Co-creating Virtual Care for Chronic Disease

Abstract

For those living with chronic disease and multiple complex health conditions, regular appointments with multiple practitioners can become an incredible burden on their quality of life. The VOICeD telehealth service, or Virtual Outpatient Integration for Chronic Disease, was designed to meet the complex needs of people with diabetes by allowing them to see multiple healthcare practitioners in one virtual appointment. The service was designed alongside consumers and clinicians, exploring their needs through a series of experience design sessions, a participatory design workshop, and user testing. Following the success of the VOICeD model for Diabetes-Renal-Cardiac, the service has since expanded to meet the needs of additional multi-disciplinary contexts, including Gestational Diabetes Mellitus and Child Development.

Hours spent in waiting rooms, long commutes to the hospital, conflicting medical advice, indecipherable medical “gobbledygook”, packed car parks, covered windows, and sterile white coats—these are just some of the things that can make the face-to-face healthcare system less-than-desirable. On the other hand, emerging digital health services that promise more efficient, accessible care may spark feelings of distrust and isolation, or create barriers for those with low digital literacy.

When Dr. Gaurav Puri, Endocrinologist and Chair of the Queensland Diabetes Clinical Network, asked a man on Thursday Island living with diabetes why he couldn’t attend his appointments, he replied that he simply “didn’t have the time”. For those managing chronic disease and multiple co-morbidities, regular appointments with multiple practitioners can become an incredible burden on their quality of life. Realising that this was a problem faced by many Queenslanders, Dr. Puri envisaged what soon became the VOICeD telehealth service—Virtual Outpatient Integration for Chronic Disease. The service was designed to meet the needs of people with chronic disease by allowing them to see multiple healthcare practitioners in one virtual appointment—bringing consistent, accessible care to patients anywhere. The Queensland Diabetes Clinical Network began to lay the foundations for the first iteration of the VOICeD model: Diabetes-Renal-Cardiac. Recognising that the patients who had first inspired and informed VOICeD should be actively involved in designing, prototyping, and testing the service, they reached out to designers from HEAL to meaningfully engage with consumers and clinicians. This chapter tells the story of how designers, clinicians, and consumers collectively imagined and implemented the VOICeD telehealth service, what they learned, and the challenges they faced.

1 Process

To design a service that met the nuanced needs of people with complex health conditions, the HEAL team needed to explore both the clinician and consumer perspectives. This exploration was led by Jessica Cheers (an experience designer, PhD candidate, and HEAL intern) and Professor Evonne Miller (Co-Director of HEAL), working closely with Dr. Gaurav Puri and Dr. Brent Knack from the Queensland Diabetes Clinical Network. The collaboration between HEAL and the VOICeD team followed seven phases: mapping, collaboratively designing, sensemaking, implementing, user testing, improving, and expanding.

1.1 Mapping

As many aspects of the service had already been imagined prior to the collaboration, understanding this vision was a crucial starting point. The vision was simple—a single videoconference appointment to combine diabetes, renal, and cardiac consults for people already accessing these services separately. How would it work? How would it impact the consumer experience, compared to a standard appointment model? Would they consult with the specialists all at once or sequentially? Do any other stakeholders need to be involved? What are the opportunities and barriers from a clinical perspective? Jessica Cheers from HEAL and Dr. Brent Knack from VOICeD sat down remotely with a group of clinicians (Endocrinologist, Diabetes Educator, Cardiac Nurse, and Telehealth Coordinator) from Cairns Hospital to explore the many complexities of a digital service that merges multiple appointments, either synchronous or asynchronous, for varying degrees and types of care. This was the start of a series of intensive journey mapping sessions, questioning and mapping the proposed VOICeD model from every angle.

