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Transcript of Designing Healthcare Technologies: Motivating Users by Decreasing Cognitive Load (Julie Rennecker...
Cognitive Overhead in Healthcare
Designing Healthcare Technologies: Motivating Users by Decreasing Cognitive LoadShannon Halgren, PhDJulie Rennecker, PhD
Good morning. Thank you for joining us. When we started designing products for healthcare, several years ago, we quickly realized that what we thought we know about design, didnt always apply to healthcare. That realization interested us enough to explore this product use environment at a deeper level and to shift our design processes to meet the unique needs of these users. In this talk well share what weve learned.
Were happy to be here this morning to talk with you about cognitive loadwhich we refer to as cognitive overhead--as it applies to healthcare technology design. Well talk about what cognitive overload is, how it affects healthcare workers, and ways that we designers can minimize it through our product designs.
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HUMAN USE ERROR
Im going to begin by taking about error.
We ALL make mistakes. And we know mistakes, or what we in Human Factors call Human Use Errors, are made in the healthcare environment.
But, what factors affect when and how often human use errors are made?
How can the design of medical devices and applications minimize human use error?
These are some questions well be exploring during this presentation.
Lets begin by taking a quick look at a few documented human use errors in the use of medical technologies2
Feeding Tube and Trach Tube
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TubingandLuerMisconnections/ucm313275.htmFatal Tubing Mash-Ups
In healthcare, a common source of human use error are what call fatal tubing mash-ups. This is where a healthcare working connect two tubes together that should not be connected.
In this case, a feeding tube was accidentally inserted into a trach tube port and milk was delivered to an infants lungs.
The result was fatal.
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EHR ExampleLab ResultK+(3.1 mEQ/L)Dr. AIV K+ Order 1(40 meQ over 4 hr)Dr. AIV K+ Order 2(100 meQ addition to existing fluid)Dr. AAttempted to cancel first order(cancelled a similar order by mistake)PharmacyFilled Order 1Changed Order 2(too much K+, used 80 meQ)Nurse(s)Carried out Order 1 Carried out Order 2(40 meQ IV bolis and 80 meQ/L drip started}Dr. BMistakes low K + lab result as NEWTreats for low K+Patient K+(7.8 mEQ/L, normal = 3.7-5.2 mEQ/L)Shift Change36 hours later
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!(ONC, Health IT: Patient Safety Action & Surveillance Report, 2013: p.4)
And, in this example, an unfortunate string of errors related to the use of an Electronic Health Record (EHR) put a patient in serious danger, though he lived.
It began whenA gentleman had a low K level, 3.1 mili equivalients. Its just a little bit low, but does require treatment.Dr. A orders a K bolus to be delivered over a short period of timeThen he noticed the pt. already has an IV so decides it would be better to add the K to the existing IV fluid for a longer delivery time which results in greater pt. comfort (K sometimes burns).He attempted to cancel the first order, but instead cancelled a similar order by mistake.Pharm. filled the first order and changed the second order to comply with hospital policy around K treatments, but did fill it.Both orders, the bolus and the slower K administration, were carried out by the nurses.Shift change: Dr. B sees the 3.1 K level and interprets is as a new, post treatment lab value and treats for low K.K now has more than doubled. I very high or low level can stop the heart. They caught this mistake
The problem wasnt that these healthcare workers didnt care or were being careless, it was that the EHR allowed these mistakes to happen. There were several places along the way where the HER could have been more helpful in preventing this series of mistakes.
While health IT presents many new opportunities to improve patient care and safety, it can also create new potential hazards.5 poor user interface design or unclear information displays can contribute to clinician errors. (ONC, Health IT: Patient Safety Action & Surveillance Report, 2013: p.4)
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Human use errors are NOT a tiny problemInstitute of Medicine, 2000, To Err is Human44,000 98,000 deaths/year
Approximately one full 747 crashing every day
We wish that these errors were isolated incidents, but theyre not--the statistics on healthcare errors are staggering..
