Usability Guidance for Improving the User Interface and Adoption of Online Personal Health Records

8/14/2019 Usability Guidance for Improving the User Interface and Adoption of Online Personal Health Records

1/34

UsabilityGuidanceforImprovingtheUserInterfaceandAdoptionof

OnlinePersonalHealthRecordsKirstenPeters,M.S.MichaelNiebling,M.S.CassandraSlimmer,B.S.ThomasGreen,M.S.

JaysonM.Webb,Ph.D.RobertSchumacher,Ph.D.

UserCentric,Inc.

February2009

UserCentric,Inc.

2TransAmPlazaDr.-Suite100

OakbrookTerrace,IL60181

+1.630.320.3900

www.UserCentric.com

Copyright2009UserCentric,Inc.


2/34

Version 1.1 Copyright 2009 User Centric, Inc. 2

RevisionHistory:

Version1.0: Initialrelease

Feb2,2009

Version1.1: Section4.4:AddedFactorAnalysistoUSEsurveydata.Feb24,2009

Sections4.3-4.5:Correctedstatisticalreportingandclarifiedsomeofthe

languagetoreduceconfusionsomereadershavereported.Therewereno

resultingmaterialchangestofindingsorconclusions.

Note: InconversationswiththeteamfromMicrosoftatthe2009TEPR

ConferenceinPalmSprings,UserCentricbecameawarethatMicrosoftdoesnot

claimorpromotethatHealthVaultisaPHRperse.Microsoftconsiders

HealthVaultarobustdataplatformwithwhichthird-partyPHRsandothermedical

informationsourcesinteract.Nevertheless,manyintheindustryandmedia

considerHealthVaultsuserinterfacetobeaPHRandoneworthyofevaluationandcomparison.

TechnicalContact:

RobertSchumacher,Ph.D.2TransAmPlazaDr.-Suite100

OakbrookTerrace,IL60181

+1.630.320.3900

[email protected]


3/34


UsabilityGuidanceforImprovingtheUserInterfaceandAdoptionofOnline

PersonalHealthRecords

1.Abstract

DuringDecember2008andJanuary2009,theuserexperienceresearchfirmUserCentricconductedan

independentcomparativeusabilitystudyoftwoexistingonlinepersonalhealthrecordapplications,

GoogleHealthandMicrosoftHealthVault.(NeitherGooglenorMicrosoftcommissionedorparticipatedin

thisstudyinanymanner.)Duringthisstudy,30participantscompletedkeytasksusingeachPHR

applicationandprovidedqualitativefeedback,ratingsandpreferencedataonfivespecificdimensions:

Overallusability,utility(usefulnessoffeatures),security,privacyandtrust.Participantsperformedupto

seventasksonbothGoogleHealthandMicrosoftHealthVault,whichincludedthreetasksthatexplored

eachapplicationsuniquefeatures.Midwaythroughthestudy,athirdPHRapplication,

MyMedicalRecords.com,wasaddedtogatheradditionalqualitativedata.

ThemajorityofstudyparticipantsfoundPHRstobeusefulandstatedthattheyhadaninterestinbuilding

theirownPHRsafterthestudy.Overall,participantsindicatedthattheyfoundGoogleHealthmoreusable

becausenavigationanddataentryofhealthinformationwaseasierthanontheotherapplications.

ParticipantssaidthattheGoogleHealthapplicationutilizedmorefamiliarmedicalterminologyand

providedapersistenthealthinformationprofilesummary.

Basedonananalysisofthestudydata,UserCentrichasidentifiedthefollowingtrends:

Usability

Overall,participantslikedhowtheGoogleHealthinterfaceallowedthemtoquicklyentermedical

information.Thelefthandnavigation,tabs,andprofilesummaryallcontributedtoafairlysmoothuser

experiencefordataentry,whichisacriticalPHRtask.However,therewasstillroomforimprovement.

Participantshadtroubleattachingdatestohealthinformation,figuringoutwheretostart,andfinding

wheretheycouldaddanotherfamilymember.

Ingeneral,participantshadmoretroublewiththeMicrosoftHealthVaultinterface.Themosttroublesome

elementsweretheconfusingnavigation,thepresentationofalltermsinmedicaljargon,andthe

inconsistencybetweendifferentdataentryelements.However,reactiontoMicrosoftHealthVaultwasnot

completelynegativeeventhoughtheystruggledtoentertheirhealthinformation,severalparticipants

stillreactedfavorablytotheveryhighlevelofdetailthesystemallowedthemtoenter.Inaddition,

participantslikedtheabilitytoadddetailstoanitemimmediatelyafteraddingtheitemitself.This

representedanefficientflowthatGoogleHealthdidnotprovide.

Utility

ParticipantsfoundPHRstobefairlydesirablebytheendofthestudy.ThePHRsbaselinefunctionality

wasappealing,andbothGoogleHealthandMicrosoftHealthVaulteachhadafewwell-received

exclusivefeatures.


4/34


GoogleHealthspreferenceonthisdimensionislikelyduetotwofactors.First,participantssometimes

seemedtoconfuseutilitywithusability,eventhoughresearchersspecificallyaskedaboutusefulnessof

features.This,alongwithGoogleHealthsbettereaseofuse,wouldexplainashiftinparticipantsutility

preference.Second,GoogleHealthincludedthehighlydesirabledruginteractionfeature,whichwas

rankedmostappealingoutofallthefeaturesinthepost-testquestionnaire.Thiswastheonlyoutstanding

featureamongthesixPHR-exclusivefeatures,soitmayalsohaveboostedtheperceptionofGoogle

Healthsutility.

Security,PrivacyandTrust

ThekeycontributorstoMicrosoftHealthVaultsmorefrequentpreferenceonsecurity,privacyandtrust

wereastrongbrandimage,professional-lookingvisualdesignandahigherperceivedinformation

content.

However,eventhoughparticipantsmorecommonlypreferredMicrosoftHealthVaultforthesedimensions,

whenratingthetwoPHRstheyscoredGoogleHealthalmostequallyashighly.GoogleHealthshigh

ratingislikelyduetoitsbrandreputationanditsup-frontpresentationofthetermsofuseandlegal

agreements.Oneimportantnegative,though,wasGooglesstrongpositioninginthesearchande-mail

domains;itislikelythatthiscontributedtoMicrosoftHealthVaultsoverallpreferencehere.

Overall

UserCentricscomparativestudyfoundthatneitherGoogleHealthnorMicrosoftHealthVaultwereperfect

applications;eachhadflawsintheuserexperiencewhichwereseentoreduceparticipantswillingnessto

adoptPHRtechnology.However,participantspreferredGoogleHealthoverMicrosoftHealthVaultonthe

whole,mainlyduetoGoogleHealthsgreatereaseofuse.Althoughfeatures,security,privacyandtrust

certainlydidinfluenceparticipantsoverallevaluations,itiscriticaltonotethattheirmajordifficultieswith

bothapplications-andtheirstrongestcriticisms-wererelatedtotheuserexperience.Improvementsto

theuserexperiencethereforerepresentthelargestopportunityforimprovingthepatientsexperiencewith

aPHR.

Basedonthisusabilitystudy,UserCentrichasidentifiedseveralbestpracticestobeincludedina

workingmodelforPHRinterfacesthatfacilitatesuseradoption.


5/34


2.Background

InJanuary2009,PresidentObamaannouncedaninitiativetoconvertallmedicalrecordsusedby

hospitalsandphysicianstoelectronichealthrecords(orEHRs)bytheyear2014.Asthisinitiativetakes

shapeandmedicalrecordsbecomemoredigitized,PersonalHealthRecords(orPHRs)willbecomeanimportantintermediarybetweendoctorsdigitalversionofmedicalrecordsandanindividualsknowledge

oftheirownhealthhistory.

EHRsarebecominganincreasinglycommontoolforphysiciansandhospitals,whereEHRsarethought

toimprovemostphysiciansefficiencyinpracticingmedicineandhelpprovidemorestandardizedcareto

allpatients(Arnst,2006).ThesebenefitshavegenerallyacceleratedtherateofEHRadoption,and

companiessuchasGoogleandMicrosoftarealreadystartingtocapitalizeonthistrendbycreatingfree

orsubscription-basedPHRs.AsPHRsbecomemoreprevalent,itwillbeimportanttogainaclearer

understandingofwhichfunctionsandfeaturesarelikelytobeadoptedbythepopulationatlarge.

Inarecentreport,keyindustryanalystspredictedthatprovidingpatientswithaccesstotheirelectronichealthrecordswouldenhancethedoctor-patientrelationshipandreduceoverallhealthcarecosts

(KaloramaInformation,2008).Oneapproachforprovidingaccesstopatientrecordsisthrougha

PersonalHealthRecord(orPHR),whichisasoftwareapplicationortoolthatismaintainedbyindividuals

basedontheirpersonalknowledgeabouttheirhealthand/orthehealthoftheirdependents.PHRscanbe

usedtocollectandtrackpastandcurrenthealthinformationincludingconditions,symptoms,

medications,allergies,immunizations,andemergencycontactinformation(AHIMA,2009a;AAFP,2006).

