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Journal Description

JMIR Human Factors (JHF, ISSN 2292-9495; Editor-in-Chief: Prof. Andre Kushniruk) is a multidisciplinary journal with contributions from design experts, medical researchers, engineers, and social scientists.
JMIR Human Factors focuses on understanding how the behaviour and thinking of humans can influence and shape the design of health care interventions and technologies, and how the design can be evaluated and improved to make health care interventions and technologies usable, safe, and effective. This includes usability studies and heuristic evaluations, studies concerning ergonomics and error prevention, design studies for medical devices and healthcare systems/workflows, enhancing teamwork through Human Factors based teamwork training, measuring non-technical skills in staff like leadership, communication, situational awareness and teamwork, and healthcare policies and procedures to reduce errors and increase safety.
JHF aspires to lead health care towards a culture of "usability by design", as well as to a culture of testing, error-prevention and safety, by promoting and publishing reports rigorously evaluating the usability and human factors aspects in health care, as well as encouraging the development and debate on new methods in this emerging field. 

All articles are professionally copyedited and typeset, ready for indexing in PubMed/PubMed Central. Possible contributions include usability studies and heuristic evaluations, studies concerning ergonomics and error prevention, design studies for medical devices and healthcare systems/workflows, enhancing teamwork through Human Factors based teamwork training, measuring non-technical skills in staff like leadership, communication, situational awareness and teamwork, and healthcare policies and procedures to reduce errors and increase safety. Reviews, viewpoint papers and tutorials are as welcome as original research.

Recent Articles:

  • A woman reviews the results of her child's developmental screen. This image was adapted from the original Rawpixel Ltd photo. Source: The Authors / Rawpixel Ltd; Copyright: The Authors / Rawpixel Ltd; URL:; License: Creative Commons Attribution (CC-BY).

    Communicating Bad News: Insights for the Design of Consumer Health Technologies


    Background: As people increasingly receive personal health information through technology, there is increased importance for this information to be communicated with empathy and consideration for the patient’s experience of consuming it. Although technology enables people to have more frequent and faster access to their health information, it could also cause unnecessary anxiety, distress, or confusion because of the sensitive and complex nature of the information and its potential to provide information that could be considered bad news. Objective: The aim of this study was to uncover insights for the design of health information technologies that potentially communicate bad news about health such as the result of a diagnosis, increased risk for a chronic or terminal disease, or overall declining health. Methods: On the basis of a review of established guidelines for clinicians on communicating bad news, we developed an interview guide and conducted interviews with patients, patients’ family members, and clinicians on their experience of delivering and receiving the diagnosis of a serious disease. We then analyzed the data using a thematic analysis to identify overall themes from a perspective of identifying ways to translate these strategies to technology design. Results: We describe qualitative results combining an analysis of the clinical guidelines for sharing bad health news with patients and interviews on clinicians’ specific strategies to communicate bad news and the emotional and informational support that patients and their family members seek. Specific strategies clinicians use included preparing for the patients’ visit, anticipating patients’ feelings, building a partnership of trust with patients, acknowledging patients’ physical and emotional discomfort, setting up a scene where patients can process the information, helping patients build resilience and giving hope, matching the level of information to the patients’ level of understanding, communicating face-to-face, if possible, and using nonverbal means. Patient and family member experiences included internal turmoil and emotional distress when receiving bad news and emotional and informational support that patients and family members seek. Conclusions: The results from this study identify specific strategies for health information technologies to better promote empathic communication when they communicate concerning health news. We distill the findings from our study into design hypotheses for ways technologies may be able to help people better cope with the possibility of receiving bad health news, including tailoring the delivery of information to the patients’ individual preferences, supporting interfaces for sharing patients’ context, mitigating emotional stress from self-monitoring data, and identifying clear, actionable steps patients can take next.

