The Next Ten Percent project: identifying what “counts” in a community

My first example comes from work started in 2001, while I was still a member of the People and Practices Research Group at Intel. This project was an attempt to explore the possibilities for information technology beyond the wealthiest ten percent or so of the world’s population who enjoyed access to the benefits of computing and the internet at that time. A couple important early themes to emerge in this project included (a) the (somewhat obvious) recognition that in most places people did not have the personal wealth to afford technology, and even when they did, did not always find personal ownership compelling; and (b) most of the really interesting uses of technology were less about consumer behavior and more focused on production. People of limited means are more likely to invest money to enhance their own ability to earn money, rather than on entertainment, consumption or even for delayed earning power represented by education of one’s children.

We harbored no delusions of people, like that adorable little old Italian woman in the commercials, suddenly marketing their olive oil on the global stage. Nonetheless, examples of productive use of technology abounded. Outside Santiago, Chile, a network of telecenters called “El Encuentro” had turned a community center and radio station into a resource for entrepreneurial training and youth employment (the kids who worked as network administrators at the community center became outsourced consultants for a government telecoms network). In Hungary, we encountered telehas operators actively seeking government grants, via the Internet, for their fellow villagers. In India, a number of social ventures had created a network of what has come to be known “village kiosks”, which are not kiosks as we know them (ie., not like ATMs) but rather tiny businesses staffed by local entrepreneurs who purchase their own PCs, get access to software and turn around to provide various services to their fellow villagers at an affordable price. These might include access to government services, insurance, banking, farm market quotes, etc..

Most fascinating about these examples were their complex and nuanced approach to entrepreneurism. These organizations were not just about making money, although all of them had that goal, without question. They were, however, just as dedicated to creating and circulating other forms of capital. The director of the Chilean telecenter operation told us explicitly “El Encuentro is about creating social capital” – the bonds of community. The use of technology at this telecenter was specifically designed to enable more mutual interdependence within the community. El Encuentro became a stage wherein the needs of the imagined community stood in tension with what were some of the more obvious uses of the technology – computer gaming, for instance, was at first ruled out as a legitimate use of the computers at the telecenter. A Chinese i-Café this wasn’t!

Similarly, in rural India, multiple forms of capital were exchanged and accrued around the village kiosks. The firm Drishtee, for example, connected rural Indians to government services via privately operated kiosks. The most obvious was economic: because of proximity, the kiosks saved villagers the expense and time of travel to district seats. Similarly obvious was the economic benefit of access without ownership – that is, community members could benefit from the technology without having to shoulder the burden of ownership themselves. The local kiosk operator, conversely, took on that burden in exchange for modest recurrent fees for use.

Less obviously, this mediated form of access also enabled citizens to benefit from technology’s presence without having to learn how to use it – a barrier that is easy to overlook in places such as Silicon Valley, where everyone seems to know how to use a PC. For kiosk operators, mastery of this skill was a source not just of financial capital. Many of the local kiosk operators we visited became more trusted agents of government services than the government itself. Kiosk operations enhanced their social standing. Social capital even accrued to some kiosk customers. One woman I interviewed, born of low caste and illiterate, would doubtlessly have been without much recourse had she been forced to visit district government offices herself. She would have been too easy for clerks to ignore. But via the kiosks, she became an effective advocate, directing many applications, complaints and petitions of her fellow villagers through the relative anonymity and assured response the kiosks enabled.

Emphasizing technology as “personal” thus tends to hide the relationships that are established, changed or disrupted by the presence of technology. Who is the “user” in the above example? Is it the village kiosk operator? Is it the woman who brings the government petitions of her friends and family? Is it the friends and family themselves? ³ Only by looking at entire community systems could we hope to identify where an appropriate opportunity for Intel might lie. To that end, the insights of cultural and political ecology seemed most appropriate for pointing out the right questions: what counts as a cost, a benefit, a resource or a need? How are these brought into alignment? Without this kind of perspective, if we had, for instance, focused too heavily on issues of personal ownership, or entertainment rather than productivity as the most interesting value proposition, we would have missed this important phenomenon.

This perspective paid off in a number of ways, the most important of which was guiding our attention to the right kinds of interventions for a product with the unfortunate, oxymoronic name of “community PC” (space doesn’t permit more detail on this product, but see Sherry, 2006). Other results included an ongoing research agenda, and the germ of work within my new organization Digital Health.

Clinicians: Building an aggregate understanding of the functioning of systems.

In 2005 I joined Intel’s newly formed Digital Health Group, where I have had the pleasure of working with a truly world-class research team. One of the first things that became obvious is that Intel got into this business without really understanding, in detail, how health care systems operate. This is not entirely a knock on Intel; I’m not sure many health care organizations understand how they really operate either – at least not at the level of decisions and work practices of their individual clinicians, health professionals and clerical staff (it’s the whole “management consultant fallacy” thing again).

