Fireside chat with Daniel Burka- Director of Product & Design, Resolve to Save Lives

How did you get started in Design? Looking back now, what did you feel like you should have known?

I got into design when I was in my teens, which is the early days of the web. I grew up in Canada, helped design a started design agency called silverorange when I was just 17 years old. That agency is 21 years old now, which is still in business. Back in the late 90s, there was no such thing as a web design school. I’ve never studied design.

I got into design through writing. I was going to study history in college and I really enjoyed writing. It’s interesting that in my era of designers, there’s quite a few designers who came in through writing. Jeff Veen, Doug Bowman (who was head of design at Twitter), Liz Danzico (creative director at NPR), John Zeratsky, Wilson Miner, among others.

I was very lucky in some ways to come into a writing background because I think writing is the most underappreciated skill in design.

It’s been a pretty organic career. I haven’t had a plan, never made five year plans. I never thought of myself as a brand designer or a product designer. Whenever a new logo had to be designed, I figured out how to do it. I’m not the world’s greatest logo designer, but I’ve been involved in designing some pretty famous logos.

I find it funny when I talk to students and their professors are like, “oh don’t be a jack of all trades and a master of none focus on one thing” and I disagree. I’m a pretty good writer, brand designer, product designer and an entrepreneur.  It’s mostly about picking things up and taking responsibility for things, because it’s your job, right?

I worked on Mozilla Firefox and Thunderbird back in the day and I moved to California, worked on a few startups including Slack. Three years ago, I left Google Ventures to join Resolve to Save Lives, started by. Dr. Tom Frieden, former director of the US Center for Disease Control (CDC).

I work on Simple, which helps clinicians to longitudinally record hypertension and diabetes patients, record their health over time in order to strengthen Public Health Systems treatment of chronic disease. This is an increasing challenge everywhere in the world, but particularly in places like India and Ethiopia where there’s rising incomes and increasing pressure on the health system with chronic disease.

Can you tell us a little bit more about Simple?

So, an application does not cure anyone from hypertension.

Hypertension alone is the leading indicator for heart attacks and strokes. If you can help more people to control their blood pressure, you’ll significantly reduce death from heart attacks and strokes. In order to control blood pressure, you need to do a lot of big public health things which have very little to do with technology.

You need to create a simpler way to treat patients.India has a massive patient scale. If you’re treating every patient differently, it becomes difficult to scale training and drug purchasing. If states can choose a simple treatment protocol, buy enough cheap medications to support that treatment and this way, you can send patients home with 30 or 90 days worth of drugs so they don’t have to come back every week. If the patients have to come back every week, they often fall off of care.

  1. Simple protocol
  2. Sufficient supply of medication
  3. Figure out your inventory supply systems and
  4. Train lots of healthcare workers.

You need to create a better flow through the clinic to make sure their blood pressures are getting taken at every visit and that patients get treated. Ideally, you start recording what happens every visit so you can treat a patient over time rather than episodic care. If you treat a patient differently, as if they are new patients each time they visit, it’s really hard to to trend them down and to make sure that their condition gets controlled over time.

This is basic healthcare, but for many people in the world, that’s a challenge to be solved. When they visit their doctor, their entire record is on a piece of paper in their hand. When they leave the clinic, that piece of paper goes in the trash can and there’s no record of their visit. The next time they come back, the doctor’s busy and barely has 3-4 minutes if they’re lucky to spend time treating them.

There’s something like 15-20% hypertension control in India. If you can get that up to 50%, you could help a lot of people. To record patients over a long period of time, paper is not great because it becomes an unnecessary burden on health care workers to manage. They might see 200 patients a day, that’s 30-40 pieces of paper that they have to manage every day and then go get them out of the drawer to treat them the next time they come.

You’ll need a digital system, but if you only have about four minutes to treat every patient you’ll have only 15-20 seconds to record them. A clinician doesn’t come to work to enter data into a device, they came to work to treat the patient who sits across from them, right? So, if you want them to do something the ROI has to be very good. It’s either very little effort or very big reward.

At Simple, we made it extremely fast to record a patient visit. We ask for almost nothing; we record their basic demographics at registration, 4 questions about their cardiovascular history, and then enter their blood pressures and their current medications.

We can register a patient in about 45- 60 seconds. When patients return, they receive a QR code which, while scanning, opens a patient record enter their BP. Enter their medicines and you can be in and out in 14 seconds. Our average recording time is 14 seconds.

Basically, I make the world’s lightest weight electronic health record. It’s extremely efficient and it works in low resource settings. A lot of these clinics have unreliable internet. What we’ve done is make a tool that can be used on a personal mobile device.