HealthcareprofessionalsandmarketersarestartingtorealizethebenefitsofPHRsandareincreasingly

focusedonhowtoincreasePHRacceptancebyimprovingtheirfunctionality.Forexample,ina

presentationgiveninAprilof2008attheCenterforDiseaseControlsNationalCenterforHealth

Marketing,thefirstrecommendationforachievingthesegoalswastoconductformalusertestingandmarketresearchonexistingPHRsystemstodetermineuserneeds,preferences,behaviorsandconcerns

(Nall,2008).

Currently,morethan60onlinePHRapplicationsareavailableforconsumerstochoosefrom(AHIMA,

2009b).MajorsoftwareorganizationssuchasGoogleandMicrosoftarestartingtocapitalizeonthe

increasingpopularityofPHRsbycreatingtheirownfreeorsubscription-basedonlinehealthrecord

applications.Unfortunately,onlinePHRsvarywidelyintheircapabilitiesandinterfaces,whichmaymake

itdifficultforindividualstochoosethebesttoolfortheirneeds.

InordertogainabetterunderstandingofwhichfeaturesarenecessaryforaPHRapplicationtobe

accessibleandacceptedbythepopulationatlarge,UserCentricchosetoexaminetwoprominentPHRsthroughausabilitytest.GoogleHealthandMicrosoftHealthVaultwereselectedforusabilitytestingdueto

thewidespreadattentiongiventoeachtool.


6/34


3.Methodology

DuringDecember2008andJanuary2009,UserCentricconductedacomparativeusabilitystudyoftwo

existingonlinePersonalHealthRecords(PHRs):GoogleHealthandMicrosoftHealthVault.(Neither

GooglenorMicrosoftcommissionedorparticipatedinthisstudyinanymanner.)ThehomepagesforbothapplicationsareshownbelowinFigure1.

Figure1:HomepagesofGoogleHealth(left)andMicrosoftHealthVault(right)astheyinitiallyappeartousers.

Thegoaloftheusabilitystudywastounderstandwhichfunctionsandfeaturesweremostpreferredby

participantsandtoobservewhichareaswereassociatedwiththemosterrorsormisstepsonthepartof

participants.DatacollectedfrombothPHRsincludedbothquantitativeandqualitativemeasuresonfive

specificdimensions:overallusability,utility(usefulnessoffeatures),security,privacyandtrust.

Overthecourseof4days,UserCentrictested30participantsduring75to90minutesessionsatitsuser

researchfacilityinOakbrookTerrace,Illinois.ParticipantswererecruitedfromtheChicagometroarea

usinganonlinerecruitmentscreenerdevelopedbyUserCentric.Participantsqualifiedforthestudy

basedontheircurrentuseofonlinetoolstomanagesomeaspectsoftheirpersonallife(e.g.,bank

accounts,onlinebillpayment,onlinecalendarsforpersonalschedules).Participantsincluded13menand

17womenwithavariedagedistribution.2oftheparticipantswereaged18-21,10wereaged22-30,7

wereaged31-40,3wereaged41-50,4wereaged51-60and4wereaged61to65.

Uponarrival,participantswererequiredtosignaconsentformandanon-disclosureagreementwithUser

Centric.Participantswerebriefedonthestudygoalsandproceduresandwereencouragedtotryto

completespecifictasksinthewaytheynormallywould.Theywerealsoencouragedtothinkaloud

duringthetasksandtoexpresstheiropinionsbothpositiveandnegativeabouttheirexperience

duringthesession.Participantswerethenaskedaseriesofwarm-upquestionstounderstandtheir

currenthabitsandinterestsinstoringandmanagingpersonalinformationonline.Next,astandardized

descriptionofaPHRwasreadtoparticipantsinordertoassesseachparticipantsinitialinterestin

creatingaPHRprofile.

Beforethetasksbegan,eachparticipantwasprovideduniquetestaccountstousewhencreatingnew

PHRprofilesoneachapplication.Allparticipantswerealsoprovidedafictionalhealthprofile,developed


7/34


byUserCentric,thatincludedbothchronicandacutemedicalconditionsaswellascommon

immunizations,testresults,medications,andgeneraldemographicinformation.

ParticipantswereaskedtocompleteseventasksoneachoftheGoogleHealthandMicrosoftHealthVault

PHRapplications.ThefirstfourtaskswerecommontobothPHRs:CreateanewPHRprofileandenter

healthinformation,addachildshealthprofiletothePHR,linkfromthePHRtoaphysiciansonlinehealth

record,andupdatethePHRprofilewithanewcondition.Theremainingthreetasksforeachapplication

addresseduniquefeaturesofthePHR.ThetasksspecifictoGoogleHealthwere:Locateadoctor,find

outaboutpotentialdruginteractions,andlearnmoreinformationaboutaspecificmedicalcondition.The

tasksspecifictoMicrosoftHealthVaultwere:Downloadinformationfromamedicaldevice,uploada

medicaldocumenttothePHR,andsharethePHRprofilewithfamilyandfriends.

Duringthetasks,researchersobservedparticipantsinteractionwiththePHRapplications,notedany

participanterrorsormissteps,andrecordedparticipantscommentsandfeedback.Followingeachtask,

participantswereaskedforadditionalfeedbackabouttheirexperience.Afterthelastfivetasks,

researchersalsoaskedparticipantswhethertheyfoundthefeaturehighlightedinthattasktobevaluable

oruseful.

TheorderthatparticipantsusedtheGoogleandMicrosoftPHRapplicationswascounterbalancedacross

participantstoreducepreferencebiasrelatedtopresentationorder.Duetotimeconstraints,notall

participantscompletedalltasks,althoughaconcertedeffortwasmadetocollectdatafromanequal

numberofparticipantsduringthePHR-specifictasks.

AftercompletingalltasksforeachPHR,participantsprovidedfeedbackabouttheiroverallexperience

andusinga7-pointLikertscaletoprovideratingsforthePHRapplicationsusability,utility,security,

privacyandtrust.TheUSEquestionnaire,astandardizedusabilitysurvey,wasalsoadministeredafter

usingeachPHRtogatherquantitativefeedbackaboutthatPHRsusefulness,satisfaction,andeaseof

use.

AftercompletingtasksonboththeGoogleHealthandMicrosoftHealthVaultapplications,participants

wereaskedtodiscusstheiroverallexperienceandgeneralinterestinPHRs.Participantsalsoprovided

forced-choicepreferencesbetweenthetwoPHRsonthefivedimensions(usability,utility,security,

privacyandtrust),andwereaskedwhichPHRtheypreferredoverallandwhatspecificallymotivatedtheir

choice.

AthirdPHR,MyMedicalRecords.com(MMR),wasaddedmidwaythroughthestudyinordertoassessthe

sitesclaimsthatitisthemostuser-friendlypersonalhealthrecordonthemarket

(MyMedicalRecords.com,2007a).UserCentricwasalsointerestedindeterminingifparticipants

commentsregardingtheGoogleandMicrosoftPHRapplicationsappliedtootherPHRs.Thelast12study

participants(outof30)wereabletointeractbrieflywithanexistingPHRprofileonMMRoncetheyhad

completedtheirexplorationofthefirsttwoPHRs.Afteraninitialfreeformexploration,participantswere

askedtocompletetwotasks:AddinganallergytotheirprofileandlinkinginformationfromtheirGoogle

HealthprofiletotheirMMRprofile.AfterinteractingwiththeMMRapplicationforseveralminutes,

participantswereaskedtoindicatewhichPHRtheypreferredoverall:MMRortheirearlierPHR

preference(eitherGoogleHealthorMicrosoftHealthVault).


8/34


Finally,allparticipantscompletedasurveyontheusefulnessofpotentialPHRfeatures(e.g.,sharing

informationwithaphysician,learningaboutsideeffectstomedications),awardingratingsforeachof

theseitemsona7-pointLikertscale.Attheendoftheirsessions,participantswerecompensatedfortheir

time.

4.FindingsfromUsabilityTestingwithGoogleHealthandMicrosoft

HealthVault

UserCentricsusabilitytestinggeneratedanumberofpreliminaryfindingsaboutparticipantsreactionsto

twoPHRs:GoogleHealthandMicrosoftHealthVault.Thissectionwilldetailtheinteractionissuesand

trendsthatwereobservedduringindividualsessions.

Thissectionwillcover:Initialreactions,usabilitytestfindings,PHR-specificfeedback,theUSEand

featuresquestionnaires,andadiscussionofMyMedicalRecords.com.Thetestfindingswillbeaddressed

astheyrelatetoUserCentricsfivedimensionsofinterest:usability,utility,security,privacy,andtrust.

4.1InitialReactiontoPHRs

Basedonparticipantsresponsestothewarm-upquestionsatthebeginningoftheirsessions,only23%

oftheparticipantswerefamiliarwiththeconceptofaPHR.However,afterlisteningtoastandardized

descriptionofaPHR,76%oftheparticipantsindicatedtheywereinterestedinbuildingaPHRor

managingtheirfamilymemberspersonalhealthinformationbyusingonlinetools.Participantslisteda

numberofreasonsforthisinterest,includingtheabilitytomanagealloftheirfamilysrecordsinone

locationandthetime-savingbenefitsofsharingofmedicalinformationwiththeirphysicianorhealth

insuranceprovider.

