About the Design Leaders series:

In Design Leaders, Pivot reaches out to individuals and companies who live and breathe design. This series explores the genesis of design and its practical applications in business. We hope that it inspires you to think expansively and create meaningfully, both at work and at play.

Check out the previous article in the DesignMeets… Design Leaders series: molo

About Dr. Joseph Cafazzo:

Dr. Joseph Cafazzo is Lead for The Centre for Global eHealth Innovation, a state-of-the-art research facility devoted to the evaluation and design of healthcare technology, hosting seventy researchers and staff. Dr. Cafazzo has been an active researcher of the use of technology to facilitate patient self-care of complex chronic conditions such as diabetes, end-stage renal disease, and congestive heart failure.

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Pivot Design Group: You’re an engineer by education. How did you become interested in Human Factors design, and specifically in patient self-care?

Dr. Cafazzo: Early in my career I was working in the hospital setting as biomedical engineer, and over time I came to realize that some of the problems we were having with health technologies were not related to the products’ functionality, or technical reliability. In fact, those things were generally well taken care of. The catastrophic failure of medical devices was increasingly rare.

Rather, the technology-related problems we were dealing with often seemed to be in the grey area of design that is considered human factors-related. The problems were with the interaction of humans with technical systems. Initially we in hospitals would simply try to address those failures with warning labels or training or user manuals, but it eventually dawned on us that we were dealing with fundamental DESIGN failures.

A design failure is not as tangible or explicit as a software feature failing, or a screen going blank, or a hardware accessory failing. In certain circumstances, people will operate a product in an unintended way—that was what we were dealing with, and that fascinated me as an engineer.

I ended up becoming very interested in the discipline of Human Factors that was emerging in the ‘90s in healthcare, and did my PhD in an area that was related to it. Eventually everything came together in the creation of the lab.

Pivot: What goes on at your lab, the Centre for Global eHealth Innovation and Healthcare Human Factors at the University Health Network, here in Toronto?

Dr. Cafazzo: Initially, we primarily focused on evaluating healthcare products using Human Factors methods. That can also include evaluating a process, such as a check-in task that nurses are required to complete as part of the post-operative process.


Our team is made up of biomedical engineers, Human Factors experts, psychologists, and a mix of professionals, researchers, and students. Over time, it became apparent that this group of people could do more than evaluate technology—we could actually design and build better products. The companies who originally approached us to critique their products began to demand more of us, and we have been designing products for nearly 10 years now.

One of the special things we have here is unprecedented access to doctors, nurses, and patients—the fact that we are embedded in the hospital is so important.

Our original work is centered on consumers and patient self-care. We put our own ideas and concepts through the whole user-centered-design process, as well as continuing to do this for client products.

Pivot: You have spoken and written about “empathetic design” and “evidence-based validation”. Can you elaborate on these concepts?

Dr. Cafazzo: A product can be elegant, easy to understand and use, and well loved by patients and nurses. But if it contributes nothing to a patient’s health, and represents no efficiency or cost savings to the healthcare system, then to us, that product is a failure. Empathetic design refers to the idea that we have a responsibility in the healthcare environment to design products that are easy to use, effective, and BENEFICIAL.

Evidence-based design is something we do primarily with the products that we design in house. The process can take two to five years to complete, but it’s really important to do rigorous evidence-based validation to demonstrate that we HAVE improved patient lives.

Pivot: Is there an eHealth application that your lab has worked on that is an example of the evidence-based validation process?

Dr. Cafazzo: Our diabetes app, called bant, is a good example of a product that went through a rigorous, iterative design process. bant helps adolescents with Type 1 diabetes to manage their blood sugar. It replaces the traditional paper logbook method of collecting and reviewing blood sugar levels by collecting BG levels as they are measured and detecting trends.

Our process was very clearly oriented toward the adolescent consumer, whereas most health apps tend to be oriented to doctors or to the app provider. But for bant, we started with ethnographic interviews and cognitive walkthroughs with teens and their parents to understand the potential needs and behaviours of the target users. bant has a number of features that fully engage youth in the process of managing their blood sugar, like a social media element to communicate with other kids with Type 1 and a competitive element as well. We started that design in 2009 and it has been available for a couple of years now and used by thousands of people around the world. The advanced version is still in clinical trials at the Hospital for Sick Children, but we hope to have it available to the general public soon.

