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Nov 15, 202038 min read

RCA Final Dissertation

Interpretation of China's Digital Healthcare Construction and Investigation & Analysis of Inclusiveness of Elderly


Shang Wu MA Service Design

9 July, 2020

Words: 8581


Content


- Introduction

- Concept Framework

  • What is Digitalisation and Digital Healthcare?

  • Common Operation Process of using Digital Healthcare

  • The Development Process of China’s Digital Healthcare

- Interpretation & Analysis

  • The Positive Impact of Digital Healthcare

  • The Negative Impact of Digital Healthcare

  • The Debate in Society

- Methodology

  • Qualitative Research: Semi-Structured Interview

  • Quantitative Research: Self-Administered Questionnaire

- Research Finding & Analysis

- Suggestions

- Conclusion

- Bibliography


 

Introduction


The advancement of technology subverted the working mode of many traditional industries and brought users unprecedented experiences. In order to maximise the value of resources and provide a more coherent experience, the development of technology has gradually moved from independence to integration.(1) Digitalisation is one of the most important ways to integrate technology. Through the wide application of high-technology, digitalisation connects data among various departments and establishes a complete ecosystem. In the process of digitalisation in human society, healthcare as the most important guarantee of human live, has naturally become an indispensable part.(2) In mainland China (use ‘China’ for the following), with the ‘Reform and Opening up’ policy in 1978, its economy has had a dramatic growth with a rapid development in the field of science and technology. After experiencing several epidemics, China has attached great importance to the construction of digital healthcare systems, and has made significant progress in recent years. Not only has it narrowed the gap with developed countries in many areas, and because of the particularity of Chinese society, digital construction is particularly important in the development of China's healthcare industry.(3)


After experiencing digital healthcare services in person, I found that the treatment process had indeed been greatly improved. The use of modern technologies such as EMR (electronic medical records), self-service machines, WeChat or networking delivered significant time savings over traditional methods, providing a good experience for the user/patient. However, from my insight, I noticed that many elderly patients experienced considerable difficulties using machines or other digital devices, and they had to turn to me or volunteers for help. It reminded me of the importance of taking a 'common sense’ approach when my parents experienced difficulties using a smartphone. This made me question the inclusiveness of digital healthcare services.


At the same time, the public often receive reports about digital healthcare in the news. For example, the powerful self-service machines are widely promoted in hospitals, telemedicine helps patients to meet experts without going out, or new micro robots assist doctors to conduct high-level surgery, etc. These all aim to promote the positive aspects of digital healthcare to the public. Nevertheless, different users give different evaluations on the experience of digital medicine. Some people think that digital healthcare is very powerful and easy to use. However, others complain that the design are unfriendly especially for older people. This makes me very curious about the positive & negative effects of digital healthcare and the actual experience of elderly users. Therefore, it aroused my interest in the topic of ‘Interpretation of China's Digital Healthcare Construction and Investigation & Analysis of Inclusiveness of the Elderly’.


After conducting significant research on digital healthcare, I found that most of them were mainly based on technical analysis, and less talk about design. Also, in the current articles about analysing the effects of digital healthcare, the perspective is often onesided, and there is a lack of comprehensive thinking when considering all healthcare service users. In addition, most of the available information about the experience of the elderly in digital healthcare can only be found in news reports, there are few academic papers.


As a Service Designer, I will mainly focus on the design of digital healthcare and inclusiveness of older users. I will use systemic thinking to interpret and analyse the China’s digital healthcare construction from various perspectives, including all healthcare service users, stakeholders, and social impacts. Furthermore, I will use a combination of qualitative and quantitative methods to conduct a first-hand survey on the elderly inclusiveness of the digital healthcare and the symbolic awareness of the elderly public. This will include in-depth 1:1 interviews and extensive questionnaire surveys. Finally, I will analyse the research content through the perspective of Service Design and make recommendations based on my findings.

This research has provided me with a great opportunity to better understand what elderly people experience when they engage with digital healthcare in China. It has also strengthened my research ability, critical thinking and encouraged me to pay close attention to inclusiveness in future design. I believe that this research will provide useful information for healthcare industry builders and designers to consider and improve the experience of elderly people in a digital healthcare experience. In the longer term I hope that this research can contribute to greater inclusiveness and help China's digital

healthcare progress towards a more humanised direction.

This document is presented in the following six sections:

  1. Concept Framework - this will explain the definition of digitalisation and digital healthcare including a detailed description about the common operation process of using digital healthcare services. The development process of China’s digital healthcare will also be introduced.

  2. Interpretation & Analysis - An analysis of the digital healthcare’ impact through both positive and negative aspects and leads to the discussion about elderly healthcare service users in the society.

  3. Methodology - a description of the methods used in first hand research, including the purpose, rules and limitations.

  4. Research Findings & Analysis - the research findings will be presented and analysed through the angle of Service Design.

  5. Suggestions - Combining second-hand research with first hand, the suggestions for the future construction of China's digital healthcare will be put forward.

  6. Conclusion - the content of the article will be summarised and personal advocacy will be published.


 

(1) Marco Iansiti and Jonathan West ‘Technology Integration: Turning Great Research into Great Products’, Harvard Business Review (May 1997) https:// 1 hbr.org/1997/05/technology-integration-turning-great-research-into-great-products (accessed 9 July 2020).

(2) Sanjeev P. Bhavnani, Jagat Narula, and Partho P. Sengupta, ‘Mobile Technology and the Digitisation of Healthcare’, PMC 37(18) (2016). 2

(3) Zhibo Zheng, ‘Talking about the Current Situation and Development Trend of Hospital Digitalisation in China’, China Market Marketing 34:25 (2013): pp. 3 121-122 (p. 121).

 

Concept Framework


What is Digitalisation and Digital Healthcare?