12outof30participantsindicatedthattheyfeltsecureaboutstoringtheirownorfamilymembers

personalinformationonlinebasedontheirpositiveexperienceswithonlinebankingsites.Theyextended

thisleveloftrusttohealthinformationaswell.28outof30participantsalsoindicatedtheywouldtrust

onlinesourcesforhealth-relatedguidanceandsuggestions.(16participantsmentionedtheycurrentlyuse

WebsitessuchasWebMDtochecksymptomsorresearchhealthtopics.)However,10participantssaid

theywouldnotrelyonaWebsitetobetheirprimarysourceofinformation.

4.2UsabilityTestFindings

ParticipantscompletedthesamesetoftasksforboththeGoogleHealthandMicrosoftHealthVaultPHRapplications.Thesetwoapplicationswerechosenasrepresentativestimulitoexploreparticipants

attitudesaboutPHRsonfivespecificdimensions(usability,utility,security,privacy,andtrust),soUser

Centricsanalysisanddiscussionoftask-specificfindingswillfocusonthesecoredimensionsand

integrateinformationfrombothPHRapplications.


9/34


4.2.1Usability

ParticipantspreferredGoogleHealthssimplehomepage.

Overall,participantsimpressionsofGoogleHealthshomepageweremorefavorablethanthoseof

MicrosoftHealthVaults.Althoughparticipantswerenotdirectlyaskedtocomparethetwo,15participants

volunteeredthattheyfavoredGoogleHealthshomepage,citingreasonssuchasitwaseasiertoaccess,itwaslessclutteredoritwaseasytonavigate.

Incomparison,while5participantslikedthewaythatMicrosoftHealthVaultcontainedmoreinformation

thanGoogleHealth,mostparticipantsdidnotperceivetheextrainformationasabenefit.Instead,they

viewedthisadditionalinformationmorenegativelybecauseitmadeMicrosoftHealthVaultshomepage

verybusy.

Participantsstruggledtoidentifywheretheycouldstartenteringhealthinformation.

ParticipantshadexpecteddirectionfrombothPHRsonwherehowtogetstartedenteringtheirpersonal

information.However,theirfeedbacksuggestedthatneitherGoogleHealthnorMicrosoftHealthVaultclearlyindicatedthisstartingpoint.Thestartscreensforbothapplicationsareshownbelow(seeFigure

2).Atleast7participantscommentedthatthelabelforGoogleHealthsAddtothisProfilelinkdidnot

clearlyindicatethatthisservedasthestartpoint.Asoneparticipantstated,IfIwasstartingout,Iwould

belookingforaninitialCreate[linkorbutton].ParticipantsalsocommentedthatMicrosoftHealthVault

hadtoomanyoptionsortoomuchinformationtoread,whichmadethemuncertainwheretofocus.

Figure2:HomepagesofGoogleHealth(left)andMicrosoftHealthVault(right)withthecurrentstartinglocationshighlighted.


10/34


Enteringmedicalinformationwasaclick-intensiveprocessonbothGoogleHealthandMicrosoft

HealthVault.

Onceparticipantsenteredahealthhistoryitem(e.g.,condition,medication,procedure),mostsaidthey

expectedtoenteradditionalrelateddetailslikedates,dosage,causes,andstatus.InGoogleHealth,

however,participantsalmostalwayshadtoclicktoadditionalscreenstoenteranydetailsbeyondthe

itemsname.Whileenteringdetailsaboutaconditionlikeasthma,forexample,participantsexpressed

frustrationthattheycouldnoteditinformationonasthmafromthehomepage.Theyinsteadneededto

clickonalinkintheleftnavigationmenuorintheProfileSummarytoaccessaseparateConditionspage

andthenselecttheEditlinkontheirAsthmaconditiontoadddetailsforit.

TheonlyexceptiontothisissuewithinGoogleHealthwastheabilitytoaddatestresult(e.g.,atotal

cholesterolresult)viaapopupwindow.Afterenteringthenameofthetestresult,participantscould

immediatelyenterthetestdetailsviathepopup.Participantsreactedpositivelytothismodeofdataentry

andsaidtheywouldhavepreferredtoentertherestoftheirhealthinformationonGoogleHealthinthe

sameway(seeFigure 3).

Figure3:AddingatotalcholesteroltestresultiteminGoogleHealth

Similarly,8participantscommentedpositivelyonhowMicrosoftHealthVaultallowedthemtousethe

samescreentoenterahealthitemandquicklypopulatedetailfields(SeeFigure4).


11/34


Figure4:AddingamedicationusingMicrosoftHealthVault

However,thesheeramountofinformationrequestedbyMicrosoftHealthVaultoftenoverwhelmedsome

participants.AlthoughsomefieldswereclearlymarkedOptional,researchersobservedatleast14

participantssufferingfromcognitiveoverloadwhilereviewingallthefields.Participantsoftenstruggledto

decidewhichfieldstopopulateandwhichtoleaveblank.Otherparticipantsinthestudyfeltdiscouraged

becausetheydidnothavesufficientmedicalknowledgetofillinallthefieldsonvariousscreens.

Ingeneral,whilebothPHRapplicationswereaffectedbydifferentproblems,participantswerefrustrated

bythelevelofeffortrequiredtoentertheirmedicalinformation.

ParticipantsappreciatedtheconfirmationprovidedbyGoogleHealthafterprofileinformationwas

entered.

Afterenteringmedicalinformation,participantsindicatedtheylikedthevisibleconfirmationprovidedby

GoogleHealthsProfileSummary(seeninFigure5)becauseitincreasedtheirconfidencethattheyhad

enteredtheirhealthdatacorrectly.


12/34


Figure5:GoogleHealthsProfileSummary

Incontrast,participantsfoundthatafterenteringahealthiteminMicrosoftHealthVault,theystillneeded

toreturntotheHealthInfoorHometabtoviewthedifferentinformationtypes.

StraightforwardnavigationonGoogleHealthmadeaddingmedicalinformationsimpler.

Overall,mostparticipantsfoundthataddinginformationwasarapidprocesswhentheyusedGoogle

Healthduetotherelativelysimplenavigation.Participantssaidtheylikedtotheabilitytoquicklynavigate

betweenthetopmenutabswhileenteringnewmedicalinformation.Thesetabscanbeseenbelow

(Figure6).

Figure6:GoogleHealthsnavigationtabs

Participantslikedtheoptionofaccessingtheirmedicalinformationusingeitherthetopmenutabsorthe

persistentleft-handmenu(Figure7).Asoneparticipantsaid,[This]sitewasmoreuserfriendly[because

of]theleftnavigationbarandthetabsversushavingtoclickbacktothehomepagetoaddmorehealthconditions.ParticipantsgenerallyfoundGoogleHealthsredundantnavigationmodelsupportiveoftheir

needs,regardlessoftheirpastexperiencewithPHRapplications.Theyalsofounditeasytolocatethe

Addbuttonadjacenttothesearchfield,whichtheyusedforaddingmultipleconditions.


13/34


Figure7:GoogleHealthsredundantnavigation

AlthoughMicrosoftHealthVaultalsousedtabsfornavigation,participantsfounditsinformation

architecturetobedeeperandmorecomplex.Thisforcedparticipantstonavigatethroughseveralscreens

toenterhealthinformation.WhenaddingasecondconditioninMicrosoftHealthVault,forexample,

participantsneededtofirstselecttheHealthInfotabeventhoughmostthoughttheywerealreadyonthe

HealthInfoscreen.Manyparticipantswereconfusedbythisandinadvertentlybecamelost,clicking

betweenmanyotherscreensandtabs(Figure8)togetbacktotheHealthInfotab.

Figure8:CommonplacesparticipantsclickedtoaddmoreinformationfromMicrosoftHealthVaultsHealthInfotab

Participantsbecamemostfrustratedwiththeextraneousclicksnecessarytonavigatetoafrequently

accessedpage.BecausetheprocessofenteringmorehealthinformationwaslessefficientwithMicrosoft

HealthVault,participantsgenerallycitedGoogleHealthasbeingeasiertonavigate.

Multiplesearchtoolsfacilitatedsearching,butmedicaljargonstymiedparticipants.

Mostparticipantslikedtheauto-completefeaturethatbothGoogleHealthandMicrosoftHealthVault

providedaspartoftheirSearchfields.BothPHRsalsoalloweduserstoenterdatanotfoundinthePHR

databases.

However,participantsfoundtheoverallprocessofsearchingfordatamucheasierusingGoogleHealth.

Participantslikedtheflexibilityofbeingabletosearchfordatainseveralways,includingasearchfield


14/34


withauto-completeandascrollablealphabeticallistwhichallowedthemtofilterbythefirstletter(see

Figure9).Thelatterwasusefulforthoseparticipantswhopreferredtoscanavailableconditions,

medications,procedures,testresulttypes,orimmunizations.

Figure9:Auto-completefunctionsonGoogleHealth(left)andMicrosoftHealthVault(right).

Dependingonthetypeofhealthinformationparticipantsentered(e.g.,conditions,medications),Microsoft

HealthVaultprovidedtwodifferentmethodsofdataentry.Forexample,itsometimesprovidedanopen

fieldwiththeauto-completefunctionality.Inothercases,itprovidedadrop-downlistofchoices.

Unfortunately,participantsoftenfeltthattheirchoicewasconstrainedbytheitemsintheMicrosoft

HealthVaultdrop-downlist,becauseituseddifferentphrasingthanexpected.Someofthemedicaljargon

wasalsoveryconfusingtoparticipants,whowerenotsurewhichofthedrop-downlistoptionstoselect.