In 2000, the IOM published a study that got a great deal of public attention. In that report, they stated that almost 100,000 people per year died due to preventable medical errors. This is the equivalent of one full 747 crashing every day, which of course, we would hear about.
This report caused a number of new initiatives, guidelines and regulations designed to prevent human use error. 5
Human use errors are NOT a tiny problemInstitute of Medicine, 2012, Best Care at Lowest CostNorth Carolina: 18% of hospital patients are harmedMedicare: 14% of hospital patients harmedClassen et al: 33% of hospital patients harmed Estimated 86% of adverse events are unreported!
James, 2013, Journal of Patient Safety New estimate of preventable deaths: 210,000 400,000/yearPreventable incidents of serious harm: 2 8 million/year
However, fast forward a little more than a decadeSubsequent studies published in 2012 and 2013 suggest that the situation has not improvedEven worse, approximately 86% of adverse events are unreported A second study found that the original study may have underestimated the problem by as much as a factor of 4, putting the number of preventable deaths as high as 400,000 per year and the incidents of preventable serious harm are as high as 2-8 million/year.
Its difficult to determine the proportion of these errors due to medical device design, but as designers, we certainly dont want to worsen the problem.6
Why do errors like these happen?
ACT II
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Designing for the Context of Use
Standards for drugs and medical devices concentrate on safe design and production, with less attention to their safe use [in context].- Institute of Medicine, To Err is Human,1999
One recommendation from the original IOM study was that device design needed to pay more attention to the use of devices IN CONTEXT, not just whether they delivered the appropriate fluid or electric current, for example, at the correct rates.
Through our own research, weve seen that a critical component of this context is the mental workload of the healthcare user.
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Were not in Kansas Anymore! Fear of Litigation Infection Control Heavy Regulation High Risk Tasks Multi-Tasking Time Critical Tasks Mistakes = Lives High Accountability Sleep Deprivation Complicated Technology Multi-Disciplinary Teams
All of us involved in healthcare know that its a complex, high-risk world full of logistical and regulatory challenges just to name a few
So it should be no surprise that healthcare workers have a lot on their mind when theyre interacting with the devices youve designed.
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An inside look at thehealthcare environment
Trauma Patient Video
The first follows a trauma patient who arrives in the ER with a head trauma.The second will provide a look at one hospital unit through the eyes of an ICU nurse.
As you watch this first video, notice the wide number of complex micro-environments found within this healthcare facility 2 minutes
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What Did You Notice?
In this video, we saw a fairly typical trauma patient sequence beginning with the LifeFlight helicopter (or other ambulance) transferring to the ER, on to surgery, and finally to an ICU bed. What did you notice that might be important for you to keep in mind for designing healthcare devices? 12
What Did You Notice?
The need for speedFrequent interruptions/multi-taskingMultiple handoffsMultiple, diverse playersLots of equipment, all with unique UIsThe pressure to get it right
Here are some things we noticed 13
An inside look at thehealthcare environment
ICU Nurse Video
The first follows a trauma patient who arrives in the ER with a head trauma.The second will provide a look at one hospital unit through the eyes of an ICU nurse.
As you watch this first video, notice the wide number of complex micro-environments found within this healthcare facility 2 minutes
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As you watch this video, try to keep track of all the different tasks and technologies this nurse works with across a few hours2 minutes
Rook ICU/Post-Op NurseRook cares for a recovering post-op patient while awaiting another from surgeryAfter working with her own patient, Rook assists in room set-up for a new admitAfter room setup, Rook gets a call another patient is arriving from surgeryThroughout the day, Rook mentors a novice CTICU nurseAfter assisting a nurse colleague, Rooks primary patient is about to arrive
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What Did You Notice?
In just 2 minutes, we saw an ICU nurse perform several tasks: Care for/monitor a post-op patientSetup for a new admitReceive a second post-op patientMentor a novice ICU nurseAssist colleagueGet suppliesEtc.