In the first session, the team created the persona of Ralph—a 54 year-old farmer from the town of Mareeba in far north Queensland—and began to imagine the service journey from his perspective. This persona was based around a “typical” patient that the team would regularly see in their practice at Cairns Hospital—one who struggles to travel to the hospital regularly for appointments, is managing multiple complex health conditions, and is often hearing conflicting medical advice from each of their specialists. To connect more deeply to Ralph and his needs, they considered his personality, interests, tech savviness, previous experience with telehealth, and reasons to use VOICeD. A handyman and caravan enthusiast, Ralph’s quality of life was diminishing with the time and costs associated with regular appointments to manage his type 2 diabetes, heart disease, and stage 3B kidney disease (common comorbidities). He would regularly drive 45 minutes to and from Cairns Hospital to see a Cardiologist, Kidney Specialist, Diabetes Team, or Allied Health professional, as well as regular trips to his GP. He has previously used telehealth at the hospital with assistance from staff. He had also started phone consultations during COVID but struggled with the lack of visual stimulus and connection. His wife Margarie, while very supportive, had her own healthcare appointments to manage. They could feel their retirement plans slipping away.

After the team had added depth and familiarity to the character of Ralph, they began to map out his experience using the VOICeD service. They considered each and every touch point: how he would learn about the service, how he could access VOICeD, any information he might receive via text, email, or traditional posted mail, what device he would use to connect to the service, how he would access tech support, what would happen if there was an unexpected wait time, what would happen before the appointment, how he would interact with each of the specialists, what would happen after the appointment, and how he would schedule his next VOICeD session. The process of intimately considering how Ralph might interact with the service at each touch point unveiled many questions and facets of the journey that were slowly pieced together over subsequent sessions. An additional layer was added, highlighting all of the practitioners and other stakeholders who would be involved at each stage of a VOICeD appointment.

These insights informed the design of an extensive journey map that encompassed both the patient (Ralph) and practitioner experience in considerable detail (Fig. 1). In subsequent workshops, the team created several simplified maps to quickly communicate different service pathways to stakeholders. The condensed maps highlighted a number of other case studies based on different health conditions, appointment needs, or patient support needs. They represented situations in which specialists would see the patient synchronously, asynchronously, or in other more complex configurations, as well as situations in which patients might need in-person support via their local General Practitioner (GP), Aboriginal and Torres Strait Islander Health Worker, or Nurse during the call.

Fig. 1

Journey Map including the patient (Ralph) and practitioner experience

For most of the clinicians who attended each workshop, this was their first introduction to visual design methods for understanding complex healthcare experiences. The process generated a rich, critical discussion, with a level of detailed questioning that led the VOICeD team to reflect on many of the assumptions they had made. It was challenging at first for clinicians to step into the mind of Ralph, and they would often revert to a clinical perspective when describing the benefits of the service. At this stage it was clearly necessary to take a step back, travel to Cairns, and connect with consumers directly, ensuring that their current needs aligned with the VOICeD vision painted by the team.

1.2 Collaboratively Designing

Once the entire service was mapped from a practitioner perspective and visuals had been created to communicate the initial concept to stakeholders and potential patients, the team planned to conduct a 3-hour Participatory Design (PD) session with five people who have chronic conditions and years of experience with healthcare services—potential future VOICeD users. The HEAL designers wanted to better understand the day-to-day lives of people with multiple chronic diseases, their positive and negative experiences with traditional face-to-face treatment, their relationship with telehealth/digital health technologies, changes to their healthcare treatment around COVID, and their ideal healthcare experience 10 years in the future. They designed a Future Workshop, a well-known Participatory Design method that was originally employed by researchers such as Jungk and Müllert [1], Dator [2], and Jansson and et al [3] to encourage participants to envision possible and imaginary futures. First, participants would critique past and present practice, before moving into the “fantasy phase” where they imagine potential futures. Finally, in the “implementation phase”, they consider what changes could be made short-term to work towards their utopian visions. To ease participants into discussions around digital health, chronic disease management, and their aspirations for their healthcare in the future, low fidelity Participatory Design methods like collaging and journey mapping would be employed.