  • Source: Flickr; Copyright: Ars Electronica; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Anthropomorphism of Robots: Study of Appearance and Agency


    Background: As the prevalence of robots increases each year, understanding how we anthropomorphize and interact with them is extremely important. The three-factor theory of anthropomorphism, called the Sociality, Effectance, Elicited agent Knowledge model, guided this study. As anthropomorphism involves a person making attributions of human likeness toward a nonhuman object, this model implies that anthropomorphism can be influenced either by factors related to the person or the object. Objective: The aim of this study was to explore factors influencing the anthropomorphism of robots, specifically the robot’s appearance (humanoid vs nonhumanoid) and agency (autonomous vs nonautonomous). We expected a humanoid robot would be anthropomorphized to a greater extent than one that was nonhumanoid. In addition, we expected that inducing an agency belief to the effect that a robot was making its own decisions would increase anthropomorphism compared with a nonagency belief that the robot was being remotely controlled by a human. We also sought to identify any role gender might play in anthropomorphizing the robot. Methods: Participants (N=99) were primed for agency or nonagency belief conditions and then saw a brief video depicting either a humanoid or nonhumanoid robot interacting with a confederate. After viewing the video, they completed 4 measures: perception to humanoid robots scale (PERNOD), the Epley anthropomorphic adjectives measure, the Fussel anthropomorphic adjective checklist, and the Anthropomorphic Tendencies Scale (ATS). Results: Findings with the PERNOD scale indicated subjects did perceive the 2 robots differently, F6,86=6.59, P<.001, which means the appearance manipulation was effective. Results with the Epley adjectives indicated that participants were more willing to attribute humanlike behavioral traits to the nonhumanoid rather than the humanoid robot, F1,91=5.76, P=.02. The Fussel adjective checklist results showed that subjects were more willing to attribute humanlike social qualities to the remote controlled than the autonomous robot, F1,91=5.30, P=.02. Finally, the ATS revealed the only gender effects in this study, with females reporting more endorsement of anthropomorphism for pets (P=.02) and less for showing negative emotions toward anthropomorphized objects (P<.001) if they had witnessed the humanoid rather than the nonhumanoid robot. Conclusions: Contrary to our expectations, participants were less willing to make humanlike attributions toward a robot when its morphology was more humanlike and were more willing to make those attributions when they were told that the robot was being remotely controlled by a person rather than acting on its own. In retrospect, these outcomes may have occurred because the humanoid robot used here had a smaller overall stature than the nonhumanoid robot, perhaps making it seem more toylike and because subjects made attributions toward the person behind the remote-controlled robot rather than toward the robot itself.

  • Source: The Authors / Placeit; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Prototyping the Automated Food Imaging and Nutrient Intake Tracking System: Modified Participatory Iterative Design Sprint


    Background: A total of 45% of older adults living in long-term care (LTC) have some form of malnutrition. Several methods of tracking food and fluid intake exist, but they are limited in terms of their accuracy and ease of application. An easy-to-use, objective, accurate, and comprehensive food intake system designed with LTC in mind may provide additional insights regarding nutritional support systems and nutritional interventions. Objective: The aim of this study was to conduct a multistage participatory iterative design sprint of a Goldilocks quality horizontal prototype for the Automated Food Imaging and Nutrient Intake Tracking (AFINI-T) system. Specific design objectives included the following: (1) identify practice-relevant problems and solutions through user-centered participatory design, (2) mitigate feasibility-related barriers to uptake, and (3) employ user-centered technology development. Methods: A 6-stage iterative participatory design sprint was developed and executed. A total of 38 participants and advisors representing 15 distinct roles (eg, personal support worker, nurse, and dietitian) were engaged in the design sprint. Subjective workload (Raw Task Load Index), subjective usability scales, and a modified Ravden checklist were used to assess project advisors’ perceptions of the AFINI-T system prototype compared with the current method of food and fluid intake charting. Results: The top priorities for this system were identified as the following: ease of use, high accuracy, system reliability, ease of maintenance, and requirement of integrating with the current PointClickCare system. Data from project advisors informed design decisions leading to a Goldilocks quality horizontal prototype of the AFINI-T system. Compared with the current food and fluid intake charting system, AFINI-T was perceived to have the following: less time demands (t10.8=4.89; P<.001), less effort (t13.5=5.55; P<.001), and less frustration (t13.0=3.80; P=.002). Usability ratings of the AFINI-T prototype were high, with a subjective usability score mean of 89.2 and the highest ratings on a modified Ravden usability checklist of “very satisfactory” for 7 out of 8 sections. Conclusions: The AFINI-T concept system appears to have good practice relevance as a tool for an intelligent food and fluid intake tracking system in LTC. The AFINI-T concept system may provide improvement over the current system, and advisors are keen to try the AFINI-T system. This research gives tangible examples of how the sprint method can be adapted and applied to the development of novel needs-based application-driven technology.