The first thing I did when I came to India, I asked the nurses “What kind of phone do you have?” Most nurses have a decent Android smartphone. Right now we have about 4,000 clinicians in India using the software, and 95% of them are doing it on their personal devices, which lets you go really wide really fast.

The trick is you need to record each individual patient. Because that’s how you treat each patient better. But the real trick is to look at your entire patient population and say are you doing a good job of controlling your hypertension patients in your facility? Is this hospital doing well? Is this block doing well? Is this entire district doing well?

For the woman in charge of the hospital, are her patients getting healthier? For the District official or Minister of Health for the state, are you identifying enough patients? Are you helping them get controlled? What activities can you take to strengthen the hypertension control program in your state?

That’s fundamentally why Simple exists, to drive those big feedback loops into the public health system.

In domains like healthcare, it becomes a case of the doctors or the clinicians getting excited about the app in the initial stages and then dropping off in terms of usage. How did you make sure that Simple was adding value on a continuous basis?

First of all, we’re a part of a big hypertension program. We’re not just selling software to hospitals. These hospitals or Ministers of Health, want to try and make a dent in hypertension. So there is top-down pressure. That’s one lever.

The second lever is to make it as painless as possible. If you ask 10 healthcare workers what you can do to help them with their jobs, 9 of them will tell you “don’t make my job harder.”

They are very overworked. They see many patients every day. Do your best not to make their job harder and take something that’s already hard for them and automate it. We met lots of nurses who were compiling lists on paper to call patients at the end of the week. That took her two hours out of her week.

Well, I can do that automatically! I can send texts or a Whatsapp message to those patients. If she knows I’m doing that for her patients, then she cares about the software. I’m taking a burden off of her shoulders so that she can focus on her patients instead of the software.

The third thing is to return feedback loops to the clinician. These clinicians must be so tired of working on public health programs that require them to fill out paper registers, right? They fill out 2-3 registers and they never get any feedback from it.

No one says “You were doing a good job!” or “Here’s where you could improve”. There is just a one-way stream. They’re putting a huge amount of effort recording data they never see it again. If you can return that feedback loop to them, they understand why they’re doing the data entry.

UX writing is talked about quite a bit. Do you think that’s a skill that a lot of designers should be working on more ? How do you think designers can improve their writing skills?

Unfortunately, most designers think writing is a writer’s job. I hate when designers leave writing to someone else.

The biggest way to improve your interface writing is user research. Create interfaces where you wrote what’s on the buttons and the content on the screen. Study this with five people and you’ll come to realise that three of them don’t understand what happens on clicking that button.

The user research is a very humbling experience for writing and it’s also when you realize how important writing is. It doesn’t matter how nice-looking the button is, if the text isn’t right, it will not work.

How much business should designers learn?

I do think designers need to understand business. It’s not that I think there’s a common misunderstanding that if designers understand business that they optimize every decision for the business. Design’s major role is to speak for the users, right?

If you look at the Product Triad, the Engineer thinks about performance and systems, the PM thinks about business and the Designers think about the users; you have to understand everyone else’s perspective in order to be effective. If you’re running off in a different direction from everyone else, they’re not going to be too happy with you.

If you want to actually advocate for users, you need to understand how your business works, where the business pressures are coming in and how to leverage those to benefit users. This way, you don’t lose sight that the business fundamentally serves customers.

How is it different to work in design in a not-for-profit vs for profit?

Basically in a for-profit world, your goals are to find high margin places to make money, you can be aiming to make the world better. The best way to get people good health care and to make money is to work through insurers. In India, individual payment payers is a very difficult way to make money because people don’t have a lot of money in their pocket in order to buy personal health insurance. But, if their employers buy them health insurance, you have a market in a big company of 10,000 potential patients who can leverage that care. It’s a much easier sales model and much more likely to work in a not-for-profit world.

In the not-for-profit world, our goal is to treat patients who are currently being treated very well, but where there is the potential to treat them better within the public health system in rural India.

There’s a lot of pressure from the government to improve that system because there is a lower standard of care right now and no one’s pursuing those patients in the for-profit world. That’s why a public system exists and it’s why not-for-profit food work in that space because you could treat massive numbers of patients with very low profit incentives. We’re not in it to make money at all. We are helping strengthen a public system for all.

How do you measure impact in a longer term, given that revenue or profits is not a priority?

A not-for-profit project, like Simple, has pretty clear metrics. The number one thing you want to track is how many patients is Simple helping to control their hypertension. And that’s literally why Simple exists.

The real metric is how many of those patients have their blood pressure controlled in the last few months. So they’re staying in care and we’re treating them well that their blood pressures are below 140/90.

