during an asthma attack. If they need to take their inhaler, Breezely visualizes that action and the bear appears in an underwater scene, just as in the storybook, activating a child’s imagination.
We also heard from doctors that even when patients report taking their medications, it is nearly impossible to tell if they are taking the inhaler correctly. To address this, the Breathing Buddy records video of a child while they are taking their inhaler, giving doctors visibility into their inhaler technique in action.
The Breezely app aggregates and visualizes data from the nightly Journal and Breathing Buddy for doctors to help inform their management plans. Doctors can see trends of symptoms, compliance with daily meds, and instances when the Breathing Buddy is used.
We heard from doctors that there is virtually no communication between primary care doctors, specialists, and ER doctors. Information is siloed, but each specialist needs the same information to help treat a patient. Because of this, the data is housed within the Breezely app so that it travels with the parent and child at all times, whether they are going for their regular check-up or have an unexpected visit to the ER.
The problem space
About 10% of children in the US suffer from asthma, and that number is is expected to grow through 2025. Besides health issues and discomfort, asthma also causes a $56 billion in healthcare and productivity costs. For kids, the main challenges are remembering to take the medicine, to take it in the right way, and to understand the amount and types of activity they can engage in, without causing an asthma attack. For parents and doctors, it is important to understand how to best support the child in managing their asthma. It is therefore important that children, parents and medical professionals to not only get the right information, they also need to receive it in the right context, timing, and presentation. Philips Healthcare had little experience with childhood asthma intervention, and tasked our class with the following HMW statement:
How might we support transition of children (4–10 years) from parental management to self-management in their asthma care?
We began our design process by familiarizing ourselves with the asthma space through secondary research and conversations with our client representatives. We explored Philips Healthcare's other service related products to better understand the tone and approach of the brand. We then brainstormed widely through sticky-note exercises and built customer journey maps through the asthma diagnosis and management plan development process. While mapping the journey of an asthma patient from symptom discovery and diagnosis to long term management, we realized there was a really interesting period when a child is put on a trial treatment for a 4–6 weeks. The child’s symptoms and responses to medication during that period ultimately inform the physician’s diagnosis and longer term treatment plan. This can also be a time of uncertainty for the parent and the child, as they are having to quickly learn how to manage new medications and deal with the emotional implications of having asthma. This process can be even more challenging for children between the ages of 4-6 years old. We decided to dig into this process and age group further.
Mapping value flows
To better understand the dynamics and information exchanges between each of our stakeholders we built out a value flow diagram.
Interviews with physicians AND parents
Since we were planning to design for children, we also reached out to parents to better understand what a day in the life of a 4-6 year old is like and the types of communication and activities that work well with this age group. We learned that:
- Mornings are hectic and stressful, nighttimes can be more flexible
- Dealing with a 4-6 year old, "Is like playing roulette, one day they are fine taking their medicine and the next they throw a fit"
- But, 4-6 years can understand more than you think. Explaining to them what to expect from a new situation or the sequence of upcoming events can help quell anxiety in situations like the doctor’s office or taking a bath
- Kids are really excited about tracking their progress over time - whether it is a homework sticker chart about practicing the piano or a board at school that color codes their behavior in green, yellow, or red throughout the day.
We then reached out to physicians to better understand the diagnosis process, what challenges they experienced, and the types of information they needed to best manage a patient's asthma. We were lucky enough to access 3 different physician perspectives: a primary care doctor, a specialist pulmonologist, and an pediatric emergency room doctor and learned that:
- It is very hard for physicians to get an accurate report of symptoms over time, making it difficult to establish the real level of severity of a case of asthma and create an effective management plan
- Non-compliance with medication is a massive challenge
- Even when patients do take their medications, it is impossible to know if they are doing it properly. Inhaler technique can be tricky, especially for smaller children, and if not taken properly, the medicine will not do any good.