Forexample,manyparticipantslookedforflushotinthedropdownlistofimmunizationsbutoftendid

notrecognizeinfluenzaasarelatedlabelforthesametopic.Oneparticipantnotedthatitwouldbe

usefultohavebothflushotandinfluenzaavailableinthesamelist.

Ingeneral,participantsexpectedtoeasilymatchtheirmedicaltermwiththecontentsofdrop-downlists.

Theydidnotfeelthatthecurrentterminologydisplayedinthelistsadequatelysupportedtheirvariedand

oftenlimitedunderstandingofmedicaljargon.

Simplemedicallanguagewasstronglypreferredovertechnicaljargon.

BothPHRsoftenusedmedicalterminologythatwasmoretechnicalthanparticipantswerecomfortable

with.Thisphenomenaoftenreflectedagapbetweenparticipantslevelofknowledgeandthespecific

medicalterminologyusedinthePHR.OfthetwoPHRapplications,GoogleHealthtendedtousemore

familiarmedicallanguageandoftenprovidedmorethanonelabelforthesametopictoaidrecognitionby

laypeople.

WhenenteringinformationintoMicrosoftHealthVault,participantstendedtostrugglemore.Theyhad

difficultyenteringboththetitleofahealthitemaswellasitsdetails.Specifically,participantshaddifficulty

figuringoutwhichmedicaltermstoselectaswellastherelevantlevelofmedicalaccuracytousein

HealthVault.Althoughseveralparticipantswantedtobeasmedicallyaccurateaspossible,theywerenot

alwaysabletomakedistinctionsbetweenthemyriadmedicalconditionslistedbythePHR.Forexample,

manyparticipantsindicatedtheyfeltuncomfortableguessingwhichtypeofinfluenzavaccinetheyhad


15/34


beengiven.Oneparticipantcommented,Aphysicianornursecoulddothis,butitsnotforaneveryday

user.

.

Figure10:MicrosoftHealthVaultdropdownlistofimmunizations

AbilitytoaddanadditionalhealthprofilewasfacilitatedinMicrosoftHealthVaultviapersistent

linkingonmostscreens.

ParticipantsweremuchmoresuccessfulinaddingafictionalrelativeshealthinformationtotheirPHR

whenusingMicrosoftHealthVaultbecauseaAddRecordlinkwasconsistentlylocatedonalmostevery

page.Incontrast,eightparticipantswereunabletolocateGoogleHealthsCreateanewprofilelink,

whichwaslocatedatthebottomoftheleft-sidemenuwithtextthatappearedpalerthantherestofthe

itemsinthemenu.

Figure11:Createanewprofilelinkoftheleft-sidemenuofGoogleHealth


16/34


However,theconsistencyofMicrosoftHealthVaultsAddRecordlinkmayhavebeenpartofthereason

someparticipantsincorrectlyinterpretedthelinkspurpose.Duringthefirsttask,someparticipants

incorrectlyassumedthatthislinkwouldallowthemtoaddadditionalhealthinformationtotheirexisting

PHR,butquicklyrealizeditstruepurposeduringtheirsessions.

4.2.2 Utility

Theusabilitystudyalsoidentifiedmanyfeaturesthatparticipantsfoundusefulandwhichmighthelp

motivatethemtoadoptaPHRfortheirownuse.

MostparticipantsthoughtPHRswouldbebeneficialfortrackingachroniccondition.

Throughouttheusabilitysessions,participantsindicatedtheysawvalueinusingaPHRtokeeptrackof

theirhealthhistory,especiallyifonehadachronicconditionthatmayinvolvefrequentchangesin

treatmentandstatus.AdditionalresultsrelatedtoparticipantsperceptionofPHRvaluewillbediscussed

inalatersection.

Abilitytostorehealthinformationforfamilymemberswashighlyvalued.

Theabilitytoeasilystorehealthrecordsformorethanoneindividual(e.g.,dependentsorspouse)was

consideredveryimportanttoparticipants.However,noneofthethreePHRswetestedtrulyprovidedthis

functionalityinaseamlessmanner.Participantsendedupprovidingvaluejudgmentsbasedontheideal

interactiontheyimaginedthisfunctionwouldproduce.

ParticipantswantedtolinkPHRhealthinformationwiththeirphysiciansrecords.

ParticipantsalsoindicatedastrongdesiretolinkthehealthinformationstoredintheirPHRwiththeirphysiciansrecords.Participantssaidtheywouldideallywantthistobeatwo-waychannel.Specifically,

participantswantedtheabilitytoautomaticallydownloadinformationfromtheirdoctorselectronichealth

recordstomakedataentryoftheirPHReasierandmoreaccurateandalsowantedtobeabletoshare

theirPHRwiththeirdoctorinordertoreducetheamountoftimespentfillingoutpaperworkduringoffice

visits.

GoogleHealthsDrugInteractionsfeaturewasperceivedasveryhelpful.

TheDrugInteractionspageofGoogleHealthwasoneofthemostappreciatedfeaturesthatparticipants

encounteredinthestudy.Participantsfoundthetwolevelsofwarning(Figure12)tobeveryusefuland

seemedtotrusttheinformation.(Thisincludedthefewparticipantswhounderstood,bywayofthedisclaimer,toconsulttheirdoctor.)Oneparticipant,forexample,pointedoutthattheinteractionbetween

prescriptionsandover-the-counterdrugsmightbeomittedfromconversationsbetweenpatientsand

physicians,whichiswhyPHRsshouldcontainthistypeofcriticalinformation.


17/34


Figure12:GoogleHealthdruginteractions

FindaDoctorfeaturewasvalued,especiallywhenlimitedtotheparticipantsinsuranceplan.

WhileusingGoogleHealth,12outofthe16participantswhousedtheFindaDoctorfeaturesaidthey

foundituseful,butthreeparticipantsindicatedtheywouldhavepreferredtheresultsbelimitedtotheir

specificinsurancenetwork.OneparticipantalsorequestedalinkontheConditionsscreentophysicians

whosespecialtiesarerelatedtotheconditionslistedintheirPHR.Mostparticipantsindicatedthelinkfor

viewingdirectionstoadoctorslocationtobeoneofthemostusefulcomponentsofthisfeature.

Referenceinformationonmedicalconditionsneededtobefromtrustedsources.

ParticipantssaidthattheGoogleHealthscreenthatdisplayedadditionalinformationaboutacondition

listedinthePHR(includingsymptoms,treatments,potentialcauses,andnews)wasalsointeresting.

However,anumberofparticipantsindicatedthattheywouldrelyonthisfeaturemoreiftheyhadaclearer

ideaofthesourceofthisreferenceinformation.

Figure13:GoogleHealthSymptoms

Nonetheless,participantsdescribedthisinformationaspresentedinanefficientwayandcommentedthat

theavailabilityofreferenceinformationintheirPHRwouldreducetheeffortneededtoresearchtheir

conditions.


18/34


AbilitytouploaddocumentstoMicrosoftHealthVaultwasconsideredpotentiallyhelpfulfor

enteringpastmedicalhistory.

ParticipantsnoticedthefeaturedofferedbyMicrosoftHealthVaultthatallowsuserstouploadamedical

documentsdirectlytotheirprofile.11ofthe17participantswhousedthisfeaturefounditveryuseful,

especiallyforthosewhoanticipatedstoringdocumentsfromtheirchildrensmedicalhistoryorcopiesof

theirowndiagnosticscans.

AbilitytoshareapersonalPHRwithfamilymembersandphysicianswasimportantforsome

participants.

12outofthe16participantswhosawthefeatureindicatedthatMicrosoftHealthVaultsabilitytoshare

theirPHRhadvalue.Participantsanticipatedthatthisfeaturewouldbeespeciallyusefulwhencaringfor

aparentorelderlyrelativewhohadaseparatePHR.However,mostparticipantsdidnotfinditusefulto

sharetheirPHRinformationwithafriendorsomeoneelseoutsidetheirfamily.

UploadinginformationfromamedicaldevicetoMicrosoftHealthVaultwasgenerallyconsidered

useful.

ParticipantswerebrieflyexposedtotheHealthVaultfeaturethatallowsuserstouploadinformationfroma

medicaldevicedirectlyintothePHR.(Duetotimeconstraints,littlesessiontimewasdevotedtogathering

feedbackonthistopic.)13outof18participantswhointeractedwiththisfeatureconsideredituseful.For

example,oneparticipantsaidThiswouldbeveryhelpful.IfIhaddiabetes,Icoulduseitforglucose

testing.OrIcoulduseitwithweightscalesorbloodpressure.However,oneparticipantexpressed

concernthisfeaturewouldonlybevaluableiftheywereabletoentermultipledevicereadingsatonce.

Thisparticipantexpectedthatsingledatauploadswouldlikelyrequiretoomuchtimeandwouldbe

inconvenient.

4.2.3 Security, Privacy, Trust

Participantsrarelyexpressedconcernsrelatedtosecurity,privacy,ortrustwhilecompletingtheirtasks

andprovidingfeedback.Ingeneral,participantsseemedtohavedifficultydifferentiatingbetweenthese

threedimensionsandrarelymentionedconcernsspecifictoanyoneofthem.However,researchersdid

recordsomenotableobservationsandfeedbackrelatedtothesethreedimensions.

ParticipantswantedtransparentsourcesforthemedicalknowledgeprovidedonGoogleHealth.