What did you notice that might be important for you to keep in mind when designing healthcare devices? [TAKE THEIR COMMENTS] --- if giving talk to smaller group16
What Did You Notice?
The pressure for accuracyFrequent interruptions/multi-taskingLots of equipment, all with unique UIsMultiple, diverse playersTraining during task performance
While the task details might vary from one hospital unit to the next or between hospital units and outpatient clinics, there are several recurring themes that span unit types and facilities[READ SLIDE]
Longer version/smaller groupIF MANY COMMENTS: Those are great observationshere are a few that we came up with: IF NONE or FEW COMMENTS: Here are some things we noticed: 17
Users Motivations: Comparison Across IndustriesOnline Retail
Social Media Healthcare
Need for speedMedMed to HighExtremely HighNeed for accuracyMed to HighLowExtremely HighConsequence of slow responseLowLow to MedMed to Extremely HighConsequence of errorMedLow to MedMed to Extremely HighUser stress levelLowLow to MedMed to Extremely HighEnvironmental distractionsLow to MedLow to MedMed to Extremely HighVariety of technologyLowLowExtremely High
To appreciate why designing for healthcare is so different, lets step back and take a look at User motivations when performing technology tasks in healthcare compared to performing technology tasks in other industries that we as a UX community more frequently support.18
How do we create technology for this unique user group & complex context?
READ SLIDE
To answer this question, wed like to review some basic concepts from cognitive psychology [Click!]
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Cognitive Psychology 101
Julie: and to do that Ill turn it over to Shannon, the cognitive psychologist member of our team.
Shannon: Lets spend a few minutes going back to Cognitive Psych 10120
Cognitive LoadWhitenton, K. (2013). Minimize Cognitive Load to Maximize Usability. Article published online. Cognitive Load:
The amount of mental resources required to operate the system
You can think of this as how much brain power is required to perform a task 21
3 Kinds of Cognitive Load Problem complexity- Starting an IV
- Using a defibrillator
- Conducting robotic surgeryUnrelated working memory load- Distractions
- Mental notes
- ConversationProcessing memory going towards building LTM schema- How is this IV pump different from the one I just used next door?
- How do I hold this transducer at each stage of insertion
Intrinsic Load - how complex the problem is All these examples have an intrinsic degree of cognitive demand even when performed on a simulator. Intrinsic load includes things like the number of steps to be remembered to complete the task, information that must be held in memory between steps in a task sequence, or activites/tasks that must be performed simultaneously [e.g., needing to hold down a button while inputting a new setting, needing to press two keys simultaneously, ]
Extraneous Load - load on working memory unrelated to problem at hand distractions--Audio or visual; information being remembered; participating in conversation with the patient, doctor, or family member
Germane Load - processing effort going towards the development of schema in LTM (creating connections, sequencing, rehearsing, building scaffolding)
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Cognitive Load is Cumulative+Intrinsic LoadExtrinsic LoadGermane Load+=Total Cognitive Load
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Cognitive load affects performance
Performance Drop with Cognitive OverloadMental CapacityCognitive Demand (Total Cognitive Load)Performance
Drews, FA et al (2009). Text messaging during simulated driving behavior. Human Factors, 51, 762-770.Pashler, HE (1984). Processing stages in overlapping tasks: Evidence for a central bottleneck. J of Experimental Psychology: Human Perception and Performance, 1, 395-403.Wickens, CD (1991). Processing resources and attention. In D. Damos (ed.), Multiple-task performance, p3-34. London, UK: Taylor & Francis.
As long as the cognitive demand is less than capacity/threshold, then performance is adequate.
But, the moment the demand exceeds threshold, performance suffers
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Let me show youwhat I mean
Im going to ask you to do a little experiment with me so I can demonstrate what it feels like to experience cognitive load.
For this exercise youll need to open the contact list on your mobile phone or tablet .
Go ahead and pull out your devices now and display your contact list.25
Dont Try This at Homein the ER!Procedural TaskCreate a new contact for Jane DoePhone number: 800-555-9634
Now, Im going to give you a simple procedural task to perform with this device: Please create a new contact for Jane Doe and enter her phone number.