Not long ago, our marketing colleagues asked us to “go study doctors” because, they believed (partly correctly) that as high status individuals with some level of say-so over their choice of technologies (more so than, say, nurses), we could get some easy sales by designing something appropriate for them. So, being the good corporate citizens, we ignored their request and went to study nurses. This was not a popular decision, I can testify, but we recognized that we needed to jumpstart Intel’s understanding of how health care works, and that the best way to do this was to start at the fulcrum. Nurses are where care happens.

Monique Lambert, a member of our health research team, proceeded to conduct a study of acute care hospital nurses on such an unprecedented scale and to a level of such amazing detail that I dare say she’s still recovering from the effort. This was not a matter of a few focus groups. Over hundreds of hours of observations she has pieced together a picture of nurses’ work practices that we’ll be mining for years. However, it’s not exactly that picture of nurses’ work that I’m interested in exploring here. One of the most important things Dr. Lambert did was to help explicate the key points at which nurses interact with fellow clinicians, with doctors, emergency medical technicians, discharge planners, social workers, pharmacists, with patients of course, and a host of others who inhabit hospital settings. Our study of nursing can be seen as one stop, one vantage point on the system of health care.

While she was doing this work, other colleagues were filling out a picture of what we call “the hospitalization cycle” by examining other perspectives: emergency medical services and the process of hospital discharge (and, all too often, readmissions).

Gina Grumke spent hours riding along with EMS teams, carefully observing and documenting incidents, and of course asking lots of apparently impertinent questions. Like the nurses research this study was complete unto itself, yielding a number of insights that are inherently valuable to our organization (including the insight that emergency services provide a huge amount of routine care in the community, a fact that we are currently exploring in more depth). Likewise, Nancy Vuckovic conducted research focused on the process and immediate aftermath of the hospital discharge process. This project has been likewise self-contained, albeit incrementally more “systemic”; that is, Nancy looked at the issue from the perspective of nurses, discharge planners, patients and others. This work has yielded a number of potential opportunities both in the hospital setting prior to discharge as well as in the home afterwards, to ensure that patients who are released “sicker and quicker” these days are better prepared to care for themselves.

I would like to point out how important this approach is to our – and hopefully Intel’s – success. By identifying more recognizable, self-contained research projects, ostensibly devoted to understanding particular types of users, we’ve been able offer an acceptable research agenda to our colleagues. ⁴ By providing concrete results on discrete portions of the healthcare system, we’ve been able to keep the wolves at bay, as it were, while gradually building up a composite understanding of how doctors, nurses, patients, information, medications, technologies, resentment, intrigue and a host of other tangible and intangible objects flow through health care organizations and interact.

A “multiple” levels approach here was thus crucial, not just for making the work more manageable and acceptable. Some insights about nursing work are most apparent when adopting a more “micro-interactional” approach, exemplified by research Nancy Vuckovic conducted before joining our group (Vuckovic, et al, 2004). This work showed how the practice of “eavesdropping” is critical for maintaining situation awareness among nurses in an intensive care unit, and opened for scrutiny the idea that our technologies must also make that kind of awareness possible. Other insights, however, can only emerge when we see more of what happens “off stage”, by following nurses, or physicians, or other clinical workers for longer periods of time, and understanding the power relations, constraints, and other factors that shape their own perceptions of their work, and responses to it. Large providers, insurance companies and governments exert tremendous forces that shape health care delivery on the ground – and these forces can be in outright conflict. Power relations among various types of physicians, between physicians and nurses, and throughout the hospital shape behaviors and understandings of work. This is all well known, but until the research is done it is hard to know, in a concrete way, ready for design, what it means for a nurse can be put on the spot for patient information by a physician, what a nurse or physician or phlebotomist might be willing to carry, or why it may be easier to introduce many new products into a hospital at one time, rather than bit-by-bit.

Perhaps more importantly, this aggregation has allowed us to better identify gaps, disparities, or other interesting aspects of broader systems in a way that few individual participants in these system would be ever able to articulate themselves. This in turn helps us to more quickly identify with our colleagues where the interesting technology and business opportunities lie. By constantly traversing between the two levels we’re able to have much more meaningful conversations about what might be interesting for a given type of individual while at the same time understanding how such a solution might ripple through health care organizations more broadly. While being realistic about the constant possibility of unexpected consequences, we also know that a detailed understanding of how health care works increases our chance of success.