WhenreviewingthedruginteractionsandreferenceinformationaboutmedicalconditionsinGoogle

Health,4outofthe22participantswhousedthisfeatureexpressedconcernsregardingthesourceofthis

referenceinformation.Itwasnotimmediatelyclearwhatthesourceoftheinformationwas,whichmadethemwaryofrelyingonthisinformation.Theseparticipantssaidtheywerelookingforthenameofa

knownmedicalcompanyoranendorsementbyaknownmedicalorganization.Someofthese

participantswereconcernedthatthemedicalinformationprovidedmighthavebeenaccumulatedfrom

variousInternetsourcesthatmayormaynothavebeenreliable.


19/34


SomeparticipantshadsecurityconcernsaboutlinkingtheirPHRtoaphysiciansEHR.

Althoughsharinginformationwithaphysicianwasoneofthemostpopularfeaturesdiscussedinthis

study,6ofthe30participantsdidmentionsomeapprehensionabouttheprivacyorsecurityofthislink.

Forexample,oneparticipantsaidthatbasichealthinformationdoesn'tbotherme,butpersonalinfois

worrisome.AnotherparticipantsaidIwouldneedsomesortofagreementorcontract.Theinformationis

confidential.

4.3PHR-SpecificQuestionsandRatings

AftercompletingthetasksoneachPHR,participantswereaskedtoprovidetheirgeneralqualitative

impressionsabouttheiroverallexperiencewiththatPHR.Participantresponsesgenerallyfocusedon

eitherusabilityissuesencounteredduringtheirsessionsorfeaturesthatwereconsideredespecially

useful(ornotuseful),whichfurtheremphasizestheimportanceofthesetwodimensionsonoverall

preference.

Duringindividualpost-PHRratings,GoogleHealthratedhigheronthedimensionsofeaseofuse

andutilitywhileMicrosoftHealthVaultwasratedhigheronthedimensionsofprivacyandtrust.

Participantswereaskedtousea7-pointLikertscaletoratethePHRacrossthesamefivedimensions:

easeofuse,utility,security,privacy,andtrust.TheresultsoftheseratingsareshowninFigure14.

Figure14:Participants'averageratingsonthefivedimensionsforeachPHR

RatingswerehigherforGoogleHealthforeaseofuseandutility,althoughtherewasalargerdifference

betweenthetwoPHRapplicationsonthedimensionofeaseofuse.Theaverageratingsforsecurity,

privacyandtrustwereverycloseforthetwoPHRapplicationsalthoughGoogleHealthreceivedhigher

ratingsforsecurityandMicrosoftHealthVaultreceivedhigherratingsforprivacyandtrust.

ThissuggeststhatalthoughthedirectionofparticipantspreferencewasinfavorofGoogleHealth,the

magnitudeofthisdifferencewasrelativelysmallbothGoogleHealthandMicrosoftHealthVault

applicationswereperceivedasfairlysecure,privateandtrustworthy.


20/34


4.4USEQuestionnaires

AftercompletingthetasksandratingsforeachPHR,participantswerealsogiventheUSEquestionnaire,

astandardizedinstrumentdesignedtocollectsubjectivefeedbackonusabilityandrelatedconcepts.The

USEquestionnairehasbeeniterativelydevelopedbyusabilitypractitionersandacademicstoestablisha

consistentmethodologyforthecollectionofsubjectiveuserratings(Lund,1998).

TheUSEQuestionnaireshowedthatGoogleHealthwasratedasbeingeasiertolearn,generally

moreuseful,andeasiertousethanMicrosoftHealthVault.

Figure15showsaverageratingsforthe29itemsontheUSEquestionnaire.GoogleHealthhadhigher

averageratingsthanMicrosoftHealthVaultonallbutonequestion,wherethetwowereequal.The29

questionsweregroupedinto4categoriesbasedontheresultsofafactoranalysisandanoverallaverage

ratingwascomputedforeachcategory.Eachofthe4categorieshadhighinternalconsistencyamong

theindividualquestions(Chronbachs>0.9ineachcase).Thenamesforthecategorieswere

generatedbasedonthewordingofthequestionscontainedineach.GoogleHealthhadhigheraverage

ratingsthanMicrosoftHealthVaultforeachofthecategories,andthedifferenceswerestatistically

significantbeyondthep=0.05levelfor3ofthe4categories.

Figure15:USEquestionnaireaverageratings.The29questionsaregroupedinto4categories(EasytoLearn,Useful,Easyto

Use,Effective)basedontheresultsofafactoranalysis.Averageratingsareshownforeachcategory.A*meansthedifference

betweentheaveragecategoryratingsforGoogleHealthandMicrosoftHealthVaultwerestatisticallysignificantbeyondthe

p=0.05level.QuestionswithineachcategoryaresortedbydescendingaverageratingforGoogleHealth.


21/34


GoogleHealthwascomparedtoMicrosoftHealthVaultforeachofthe4ratingcategoriesusingbotha

matched-pairst-testandaWilcoxonmatched-pairssigned-rankstest,whichproducesazscore.Table1

summarizestheresultsofthesetwotypesoftests.Thepvaluesarefortwo-tailedtestsinbothcases.

Google Microsoft Matched-pairst-test

Wilcoxonmatched-pairs

signed-rankstest

M SD M SD t(df) p z p

EasytoLearn* 5.60 1.00 4.97 1.32 t(29)=2.72 0.011 z=2.35 0.019

Useful* 5.06 1.23 4.43 1.36 t(29)=2.60 0.014 z=2.39 0.017

EasytoUse* 4.85 1.27 3.89 1.54 t(29)=3.25 0.003 z=2.78 0.005

Effective 4.43 1.56 4.11 1.72 t(29)=1.57 0.128 z=1.02 0.307

Table1.SummaryofstatisticaltestsonthedifferencebetweenaveragecategoryratingsforGoogleandMicrosoft.A*

indicatesthatthedifferencewassignificantbeyondthep=0.05level.

TheEffectivenesscategoryofquestionshadthelowestoverallaveragerating,andhadthesingle

questionwiththeoveralllowestaverageratingsforbothproducts,IfeelIneedtohaveit.Thismight

reflecttheperceivedvalueofPHRfunctionalityrelativetocurrentlifecircumstances.Participantswho

reportedhavinghadfewerchronichealth-relatedissuesgenerallysawPHRsaslesscompellingthan

thosewithchronicconditions,dependents,ormultiplemedications.

EasytoUseratingsshowedthebiggestdifferencebetweenthetwoPHRapplicationsintermsofthe

averagecategoryratingdifferencerelativetothestandarddeviations.Inaddition,thelowestoverall

averageratingforMicrosoftHealthVaultwasgivenintheEasytoUsecategory.Theadvantagefor

GoogleHealthwasconsistentacrossall10itemsinthiscategory.Asthenextsectiononfinal

impressionsandoverallpreferencessuggests,participantsfoundGoogleHealthtobemorefamiliarand

straightforwardanddirectoverallpreferenceratingsofEaseofUsewereconsistentwiththeEaseofUse

categoryratingspresentedhere.

4.5FinalImpressionsandOverallPreferences

OnceparticipantshadtheopportunitytoreviewbothPHRtools,theywereaskedtocomparetheir

experiencesusingboth.WhilemostparticipantsstartedtheirsessionnavetotheconceptofPHRs,most

lefttheirsessionperceivingsomevalueintheconcept,with60%oftheparticipantsinterestedinbuilding

theirownprofilesonline.

Neartheendoftheirsession,participantswereaskedtoselectwhichPHRtheypreferredoveralloneach

ofthefivedimensions:Overalleaseofuse,utility,security,privacyandtrust.Thepreferenceresultsare

showninFigure16below.


22/34


Figure16:Overallpreferences

GoogleHealthwasperceivedsignificantlyeasiertouse.

MostparticipantspreferredGoogleHealth(80%)toMicrosoftHealthVaultintermsofperceivedeaseof

use,2(1,N=30)=10.80,p=0.001.ParticipantscommentedthattheyfoundGoogleHealthsterminologyto

bemorefamiliar,itsnavigationtobecleareranditsoverallprocessofenteringdatatobemore

straightforward.TheyalsoperceivedtheoverallflowwithintheGoogleHealthasmoreefficientthan

MicrosoftHealthVault.

ParticipantsfoundperceivedutilityinGoogleHealthsfeatures.

Intermsofutility,GoogleHealth(70%)waspreferredtoMicrosoftHealth, 2(1,N=30)=4.80,p=0.028).

Participantsmostoftenindicatedtheyfoundthemostvalueinthedruginteractionsfeatureandthereferenceinformationaboutacondition(e.g.asthma).

PreferencestowardsMicrosoftHealthVaultintermsofsecurity,privacyandtrustwerenot

statisticallysignificantbeyondthep=0.05level.

HealthVaulthadapreferentialedgeinthethreeremainingdimensions,althoughtheresultswerenot

statisticallysignificantbeyondthep=0.05level.ParticipantspreferredMicrosoftHealthVaultintermsof

security(60%),2(1,N=30)=1.20,p=0.27,privacy(66%),

2(1,N=30)=2.79,p=0.06,andtrust(60%),

2(1,N=30)=1.20,p=0.27).Participantsgavesimilarreasons(e.g.,brand,priorexperience)forpreferring

MicrosoftHealthVaultforeachoftheseareas.