The idea of Digitalisation comes from Informatisation, and it is the upgrading version. Previously, Informatisation transformed physical information into data, which was stored and managed through a computer. However, Informatisation is more likely used in local or single departments, and it lacks integrity and connectivity. This has led to inefficient data applications and slow responses, as well as the inability to connect and share content between departments. Digitalisation establishes connections on the basis of Informationization of different departments, realises inter-departmental interconnection, and opens up data integration across the board, thereby establishing a complete service platform or ecosystem.(4) In this article, Digital healthcare refers to the introduction of advanced computer, network, communication, information science, AI, big data, cloud services and other digital technologies into the medical field, to achieve scientific management of medical information, innovative development of medical equipment and effective use of medical resources. For example, all patient information and records are bound to a unique medical number, and all medical behaviours of medical workers are also managed electronically.(5)


Common Operation Process of using Digital Healthcare

Generally, the main processes are:

  1. Establish an EMR (electronic medical record)

  2. Make a digital appointment

  3. Visit the doctor

  4. Pay

  5. Get treatment / laboratory test

  6. Collect medicine.

In detail, during the first time, patients need to use the traditional service counter to register electronic medical records with their personal information, then the personal medical number will be received and it can be used for the future reservation without using the counter again. The reservation process can be done by computer, smartphone or self-help machine, and the function of reservation in WeChat allows patients to pay online and also reminds patients automatically before the appointment is approaching. If the patients do not pay within a period, the system will automatically cancel the appointment, so that other patients can fill the vacancy. When the time of appointment arrives, the patient will receive a notification via the large screen which is set in front of the consulting room or on WeChat. After arriving at the consultation room, all personal information and previous medical records will be found by the doctor on the computer through the Intranet, meanwhile, the latest diagnosis, prescription and test requirements will be directly entered into the Electronic Medical Records. After that, all the charges will be immediately generated on the screen for the cashier, patients are also allowed to choose their preferred payment methods to pay including cash, bank cards or mobile. After payment, patients can go for treatment, testing or medicine collection. All the treatment or testing materials will be prepared before patients arrive as the information has been transferred to the relevant departments directly. After testing, patients can also collect the test report through the self-help machines or mobile app.(6)


The Development Process of China’s Digital Healthcare

China began to explore the construction of digital healthcare in the late 1990s, and listed it as one of the most important tasks in the modernisation of the country. The development process of medical digitalisation has mainly gone through the following four stages:

  1. Single-level application

  2. Department-level LAN (Local Area Network)

  3. Complete hospital information system

  4. Telemedicine.

With the growth of China's economy and the increase in population, health services have developed rapidly. After experiencing several public health incidents, such as SARS, H1N1, COVID-19, etc., the digital construction of healthcare becomes even more important. Yanjie Gao (2013), the director of the Digitalisation Office in the Ministry of Health, mentioned that after SARS the new management model is challenging the traditional way.(7)


 

(4) Paulin Alois, ‘Digitalisation vs. Informatisation: Different Approaches to Governance Transformation’, Central and Eastern European eDem and eGov 4 Days, 004:351/354 (2018): pp. 251-262.

(5) Sanjeev P. Bhavnani, Jagat Narula, and Partho P. Sengupta.

(6) Shenxue Shi, ‘Conception and Discussion of Hospital Electronic Network Management’, Chinese Health Economics (2002) https://www.ixueshu.com/document/1b154ecb637fc9ea5fd1125615c74943318947a18e7f9386.html (accessed 9 July 2020).

(7) Zhibo Zheng.

 

Interpretation & Analysis


The Positive Impact of Digital Healthcare

The construction of digital healthcare is of great significance to China, because it improves China’s medical level dramatically, and alleviates the huge medical demand and uneven medical resources in China. In addition, digital healthcare construction optimises the management of Chinese hospitals, reducing the work pressure of medical workers and brings a more friendly medical experience for patients.


First of all, China’s medical care has long been at a relatively low level in the world, However, the construction of digital healthcare have greatly improved China's medical level, which is reflected in clinical service capabilities, technological innovation & transformation capabilities, major event medical treatment guarantee capabilities, and inpatient mortality. In the ranking of global medical quality and accessibility published by ‘The Lancet magazine, China has improved from the 110th place in 1990 to the 48th place in 2016, and the progress rate ranks third in the world.(8)


Next, during the development process, China has shown a huge demand for medical care. The most obvious reason for this phenomenon is the huge population base. From 1965 - 2020, the population of China doubled in this 55 years, and the huge population of 1.4 billion now accounts for 18% of the world's total population.(9) In order to control the population, the Chinese government began to implement the ‘One-Child Policy’ in 1979, while it slowed down the population growth rate, it heavily shifted the country towards an ageing society with all its health-related problems.(10) According to Source United Nation (2012), one out of every four Chinese will be sixty-five or older by 2050.(11) Elderly people have lifestyle and age related medical conditions resulting in a much higher demand for healthcare and medical intervention than younger people. This will undoubtedly seriously increase the medical pressure.(12) The increasing number of medical needs challenge the capacity of the healthcare system and hospitals. Due to the inefficients peed of dealing with patients in traditional hospitals, a large number of patients who flow into hospitals cannot be properly attended to quickly ‘I remember that only for one or two days in the past six months, the space of the corridor was used according to the original design, and in most of the time, it was occupied by a row of temporary beds.’- Changqing Li (2017).(13) Digitalisation has greatly improved the hospital's capacity and management efficiency. Due to the fast processing speed of machines and the real-time synced information via networking, hospitals were able to handle requirements from more patients. It is reported that the total number of medical personnel in 2017 was 8.18 billion, nearly four times that of 2001 (2.087 billion) .(14)


In addition to the large number of medical needs, there are serious medical resource imbalances in Chinese society. First, there is a huge difference in healthcare construction level between urban and rural, developed and underdeveloped areas in China. It let to a large number of people seeking medical treatment from all over the country flooded into big cities with rich medical resources to seek medical treatment. According to the "Liaowang" News Weekly, Beijing, a ‘national treatment centre’, treated nearly 220 million patients every year, and it included almost 700,000 non-local patients visiting daily (2014).(15) In addition, due to the lack of primary care systems, such as community clinics, patients who come to large hospitals for treatment have not been screened, and almost everyone regards large hospitals as the first stop. ‘People rush to the hospitals to see specialists, even for fevers and headaches.’ Wee (2018) reported.(16) The emergence of telemedicine has effectively alleviated the problem of imbalanced medical resources in China. For example, the ‘Robot Doctor’ allows villagers to meet with the expert doctors virtually without traveling long distances.(17) At the same time, telemedicine make up for the lack of primary care in China. Through the telemedicine, the basic medical needs of many patients are solved, thereby reducing the considerable demand on larger hospitals. A newer example of telemedicine is the ‘Ping An Good Doctor’, launched in 2015 by Ping An Insurance, one of China’s largest insurance companies. Through self-employment and contracting, it brings together more than 800 professional doctors, and uses the Internet platform to provide professional consultation services for patients across the country. It includes pre-diagnosis services such as preventive health care, initial medical consultation, appointment registration, and post-diagnosis services such as follow-up visits, rehabilitation guidance, chronic disease management, and medication reminders.(18)


Additionally, there are many problems in the management of traditional medical service in China, including non-standard information, high costs, and easy data loss. These problems have affected the healthy development of the hospital to a great extent and the following four points are common occurrences:

  1. Previously, the cases in hospitals are mainly written by hand. However, many irresponsible doctors filled the medical records without following the standardised specifications. For example, the description of the patient's condition was not scientific and accurate, inconsistent wording was used alongside with wrong spelling, and scribbled handwriting. Therefore, the value of these nonstandard medical records is usually very low.