The Global Aging Experience project: beyond individual values

In a fashion quite similar to the clinic-based research we have a team pursuing a project called the Global Aging Experience project, which consists of both an over-arching agenda and a series of discrete projects. One of the key areas of opportunity being pursued by the Digital Health Group as a whole is the huge wave of adults now reaching an advanced age. There are a number of reasons for this interest. The vast majority of all care for seniors with any form of disability or chronic disease is provided informally by daughters, sons or other loved-ones who may not live under the same roof as the elder. Technology could assist with some simple aspects of daily monitoring and care. Health care organizations currently provide little direct care to seniors – and will provide proportionally much less as the coming wave of aging boomers reaches full maturity, yet they are still facing spiraling costs. Operators of retirement homes and nursing homes may be interested in expanding their services “virtually” via technology, without the heavy capital investment of additional real-estate. All these factors suggest the need – felt perhaps most acutely by most elders themselves – to let people age more gracefully at home.

This work intentionally built on prior research at Intel (Morris et al, 2003). A familiar mantra of that prior work was “aging in place” (that mantra is employed much more broadly than just at Intel, of course). At its best, it means enabling people to avoid unwanted institutionalization. Our progenitor group had put much emphasis on networks of sensors and other technologies to be placed in the home to allow aging adults to avoid or recover from cognitive decline, falls or other adverse events that might land them in a nursing home.

In what looks like a fairly standard qualitative research project for this large and heterogeneous “market segment”, members of my team conducted a massive, multi-country study of the subjective experience of aging across western Europe as a first step in gaining a broader global understanding of what it means to grow old and whether “aging in place” is indeed a universal value. As with the clinics project, our success in pursuing our research agenda has hinged on our ability to deliver, along the way, results that are recognizable and useful to our colleagues. One of the things we produced last fall, for instance, was a somewhat rough approximation of a segmentation model, along with fairly simple personas. These include categories that segment people according to both their ability and motivation to care for themselves, and their orientation towards future uncertainties.

We’ve also produced a “reframing” of a sort that anyone at this conference might recognize, in this case, an emphasis on the importance of moving away from a medicalization of old age to an emphasis on healthiness, ability and aspirations, which is certainly reflected in our data. But this simple reframing almost immediately entailed the need to understand whole communities. “Aging in place,” it turns out, is fraught with implications about what needs to be “in place” throughout entire communities – good old fashioned geographic communities, that is – to make the proposition desirable or even feasible.

Part of this is obvious: many of the services that an assisted-living facility might provide (for instance, assistance with nutrition, hygiene or other so-called activities of daily living) are material. They need to be made locally available for a senior to access them from home. And other services – home maintenance, lawn care, etc. – must be available locally from trusted providers as well. Many of these resources are already found in the physical communities that people already inhabit. The challenge, however, is how to motivate and align these resources in such a way as to make them available, recognizable and useful to seniors.

Additionally, quite explicit in the discourse of seniors themselves is the expressed desire to remain active, productive members of their communities, to be able to participate in the life of these communities in various ways. If we focus too heavily on instrumenting households, the mantra “aging in place” can quickly devolve into a form of imprisonment, perhaps less desirable even than a nursing home. It doesn’t just take a village to raise a child, it also takes one to enable graceful aging.

Transportation resources offer a perfect example. In most communities – modestly affluent places, at least – transportation is not a scarce resource. And yet, lack of access to transportation is one of the key causes of isolation and institutionalization among elders. Perhaps not surprisingly, transportation is intimately tied to social participation; cognitive and physical stimulation; household provisioning and numerous other services that make staying at home viable. One of our first follow-on studies, conducted by Simon Roberts and team in Ireland, was on rural transportation systems. There are some groundbreaking experiments underway in alternative forms of transportation for the elderly, both in the US and in Europe. From the perspective of technology, there are interesting possibilities for facilitating a better linking of available resources (volunteer drivers, community-based transport systems) and those in need of a lift. This is not to say technology is the answer. Some of the weakest projects we’ve seen are the heaviest users of technology. But done correctly, technology could provide a tremendous tool for linking providers with those in need.

Our study of aging has thus become less a question of what gadgets to create for individual seniors and more an exploration of how technology can be used to catalyze networks to serve the needs of seniors, to help bring alignment among a variety of actors to enable transportation, nutrition, home maintenance, medical care, social engagement and numerous other yet-to-be discovered services people of advanced age will need to age in a fashion they desire. This is no mean feat, and it explains why we actively cultivate research and development collaborations. It would be foolhardy to try this alone. Our research has involved a number of academic, private and non-profit organizations, and will continue to do so. But one of the distinct values we can offer as social scientists in these collaborations is to help uncover, through careful observation and questioning, not just unarticulated needs but also the resources and assets that lie unrecognized in the community, along with a careful understanding of how these might be mobilized.

Which, in fact, applies to all of the above examples. I have grown to view our work as less a job of “understanding the user” and much more a task of understanding these alignments, these interactions by which people create their own complex systems, exchanging value and establishing bonds and constraints of various types. We can’t do this until we look at these systems “inside and out,” as it were.