In the “past and present” phase, the first activity was a weekly calendar, designed to better understand the interplay between multiple appointments, procedures, and treatments by visually mapping all of their interactions with the medical system in a week. The second exercise was to map what an appointment looked like for them before and during COVID, including travel and preparation, before labelling which aspects of each journey were positive or challenging with coloured stickers. They would then move into the “fantasy phase”, creating a collage to represent both their utopian and dystopian visions of their healthcare future in the year 2030, drawing from a large array of photos and illustrations. Finally, they would present their future visions to the group, and together discuss what principles could be embedded into emerging healthcare services to move towards their utopia (Fig. 2).

Fig. 2

Workshop in Cairns

Armed with an array of workshop supplies, Jessica and Evonne travelled to Cairns Hospital, meeting with the Statewide Diabetes Network Team in person to facilitate the session. One of the barriers the VOICeD team faced was in the recruitment process—to effectively connect with potential users in person, given they are people who already struggle to attend hospital for appointments, was an obvious challenge. While the workshop was designed for people who have lived experience with multiple chronic diseases including diabetes, the workshop attendees were largely limited to those who were attending the hospital that day, many of whom did not have this experience. This led the HEAL team to adapting methods on the day, deemphasising the weekly calendar—as many participants didn’t have multiple complex health conditions—and focussing more on the structure of appointments, their experiences with digital health technologies through COVID, and their aspirations for their care in the future. This was an undeniable challenge, resulting in more broad themes rather than specific recommendations that related to complex chronic disease management. Broad themes did, however, make it easy to connect this work to experiences of other telehealth initiatives and guide future development of technical functionality of telehealth software (Fig. 3).

Fig. 3

Collages depicting utopian visions of the future of healthcare

1.3 Sensemaking

The workshop was filmed, recorded, and photographed, generating a huge amount of audio and visual data. Insights were also documented on post-its during the discussion towards the end of the session, as well as on the templates provided for each activity. The HEAL team pored over this rich documentation and organised it through the process of thematic analysis, distilling the discussion into key themes and actionable steps to achieve participants’ utopian visions. This followed a six-phase approach: (1) familiarisation with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing potential themes, (5) defining and naming themes, and (6) producing the report [4]. Each theme was presented with quotes and exemplifying ideas from the discussion, as well as actionable recommendations, in a comprehensive report given to the VOICeD tea team to inspire and inform the design of the service.

The first theme was human connection. Participants shared that they dislike impersonal appointments, the notion of machines replacing humans and losing (or chasing) doctors when they move to other clinics. They wanted more time to spend with those close to them rather than driving hours to and from appointments, wanted to build connections with their practitioners and feel that their care team actively maintained that connection. In relation to VOICeD, participants felt that telehealth should be reserved for more generic appointments. They wanted to meet practitioners before using a virtual service if they were going to be a part of their primary care team. They also wanted follow-ups after their appointments, as well as elements within the virtual appointment to make it feel more “human”—like an image of their doctor on the wait screen.

The second theme was time. Participants were exhausted by hours spent in waiting rooms, particularly when there were no expectations set as to how long the wait time might be. Long access routes from parking to in-person clinics were a problem, as well as all of the issues that come with parking, waiting room systems, traffic, and doctors getting called away from appointments. Interestingly, they also mentioned that waiting until business hours to book an appointment became a significant barrier. Participants suggested that VOICeD appointments could be booked online, creating fewer barriers to care. They also suggested that wait times could be made more transparent to manage expectations, letting them know if the practitioner was running late or about to enter the virtual call. When asked about information, prompts, or entertainment options that could be included on the wait screen, they suggested prompts that would encourage them to make a list of the questions they had for the appointment rather than educational information, which would be “depressing”. They also suggested that games like solitaire or crosswords could be a fun and engaging way to pass the time.