All done? How did that go? Most of you probably found it pretty simple to do - its something youve done a least a few times before.
----Now, Im going to ask you to do that same task again, but this time, were going to add some cognitive load.
DONT start the next task until I tell you to begin.
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Distraction
Dont Try This at Homein the ER!Procedural TaskCreate a new contact for John DoePhone number: 800-555-5678
Cognitive TaskCount by 2s
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What if these were health care tasks?Procedural TaskSetup an IV
Cognitive TaskCalculate fluid rateAnswer patient questions
DistractionChild cryingOverhead page
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Humans have limited cognitive capacitybutthe cognitive demands on healthcare workers continue to increaseCapacityDemand
The ConflictPerformance
This leads us to a dilemma in healthcare.
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But what does this have to do with product design?
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The Resolution
Medical technology must be designed to require less cognitive overhead.
Product design simply can not be part of the problem. We need to contribute to the solution.
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Design Rules for Reducing Cognitive LoadBe Simple1Be Consistent5Be a Team Player6Be Helpful2Intrinsic LoadExtrinsic LoadGermane Load Be Smart Be Calm43
Weve developed a set of SIX design principles addressing the three aspects of cognitive load:[Read through list]
Now, well look more closely at each one.32
Design Rules for Reducing Cognitive LoadBe Simple1Be Consistent5Be a Team Player6Be Helpful2Intrinsic LoadExtrinsic LoadGermane Load Be Smart Be Calm43
First, we need to address the intrinsic load imposed by whatever device were designing.
The two key principles here are Be Simple and Be Helpful.33
Be Simple1
The subject matter can be complex, but the UX should not be
[READ SLIDE].
One key to simplicity is34
Be MinimalLess is moreShow only what you really needGroup related informationUse a clean visual design
Be Simple1
Read slide35
Be Simple1
Be Minimal
Heres an example: Youre 10 minutes late out the door. Which would you rather use to decide if you need to grab a coat?
The example on the right is a great example of less is more - It provides only what you need
Even a visual design can be distracting36
Be MinimalLess is moreShow only what you really needGroup related informationUse a clean visual design
Be DirectCareful use of abbreviationsCareful use of iconsMake alert states obvious
Be Simple1
A second key to Being Simple is Be Direct37
Be Direct use obvious alert statesBe Simple1FusionCharts Patient Monitoring System
Patient Monitoring System by Fusion Charts
Status is clear at a glanceGraphics support rather than distractAppropriate visual heirarchy
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Be Helpful2Think guided workflows, not features
[Read slide]39
Provide GuidanceThrough the workflowNext stepsAccess to help
Be Helpful2
One of the best ways to be helpful is to provide guidance to assist the user during task performance
[read slide]40
Be Helpful2Before: Where do I start? Where can I get help?
Provide Guidance - Provide a place to start
OnOffButtonButtonButtonButtonButton
ComplexInformation DisplayStatus Display
ON
ON
ON
ONStatus Display
ON
ONLinkLinkLinkLink
Heres a conceptual example from one of our projects:
If you were a new user, where would you start? How would you get help? 41
Be Helpful2After: Guided Workflows, Grouped content
Provide Guidance - Provide a place to start
Our redesign took a guided workflow approach and provide a clear place to start and immediate access to additional help.
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Provide GuidanceThrough the workflowNext stepsAccess to help
Prevent ErrorsMake it obviousMake it easyMake it dummy-proofPrevent omissions
Be Helpful2When you are stressed out, [making it] dummy proof is better. OR Nurse
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Be Helpful2
Prevent Errors Make it dummy proof
Hungarian designer Kevin Harald Campean
http://designtaxi.com/news/360796/A-Bold-Sleek-Redesign-Of-The-First-Aid-Kit/?goback=%2Egde_63344_member_275785103#%21
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Be Helpful2
Prevent Errors Make it dummy proof
Designer: Kevin Harald Campean
Hungarian designer Kevin Harald Campean
http://designtaxi.com/news/360796/A-Bold-Sleek-Redesign-Of-The-First-Aid-Kit/?goback=%2Egde_63344_member_275785103#%2145
Design Rules for Reducing Cognitive LoadBe Simple1Be Consistent5Be a Team Player6Be Helpful2Intrinsic LoadExtrinsic LoadGermane Load Be Smart Be Calm43
It isnt enough to only focus on the intrinsic load of our product.