  2. Such manpower-based management is inefficient, resulting in a lot of wasted time, and as hospitals continue to expand, the cost of human resources also increases.

  3. The safety of medical records was worrying as the cabinets were very likely to be damaged.(19)

Moreover, the proportion of man-made operations in traditional medical work is high, which leads to high work intensity and high pressure. For instance, the patients’ medical records need to be collected by staff from the medical record room and then, they need to be transferred manually to different divisions. As a result, staff in the hospital normally have complicated tasks to do and a heavy work load. However, the working pressure of medical workers has been greatly reduced by the digital healthcare. The use of high technology not only liberates manpower but also assists medical staff to complete their work more efficiently. Dr. Cheng (2005) of the Department of Dermatology at Chaoyang Hospital said that when he hand-wrote prescriptions, he could see 60 to 80 patients a day, but now he can deal with 80 to 110 patients with electronic prescriptions.( ion. For example, the staff only need to input the rules and set a daily workload on the system, then all patients' treatment and tests can be arranged automatically.(20) Most importantly, due to the endless development of technology, there is no limit to what digital healthcare can be achieved.(21)


Moreover, the proportion of man-made operations in traditional medical work is high, which leads to high work intensity and high pressure. For instance, the patients’ medical records need to be collected by staff from the medical record room and then, they need to be transferred manually to different divisions. As a result, staff in the hospital normally have complicated tasks to do and a heavy work load. However, the working pressure of medical workers has been greatly reduced by the digital healthcare. The use of high technology not only liberates manpower but also assists medical staff to complete their work more efficiently. Dr. Cheng (2005) of the Department of Dermatology at Chaoyang Hospital said that when he hand-wrote prescriptions, he could see 60 to 80 patients a day, but now he can deal with 80 to 110 patients with electronic prescriptions. (22)


Finally, the medical experience for patients was poor. ‘It is already overcrowded with patients, so the medical experience is the last concern of the hospital.’ Dr. X pointed out.(23) For a long time, Chinese patients have to deal with long queues, unfair prices and complex medical procedures while suffering in pain. In order to see specialists, many patients need to line up all night. ‘The long lines, a standard feature of hospital visits in China, are a symptom of a health care system in crisis’. (2018)(24) Additionally, scalpers often monopolise and profit from the popular specialists. In order to obtain from the price difference, they even double the price and then sell it to the eager patients, and this makes patients miserable. "I wanted to queue myself and not pay so much money, but I just couldn't wait any more. I didn't have time," said Zhang (2016).(25) In addition, the traditional treatment process is very complicated. ‘The registration, queuing and payment procedures were overly complicated. We needed 4 adults to divide the work clearly to ensure that my child can see the doctor properly.’ Xiaoxiao's father recalled (2018).(26) The digitalised healthcare optimised the experience of patients to a great extent. The realname registration system on the Internet effectively suppresses the scalpers to raise the fare, and the appointment mechanism also helps patients relieve the pain of early queuing and the risk of time-wasting. At the same time, the simplified medical treatment process and seamless connection between various steps reduce the patient's workload, saves physical strength, and saves time. According to the calculation of 20-year-old Mr. Zhang (2018), after the Armed Police General Hospital upgraded to digital, his entire medical treatment process took only 23 minutes, which previously required at least 50 minutes.(27) EMR (Electronic Medical Record) also increases the possibility of patients getting medical treatment anytime and anywhere. Patients no longer have to worry about forgetting to carry or lose cases. The unique medical number will include all personal information and medical history. All these make the process for the patient more relaxed and enjoyable during the treatment.


The Negative Impact of Digital Healthcare

Through the text above, it is not difficult to realise that the construction of digital healthcare is of great significance to China, and it has brought many positive effects on the society, hospitals, medical workers and patients. However, there are also some problems in the process of digital healthcare construction.


The rapid technological development process has formed a ‘Digital Divide’ in Chinese society. ‘Digital Divide’ is the trend of increasing the distance between information and wealth due to the different level, application and innovation capabilities of digital technologies among separated places. ‘Digital Divide’ not only occurs among different countries but also within the same country. Differences in class, race, industry, age, income, gender or educational background have led to unequal access to social resources and opportunities.(28) In the book ‘Powershift', which was published in 1990, the famous American futurist Toffler proposed the concepts of the 'Information Rich’ and ‘Information Poor’.(29) The consequences of ‘Digital Divide’ could be found in people’s daily life. During the pandemic period of the COVID-19, the Chinese government widely used health QR codes to manage people’s travel, with high efficiency and remarkable results. However, there were frequent occurrences of the elderly and low-income people who could not live easily due to lack of smartphones or unfamiliar with technology. Most public places and public transportation require scanning codes or showing health codes, which makes them hard to travel in cities.(30) The ‘Digital Divide’ between the urban and rural areas in China is also significant. For the popularity of the Internet, it is calculated that although Chinese Internet users continue to grow, the popularity and application mainly occur in cities. Only 0.3% of Internet users are farmers, and the urban penetration rate is 740 times that of rural areas.(31) In terms of medical construction, due to the difference between technology and budgets, there is a huge disparity between the urban and rural medical level. It is reported that Beijing (91.5) with the highest comprehensive medical level score is nearly twice as close as Tibet (48.0) with the lowest score, and this gap has not narrowed significantly from 1990 to 2016.(32) In addition, digital equipment is expensive, which also puts a heavier burden on the developing area that already has a very limited budget. Although telemedicine relieves the shortage of medical recourse to a certain extent, not all problems can be solved online, such as laboratory tests and professional surgery. This clearly shows that the ‘Digital Divide’ has turned from a technical issue to a social issue.