The third theme was accessibility and tech literacy. Poor mobile service and lack of access to technology were barriers in accessing telehealth during COVID, and reliance on digital gadgetry was challenging. Several participants who had low tech literacy required further support, and noted that there are not measures in place for deaf and blind patients. Forms and medical paperwork could be equally confusing and inaccessible, and the reliance on traditional posted mail could mean that appointments were missed. A good telehealth service would be offered alongside in-clinic services with tech support staff located locally, as well as ease of use on all devices. In order to navigate some of these barriers in the VOICeD service, they suggested that the introductory letter to the service should clearly explain how to use the technology. There should also be a test call before the first session to check that service and tech access were suitable, giving them the opportunity to access the service from a local clinic if needed. They wanted to see a continued push away from traditional posted mail to digital confirmations and information letters, and that the design of all digital touch points was seamless and intuitive.

The fourth theme was consistency and communication. Time and time again, consumers struggled to receive consistent and cohesive care. It appeared that practitioners were not communicating with each other, were repeating information, speaking in indecipherable medical “gobbledygook”, providing different dietary advice and information, not making follow-up calls, and failing to communicate important information about their treatment. Consumers felt that if all practitioners were adding to the same patient notes and sending them to their GP or other members of their care team, it would reduce the burden of having to mediate conflicting information. Communication could be improved—clearly summarising the outcomes of an appointment and communicating them to patients, as well as making their records more accessible. Finally, follow-ups after the appointment would make participants feel more at ease, especially when they need to adjust or stop medication, require additional testing, or need to change treatment.

The fifth and last theme was the” medical feeling”. When speaking about the traditional face-to-face hospital appointment, consumers said that the cold, sterile feeling associated with white coats, covered up windows, and medical equipment made their blood pressure rise before the appointment had even started. They wanted VOICeD to be warm and inviting, using friendly imagery, and emphasising that the service allows them to be comfortable in their own home environment rather than confined in a clinical setting.

Many of these insights mirrored and confirmed clinician expectations, which was an important outcome of session in itself. Beyond this, there were many insights that prompted further discussion and consideration of aspects the team hadn’t considered. For example, consumers struggled in telehealth sessions when they weren’t warned that the clinician was about to enter the session—if the wait time was longer than expected they might be across the room making tea when the call began. They raised important issues around accessibility for blind and deaf patients, as well as aesthetic considerations that would guide the design of VOICeD imagery.

1.4 Implementing

The VOICeD team began implementing these suggestions in the lead-up to the soft launch of the service. While some of these recommendations couldn’t be incorporated before the launch, the continual evolution of the service allows these features to be added over time. Suggestions incorporated before testing included reducing the number of virtual waitrooms, humanising the administration and clinical staff by displaying their picture and names on screen while waiting, and developing the conversations for administration staff before and after seeing the clinicians. Prior to the launch, and after implementing recommendations that were feasible short-term, participants from the first workshop were invited to test the VOICeD service.

1.5 User Testing

Several weeks after the initial workshop, participants were led through the VOICeD appointment experience, as were the HEAL team. This process of user testing would generate additional recommendations that were focused specifically on usability. Consumers experienced the virtual clinic model first-hand, while clinicians learned how to manage consumers between wait rooms and consult rooms.

Participants received instructional documents by email in advance, attended their “appointment”, checked in with administrators, and transferred between practitioners. Following their “appointment”, each participant then spoke to the HEAL team individually over the phone to gauge their response to the process, following the typical feedback questionnaire that new patients would receive while also allowing for more open-ended discussion. This included questions like “how was your overall experience with the VOICeD Diabetes-Renal-Cardiac clinic?”, “what did you like?”, “what didn’t you like?”, “do you prefer combining 3 consultations into one appointment or 3 separate appointments?” and “how were the waiting rooms? is there anything you would improve? (audio, visuals etc.)”.