As we saw in the video, our products will be used in complex environments, so we also need to think about helping users dealing with a heavy extrinsic load.
The key principles here are Be Smart and Be Calm.46
Technology should serve as a natural extension of our task performance rather than a barrier to overcome.
Be Smart3
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Be a Natural Extension of the userHold information in memory for the userPerform calculations for the user
of the taskProviding the right tools at the right timeRecognize errors or alert conditionsBe easy to ignore when not neededBe difficult to ignore when theres danger
Be Smart3
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Be Smart3LabK+(3.1 mEQ/L)Dr. AIV K+ Order 1(40 meQ over 4 hr)Dr. AIV K+ Order 2(100 meQ addition to existing fluid)Dr. AAttempted to cancel first order(cancelled a similar order by mistake)PharmacyFilled Order 1Rejected Order 2(too much K+, suggested 80 meQ)Nurse(s)Carried out Order 1 Carried out Order 2(80 meQ/L drip and 40 meQ IV bolis started}Dr. BMistakes lab result as NEWTreats for low K+Patient K+(7.8 mEQ/L)Normal K+ Level: 3.7-5.2 mEQ/LShift Change36 hours later
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!
!
!
!EHR: - Recognize patient already has fluids and suggest Order 2 to reduce pain.EHR: - Recognize unsafe levels of K+EHR: - Recognize unsafe levels of K+EHR: - Recognize unsafe levels of K+EHR: Better shift change updates & alertsImproved usability around date & time on lab results- Recognize unsafe levels of K+
Lets take a look at how the EHR could have been more helpful during this series of unfortunate events.49
Be Calm4
Provide a calm & soothing user experience
Healthcare workplaces are over stimulating and stressful environmentsThe technology, in contrast, needs to be calm50
Be AttractiveUse soothing colorsUse a neutral color paletteProvide ample white space
Be Calm4We assume if it looks nice, its a good product.- OR Nurse
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Be Attractive Pay attention to colorBe Calm4
Well use the color palette we selected for this presentation as an example. If we did our job right, you didnt even notice the colors until we pointed them out. Or, if you did notice them, it was because you liked them.52
Some might feel this color palette is more exciting, but its also is more tiring to view over long time periods53
Be Attractive Pay attention to colorBe Calm4
!
A subtle color palette allows more attention to be given to alerts. This allows alerts to be less demanding themselves.54
!
!
This color palette demands more vigilance to detect alerts.55
Be AttractiveUse soothing colorsUse a neutral color paletteProvide ample white space
Be MindfulCareful use of animationPay attention to use of audioAvoid causing alarm fatigue Be Calm4
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Be Mindful of audio and animation useBe Calm4
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Design Rules for Reducing Cognitive LoadBe Simple1Be Consistent5Be a Team Player6Be Helpful2Intrinsic LoadExtrinsic LoadGermane Load Be Smart Be Calm43
Finally, we need to recognize the contribution to Germane Load made by each additional device added to the users world.58
Be Consistent5
Provide a predictable user experience routine is important
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Provide simple, consistent workflowsWithin the designAcross your product line Across similar medical devicesWith users expectations
Be Consistent5
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Within and between your product(s)
Be Consistent5
Use templates and style guides
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Within and between your product(s)
Be Consistent5Inventory interaction behaviors (alerts, modes, button states, controls, feedback, etc.)
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With users expectations
Be Consistent5Measure users mental models
Formative research techniques can be used to gather data on user expectations.