What you want to see is those two numbers go up at the same time. If we can help register enough of them, but also help at least half of them get controlled in the last three months that will be a massive accomplishment. That’s the main goal and then the secondary goals are to do it at reasonable cost. Simple is relatively expensive in the public health world. The trick is to make that sustainable so the government can start doing more of the development so we can start reducing the cost of development.

It’s those types of sustainability versus profitability that are the big measure in the not-for-profit world. Are we accomplishing our goals of controlling patients? Are we doing it at a cost that is sustainable over the long term? It doesn’t need to be sustainable today. But in a few years it needs to be sustainable.

How did you first try and understand the Indian public healthcare system when you started to work on Simple?

The trick is first to work with people who are involved in the health system. I will never understand the health care system as well as a doctor who spent 20 years practicing in that system.

The second thing is to be humble. And then the third thing is do lots of user research. Watching people use our software in the middle of care because your software is only one hundredth of what that nurse is doing in a day. She’s running down to the pharmacy to get more medicine. She’s coming back to her office with a line of patients.

Their job isn’t to enter data into your software. So it’s really important to watch their jobs and not oversimplify. But at the same time if you keep your software really simple, it’s easier to fit into her workflows. If you create a very specific software for a very specific workflow you’re not going to work very well in India because everyone’s got a different workflow.

You’ve been in design for more than 20 years now, can you tell us a little bit about how you’ve kept yourself up to date?

Honestly, it’s mostly working on interesting projects for a long time. I’ve read the same books that you folks do. I follow a few people on Twitter, I like when they send updates that expand my mind. I don’t go to conferences very much.

The biggest thing you’ll learn by doing is by making stuff on teams and learning how to create great teams that can succeed. I spend 90% of my time not designing right now. Most of my time is spent working on product direction, creating partnerships, coordinating with everybody and making sure we’ve got a great team that’s executing well.

I’m still a pretty good designer as an Independent Contributor. I’ve chosen not to go a hundred percent down the managerial or a hundred percent down the product road. I can still design software. I think the best way to grow as a designer is to keep making, keep testing. I feel like I’m never good enough, I’m always trying to improve.

Do you have advice for who are the sole designers on their team and how do you conduct enough research in that context?

What we do on the Simple project is, we run two tracks. One is most designers and on my team. There’s only four of us for design product designers on the team. But we’re all working on two tracks at the same time and one track is thinking ahead into the future about what we’re going to build two three months from now.

We have a plan and you have to be working on that production track all the time in order to keep the train moving. If you can do that, carve out time to be prototyping and testing into the future. That’s the best bang for your buck with user research. Then you use usability testing before you launch. If you have a boss, you’re going to have to Advocate to your boss how important prototyping and testing is but it’s really efficient.

If you can convince your product manager or your boss that driving in the wrong direction is very expensive, you can do a bit of prototyping for better testing and significantly increase your chances of driving in the right direction with your engineering team. It’s very very good ROI for your product.

Assuming Simple is hiring in a few months from now, what skills do you look for while hiring for a Product Designer role?

We have the best people who work on our project. One woman who works for me out of Bangalore, is one of the best designers I’ve ever worked with. What makes her great is that at our scale you need pretty T-shaped skills. Fairly good at one thing, pretty good at other things. She’s a good user researcher and that’s her primary skill. But she’s also a good UI designer and can take something that already exists and apply it consistently.

It’s kind of surprising to find UX or product designers who aren’t very good UI designers. UI design is not that hard. It doesn’t hurt to be a good UI designer, it just takes a bit of practice.

The next best thing you can do is to show a great deal of ownership. I’m always impressed when junior folks stop and say “Hey, if I was in charge of this product and if I had to make this decision, this is the way I would make it and here’s my opinion.”  It doesn’t mean you’ll win, the other person might know more than you do, but it really helps to understand your thought process and forces you to think through decisions like a PM.

It helps to go talk to your product manager and ask “what are our goals for the next quarter or the next six months? What are the things that keep you up at night?”  It’s not design problems. It’s never design problems.

You don’t have to be a genius about this. You don’t have to know everything about the business, but start learning about more than just the design realm and you’ll be more effective.

What advice do you have for designers who are looking to become a product designer?

A piece of advice I got back in the day from Tom Hughes. He was head of design at Lotus Software. He’s a humble guy and we got introduced to him randomly by my friend’s dad. I was impressed that he had the humility to talk to us 17-year old teenagers like we were colleagues and I still greatly appreciate that today.

One piece of advice he gave us was “Do good work and care about humans: everything flows from there.”  He’s not wrong. Your design affects real people who are trying to accomplish real things in their lives. I get the most joy from helping others accomplish these things. Humans first. Designing to improve people’s lives. Everything flows from that.

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