Mobile health for older adult patients: Using an aging barriers framework to classify usability problems.

BACKGROUND: With populations aging, digital health tools and mobile health applications (mHealth) are becoming more common to assist older people in independent living and self-management of (chronic) illnesses. These mHealth services can be beneficial to older patients, provided that they are adjusted to their needs and characteristics, as the current mHealth landscape lacks user-friendly services for this target group. Understanding of intrinsic aging barriers, which cause and impact usability problems older patients encounter, is needed to achieve this. OBJECTIVES: This study set out to assess usability problems older patients encounter in two mHealth apps and aims to show the value of MOLD-US, a recent aging barriers framework, as a classification tool to identify the intrinsic cause of these problems. METHOD: A case-study design, with in-depth analysis of usability issues older adult patients' experience. Data on usability issues were collected using the Think Aloud Protocol for two mHealth apps. The MOLD-US framework and Nielsen's severity rating were used to classify identified issues and their potential impact. RESULTS: In total 28 high severe usability issues of the mHealth apps were identified. Core natures of most issues were related to motivational and cognitive barriers of older adults. Participants had difficulties in understanding the navigation structure of the apps. Important text, buttons and icon elements were overseen. CONCLUSION: Current knowledge on creating interfaces for older target groups is not well applied within the assessed mHealth designs. Specifically, design guidelines should address older adults' diminishing cognition skills, physical ability and motivational barriers. By classifying usability problems with MOLD-US, insights on these barriers can be enhanced to adequately address these issues in new designs. In addition, we propose that future research focuses on investigating suitable usability evaluation methods adapted to older patients' characteristics to ultimately be able to gain unbiased sight on usability issues older patients may experience while interacting with technology.

Factors influencing implementation success of guideline-based clinical decision support systems: A systematic review and gaps analysis.

OBJECTIVE: To provide an integrated and differentiated understanding of factors influencing guideline-based CDSS implementation and illustrate the gaps in the current literature. MATERIALS AND METHODS: A systematic literature review and in-depth exploration of factors impeding or facilitating successful implementation of guideline-based CDSS supporting physicians in clinical decision-making was performed. Factors were identified thematically by textual analysis of the included publications and were individually mapped to the human, organization and technology-fit (HOT-fit) framework for evaluating implementations of health information systems. RESULTS: A total of 421 factors were found in 35 included publications from a total of 3676 publications. The mapping of factors concerning CDSS implementation on the HOT-fit framework revealed gaps in each domain of the framework and showed that research has mainly focused on human and technology factors and less on organizational factors. CONCLUSIONS: Future research within the field of guideline-based CDSS should focus on evaluating implementations through the use of socio-technical models to study guideline-based CDSS system implementations from a multidimensional view. Furthermore, research is needed to explore whether use of these models during the planning phases of a CDSS project is useful in anticipating and preventing implementation barriers from occurring and exploiting facilitators to a successful implementation of the system.

Impact of Patient-centered eHealth Applications on Patient Outcomes: A Review on the Mediating Influence of Human Factor Issues.

OBJECTIVES: To examine the evidence of the impact of patient- centered eHealth applications on patient care and to analyze if and how reported human factor issues mediated the outcomes. METHODS: We searched PubMed (2014-2015) for studies evaluating the impact of patient-centered eHealth applications on patient care (behavior change, self-efficacy, and patient health-related outcomes). The Systems Engineering Initiative for Patient Safety (SEIPS 2.0) model was used as a guidance framework to identify the reported human factors possibly impacting the effectiveness of an eHealth intervention. RESULTS: Of the 348 potentially relevant papers, 10 papers were included for data analysis. None of the 10 papers reported a negative impact of the eHealth intervention. Seven papers involved a randomized controlled trial (RCT) study. Six of these RCTs reported a positive impact of the eHealth intervention on patient care. All 10 papers reported on human factor issues possibly mediating effects of patient-centered eHealth. Human factors involved patient characteristics, perceived social support, and (type of) interaction between patient and provider. CONCLUSION: While the amount of patient-centered eHealth interventions increases, many questions remain as to whether and to what extent human factors mediate their use and impact. Future research should adopt a formal theory-driven approach towards human factors when investigating those factors' influence on the effectiveness of these interventions. Insights could then be used to better tailor the content and design of eHealth solutions according to patient user profiles, so as to enhance eHealth interventions impact on patient behavior, self-efficacy, and health-related outcomes.