Participants had very few issues using the service, however their feedback was crucial in refining the technology and consumer experience. Consumers wanted the appointment link to be sent on time or earlier, as some received it later than the appointment. Mobile and desktop experiences were very different—on mobile there was a confusing video-nesting feature that made the call quite disorienting, while desktop was far more seamless. Adding additional questions for each type of device in the feedback survey helped to capture these insights and device-specific issues. The patient letter required a re-design to more clearly communicate exactly what the patient needed to do on the day, perhaps incorporating visuals or videos to explain what the experience looks like. Captioning and translation features needed to be added to address hearing impairments and language barriers, making VOICeD accessible to all consumers. A spinning wheel would appear on the screen to suggest they were about to be connected to the appointment, however for those off on a bathroom break or distracted doing something else, an audio voice-over would be useful to include several seconds prior. Finally, at the end of the appointment, consumers wanted clear communication around the next steps, who they would be seeing for their next appointment, and any additional information they need in the interim. This information is often communicated via traditional posted mail weeks or months later, leaving them in the dark.

Most of the recommendations that came out of this process were implemented through a series of staged software upgrades. Recommendations relating to usability included: simplifying the onscreen layout, controls, and information overlays for consumers; incorporating ‘SMS invitations’ to be initiated from within the virtual clinic environment; and incorporating inter-specialist text messages that were ‘pinned’ to the consumer being transferred.

1.6 Improving

From the outset, the VOICeD team had committed to continue to improve, test, and evaluate the service long-term, and are continuing to implement recommendations from the HEAL collaboration. They are also collecting qualitative data from patients on an ongoing basis to better understand the patient experience.

Qualitative measures were developed to focus on the experience of patients and those providing the service. From the beginning of the project, the intention was to adapt how VOICeD was delivered, as the team learned from consumers, clinicians, and others in the health service. The first three clinics trialled substantially different workflows, communication, and prioritisation methods. During weekly post-clinic conversations, the team would collaboratively decide how to operate in the following week, testing and exploring different ways of working. Collective consumer and clinician experiences soon indicated that a case conference configuration worked best, providing the most supportive experience while reducing administrative complexities. Other aspects of service design continued to be adapted and modified week by week, improving efficiency before, during, and after the clinical interaction.

After the first VOICeD Diabetes-Renal-Cardiac clinic, the team collected information about the experiences of 18 out of 20 consumers. The remaining two chose not to provide feedback. All respondents reported they felt their care was safe and private, and would recommend VOICeD to others. 89% (16) felt that it was easier than travelling to hospital, and 94% (17) preferred one combined appointment. Consumers unanimously liked having fewer appointments and reduced wait times. Surprisingly, they also highly valued seeing their specialists speak to each other and formulate a unified plan for their care, informing the use of a case conference format.

These static experience metrics go only a small way to describing the emotional responses of people accessing care. The ability to access care with support, either with their family at home or within their community, was profound for many people. Stories soon emerged: a participant crying, sharing how supported she felt when specialists came together to provide her care; a young mother who could not physically attend the hospital, no longer having to be re-referred due to not booking or non-attendance; and a man on home oxygen who would normally risk running out of oxygen before reaching his appointments, now dialling into a single appointment from home. The time consumers spent waiting in clinics was reduced by around 350%, creating more time for their life, work, and family.

Feedback from clinicians was also incredibly rich. Like consumers, clinicians valued having a single care plan, and being able to directly discuss the plan with diverse specialists in real time. A short conversation between the specialists (and with the patient) saved months of navigating separate face-to-face appointments as the underlaying health conditions changed or worsened. Clinicians also found they were upskilling, becoming more aware of considerations and management preferences of other specialties. Some clinicians raised that their time spent with one patient was longer in VOICeD than in a traditional face-to-face appointment. From the perspective of a health service, for the same amount of clinician time, VOICeD created 16% more capacity release than face-to-face, reduced the patient time in clinic by 350%, required 3x less appointments per year, and reduced patient travel. Economic analysis showed that standard funding mechanisms could cover the cost of the clinic, making it an attractive service model for a relatively small proportion of the people entering diabetes, renal, or cardiac services.