Card sorts can be used to understand users mental models 63
With users expectations and needs
Be Consistent5Interview and observe users in context
And field research can be used to gain an intimate understanding of users environment, tasks, motivations and needs.64
Be a Team Player6
Recognize that you are part of a technology team whether you want to be or not
Beyond consistency within your own product, it is important to recognize that your product is part of a technology teamwhether you want to be a team player or not!
Free clip art65
Be a Team Player6The product teams world view
Our Other Awesome ProductACME
Our Other Awesome ProductACMEOur New Awesome ProductACMECompeting ProductCompeting ProductCompeting ProductCompeting ProductCompeting ProductRelatedProductRelatedProductRelatedProductRelatedProduct
Free clip art
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Our New Awesome ProductACMEOur New Awesome ProductACMEBe a Team Player6The users world view
Competing ProductOur Other Awesome ProductACMERelatedProductRelatedProductRelatedProductCompeting ProductCompeting ProductUnrelated ProductUnrelated ProductUnrelated ProductUnrelated ProductUnrelated ProductOur Other Awesome ProductACMERelatedProductUnrelated ProductUnrelated ProductUnrelated ProductUnrelated ProductUnrelated ProductUnrelated ProductUnrelated ProductUnrelated ProductUnrelated ProductPolicySafetyPatient ManagementStress ManagementAccuracyEfficiencyProtocolsRegulationInterpersonal RelationshipsRiskRecord KeepingFatigueHuman EmotionsDistractionsQuality
Free clip art
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Take a systems engineering perspectiveAvoid local success, global failureConsider the other technology being used in conjunction with yoursCompetitors productsOther products from your companyNon-related technology (smart phones, tablets, medical devices, EHRs, patient monitors, etc.) Each technology might have their own uniqueWorkflowsAudio soundsVisual alertsIcon sets & color palette
How will your product fit in with the existing technology?Be a Team Player6
[Ascom could be a good example here: In some facilities, the client uses their entire suite of products; in others, only the handset or only the console, etc.]68
Be a Team Player6then find a way to complement rather than compete
Study competitors, related products, industry standards, and the use environment
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Be a Team Player6Be different ONLY if you improve the global user experience.
Dont be different, just to be different.
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Design Rules for Reducing Cognitive LoadBe Simple1Be Consistent5Be a Team Player6Be Helpful2Intrinsic LoadExtrinsic LoadGermane Load Be Smart Be Calm43
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How do I know if my designs cognitive load is manageable?
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Evaluating Your Design for Cognitive LoadCommon methods used in uncommon waysDesign ReviewCognitive WalkthroughSimulated Use Usability TestingField ResearchCompetitive Product ReviewDirect Observation
Evaluating the cognitive load of your design doesnt require new research methods so much as attending to additional aspects of the design while using familiar methods, such as Design Reviews, Cognitive Walkthroughs, Usability testing & field research, etc.
