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

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

Documents

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