1.7 Expanding

Since the success of the first VOICeD clinic—Diabetes-Renal-Cardiac—the service has expanded into other contexts: Gestational diabetes care, Diabetes paediatric to adult transition (also known as Adolescent and Young Adult care), and Child Development. The team have also continued to launch Diabetes-Renal-Cardiac across additional sites. It quickly became clear that VOICeD had the potential to improve consumer experiences beyond the realm of chronic disease, and the team decided to rebrand to Virtual Outpatient Integration for Care Delivery.

In 2021, former HEAL intern Jessica Cheers was offered a year-long Experience Design Fellowship with the Healthcare Improvement Unit (HIU) within Clinical Excellence Queensland—an embedded role which was modelled largely on her work on VOICeD and other HEAL projects. As part of the fellowship, she travelled to Rockhampton with Dr. Brent Knack, meeting with health professionals operating in the Central Queensland Hospital and Health Service (CQHHS) to explore opportunities to embed the same multi-clinician telehealth model for patient groups in their HHS. Jessica assisted the team in designing a workshop for the group, acknowledging that there would be many complex dynamics in the room. In group, health professionals would “pitch a patient group”, following a template that explored the who, how, why, and what-if’s. The pitches would be presented to the room, and after each pitch anyone in the room could adopt the role of “Devil’s Advocate” (complete with a paper devil’s hat) to critique their proposal, identifying potential issues and opportunities, and challenging the team to overcome them (Fig. 4). This method was very successful in breaking through surface-level discussions and allowing participants to express their concerns comfortably, prompting many continued discussions. It also prompted the group to tangibly document their ideas and bring them to life, beginning the early stages of prototyping what the service could look like for them.

Dr. Gaurav Puri and Dr. Brent Knack have continued their crusade, establishing new VOICeD services across the state. They continue to learn from each experience and make a point of embedding creative design approaches in their practice, having seen the value they bring to service development. VOICeD has become a community, with all project documentation, promotional materials, and lessons shared among the Community of Practice. People interested in establishing a VOICeD service within their own clinical contexts now have direct access to stories and lessons learned across Queensland.

Each location, consumer base, combination of specialists, and local health system has distinct characteristics and ways of working. The VOICeD team champion the use of design methods to rapidly iterate and develop a service that’s fit-for-context, rather than assuming “one size fits all” or adopting a scale-and-spread method based on an approved modification of Diabetes-Renal-Cardiac.

While this means that VOICeD is a relatively loosely defined model of care, it has enhanced the ability of the service to deliver value to consumers and the health system by remaining true to the original vision: bringing multiple healthcare providers to people with complex healthcare needs in a way that is easy to access.

Fig. 4

The ‘Devil’s Advocate’ hat

2 Outcomes

The VOICeD launch was a success, and patients continue to respond positively to the service. 100% of users surveyed would recommend the service, and 83% described it as a “very good experience”. The participatory process—including both the in-person workshop and subsequent user testing—allowed the team to test their assumptions around the benefits of the service. Participants largely confirmed the benefits of a multi-practitioner telehealth model, while also challenging aspects of its delivery. The process of thematic analysis following the first workshop can be used as an at-a-glance embodiment of the kind of themes practitioners may want to consider embedding into new digital health services moving forward, and the user testing session gave very specific and actionable improvements to encourage further iteration. The team are continuing to work towards implementing further improvements based on the recommendations. The VOICeD project has won a number of awards, including the Consumer Choice Award at the Clinical Excellence Queensland Showcase in 2021, as well as Department of Health Awards for Reforming Healthcare and Consumer Engagement in 2022.