Inafewcases,peoplegavesimilarreasonsforpickingHealthVaultforsecurityandprivacy:Idonttrust

GoogleorImmorefamiliarwith[GoogleorMicrosoft]ortheymayhavehadexperiencewithMicrosoft

fromasoftwaresecuritystandpoint.Overall,however,familiaritywithMicrosoftsbrandwastheprimary

reasonforparticipantspreferenceshere.Also,someparticipantsfeltGoogleHealthwouldbelesssecure

orprivatebecauseitwaslinkedwithsearchande-mailthroughtheGoogleWebapplicationsuite.


23/34


GoogleHealthwaspreferredoverall.

WhenaskedwhichPHRtheypreferredoverall,participantschoseGoogleHealth,19to11(63%),

2(1,N=30)=2.13,p=0.14.Thisresultisnotstatisticallysignificantbeyondthep=0.05level,butitdoes

suggestthatearlierresultsregardingeaseofuseandusefulnesscouldbeimportantforoverall

preference.RegardingtheiroverallpreferenceforGoogleHealth,15ofthe19participantsindicatedease

ofuseasthedecidingfactorandothersindicatedtheypreferredGoogleHealthbecauseofthe

usefulnessofitsfeatures.Onlytwoparticipantsbasedtheiroverallpreferencechoiceontrustor

familiaritywithabrand.

Patternsinpreferenceselectionswereevident.

Therewasaninterestingpatterninthepreferencedatawhichseemstosupportaconnectionbetween

easeofuseandutility.IfparticipantschosethesamePHRforeaseofuseandutility,theyalwayschose

thatPHRoverall.Meanwhile,ifparticipantschosedifferentPHRsforeaseofuseandutility,whichever

PHRtheypreferredforsecurity,privacyandtrustwasthesamePHRtheypreferredoverall.Onlytwo

participantsviolatedthisrule,andtheychosethePHRtheypreferredforeaseofuse.

Figure17:Patterninpreferencedataexplained

Finally,therewasapatterninpreferencesbasedonageaswell.AsshowninFigure18below,younger

participants(18-40yearsold,n=19)weremorelikelytochooseGoogleHealthasbotheasiertouseand

preferredoverallascomparedtoolderparticipants(41-70yearsold,n=11).Apossibleexplanationhere

isthatyoungerindividualsaremorefamiliarwithGooglescommonWebapplicationinterface,which

madeGoogleHealtheasiertolearnandinturninfluencedparticipantsoverallpreferences.Itisalso

tellingthattheageeffectislargerineaseofusethaninoverallpreferencethissupportstheconclusion

thateaseofuseisastrongcomponentofoverallpreference,butnottheonlycomponent.


24/34


Figure18:Patternrelatedtooverallpreferenceandagegroup

4.6FeaturesQuestionnaire

Aftercompletingtheforced-choicepreferencesandprovidingfinalimpressions,participantsweregivena

questionnairethataskedthemtorankhowusefultheywouldfindseveralfeatures.Thequestionnaire

includedallsixofthePHR-exclusivefeaturesshownintesting,severalfeaturessharedbybothPHRs,

andafewhypotheticalfeatures.TheresultsoftheseratingsareshowninFigure19below.

Figure19:Usefulnessratingsofexclusive,sharedandhypotheticalfeatures

Overall,GoogleHealthsexclusivefeatureshadhigheraverageratings,whichsupporteditsoverallutility

preference.ThemostappealingfeaturewasReceivingautomateddruginteractionwarningsfromthe


25/34


PHR,whichonlyGoogleHealthsupported.Althoughtheotherexclusivefeatureshadsimilarratings,the

inclusionofthedruginteractionsmayhavebeenenoughtopushGoogleHealthoverthetopwhen

participantsgavetheiroverallpreferencebetweenthetwoPHRs(itwaschosenasmoreusefulby21of

the30participants).

Theleastdesirablefeatureshighlightedaninterestingtrendwhichmayberelatedtotheperceivedquality

ofinformation.Threeofthelowest-rankedfeatureswereallowingotherstomodifyarecord,getting

automatedtreatmentrecommendations,andreadingotherscommentsaboutdoctorsormedications.

Sinceallthreeofthesefeaturesaresimilarinthattheyinvolvefindinginformationfromexternalsources

otherthanhealthcarepractitioners,itcouldbethecasethatparticipantssimplywerenotconfidentinthe

qualityofmedicalinformationtheywouldobtainbyusingaPHR.

Finally,participantinterestwaspositiveformostofthehypotheticalfeatures,Thehypotheticalfeatures

LearningaboutmedicationsideeffectsandCustomizingviewswereseenasespeciallydesirable.This

isimportantinformationtoconsiderforthoseinterestedincreatingabetterPHRinterface.

5.QualitativeParticipantFeedbackonMyMedicalRecords.com

Midwaythroughthestudy,researchersatUserCentriclearnedofathirdPHR,knownas

MyMedicalRecords.com(MMR),thathadbeencommonlyadvertisedasaneasytousetoolwithfeatures

thatmanyoftheearlierparticipantshadexpressedinterestin(MyMedicalRecords.com,2007b).

Therefore,UserCentricdecidedtoaddtasksrelatedtothisthirdPHRtotheendoftheremaining

usabilitysessionsandcapturequalitativefeedback.

AftertheyexploredthefirsttwoPHRs,thelast12participantswereabletobrieflyinteractwithMMR.

However,sinceparticipantsexposuretoMMRwaslimitedcomparedtotheirmorethoroughexplorationofGoogleHealthandMicrosoftHealthVault,thethreeapplicationscannotbedirectlycompared.Figure

20belowshowstheMMRmembershomepage.


26/34


Figure20:MyMedicalRecords.commembershomepage.Thefoldericons,pagebreak,andthelinktoaddmedicalinformationarehighlighted.

Uponinitialinspectionofboththeinitiallandingpageandthemembershomepage,4outof12

participantshadpositivereactions,sayingthepageseemedformalorpolished.However,8

participantsdidnotpreferthehomepagesvisualpresentation,sayingitseemedbusyorunorganized.

Participantsstruggledtofigureouthowtoentermedicalinformation.

WhenparticipantswereaskedtoaddanitemtotheirexistingMMRprofile,manyindicatedtheyexpectedtobeabletoaddhealthinformationthroughoneofthetwelvefoldericonsshowninthemiddleofthe

homepage.9outof12participantsexpressedfrustrationonthistask,sincethelinktoaddmedical

informationwaslocatedbelowthefoldofthehomepageandmanyparticipantsrequiredthemoderators

assistancetofindit.

OncetheylocatedthecorrectlinktotheMedicalHistorypage,participantsagainstruggledtofindaway

toaddmedicalinformation.Thetargetlinkforaddingnewitemswaslocatedontheverytopofthepage

amongunrelatedfilteringfunctions.Instead,mostparticipantsattentionwasfirstdrawntotheredEdit

linkswithinthemainbodyofthepage.BothoftheseitemsarehighlightedinFigure21below.


27/34


Figure21:MyMedicalRecords.commedicalhistorypage

ParticipantslikedMMRsdataentryform.

Theprocessofaddingmedicalinformationwaspositivelyregardedbythoseparticipantswhosawit.One

positivefeatureofMMRwasthatsomeoftheformfieldswoulddynamicallyupdatebasedonwhatwas

chosenfromtheDescriptiondropdown.Oneparticipantsaidthatthismadeiteasiertoinputdataon

MMRthaneitherGoogleHealthorMicrosoftHealthVault,becausetheywouldbeabletoenteracategory(e.g.,Condition,Immunization,Medication)anditsdetailsinasinglestep.

Figure22:Descriptiondrop-downwhenaddinginformationonMMR

MostparticipantsdidnotseevalueinlinkingtheinformationoftwoPHRs.

10ofthe11participantswhoattemptedtolinktheirGoogleHealthprofiletotheirMMRprofilewere

successful.Twoparticipantscommentedthatthebuttonwaseasytofindandthatthefunctionwaseasy

toaccessinoneclick.

However,8ofthe11participantswereunsurewhytheywouldneedtolinktwoPHRsorevenwhyone

wouldusemorethanonePHRatall.Threeparticipantssuggestedthatthefunctioncouldbeusefulif,for

example,theirphysicianusedMMRwhiletheyusedGoogleHealth,oriftheywantedtoimport


28/34


informationfromanoldPHRastheymadeapermanentswitchtoanother.Twoparticipantsalsofelt

unsureaboutthesecurityoflinkingtwoPHRsbecausetheirpasswordswouldbestoredinmorethanone

place.

AttheconclusionoftheirexperienceinteractingwithMMR,sixparticipantsreiteratedthattheyfound

MMRunorganized,whichmadeithardertofindwhattheywerelookingfor.Whiletwoparticipants

discoverednovelfunctionsandfeaturesontheapplication(e.g.,DentalandVeterinarianrecords),only

oneofthe12participantssawenoughadditionalvalueinMMRtorankithigherthantheirearlierPHR

preference.8ofthe12participantsindicatedtheyfoundtheirearlierpreferenceeasiertouseandtwo

participantsmentionedthiswasespeciallytruesinceMMRrequiresasubscriptionfee.