At the same time, digital healthcare put forward higher requirements for users, and challenge people's cognition and ability to use modern technology. The high cost of learning also keeps a part of people out of digital healthcare. The United Nations (2008) promulgated a redefinition of illiteracy standards: the first category which is the traditional sense is people who cannot read; the second category is people who cannot recognise modern social symbols and the third category is people who cannot use computers for learning, communication, and management. As we can see, the latter two categories are considered to be functional illiteracy, because although they are educated, they have considerable difficulties in social life where modern information dissemination is highly developed.(33) This shows that illiteracy is no longer a ‘past tense’, but a ‘present tense.’


From the patient's perspective, according to the survey (2016), which was carried out by the ‘Citizen Observation Group’, about the response from the patients of 60 to 80 years old, the most frequent complaint is using a machine.(34) Lots of elderly patients struggle to handle the complex process and they get stuck at various steps, such as selecting a specific department, entering a password or paying via mobile devices. Once they fail they have to rejoin the queue of service windows. Some elderly people with low education cannot even use digital healthcare without the help of their children. “They are becoming increasingly isolated by technological advances in society” said Gammell Caroline (2008).(35)


From the perspective of medical workers, although digital healthcare have reduced a lot of work pressure, they have neglected the acceptance of older doctors. Older doctors usually decline in their ability to acquire skills due to age increase, including working memory, ability to store and process information, intellectual speed, vision, hearing, and hand dexterity. According to reports (2019), the increase of age will cause doctors to lose the ability to deal with more complicated tasks.(36) In China, elderly doctors often have higher trust and greater reliance from patients. Patients generally believe that the experience of older doctors is more abundant and the diagnosis is more credible. However, in the face of digital healthcare, elderly doctors also have difficulties in using them, and even become their burden. Dr. Zhao of the Department of Respiratory Medicine of the Xie He Hospital said that most of the popular doctors in their hospital are old specialists around the age of 50. They are slow to get started with electronic prescriptions. In addition, there are too many patients, so it is more time consuming for them to write electronic prescriptions than handwriting.(37)


The Debate in Society

In view of the problems of elderly users encountering difficulties in using digital healthcare, the society holds different views. Some people questioned the inclusiveness of digital healthcare and thought that they did not value the elderly voice enough. For example, the cognitive level and learning ability of elderly users are not considered, and the design is not optimised for the physical characteristics of the elderly. However, the other side of view points out that some old people feel reluctant to learn or even reject modern technology. The research (2018) found that traditional thinking, stereotype, negative attitude, lacking confidence, such as fears of breaking equipments or making things wrong, and social isolation are the noticeable factors for elders to hold back technology use. Bran Knowles (2018) said: “Older adults themselves are often the worst perpetuators of the myth that old age precludes engagement with a myriad of digital technologies.”(38)


 

(8) Christopher J L Murray, ‘Healthcare Access and Quality Index Based on Mortality from Causes Amenable to Personal Health Care in 195 Countries and Territories, 1990–2015: a Novel Analysis from the Global Burden of Disease Study 2015’, The Lancet, 390:10091 (2017): pp. 231-266(p. 237).

(9) Worldometers, ‘China Population(LIVE)’ (2020) https://www.worldometers.info/world-population/china-population/ (Accessed 9 July 2020).

(10) The Medical Futurist, ’China is Building the Ultimate Technological Health Paradise. Or is it?’ (2019) https://medicalfuturist.com/china-digital-health/ (accessed 9 July 2020).

(11) Zhanlian Feng, Chang Liu, Xinping Guan and Vincent Mor, 'China’s Rapidly Aging Population Creates Policy Challenges In Shaping A Viable Long-Term Care System', Topics in Public Health, Medicare Advantage, Health Reform Post Election, 31:12 ( 2012) https://www.healthaffairs.org/doi/full/10.1377/ hlthaff.2012.0535 (accessed 9 July 2020).

(12) Peter Wilson, ‘Hospital Use by the Aging Population’, Inquiry, 18:4 (1981): pp. 332-344 (p.332).

(13) Changqing Li, ‘Li Changqing: What I understand the shortage of medical resources’, Sciowl (2017) https://www.sciowl.com/2017/12/19/yi-liao-zi-yuan-duanque/ (accessed 9 July 2020).

(14) Hao Yu, ‘China’s Medical Quality Continues to Improve, Showing a Trend of "Four Rises and One Fall”’, Economic Daily (2018) https:// baijiahao.baidu.com/s?id=1602679596099892814&wfr=spider&for=pc (accessed 9 July 2020).

(15) Wu Sun, ‘Beijing Becomes "National Medical Centre" with 700,000 Patients From Other Places’, Guachazhe (2014) https://www.guancha.cn/society/ 2014_05_20_231156_s.shtml (accessed 9 July 2020).

(16) Sui-Lee Wee, ‘China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’’, New York Times (2018) https://www.nytimes.com/2018/09/30/ business/china-health-care-doctors.html (accessed 9 July 2020).

(17) Xuanchengtoutiao, ‘Robot Doctor Walks into the Homes of People in Xuancheng’, Tencent News (2018) https://xw.qq.com/cmsid/20181210B1JDTY00 (accessed 9 July 2020).

(18) The Medical Futurist.

(19) Yongmei Zhang and Hong Ma, ‘Digitalisation is an Inevitable Trend of Modernisation of Hospital Medical Records Management’, CCME, 3(2015): pp. 14-15.

(20) Shenxue Shi.

(21) Jinsong Li and Xiaoguang Zhang, ‘Construction Goals and Development Trends of Digital Hospitals’, Chinese Medical Equipment Journal (2010) https:// xueshu.baidu.com/usercenter/paper/show?paperid=9c8eecdf3eb5477b29fdba6703431717&tn=SE_baiduxueshu_c1gjeupa&ie=utf-8&site=baike (accessed 9 July 2020).

(22) Beijing Daily Messenger, ’Electronic Prescriptions are Difficult for Old Doctors, Some Old Doctors are Not Skilled in Operating Computers’, Sina News (2005) http://news.sina.com.cn/o/2005-08-17/02336707754s.shtml (accessed 9 July 2020).