Influence of Human Factor Issues on Patient-Centered mHealth Apps' Impact; Where Do We Stand?

This paper discusses the preliminary results of a literature review on studies published in 2014-2015 concerning patient-centered mHealth applications' (apps) impact. Abstracts were included when they described a mHealth app targeted at patients and reported on the effects of this app on patient care. From a total of 559 potentially relevant articles, 17 papers were finally included. Nine studies reported a positive impact of the patient-centered mHealth app on patient care; 4 of these studies were randomized controlled trials. Measured impacts in the 17 studies focused on improving patients' physical activity, self-efficacy and medication adherence. Human factors issues potentially mediating these effects were discussed in all studies. Transitions in the interaction between healthcare providers and their patients were most often discussed as influencing the impact of the mHealth app. More research is needed, focussing on human issues mediating the effect of patient-centered mHealth apps to precipitate knowledge on the effectiveness of mHealth. This research should preferably be guided by socio-technical models.

Uncovering healthcare practitioners' information processing using the think-aloud method: From paper-based guideline to clinical decision support system.

OBJECTIVE: To investigate whether the use of the think-aloud method with propositional analysis could be helpful in the design of a Clinical Decision Support System (CDSS) providing guideline recommendations about long-term follow-up of childhood cancer survivors. MATERIALS AND METHODS: The think-aloud method was used to gain insight into healthcare professionals' information processing while reviewing a paper-based guideline. A total of 13 healthcare professionals (6 physicians and 7 physician assistants) prepared 2 fictitious patient consults using the paper-based guideline. Propositional analysis was used to analyze verbal protocols of the think-aloud sessions. A prototype CDSS was developed and a usability study was performed, again with the think-aloud method. RESULTS: The analysis revealed that the paper-based guideline did not support healthcare practitioners in finding patient-specific recommendations. An information processing model for retrieving recommendations was developed and used as input for the design of a CDSS prototype user interface. Usability analysis of the prototype CDSS showed that the navigational structure of the system fitted well with healthcare practitioners' daily practices. CONCLUSIONS: The think-aloud method combined with propositional analysis of healthcare practitioners' verbal utterances while they processed a paper-based guideline was useful in the design of a usable CDSS providing patient-specific guideline recommendations.

A Concise and Practical Framework for the Development and Usability Evaluation of Patient Information Websites.

BACKGROUND: The Website Developmental Model for the Healthcare Consumer (WDMHC) is an extensive and successfully evaluated framework that incorporates user-centered design principles. However, due to its extensiveness its application is limited. In the current study we apply a subset of the WDMHC framework in a case study concerning the development and evaluation of a website aimed at childhood cancer survivors (CCS). OBJECTIVE: To assess whether the implementation of a limited subset of the WDMHC-framework is sufficient to deliver a high-quality website with few usability problems, aimed at a specific patient population. METHODS: The website was developed using a six-step approach divided into three phases derived from the WDMHC: 1) information needs analysis, mock-up creation and focus group discussion; 2) website prototype development; and 3) heuristic evaluation (HE) and think aloud analysis (TA). The HE was performed by three double experts (knowledgeable both in usability engineering and childhood cancer survivorship), who assessed the site using the Nielsen heuristics. Eight end-users were invited to complete three scenarios covering all functionality of the website by TA. RESULTS: The HE and TA were performed concurrently on the website prototype. The HE resulted in 29 unique usability issues; the end-users performing the TA encountered eleven unique problems. Four issues specifically revealed by HE concerned cosmetic design flaws, whereas two problems revealed by TA were related to website content. CONCLUSION: Based on the subset of the WDMHC framework we were able to deliver a website that closely matched the expectancy of the end-users and resulted in relatively few usability problems during end-user testing. With the successful application of this subset of the WDMHC, we provide developers with a clear and easily applicable framework for the development of healthcare websites with high usability aimed at specific medical populations.

A framework for evaluating mHealth tools for Older Patients on Usability.

Mobile health (mHealth) apps can play a significant role in supporting older patients. The aging process is yet related to progressive degradation of sensory, physical and cognitive abilities. mHealth apps with touch screen based interfaces thus need to be adapted to the, often impaired, skills and special needs of older patients. However, existing design guidelines for mHealth apps do not address the aging barriers that older users face in working with touch screen based applications. By means of a constructed conceptual framework on cognitive, motivational, physical and visual impairments of older adults, this study revealed possible aging barriers concerning identified usability issues of an mHealth app for older patients. Insights into the aging process barriers that underlie usability issues supports developers in (re)designing mHealth apps that are better attuned to the needs of the older patient population.