6.RecommendationsforImprovingPHRInterfaces

ThisusabilitystudyallowedUserCentrictogainabetterunderstandingofwhatdidanddidnotworkin

threePHRapplications:GoogleHealth,MicrosoftHealthVaultandMyMedicalRecords.com(MMR).WhilenoneofthePHRsstudiedhadaperfectinteractionmodel,thedatamotivatedUserCentrictodevelopa

seriesofbestpracticestobeconsideredwhenimplementingaPHR.Thebestpracticesdiscussedbelow

arebasedsolelyontheissuesobservedandfeedbackgivenbyparticipants,andleaveroomforfurther

developmenttowardabetterPHR.

Sinceperceivedsimplicityandeaseofusearekeystouserpreference,aPHRhomepageshould

avoidunnecessaryvisualcomplexity.

Duringtheusabilitytest,participantsshowedastrongpreferenceforthelayoutofGoogleHealths

homepagewhencomparedwithMicrosoftHealthVaultshomepage,mainlyduetoitssimplicity.Google

Healthusedaplaindesignonitshomepagewithonlycriticalnavigationandafewlinksprominentlydisplayed.Participantsfounditeasiertoaccess,lesscluttered,andeasytonavigate.Thisfocusona

fewimportantpointsalloweduserstoquicklyscantheinformationpresentedandfindwhattheycamefor.

APHRshouldonlydisplaynavigationandinformationnecessarytocompletecoretasksonits

homepage.

APHRshouldprovidestrongcuestohelpusersstartenteringhealthinformation.

SincenewuserswillnotgenerallybetrainedtouseaPHR,aPHRapplicationshouldbedesignedto

supportusersfromtheirfirstinteractionwithit.Inthestudy,participantshaddifficultywithhowtobegin

enteringhealthinformationintoallthreePHRsandindicatedtheywerelookingforguidancefromthe

applicationsonhowtostartthisprocess.ThisisespeciallyproblematicbecausethemainfunctionofaPHRistoenterhealthinformation,anditshouldbeeasyfornewuserstojumpinandenterhealthdata.

Instead,aPHRshouldprovideastrongvisualcuetotheuserforhowtobeginenteringthisinformation,

suchasawelcomepage,largebuttonorlinkrepresentingastartingpoint.


29/34


Usersshouldbeabletoadddetailsaboutahealthitem(e.g.,medication)immediatelyafter

enteringitsname.However,thenumberofdetailfieldsdisplayedatonetimeshouldbelimitedto

avoidoverwhelmingusers.

Theprocessofenteringdatashouldbeassimpleaspossible,allowinguserstoenteritemsquicklywhile

alsoprovidinganopportunitytoenterdetailsimmediately.BothofthetwoPHRstestedproveddifficultfor

participantsinsomeaspectofdataentry.Forthemostpart,GoogleHealthprovidedaquickpathto

enteringthenamesofhealthitems,butrequireduserstonavigatethroughmultiplescreenstoadddetails

aboutthoseitems.Ontheotherhand,MicrosoftHealthVaultalloweduserstoadddetailsrightaway,but

thesheeramountofentryfieldsdisplayedforeachhealthitemwasoverwhelmingforparticipants.

BothendsofthisuserexperiencemustbeconsideredwhendesigningthedataentryprocessforaPHR.

Participantsoverwhelminglypreferredtobeabletoenterdetailsaboutahealthitemonthesamescreen

asitsname,soaPHRshouldsupportthisprocess.However,thePHRmustalsobedesignedtoensure

thatitsusersarenotoverwhelmedwiththeamountofinformationtheyneedtoenter,possiblybylimiting

theamountofdataentryfieldsdisplayedatonetime.

Medicalinformationshouldbepresentedwithouttechnicaljargon.

Non-technicallanguageshouldbeusedbyinPHRapplicationswheneverpossiblebecauseparticipants

werefrequentlyconfusedbythemedicalterminologytheydidnotunderstand.Thiswasespecially

apparentwhenmedicaltermswereusedasfielddescriptionsinMicrosoftHealthVault.Byusingfamiliar

terminologyinlinks,fielddescriptions,andotherareas,aPHRwillprovideuserswithamuchcleareridea

ofwhatinformationtheyarebeingaskedtoenter,whichwillinturnhelptoensuretheaccuracyofusers

healthprofiles.

Multiplemethodsofdataentryandsearch(e.g.,textentryfield,A-Zlist)shouldbesupported.

BothGoogleHealthandMSNHealthVaultofferedauto-completefunctionalityforusersastheyentered

text,butonlyGoogleHealthalsoofferedanA-Zlistofmedicalitemstochoosefrom.Participantsfromthe

usabilitystudyenjoyedGoogleHealthsflexibility,withsomeparticipantspreferringtoidentifytheir

specificmedicalissuesbybrowsingthroughtheA-Zlist,andotherspreferringtousethetextentryfield.

BothofthesemethodsforenteringhealthinformationshouldthereforebeincludedinaPHRto

accommodateabroadrangeofusers.

Databasesofhealthinformationshouldincludemultipledescriptionsofthesamehealthitemsto

accommodateusersdifferinglevelsofcomfortwithmedicalterminology.

Participantsoftenfeltconstrainedbytheterminologysuggestedbytheauto-completefunctionalityinboth

PHRsandsometimesdidnotknowwhichitemtochoosewhentheydidnotunderstandthelanguage

used.Textentryfieldsshouldbeflexiblewhenidentifyingthemedicalitem(e.g.,medication,testresult,

condition)userstypeintothem.ThePHRdatabaseshouldbeabletorecognizewhateverlevelof

technicalterminologyusersarecomfortablewithbystoringmultipledescriptionsofthesamemedical

item.Itshouldalsohelptobridgethegapbetweenlaymansknowledgeandmedicalterminologyby

helpinguserstotranslatetheirunderstandingintoprecisemedicalterminology(e.g.,suggestingspellings,

filteringconditionsvianaturallanguageprompts).


30/34


Aconfirmationshouldbedisplayedasitemsareaddedtoausersprofile.

Duringthestudy,participantswerepleasedwiththeimmediate,detailedonscreenconfirmationprovided

byGoogleHealthastheyaddedhealthitemstotheirprofiles.Theseusersfeltmoreconfidentthattheir

itemswereaddedsuccessfully.OnMicrosoftHealthVault,however,changeswerenotconfirmed

immediatelyforusers,insteadforcingthemtoclickbacktotheHealthInfoorHometabtoviewalistofall

informationtypestheyhadentered.Aclearlyvisibleconfirmationofchangesmadetohealthitems,such

asawindow,message,icon,orrunningprofile,shouldbeimplementedinPHRapplicationstoconfirm

successfuldataentry.

ProfilesummaryinformationshouldbedisplayedoneverypageofaPHR.

AsparticipantsenteredmedicalinformationintheirGoogleHealthprofiles,theyappreciatedthe

persistentProfileSummarythatupdatedeverytimetheyaddedanewitemormadeachange.This

ProfileSummaryconfirmedchangesmadetotheprofileaswellasremindingparticipantswhat

informationtheyhadalreadyenteredaboutthemselves.Thistypeoffunctionalitywouldbeausefulway

foraPHRtoallowuserscontinualreferencetotheirprofiledata.

PersistentnavigationshouldbemaintainedthroughoutaPHR.

ManyparticipantsalsoindicatedtheyfoundGoogleHealtheasiertousebecauseofitsredundant

navigationmodelwhichutilizedbothtab-basednavigationandapersistentleftnavigationmenu.Asa

result,userscouldeasilynavigatefromonehealthhistoryitemtothenextbyusingeithermenu.PHR

applicationsshouldincludesuchpersistentnavigationtoallowuserstoaccessanyfunctionontheWeb

siteapplicationfromtheeachscreen.

Theabilitytoaddafamilymembersprofileshouldbeprominentlydisplayedandeasytofind.

Whileparticipantswereabletosuccessfullyfindthepersistentlinktoaddafamilymembershealthrecord

onMicrosoftHealthVault,theywereveryfrustratedbyitslackofprominenceinGoogleHealth.Sinceone

ofthecorefunctionsofaPHRistoenableuserstoinputdatanotonlyforthemselvesbutalsofor

dependents,thisabilityshouldbeemphasizedinanyPHR.

SomeparticipantswerealsoconfusedaboutthedifferentlabelsforthisfunctiononeachPHR,mainly

duetotheuseofthepotentially-confusingtermsrecordorprofile.APHRthatusesaclearlabel(e.g.,

AddaFamilyMember)wouldallowitsuserstoavoidthisissue.

DrugInteractionfunctionalityshouldbeincluded.

Oneofthemostpositivelyreceivedfunctionsthroughoutthestudywasthedruginteractiontoolavailable

onGoogleHealth.Participantsalsoratedtheabilitytolearnaboutpossiblesideeffectstomedications

quitehighlyinthefeaturesquestionnaireadministeredattheendofthestudy.However,some

participantssaidthatthesefeatureswouldonlybevaluableiftheycamefromatrustedsourceandthey

wouldlikelylooktotheirdoctorasaprimarysourceforthisinformation.


31/34


IfitispossibletointegrateinsuranceinformationintoaPHR,thetoolshouldincludetheabilityto

findadoctor.

AstheyusedthefeatureonGoogleHealth,someparticipantswereinterestedinbeingabletofinda

doctor,butthisinterestwaslimitedtofindingdoctorswithintheirhealthinsuranceprovidersnetwork.