(23) Dr.X, ’The Collapse Experience from Doctor to Patient - Seeing a Doctor is Really Difficult’, Zhihu (2016) https://zhuanlan.zhihu.com/p/21565129 (accessed 9 July 2020).

(24) Sui-Lee Wee.

(25) Reuters Thomson, ‘Want to See a Doctor in China? Wait in Line or Pay an Illegal Scalper to Jump it for You’, The Word (2016) https://www.pri.org/ stories/2016-04-11/want-see-doctor-china-wait-line-or-pay-illegal-scalper-jump-it-you (accessed 9 July 2020)

(26) Sui-Lee Wee.

(27) Beijing Daily Messenger.

(28) Ming-te Lu, ‘Digital Divide in Developing Countries’, Journal of Global Information Technology Management, 4:3 (2014), 1-4.

(29) Toffler Alvin, Powershift: Knowledge, Wealth, and Power at the Edge of the 21st Century (New York: Bantam, 1991).

(30) Moduan ‘I Don’t Know How to Use a Smartphone. Are You Ready to Let me Die?’, (2020) https://mp.weixin.qq.com/s/mksgTD_fcXhT2j81MANNmA (accessed 9 July 2020).

(31) James Jeffrey, Digital Interactions in Developing Countries: An Economic Perspective (Routledge Studies in Development Economics) (Abingdon: Routledge, 2013), p. 45. Google ebook.

(32) Christopher J L Murray, p. 237.

(33) UNESCO, ‘From Illiteracy to Computer Literacy (Teaching and Learning Using Information Technology)’, (2008) https://unesdoc.unesco.org/ark:/48223/ pf0000181033 (accessed 9 July 2020).

(34) Hangzhouwang, ‘Two Days in 8 Hospitals, Why Self-service Machines Confuse the Aged’, (2016) https://xw.qq.com/zj/20161206006086/ ZJC2016120600608600 (accessed 9 July 2020).

(35) Caroline Gammell, ‘Poor and Elderly Left Behind by Digital Age’, (2008) https://www.telegraph.co.uk/news/uknews/1574801/Poor-and-elderly-left-behindby-digital-age.html (accessed 9 July 2020).

(36) American Medical Association, ‘Competency and Retirement: Evaluating the Senior Physician’, (2015) https://www.ama-assn.org/practice-management/ physician-diversity/competency-and-retirement-evaluating-senior-physician (accessed 9 July 2020).

(37) Beijing Daily Messenger.

(38) Lancaster University, ‘Why some older people are rejecting digital technologies’, (2018) https://www.sciencedaily.com/releases/ 2018/03/180312091715.htm (accessed 9 July 2020).

 

Methodology


In order to have a better understanding of the real situation in digital healthcare, as well as the tolerance of older users and the level of knowledge of older users of technology, I decided to combine Qualitative Research (mainly) and Quantitative Research (subsidiary) together to carry out the first-hand research for further analysis. This will make my research results more professional, complete and credible.


For Qualitative Research I chose 8 representative interviewees from different ages (all 40+), occupation and education background, all share the common background that they are medical service users. Based on their personal experience, I have a relatively comprehensive understanding of the current status of digital hospitals in China. Through in-depth conversations and perceptual language descriptions of the interviewees, I have investigated their deep-rooted motives, hidden reasons, and real demands. Through indepth analysis and comparison of different cases, I have summarised the common problems of the elderly with digital healthcare, which has also helped me think about how to build a more humanised environment. Most importantly, in this fast paced world, few people are willing to take the time to listen carefully to the real thoughts and demands of users. This interview process also made the interviewees feel very respected.


In addition, due to the wide use of electronic devices in digital hospitals and the use of a large number of abstract symbols in the interactive interface, I also explored the level of scientific and technological awareness of elderly people, especially the cognitive ability of icons. However, there are very few sample cases from Qualitative Research, which cannot accurately reflect the situation of the public, this prompted me to use a questionnaire survey to conduct a Quantitative Research. My main research subject is 40+ middle-aged and elderly people in mainland China. The questions in the questionnaire are also related to common symbols in medical equipment. Quantitative Research has a higher sample size, which has undoubtedly increased the breadth and credibility of my research. After a statistical analysis and classification discussion on the questionnaire results, I finally got a more convincing result and a new perspective on problem discovery. The most meaningful thing is that through the extensive survey method, I have influenced more people to pay attention to and started discussion on this topic.


As a Service Designer, I oversee the overall first-hand survey process while doing systematic thinking, and I analyse the survey results from the perspective of all participants and stakeholders in the medical environment, and make rational recommendations for the problems found. For the section below, first of all, I will introduce the specific operation steps, principles, objectives and some other related information of the methods, such as control variables and limitations. I will also attach the key insights of the survey. What follows is my systematic comparison and in-depth analysis of findings. In the end, I will give my suggestions and summary from the perspective of Service Design.


(Please see the attachments if you want to know more information of the investigation process)


Qualitative Research: Semi-Structured Interview

Target: patients and medical workers (40+)

Methods: VOIP(Voice of Internet Phone)

Length: 30 - 60 mins / person

Guidance & Rules:

  • Start the conversation with interviewees by talking about their use of healthcare services, use simple words to explain the idea of digital healthcare (do not read the definition).

  • Encourage interviewees to talk freely about their experience with digital healthcare including their insight of other users, and do not interrupt.

  • Find interesting points through the talking and ask questions without direction leading, guiding or hint.

  • Encourage them to provide opinions for the future digital healthcare construction from their own perspective, which can be any aspect.

  • Collect basic information about the interviewees including age, work, important experience (related to Modern technology), etc.

  • Record the interview content by writing down the key information.

  • Analyze the content of the interview, highlight the unexpected results, classify and summarise them, and finally find the association between each category.

Aims:

The chat at the beginning relaxes the interviewees’ mind and ensures that they fully understands the content of the follow-up interview. Allowing interviewees to talk about their experience of using digital healthcare services without interruption allows me to have a more holistic understanding of their situation and position. Through their observations, I am able to understand more of the real situation of digital healthcare in China. Looking for the latter topic from their narration can effectively narrow down the focus of the interview and at the same time make the interviewee feel respected. Non-subjective communication and unguided questions help the interviewee express more personal ideas, and through continuous questioning allows me to dig out the hidden reasons behind the phenomenon, so as to be closer to the truth. Asking them for their suggestions can help me understand the real needs of different groups, which helps me put forward design suggestions from a more user-friendly perspective. Collecting personal information of interviewees can help me classify and analyse them more deeply.