Pivot: Any other examples?

Dr. Cafazzo: Our medly hypertension management app is an excellent example. The problem of hypertension is significant, because the long-term effects include cardiovascular disease, blindness, and so on.

With this app, we targeted individuals aged 45 and up who had uncontrolled blood pressure. We tracked two groups of people over a year: one group using a manual blood pressure monitor, and another group using a smartphone app with a Bluetooth blood pressure monitor. The app sent them reminders and let them track their blood pressure in a very interactive and visual way.

After a year, the group using the manual monitor saw no change in their blood pressure. It’s important to realize that hypertension is a condition with no symptoms so it’s very easy to overlook, and that group did overlook it. But the group that had used the smartphone app dropped their risk of heart attack and stroke by 20%.

Not only did we gather that data but we learned a great deal about the mechanics of the behaviour change that the app elicited.

Pivot: How do you evaluate whether a product or idea is worth pursuing?

Dr. Cafazzo: We think about it in terms of impact, meaning that what we do has to be effective in really changing the patient’s life for the better. That’s really our measurement stick. So we might turn down things that look like good ideas but that are perhaps another iteration of something already on the market and not particularly innovative. In many cases we turn down good ideas that we just don’t think will really change lives.

Pivot: How do you begin the process of design of a new product?

Dr. Cafazzo: We don’t like to go to patients with a “blank page” for whatever issue we are trying to address. We start with a reference document that is our “best guess” for the design, and we gather patient reactions to that. We have learned that our design tactics have to be multifaceted. Especially when you are trying to elicit a change in behaviour, the design has to go after that in different ways. That is always a critical element in our discovery process.

Pivot: Is there anything you do at the lab that you think can and should be applied to any business?

Dr. Cafazzo: Generally, I think that in order to create really great products there has to be a perfect storm of design, technology, and user. What we have here at the lab, which I hope others can emulate, is the chance to embed designers into the users’ environment.

If our designers or Human Factors professionals were at the university, or sitting in cubicles, just speculating about the user and what the user wants, it would be difficult to produce empathetic and impactful products. Being exposed to the chaotic clinical environment, experiencing what a patient or nurse is actually going through–that is invaluable.


Too many designers and engineers spend too much time within the walls of their companies and not enough time with the users of their products. That is not unusual. But what if organizations made it part of their design process to send a designer or engineer for six months to spend time with the end users?

Pivot: What keeps you and your team inspired to continue to innovative, or to constantly improve upon and develop ideas?

Dr. Cafazzo: Our lab is like a theatrical stage in some respects, and we can make it into any environment that we need. We ask patients to come away from the clinical environment into our “theatre”, where they can focus and feel more relaxed than they do in a hospital. This approach fosters new thinking and new ideas.

Because we are also an academic institution we are constantly being reinvigorated by students, who carry no baggage. They often come up with brilliant ideas that they aren’t even aware are brilliant. It is key to foster an environment where academic inquiry is allowed. It’s a constant source of refreshing ideas. I think that all companies should consider budgeting for resources towards projects that may or may not lead to a product. It’s also still a worthy cause to hire students.

Pivot: Do you have any thoughts about the future of patient self-care that you could share with us?

Dr. Cafazzo: One area where I feel we are at a tipping point is with wearable devices. Most people know about devices like the Nike Fuel band or Jawbone—activity monitors that let consumers monitor their activity levels. But I believe we’re really just scratching the surface. These types of devices can be developed to manage things like cardiac illness or even mental health issues. Imagine a personal device that is able to track levels of stress or anxiety, and communicate that information not only to the wearer but to a doctor or nurse or immediate informal caregivers like family and friends.

We are working on this now, and hope to test its value soon.

Join us at our upcoming DesignMeets… HealthCare event at the Centre for Global eHealth Innovation on June 26th.

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