Mostparticipantsfoundthelinktoseedirectionstoadoctorslocationtobeoneofthemostuseful

componentsofthisfeature.Thisfeature,then,shouldonlybeincludedinaPHRifthetoolwasalsoable

tointegrateusersinsuranceinformationtobettertargetsearches.

IfanonlinePHRprovidesmedicalknowledge,thesourceofthatinformationshouldbeplainly

showntouserssotheycanmaketheirownjudgmentsabouttheinformationsreliability.

SomeparticipantswereinterestedintheReferencefeatureonGoogleHealththatdisplaysgeneral

medicalinformationaboutaparticularcondition.However,theseparticipantswerealsoconcernedabout

thereliabilityoftheinformation,sincethesourceswerenotvisible.APHRshouldconsiderimplementing

afeaturethatdisplaysmedicalinformation,butthatalsoclearlylinkstoitssources.

APHRshouldallowusersasecurelinktotheirphysicianshealthrecordsandallowthemtoboth

uploadtoanddownloadfromtheirphysiciansEHRs.

Sharinginformationwithaphysicianwasseenbymanyparticipantsasamainreasonformaintaininga

PHR,makingitanessentialfeaturetoinclude.Usersshouldbeabletoimportdatafromaphysicians

EHRtoavoidtherepetitionofdataentryintothePHR.Theabilitytoexportandsharefamilyhistory

informationandsymptomswithaphysicianorotherfamilymemberswasalsohighlypraised,andshould

besupportedbyPHRs.

However,whenaccessinghealthinformationfromaproviderssystem,privacystandardsmayrequirea

certainlevelofauthenticationwhichmustbeconsideredinthePHRdesign.Itmaybenecessaryfora

PHRtoemploysecurepasscodesorothermeansofreliablyidentifyingindividuals.

Itisimportanttoestablishbrandcredibility,asitisamotivatingfactorforuserstochooseaPHR.

Asmentionedearlier,participantssaidtheywouldfeelmorecomfortablewiththeinformationgivenina

PHRifitwasfromorendorsedbyaknowncompanyormedicalassociation.Brandcredibilitywillhelpto

ensurethesuccessofanyPHR.

APHRshouldhaveeasilyaccessibleprivacyagreementsandotherlegaldisclosures,inlanguage

thatissimpletounderstand.

Someparticipantsmentionedthattermsofuseandprivacypolicieswereunusuallyimportantinthe

contextofaPHR.Becausetheseapplicationsinvolvepersonalhealthinformation,aPHRshouldmake

certaintoprominentlyexplaintousershowtheirdatawillbehandled.However,itisalsocriticalthatthis

informationbepresentedinareadableandsimpleformat,sothatusersarenotintimidatedbypagesof

legaljargon.


32/34


Differenttypesofusersandtheirhealthneedsshouldbeconsciouslyaddressedwhendesigning

functionalityforaPHR.

BecausemanyparticipantssawsignificantvalueinusingaPHRiftheyhadachroniccondition,itis

importantthattheidealPHRistailoredtothistypeofsituation.Althoughnotincludedinaspecifictaskin

thestudy,theprocessofaddingmultipleupdatestothesameconditionwasnotstreamlinedbyanyofthe

threePHRsstudied,whichmaylimittheirutilityforuserswiththesetypesofconditions.Considerauser

withacomplicatedconditionlikebreastcancer.WhenthisuserinitiallysetsupherPHRprofile,shemay

wanttoinputhercancersentirehistory,includingrelatedtestresults,treatmentregimens,medications

andprocedures.

Then,eachtimethestatusinherhealthchanges,thePHRwillneedtobeupdated.Thecurrentmodel

usedbyallthreePHRsinthisusabilitystudysimplyallowsfornewlineitemstoasinglecategoryof

information(e.g.,conditionormedication).TheidealPHRshouldallowuserswithsuchconditionstotie

differenttypesofinformationtogetherundertheumbrellaofasinglemedicalissueandenableeasy

updates.

7.NextStepsforPHRApplications

PerformingusabilitytestingonseveralpopularPHRsallowedUserCentrictogetacloser,morestudied

perspectiveontheuserexperienceofPHRsaswellastheirmostvaluablefeaturesandfunctions.The

wealthofdatagatheredfromtheresearchwasusedtoinformthedevelopmentofsomedesignbest

practicesforPHRs.UserCentricencouragesfurthervalidationofthepreliminaryideassuggestedfor

thesebestpracticesabove.

Whilethereisstillmoretobelearnedinthisdomain,obtainingactualusersfeedbackandexperiencesisanessentialsteptoincreasingtherateofPHRadoption.Asafollow-uptothePHRusabilitytesting

describedinthiswhitepaper,UserCentricconductedanonlinesurveytogatherfurtherdataonattitudes

towardsPHRs.Althoughanalysisofthesurveydataiscurrentlyongoing,severalrelevanttrendshave

beenidentified.

Onecriticalpointisthatsurveyrespondentswerenottypicallypreparedtoinvestalargeamountoftime

inconfiguringorupdatingtheirPHR.Mostcommonly,respondentswerewillingtospendbetween10and

30minutessettinguptheirPHRandwerewillingtoupdateitonlymonthlyoryearly.Thishighlightsthe

importanceofthePHRuserexperiencetoadoption;ifdataentryisdifficultorinefficient,thePHRmaynot

beworththeuserstime.

AnotherinterestingfindingincludedthefeaturesthatwouldmostdriverespondentstoadoptaPHR.

Thesewere:

Trackimmunizationrecords

Securelyreceivetestresultsandinformationfromyourphysician

Shareyourhealthinformationwithyourprimaryphysician

Manageinsuranceinformationandmedicalbills

Getremindersaboutregularcheckupsorrecurringtreatments.


33/34


Sharingonesinformationwiththeirphysicianwastheonlyoneofthesefeaturestobeincludedonthe

questionnairegivenduringtheusabilitytesting,anditscoredhighlyinboththetestingandthesurvey.

Theotherfourfeatureswereamongthosenewlyintroducedforthesurvey.

Inadditiontothisonlinesurvey,UserCentricisconductinganonlinetestoftask-basedfirst-click

responsestoassesstheeffectivenessofpagelayoutandterminologyusedinthethreePHRsevaluated

intheusabilitystudy.

Inthefuture,UserCentricwillreleaseamoredetailedreporttodiscussthesurveydataandits

implications.Additionally,focusgroupsfeaturingindividualswithdistincthealth-relatedprofiles(e.g.,

healthprofessionals,parents)arealsoplanned.


34/34

8.References

AAFP(AmericanAcademyofFamilyPhysicians).(2006).AnintroductiontoPersonalHealthRecords.

RetrievedJanuary26,2009,fromAAFPNews&PublicationsWebsite:

http://www.aafp.org/fpm/20060500/57anin.html

AHIMA(AmericanHealthInformationManagementAssociation).(2009a).WhatisaPersonalHealth

Record?RetrievedJanuary26,2009,fromMyPHR.comWebsite:

http://www.myphr.com/what/what_is_a_health_record.asp

AHIMA(AmericanHealthInformationManagementAssociation).(2009b).HowtochooseaPHRsupplier.

RetrievedJanuary26,2009,fromMyPHR.comWebsite:http://myphr.com/resources/phr_search.asp

Arnst,Catherine.(2006).ThebestmedicalcareintheU.S.RetrievedJanuary26,2009,from

BusinessWeekWebsite:

http://www.businessweek.com/magazine/content/06_29/b3993061.htm?chan=tc&chan=technology_technology+index+page_best+of+the+magazine

KaloramaInformation.(2008).OnlineaccessofpatienthealthrecordsaddsnewdimensiontoEMR.

RetrievedJanuary26,2009,fromMSNBCMarketwireWebsite:

http://www.msnbc.msn.com/id/28437746/

Lund,A.M.(1998).Theneedforastandardizedsetofusabilitymetrics.Inthe Proceedingsofthe

HumanFactorsandErgonomicsSociety42ndAnnualMeeting.SantaMonica,CA:HumanFactors

andErgonomicsSociety,688-691.

MyMedicalRecords.com.(2007a).MyMedicalRecords.comoffersfreeadvanceddruginformation/interactiontooltothepublic. RetrievedJanuary27,2009,fromMyMedicalRecords.com

Website:http://www.mymedicalrecords.com/pressRoom.jsp

MyMedicalRecords.com.(2007b).FormercongressmanRichardGephardtjoinscampaigntopromote

availabilityofelectronichealthrecordsforallworkingAmericans. RetrievedJanuary26,2006,from

PRNewsWire.comWebsite:http://www.prnewswire.com/cgi-

bin/stories.pl?ACCT=104&STORY=/www/story/02-12-2007/0004525403&EDATE

Nall,Janice.(2008).Proposedrecommendationsforusingsocialmediatoincreaseadoptionofand

enhancethefunctionalityofPersonalHealthRecords(PHRs)[PowerPointslides].RetrievedfromU.S.

DepartmentofHealthandHumanServicesWebsite:http://www.hhs.gov/healthit/ahic/materials/04_08/ce/nall_recs_files/textonly/index.html

Date post:	30-May-2018
Category:	Documents
Upload:	user-centric-inc
View:	214 times
Download:	0 times

Usability Guidance for Improving the User Interface and Adoption of Online Personal Health Records

Documents