Limitation:

  • Limited number of interviewees and diversity (region, education level)

  • Guided conversations or biases cannot be completely avoided

  • The results of the interview are influenced by the personal factors of the interviewer and the interviewee (such as the relationship in the real life of the two, speech attitude, communication method, etc.)

  • Deviations in semantic understanding between interviewers and interviewees


Quantitative Research: Self-Administered Questionnaire

Target: 40+ people

Methods: Online questionnaire (via WeChat)

Quantity: Ideally, I wish to have 2000 samples, but based on geographical restrictions and social conditions (COVID-19) and time limitation, only 723 samples are collected.

Guidance & Rules:

  • Explain to the respondents the survey with contextual information and answering rules at the beginning of the questionnaire, and ask the respondents to answer without using any other tools or helps.

  • The questionnaire combines the Recognition Methods and Information-Scent Methods. It has 10 main questions which contain 10 most commonly used symbols on electronic devices.(39)

  • Each question has four different options and one ‘don't know’ option.

  • Respondents can choose from more than one answer, and they are expected to choose all the meanings that the symbol could represent (only in the digital environment) ,or what they would expect to happen if they selected a certain symbol.

  • Respondents’ basic information will be collected at the end.

  • After submission, the test purpose, relevant contexts and correct answers will be showed to the respondents.

  • Collect all the answer sheets, exclude invalid data (for example: below age requirements, repeated answers or incomplete personal information, etc.), and conduct data analysis and classification discussions based on variables.

Independent variables: age, occupation, frequency of using electronic products, years of exposure to electronic products.

Dependent variable: accuracy of answer, time required to answer

Control variables: questionnaire form and questions (WeChat), answering environment (mobile phone screen), leading the answer (did not indicate whether there was a single or multiple answers), random answers (provided 'don't know' option)

Main points of analysis: the relationship between the age of the tester, occupation, frequency of using electronic products, years of exposure to electronic products, to the accuracy of answering questions, answering content, and time required for answering


Aims:

The introduction at the beginning of the questionnaire helps respondents understand the test content, and the explanation of the answering rules can better control the variables. The question does not put the 10 common icons on a real interface of an electronic screen, because the test uses the out-of-context method to test the respondents’ ability to recognise the symbol itself. It is also not stated separately whether each question is a single-choice or a multiple-choice question, in order to avoid influence of their judgment. The ‘don’t know’ option was added to prevent random selection due to ignorance, which could interfere with the experiment results. Collecting the basic information of the respondent is a key reference for later independent variable analysis. After submission, showing the purpose of the test and raising relevant contexts can make respondents to have a more in-depth understanding and awareness of this topic, and the indication of the correct answers can also make the respondents learn. The analysis and comparison of the answer sheets will help in intuitively understanding the elders knowledge of modern technology and problem finding.

Limitation:

Insufficient numbers of samples.

  • Questionnaire with insufficient coverage of questions.

  • Inconsistent understanding of the answers by designers and respondents.

  • Poor control of variables.

  • Quantity: 723

Result Link: https://ks.wjx.top/jq/69529956.aspx

Questionnaire recovery rate = 100%

Effective questionnaire rate = 85%


 

(39) Aurora Harley, ‘Usability Testing of Icons’, Nielsen Norman Group, (2016) https://www.nngroup.com/articles/icon-testing/ (accessed 9 July 2020).

 

Research Finding & Analysis (40)


After the questionnaire survey and in-depth communication with 8 interviewees, I have gathered different perspectives, including elderly patients, health care workers, hospital employees and the general public. Therefore a more in-depth understanding of the current situation of digital healthcare in China, as well as its inclusiveness towards the elderly. First of all, I found that in general, the elderly have a high degree of acceptance of digital healthcare services, and their convenience is generally recognised. They think that digital healthcare improve speed, experience and work efficiency. Moreover, in China's digital healthcare, the use of machines is relatively high. All the interviewees mentioned that they would often use machines in hospitals for medical treatment or office work. Especially during the COVID-19 epidemic, the use of machines is more relied than before, people are more inclined to use self-service machines to reduce direct contact with people (Junxia). Through their observation, I also noticed that the number of elderly people using machines is gradually increasing, but digital healthcare services have brought inconsistent user experiences to different users. Yan said ‘I feel like the machine divided patients into two, old and young. The young people normally use it very well, but most of the old seem a bit slow and unskilled.’ Although the elderly generally said that they have benefited greatly from learning to use digital healthcare, they still encountered many difficulties and obstacles in the learning process. The pain period during the transition from the traditional physical method to the virtual interface is more obvious. Many elderly patients said that they need to go through multiple inquiries and exercises to master their skills, and some of them just choose to give up. For example, Junying, 62 years old, chose to give up using the online hospital, because her name was registered by other people and felt her identity information was leaked. In addition, although doctors have specialised training courses, there are still some elderly doctors who cannot quickly adapt to using computers for office work. They often struggle with computer operation logic and think that their work ability is greatly restricted. They may even face the risk of being expelled if they cannot use the computer, which makes them feel forced. (Leying)


Through further inquiries and communication, I found some reasons which make the learning process difficult. Most elderly people said that the operation of the machine in the hospital is hard, manifested in an unfriendly operation interface, with complicated steps, sometimes the content was too professional, the fault tolerance rate was low, and there were too many different types of equipment.