Ill walk through a few examples to show you what I mean73
Evaluating Your Design for Cognitive LoadMinimalismAbbreviation & icon useConsistency across screens & workflows
Intrinsic LoadExtrinsic LoadGermane LoadDesign Reviews Cognitive WalkthroughGuided workflowsPaths for novice v. expert usersContextually-specific use cases (e.g., surgery, ER, home care)
Intrinsic Load
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Evaluating Your Design for Cognitive LoadSimple to useEasy interpretation of status
Obvious next stepsTo ensure workflows and content are accurate and usefulTo test audio and animation use
To ensure product is usable when used in conjunction with other technologyTo ensure product is easy to learn when experienced with other brands or past versions
Extrinsic LoadGermane LoadSimulated Usability TestingIntrinsic Load
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Evaluating Your Design for Cognitive LoadTask performance in a realistic settingSimulation lab in a medical facilityResearch lab modified to mimic use settingReal world environment
With a realistic level of cognitive loadDistractionsAmbient NoiseInterruptions (major and minor)Multi-tasking Finger or foot tapping while performing task Reading the time from a wall clock when each step of task is performed
With appropriate pre-use training
Intrinsic LoadExtrinsic LoadGermane LoadSimulated Usability Testing
Real world environment: coffee shop; subway; living room
Modified Research Lab:Room setup to mimic patient care settingEquipment placement similar to actual use
Interruptions:Answering unrelated questionsDoctor asking for a new task statPhone call/Text message
Provide Appropriate Level of Training prior to testingTeam trainingsSales Rep trainingInstructions for Use availableConsider lag time between training and task performance
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Evaluating Your Design for Cognitive LoadTask analysisWorkflowsContext analysis
Extrinsic LoadGermane LoadField Research: Pre-designCompetitive Product & Regulation ReviewIndustry standardsRegulatory guidelines
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Considering Cognitive Load During Design ValidationIntrinsic LoadExtrinsic LoadGermane LoadBe Simple & HelpfulDesign Walkthrough / Heuristic EvaluationCognitive WalkthroughIterative Usability Testing
Be Smart & CalmField ResearchTask AnalysisIterative Usability TestingBe Consistent & a Team PlayerCompetitive Product ReviewRegulation and Guidance ReviewDesign ReviewSimulated Use Usability TestingDirect Observation
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Sounds good, but how am I going to remember all this?
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Checklist for Reducing Cognitive Load Through DesignFor a copy, email one of us orsee me after the session.
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Design can save lives.
The bottom line.
What you [designers] do matters. Medical device design can mean the difference between injury & safety, life & death.Your designs can be the difference between a manageable level of cognitive load81
Manageable level of cognitive load
where your users feel like super heroes 82
Unmanageable level of cognitive load
or an unmanageable level of cognitive load which leads to human use error.
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THANK YOU!Julie Rennecker, PhD RNPrincipal ConsultantThe Management Doc, [email protected]
Shannon Halgren, PhDChief HF/UX ConsultantSage Research & Design, [email protected]
We hope this has been helpful. Be well & do good work.
. And now well take any questions.
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ReferencesDrews, FA et al (2009). Text messaging during simulated driving behavior. Human Factors, 51: 762-770.Eriksen, CW & Eriksen, BA (1974). Effects of noise letters upon the identification of a target letter in a non-search task. Perception and Psychophysics, 16: 143-149.Gasper, JG et al (2014). Are Gamers Better Crossers? An Examination of Ation Video Game Experience and Dual-task Effects in a Simulated Street Crossing Task. Human Factors, 56(3): 443-452.Horsky, J et al (2003). A framework for analyzing the cognitive complexity of computer-assisted clinical ordering. J of Biomedical Informatics, 36: 4-22.Institute of Medicine (2000). To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, LT Kohn, JM Corrigan, & MS Donaldson (eds). Washington, DC: National Academies Press.Institute of Medicine (2012). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. M Smith et al (eds.), Committee on the Learning Health Care System in America. Washington, DC: National Academies Press.James, JT (2013). A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. J of Patient Safety, 9: 122-128.Katidioti, I and Taatgen, NA (2014). Choice in Multitasking: How Delays in the Primary Task Turn a Rational into an Irrational Multitasker. Human Factors, 56(4): 728-736.Kalyuga, S (2011). Informing: A Cognitive Load Perspective. Informing Science: the Intl J of an Emerging Transdiscipline, 14: 33-45.Pashler, HE (1984). Processing stages in overlapping tasks: Evidence for a central bottleneck. J of Experimental Psychology: Human Perception and Performance, 10: 395-403.Pashler, HE et al (2001). Attention and Performance. Ann Rev Psychology, 52: 629-651.Posner, MI & Petersen, SE (1990). The Attention System of the Human Brain. Ann Rev Neurosci, 13:25-42.Wickens, CD (1991). Processing resources and attention. In D. Damos (ed.), Multiple-task performance, p3-34. London, UK: Taylor & Francis.Wicklund, M., Kendler, J. and Strochlic, A. (2011). Usability Testing of Medical Devices. CRC Press, Taylor & Francis Group, Boca Raton, FL.
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