Factors known to influence acceptance of clinical decision support systems.

Clinical Decision Support Systems (CDSS) have been shown to improve clinical performance and patient outcomes, but the failure rate of such systems is still over 50 percent. To contribute to a wider understanding of issues surrounding CDDS acceptance, we performed a systematic review of studies that evaluated CDSS implementations in clinical care to determine the factors that are associated with acceptance of CDSS by physicians. The factors that were found were categorized according to the HOT-fit framework. The mapping of factors concerning CDSS acceptance on the HOT-fit framework revealed gaps in each domain of the framework and showed that research has mainly focused on human and technology factors and a lack of research on organizational factors. A potential area of research could thus be studying the organizational factors that may influence CDSS acceptance.

Reducing clinicians' cognitive workload by system redesign; a pre-post think aloud usability study.

Interactive Health Information systems are often considered cognitively complex by their users, leading to high cognitive burden and increased workload. This paper explores if Think Aloud usability testing provides valuable input to effectively redesign a web-based Data Query Tool in Intensive Care and to reduce physicians' cognitive workload during system interaction. Pre and post redesign usability testing demonstrated a major reduction in the cognitive task workload after redesign of the tool. Classification of revealed usability problems by means of the User Action Framework pointed out that usability problems related to the cognitively planning of actions by system users foremost affected cognitive task workload. This result may support Health Information system (re)design efforts on how to tackle the system's cognitive complexity and in so doing improve on its usability.

Impact of alert specifications on clinicians' adherence.

Computerized alerts provided by health care information systems have been shown to enhance clinical practice. However, clinicians still override more than half of the alerts. This indicates that certain aspects of alerts need improvement to fulfill their purpose of supporting clinicians in decision making. This paper reports on a systematic review on studies evaluating alert specifications and their impact on clinicians' alert adherence. The review revealed that use of colors and icons to distinguish different alert severity levels and presenting high severity alerts in an interruptive fashion increases clinicians adherence to alert recommendations. Alert message contents that lack clinical importance or provide incorrect texts increase alert non-adherence. Few studies have yet focused on the impact of alert specifications on clinicians' adherence. A research agenda is needed on alert specifications and their impact on clinicians' adherence in order to develop alerts that truly support clinician decision making.

Classification and prioritization of usability problems using an augmented classification scheme.

Various methods exist for conducting usability evaluation studies in health care. But although the methodology is clear, no usability evaluation method provides a framework by which the usability reporting activities are fully standardized. Despite the frequent use of forms to report the usability problems and their context-information, this reporting is often hindered by information losses. This is due to the fact that evaluators' problem descriptions are based on individual judgments of what they find salient about a usability problem at a certain moment in time. Moreover, usability problems are typically classified in terms of their type, number, and severity. These classes are usually devised by the evaluator for the purpose at hand and the used problem types often are not mutually exclusive, complete and distinct. Also the impact of usability problems on the task outcome is usually not taken into account. Consequently, problem descriptions are often vague and even when combined with their classification in type or severity leave room for multiple interpretations when discussed with system designers afterwards. Correct interpretation of these problem descriptions is then highly dependent upon the extent to which the evaluators can retrieve relevant details from memory. To remedy this situation a framework is needed guiding usability evaluators in high quality reporting and unique classification of usability problems. Such a framework should allow the disclosure of the underlying essence of problem causes, the severity rating and the classification of the impact of usability problems on the task outcome. The User Action Framework (UAF) is an existing validated classification framework that allows the unique classification of usability problems, but it does not include a severity rating nor does it contain an assessment of the potential impact of usability flaws on the final task outcomes. We therefore augmented the UAF with a severity rating based on Nielsen's classification and added a classification for expressing the potential impact of usability problems on final task outcomes. Such an augmented scheme will provide the necessary information to system developers to understand the essence of usability problems, to prioritize problems and to tackle them in a system redesign. To investigate the feasibility of such an augmented scheme, it was applied to the results of usability studies of a computerized physician order entry system (CPOE). The evaluators classified the majority of the usability problems identically by use of the augmented UAF. In addition it helped in differentiating problems that looked similar but yet affect the user-system interaction and the task results differently and vice versa. This work is of value not only for system developers but also for researchers who want to study the results of other usability evaluation studies, because this scheme makes the results of usability studies comparable and easily retrievable.