- Information is siloed and there is very little communication between primary care doctors, specialist, or ER doctors. If a child has a chance visit to the ER, those doctors most likely will not have access to a patient's history and will have to start from square one to understand a patient's symptoms. Similarly, when that patient goes back to see their primary care doctor, it is highly possible the PCP will not have access to the medical records of the ER visit.
Backdoor research method
Since we did not have direct access to any families managing childhood asthma, we explored other ways to learn about parent's experience with managing their children's asthma and discovered insights in an unlikely place - Amazon reviews! One of the physicians we interviewed had mentioned that she wished that she had a storybook to explain asthma to her young patients, and on that hunch we went looking to see if such a book existed. We found a few such books on Amazon and realized that the reviews left by parents provided incredible perspective into the emotional experience of managing asthma with a small child:
"Putting the required mask on his face had become quite a battle and made taking his treatments that much worse. Then we discovered The Lion Who Had Asthma. Our little boy responded instantly to Sean who is the main character in this book. The idea to treat the mask from his machine as the mask to a jet fighter plane was ingenious. Now we read this book during his treatments and using the nebulizer has become less of a struggle." - Parent of a 5-year old, Amazon review
“[My son] really enjoys this book, and it has helped us talk to him about his breathing. Sometimes we ask him if he feels like the lion or if the lion is scared. It also seems to help when he doesn’t want to use his nebulizer.” - Amazon review
"It never occurred to me to find a book to help her cope and deal with the fear she might be experiencing until someone suggested it to me. She relates to Sean coughing when he plays, having to do his nebulizer treatments, and how scared he feels when he is having an attack. But then, Sean feels better after his therapy and goes off happy and playing again. My daughter loves looking at this book when we are doing her nebulizer treatments at bedtime. I think it has helped her grasp the concept that she is not the only one that experiences this since nobody in our house has asthma except for her. I really appreciate this book and I thank the writer for creating it!” - Amazon review
Ideation with scenarios
Based on the feedback from our interviews and initial research, we began to develop an initial service proposition:
A service that improves communication and information exchange between physicians, parents, and young asthma patients during the diagnosis and initial trial treatment period in order to improve a physician’s diagnostic confidence and make the experience less emotionally traumatic for patients and parents.
We were inspired by the asthma storybooks being the core of the service, but spent a lot of time exploring when and how the story could be introduced and used. How could the story be interactive and collect data over time? We thought about things like an asthma lunch box, with an asthma report card, that children could take to school.
We eventually narrowed our focus to 3 key moments and touch points in our service experience: at the doctor’s office (storybook), during a daily story time (interactive journal), and during an asthma attack (app).
We were excited by the premise of using an interactive storybook or journal to collect data about symptoms, but had serious questions about the feasibility of being able to collect meaningful data from a parent and child at the end of each day. Would children 4–6 years old be able to recall events during their day? Would they be able to recall their emotional state? Can 4–6 year olds accurately (enough) remember the sequence of events from their day?
In order to test this, we developed a service experiment to assess 4–6 year olds ability to (a) sequence events from their day, (b) report emotional states from their day, and (c) call out when certain activities happened within the sequence of their day. We were not able get access to kids with asthma, but realized that tooth brushing could be analogous example to taking daily medications, and could be used to check recall of events. We designed a sticker and coloring activity to ask kids about their day and recall of brushing their teeth.
We conducted the service experiment a sunny afternoon on a playground at city park, and learned some interesting things about kids:
- They really love telling you about their day
- Their sense of time can be really warped
- But, when prompted, they can effectively recall a sequence of activity
- The activity was most effective when done in collaboration with a parent
Photo credit: Michelle Tai
REfining the concept with Body Storming & Paper Prototypes
We took what we learned in our service experiment and went back to the drawing board to refine our approach. We decided that educating, tracking symptoms, and calming during an asthma attack were the goals we wanted our service to achieve. The storybook, phone, and tablet app rose up as the most natural touch points to fully develop.
We body stormed scenarios around doctor conversations and parent-child interactions to help us find the right tone for our content.
We then made paper prototypes of each of our touch points to find the right interaction flows before bringing the designs to the next level of fidelity for our pitch to clients.