First, the device operation interface in hospitals is not optimised for elderly users. For example, the font is very small or the colour contrast is low, which increases the recognition difficulty for the elderly who have reduced vision. It is reported that people, who turn 70 and over, normally loose 30 to 50% vision, including presbyopia and colour weakness.(41) There are also medical workers reporting the need to take glasses back and forth between screens of different medical devices (Leying). Abstract interfaces and logic also make it difficult for elderly people who are not familiar with electronic devices, which is more prominent when it comes to the recognition of symbols by elderly people (questionnaire). Second, too many operation steps often make old users feel confused or impatient, such as requesting to insert a card, put the card, scan the phone code or enter numbers. ‘I think the process is still a bit complex, sometimes it just messes me up.’ (Junxia). Third, the content information is too professional, so that elderly patients who do not have the relevant knowledge do not know how to choose. For example, the self-service registration machine requires patients to choose the department they want to see. However, the department name of the hospital usually uses very professional terms and has not been explained. ‘I always get lost and have no idea about which department I should book. It used to be quite simple when I was young.’ (Yan). Fourth, the machine's fault tolerance rate for older users is lower, and older people often start from scratch after operating errors, 'The machine only tell me my mistakes when I use it in the wrong way, but never show me the right way , so I have to try again' Xuemei said. Once a multiple wrong operations mistake occurs, the elderly often show distrust of the machine and may not use it anymore. Fifth, due to the different type of machines in different hospital, even the functions of the same machine are various, such as supporting different payment methods. This exacerbates the difficulty of use by the elderly. In addition, because the Chinese medical electronic system is still in the development stage, the different systems used by each hospital have caused serious compatibility problems. And this doubled the doctor’s work load. (Leying)


Next, the current social assistance to the elderly is generally passive, and only help or replace the operation when the elderly encounter difficulties. This cannot fundamentally solve the problem and is not sustainable. (Xiuqin) For example, in hospitals, volunteers are often arranged to assist the elderly to operate next to the machine. They only provide help when the elderly actively ask. In many cases, they will even complete the operation on behalf of the elderly in order to save time, which is not helpful for elderly learning. Volunteers’ abilities and energies are also limited, there have been many cases when volunteers are too busy to take care of all the patients or they are unclear about the system themselves. For elderly doctors, the hospital usually arranges young doctor assistants to replace the operation. Although it can save the physical strength of the elderly doctors, it is often difficult for the elderly doctors to continue to use electronic equipment for diagnosis and treatment without the help of assistants. Leying mentioned that some old doctors cannot input on computers by themselves as they never learned Chinese Pinyin. Nevertheless, it is gratifying that some hospitals have specially set up a service counter only for the old age. In addition, people who have learned to use often give generous help to people in difficulty, and doctors always communicate and learn from each other. Finally, whether or not the elderly can quickly adapt to a digital healthcare has a great relationship with their personal experience and willingness. Old people who have been exposed to electronic products earlier often have lower learning costs, and it is easier to understand the logic of electronic devices. (Questionnaire survey). For the elderly who have little exposure to electronic products, with an open mind to new things can also help them master new skills more happily. Xuemei said: “They（her parents）have totally different personalities and attitudes to technology. My father is stubborn, so he refuses to learn and doesn't know how to use the machine at all. But my mom is quite open minded, then she can use them very easily.”


With the more widespread and rapid development of digital healthcare, using modern technology to see a doctor has become an essential skill for patients, and skilled use of electronic medical equipment has also become a basic requirement for medical workers. However, as the problem of an ageing society in China continues to increase, the gap between the aged and modern technology is increasing. This not only keeps the elderly from being frequently hindered, middle-aged people are also worried that they will be eliminated soon. However, this situation may be changed if technology development and design can improve its inclusivity for the elderly. ‘It is opening up the potential of things that look interesting to them (old people)’ by the Centre for Ageing Better.(42) As a Service Designer, I will make recommendations for the future development of China's digital healthcare from the perspective of all medical process participants and stakeholders.


 

(40) Author interview with 8 elderlies, medical users, 31 March 2020.

(41) Ziying Song, ‘Every Details are Design for the Elderly, This Hospital make Them Feel like Home’ (November 2017) http://www.sohu.com/a/ 205182058_612534 (accessed 9 July 2020).

(42) Good Things Foundation, Digital Skills and Older People - Embedded Informal Learning, online video recording, YouTube, (April 2019) https:// www.youtube.com/watch?v=P6Q7q5pg4GY (accessed 9 July 2020).

 

Suggestions


For the future, I suggest that the construction of digital healthcare in China could pay more attention to service awareness, empathy, and inclusiveness. Designers need to fully consider all participants and stakeholders in the medical environment, and recognise that the social problem of ageing will arise onto all people, including patients, doctors or other medical workers. For older users, designers need to think differently and provide flexible solutions based on group diversity. Digital healthcare should fully implement appropriate ageing treatments in order to improve the inclusiveness of elderly users and make the environment "elderly friendly", and more importantly, "universally user friendly".


In response to the diversity of the elderly group, I suggest that digital healthcare carefully consider solutions from different user conditions, such as age, physical condition, learning ability, or education level. In terms of age, the elderly can be divided into younger/middle-aged, middle-aged and elderly. For younger/middle-aged people (40-60), they normally have sufficient experience in using electronic devices, so they are generally very adaptable and self-learning sufficient. Designers could make full use of their previous experience and provide them simple and clear teaching and guidance. For middle-aged elderly (60-80): Most of them have experience in using electronic devices, but due to the age growing, response speed and acceptance normally decline. So that designers should provide them with more targeted aids, such as specially designed machines or group learning lessons. Using real life examples in the teaching process is also suggested to clear up virtual concepts. For senior citizens (80+): Generally speaking, they have limited electronic devices using experience, and some of their physical conditions may not be suitable for learning things which are too complicated. If they are forced to operate digital equipment, it not only violates the intention of using machines to improve efficiency, but also may affect other users. So designers might change the way of thinking and follow their habits to provide them with familiar solutions, such as keeping traditional service counter, cash payment or personal service. (Xiuqin) However, the above example is just one of the dimensions that need to be considered when designing a solution. The actual design should take into account more specific situations and adapt to the real world.(43)


In addition, in terms of design, machines and operation interface could be specially optimised for the elderly. For example, enlarge the screen, use physical buttons, or design the style of the machine for the special physical condition. The interface could be added with options for the elderly users, including appropriately increasing the font size, enhancing the contrast of the picture, and reducing the use of abstract symbols. This is clearly reflected in the results of the questionnaire. In addition, the interaction logic could refer to the real life, and diversify the interaction methods as much as possible. For example, to provide voice input options for the elderly who cannot do pinyin, and the design should also fully consider the environment such as noise or heavy accent. During the operation, the steps could be simplified and the information content should translate professional terms into understandable context. At the same time, more timely guidance and assistance should be given to the elderly users, such as using more voice prompts instead of stacking all the information on the screen. More importantly, designers need to ensure that the design can actually be implemented.(44) I believe that by considering these suggestions, the digital healthcare in China will greatly enhance the inclusiveness.


