What Does Envelope Design Teach Us about Bad Healthcare Design?
Do you know the history of the windowed envelope?
According to Wikipedia, it was patented by Americus F. Callahan of Chicago, Illinois in 1902. It was called the “outlook envelope” and in the original design rice paper was placed in the window to create a transparent area. The motivation for the windowed design was to improve efficiency and save time. Back in the 1900's, the mailing address and the return address had to be added manually to the envelope using a typewriter. With a windowed envelope, the mailing address of the recipient and the return-address of the sender could now be printed on the letter and made visible by the window, eliminating the need for additional work.
Many companies still use windowed envelopes as part of their communication to customers, including banks, credit card companies, and health insurers. This summer Aetna, a US health insurer, used windowed envelopes to send letters communicating a change in pharmacy benefits for a group of approximately 12,000 customers taking HIV-related medications.
Below is a photograph of the letter that was sent.
The window revealed the name and address of the individual as would be required for a mailing address, but also included additional text from the first few lines of the letter, including the words:
“when filling prescriptions for HIV Medici…”
This was a major Health Insurance Portability and Accountability Act (HIPAA) violation.
Because of the careless design of the windowed envelope, the sensitive medical history of individuals was revealed to strangers, neighbors, friends, and family.
Here is what happened to one individual who received the letter:
[The sister of] a 52-year-old Bucks County [Pa.] man learned from an unopened large-window envelope that arrived in their mail that he was taking HIV medications.
He was, in fact, HIV-negative but on a regimen of prophylactic medication meant to guard against getting HIV.
Individuals who are taking the prophylactic HIV medication Truvada were among the approximately 12,000 people who received the mailings, meant to alert them to a change in pharmacy benefits.
Multiple recipients of the letters told STAT that they were no longer taking Truvada at the time they received the letter but had used it previously.
Aetna notified their members of the privacy breach in a letter:
On July 31, 2017, we were first made aware that, in some cases, personal health information was visible through the window of the envelope used to send the letter…The information displayed in the envelope’s window was your first name, last name, address, and in some cases, a reference to filling prescriptions for [certain] medications.
Upon learning of the issue, we took immediate steps to investigate what happened. We then confirmed that the vendor handling the mailing had used a window envelope, and, in some cases, the letter could have shifted within the envelope in a way that allowed personal health information to be viewable through the window.
In response to the letters, the Legal Action Center and the AIDS Law Project of Pennsylvania, sent a demand letter to Aetna calling for an end to the letters with that design. In addition, they filed a class-action lawsuit against Aetna for violating the privacy of its customers:
This incident provides two important takeaways for healthcare design:
1. Take full responsibility for when your design fails
The passive voice in the letter from Aetna is almost comical. Let’s read between the lines:
“the vendor handling the mailing had used a window envelope”
Interpretation: It wasn’t us, it was the “the vendor”!
“the letter could have shifted within the envelope in a way that allowed personal health information to be viewable through the window”
Interpretation: It wasn’t us, the letter “shifted”. We can’t control the motion dynamics of a piece of paper!
Whether internally or through the vendor, and with or without “shifting” paper, you sent the communication, so own it.
2. The Microdetails of Design Matter, Particularly for Healthcare
The choice of vocabulary
The formatting of the letterhead
The use of an envelope with a slightly larger window size
Attention to any and all of these design details probably would not have mattered in almost any other consumer scenario, but could have changed the catastrophic outcome of this incident.
This is just another example of how design matters for healthcare!
I tweet and blog about design, healthcare, and innovation as “Doctor as Designer”. Follow me on Twitter and sign up for my newsletter.
Click here for information about creative commons licensing. Disclosures: JAMA Pediatrics, Unitio, Grant funding from Lenovo.
Thanks to Geoffrey Clapp for the tipoff on this!