Each instance of VOICeD has brought unique value and lessons learned. Yet, in each case, the experience and accessibility for consumers has been the highlight. There are many nuanced ways in which the service has improved consumer experiences—making early personal contact with booked patients, facilitating clinical investigations (e.g. blood tests) prior to the appointment, integrating other services such as nurse navigation, and adding technical enhancements to the virtual clinic.

3 What we Learned

The collaboration between VOICeD and HEAL shows how clinicians, designers, and consumers working together can create digital health services that reduce the burden on consumers rather than introducing even more complications to the day-to-day lives of those managing complex health conditions. It’s a case study in rapid iteration, prototyping, and good design—bringing ideas to life and creating robust services that can infectiously influence and spread throughout the healthcare system. The participatory process uncovered broad themes to be embedded in the VOICeD service, as well as specific and directly actionable recommendations. The team are continuing to implement changes, such as accommodating hearing, speech, and vision impairments, restructuring the patient letter for further clarity, implementing voice-overs in the virtual waiting room, and presenting clear and actionable next steps at the end of each appointment.

The VOICeD model was born out of conversations with patients and the clinical experience of diabetes practitioners. However, in initial discussions with the VOICeD team at Cairns Hospital it became clear that the team were making several fundamental assumptions about what people with chronic disease wanted and needed, informed by their perspective as health professionals. When developing personas and mapping the journey of patients, practitioners struggled to step into the patient perspective, projecting their imagined clinical benefits. While many of these assumptions were affirmed by the participatory process, speaking to a group of end-users directly was crucial in challenging the expectations of the team, uncovering surprising nuances and preferences around aspects like the waiting room experience and information delivery.

One of the more fulfilling aspects of the collaboration for HEAL designers was experiencing the lightbulb moments in healthcare practitioners as they went through the lengthy process of intricately mapping the service experience. This process brought to light aspects of the service that they hadn’t yet considered, while also bringing the service to life in a tangible way. Initial collaborative maps were extremely exhaustive, representing the role of all practitioners, stakeholders, and end-users in achieving a fluid patient experience. The process of simplifying this information and connecting it to real end-users translated the knowledge into digestible, shareable visualisations that could easily communicate the intention of the service. Similarly, the process of translating the knowledge of workshop participants into actionable recommendations ensured their visions could be directly and concretely implemented.

The HEAL team took away many learnings from the workshops with consumers. They found the future-oriented approach to consumer engagement very beneficial—the Future Workshop format allowed participants to consider both their current, emerging, and future needs and desires, which the team could embed in the VOICeD service to ensure it aligned with their aspirations for the future of healthcare. Playful and provocative prompts like the devil’s advocate hat used in the CQHHS workshop broke up tensions in the room, and helped to navigate complex dynamics between health professionals while bringing levity to the workshop environment. There were some barriers to achieving a truly co-designed service—namely that consumer engagement didn’t occur early in the process, and difficulties around recruitment meant that some participants didn’t necessarily have the lived experience needed to engage in the workshop activities as they were designed. In the future, perhaps the format of consumer involvement could be adjusted to involve more asynchronous engagement or virtual interviews, allowing more perspectives to be captured without the challenges of a face-to-face session.

Finally, the HEAL and VOICeD teams were often surprised by what had the most impact. While the designers produced a number of journey maps, design assets, illustrations, and branding elements for the team to use where needed, a simple slogan—“Bringing you care, anywhere”—was one of the contributions that the VOICeD clinicians connected to the most. The early stages of the process were unanimously the most enlightening, pulling apart the vision, beginning the process of its grand design, and realising the need to reconnect with the very people the service was for.

4 Conclusion

The collaboration between HEAL and VOICeD resulted in an exciting and fruitful partnership between designers, health professionals and people with chronic disease, each illuminating new possibilities for the development of future healthcare services. The VOICeD team are continuing to bring on new patients, implement recommendations, and foreground the experience of people using the service at every stage. The successful relationship between designers and health professionals has sparked additional opportunities for collaboration, both in telehealth and across diverse Queensland Health projects.