Case Study:

The Samsung Hospital in South Korea places great emphasis on patient safety, rights, and doctors’ work experience. For example, when doctors perform the drug prescription, the system will double check if the doctor has chosen to mix two contraindications, and a corresponding alert will appear. If the doctor does not change, then the doctor's prescription cannot be issued normally. Also, if the doctor chooses a high-priced medicine, the system will notice for three times. In addition, the mobile medical concept runs through the entire medical process. The system can provide voice call services and various data services including diagnostic information, which brings great convenience to the treatment and care of medical staff who move frequently. Many similar doctor-centric designs are designed to allow doctors to devote themselves to the work of serving patients with a better emotion.


In order to alleviate the ageing problem and the gap between the elderly and the development of science and technology, of course，we cannot rely solely on designers .

The government and the entire society could give more care to the elderly. Traditionally, the family, as the primary source, always hold the responsibility of taking care of the elderly in China, as it was required in the culture of traditional Confucianism. However, the trends of family structure changing, migration and low incomes are eroding the possibility of traditional aged-care mode. A survey from World Bank (2016) shows that over 80% of Chinese are expecting the government to improve the aged-care services and infrastructures.(45) The government could encourage more popularisation of everyday technology, including TV shows or community schools, ‘China has very strong community culture, so learning from neighbours and building a community networking can be widely applied’ Xiuqin suggested. In addition, the teaching process could focus on encouragement, and give the elderly fully affirmation. Old people generally have strong self-esteem, and they don’t want to appear stupid in front of others. Service provider, especially young people, should not enforce their standards on the elderly, and everyone would benefit if they were more friendly and patient. We need to make clear that the purpose of teaching is not to force the elderly to accept new things, but to allow them to better enjoy the technological development. Finally, for the problem of complicated models of machines and incompatibility systems, the government needs to take the lead in unifying standards.(46)


 

(44) Marc Stickdorn and Schneider Jakob, ‘UPMC and Carnegie Mellon University: Service Design for a Hospital’, in This is Service Design Thinking: Basics, Tools, Cases (Amsterdam: BIS Publishers, 2017), pp. 267-279 (p. 275).

(45) Elena Glinskaya and Zhanliang Feng, ‘Overview’, in Options for Aged Care in China: Building an Efficient and Sustainable Aged Care System (Washington, DC: World Bank Publications, 2018), pp. 1-73 (p. 2).

(46) Author interview with 8 elderlies.

 

Conclusion


To Summarise, digitalisation as an important process in the development of technology, intended to break the barriers and provide users with a more holistic and joyful experience. The fast development of digitalisation in the Chinese medical field not only brings a revolutionary experience to users, but also plays a great role in alleviating social problems. This also makes the construction of digital healthcare particularly important in China.


With the continuous growth of the Chinese population and the ageing problem caused by the ‘One-Child Policy’, Chinese society has a great demand for medical treatment.

However, due to the uneven medical resources and lack of basic medical construction in various regions, this not only forced patients across the country to squeeze out hospitals in big cities, but also appeared a malformed situation where people directly chose a big hospital for any treatment. To face problems, traditional medical model seems to be inadequate. Traditional medical models s often criticised for its poor capacity, low efficiency, non-standard information, high management costs, and insecurity. These have restricted the Chinese medical industry growth in a healthy way. In addition, the manpower-led management has also caused great pressure for medical workers. The unsatisfied design, complicated medical procedures and interference of the scalpers make patients suffer. All of these problems show an urgent need of promoting and upgrading the traditional medical model. Digital healthcare has brought the dawn of China's medical industry. Digital healthcare relies on a large number of technologies as the basis, bringing more complete solutions to the medical industry. Digital healthcare has significantly improved China's medical standards, while at the same time allowing hospital management, medical staff work and patient experience to be greatly optimised. The widespread use of the Internet has aslo enabled digital healthcare to have strong coverage, and to a great extent, has eased the problem of uneven medical resources in China. All of these features have undoubtedly brought huge benefits to Chinese society. However, the rapid development process of digitalisation in medical field has also created a ‘Digital Divide’, which not only splits the urban and rural development, but also rejects the ‘functional Illiterate’, By putting forward higher requirements for hospital users, it causes them to struggle and even unable to use the hospital independently. This problem is particularly strong in the elderly groups. The confusion about technology and the inability to use machines are not only reflected in elderly patients, but also medical workers. However, there are different views in Chinese society. Some people think that the hospital does not value the elderly, and others blame the elderly’s reluctant attitude.


Through personal interviews and questionnaire, I found that the acceptance of digital healthcare by the elderly is generally higher and more agreed, but I also realised the difficulties during the learning process, and found out the cases. The personal experience and willingness of the elderly certainly account for a big reasons, but the complex equipment operation, unreasonable design and improper help from the hospital have also contributes to the slow adaptation process for the elderly, and even made them resist.


In the Chinese society where ageing continues to intensify, I realise that the gap between the elderly and technology is being further widened, which not only makes elderly feel uncomfortable, but also causes anxiety to other generations. As a Service Designer, I encourage the future development of China's digital healthcare to be more elderly friendly and make full use of Service Design awareness and empathy to enhance inclusiveness. This is reflected in the flexible solutions provided based on the diversity of the elderly group, as well as special optimised design for elderly users in terms of design, including products and user interfaces. I also believe that, the goal of reducing the gap between old people and technology cannot be easily achieved without the help of the government and society. More weight and care should be provided to the elderly group in order to encourage them face the rapid development of technology with active attitude.


It could be widely agreed that the significance of technological is to bring convenience to people work and life, improve efficiency, and more importantly, benefit everyone. The development of technology should not create a wall for a certain group or becomes their burden. The purpose of my investigation is not only to understand the real situation of the elderly group in digital healthcare, but also I wish that more designers and the general public could be encouraged through this article and start to aware of the diversity of people. In order to create a humane caring living environment, we should provide more active caring to different groups on both design and emotion. Let us not leave the elderly behind on the road of rapid development of technology and digitalisation, the joy should be shared together with the elderly and everyone else.


 

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Interview

Author interview with 8 elderlies, medical users, 31 March 2020

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