  • Source:; Copyright: Pexels; URL:; License: Licensed by the authors.

    Creating an mHealth App for Colorectal Cancer Screening: User-Centered Design Approach


    Background: Patients are increasingly using mobile health (mHealth) apps to monitor their health and educate themselves about medical issues. Despite the increasing popularity of such apps, poor design and usability often lead to suboptimal continued use of these apps and subsequently to poor adherence to the behavior changes at which they are aimed. One solution to these design problems is for app developers to use user-centered design (UCD) principles to consider the context and needs of users during the development process. Objective: This study aimed to present a case study on the design and development process for an mHealth app that uses virtual human technology (VHT) to encourage colorectal cancer (CRC) screening among patients aged 50 years and above. Methods: We have first provided an overview of the project and discussed its utilization of VHT. We have then reviewed UCD principles and how they can be incorporated into the development of health apps. We have described how we used UCD processes during the app’s development. We have then discussed the unique roles played by communication researchers, computer scientists, clinicians, and community participants in creating an mHealth app that is credible, usable, effective, and accessible to its target audience. Results: The principles of UCD were woven throughout the project development, with researchers collecting feedback from patients and providers at all stages and using that feedback to improve the credibility, usability, effectiveness, and accessibility of the mHealth app. The app was designed in an iterative process, which encouraged feedback and improvement of the app and allowed teams from different fields to revisit topics and troubleshoot problems. Conclusions: Implementing a UCD process contributed to the development of an app, which not only reflected cross-disciplinary expertise but also the needs, wants, and concerns of patients.

  • Source: Freepik; Copyright: jcomp; URL:; License: Licensed by JMIR.

    The Effect of Age on Electronic Health Literacy: Mixed-Method Study

    Authors List:


    Background: The world’s internet penetration rate is increasing yearly; approximately 25% of the world’s population are internet users. In Asia, Taiwan has the fifth highest internet usage, and has an internet penetration rate higher than the world average. Electronic health (eHealth) literacy is the ability to read, understand, and utilize Web health information. eHealth literacy is gaining attention worldwide. Objective: This study aimed compare the differences in eHealth literacy between traditional college students (aged between 18 and 22 years) and older adult students (aged between 55 and 72 years). It also summarizes the experiences and performances of these 2 groups in terms of searching online health-related information. Methods: A mixed-method approach was used, including questionnaire surveys and interviews. A total of 208 respondents were interviewed: 65 traditional college students (31.3%) and 143 older adult students (68.7%). The results of the interviews were used to compare the eHealth literacy scores of the 2 groups. Results: There were significant differences in the overall eHealth literacy scores (t207=2.98; P=.001) and the functional eHealth literacy dimension (t207=12.17; P<.001). The findings showed a significant gap in eHealth literacy between the 2 groups. Most participants believed that online health information could be largely read and understood. However, they were skeptical about the quality of the information and noted that it consisted of either subjective judgments or objective standards. Conclusions: Traditional college students preferred esthetically pleasing health information, whereas older adult students focused on its promotion. Furthermore, the first group often used websites for solving health problems, whereas the second group forwarded health information through communication software.

  • Source: Flickr; Copyright: US Pacific Fleet; URL:; License: Creative Commons Attribution + Noncommercial (CC-BY-NC).

    A Hazard Analysis of Class I Recalls of Infusion Pumps


    Background: The adverse event report of medical devices is one of the postmarket surveillance tools used by regulators to monitor device performance, detect potential device-related safety issues, and contribute to benefit-risk assessments of these products. However, with the development of the related technologies and market, the number of adverse events has also been on the rise, which in turn results in the need to develop efficient tools that help to analyze adverse events monitoring data and to identify risk signals. Objective: This study aimed to establish a hazard classification framework of medical devices and to apply it over practical adverse event data on infusion pumps. Subsequently, it aimed to analyze the risks of infusion pumps and to provide a reference for the risk management of this type of device. Methods: The authors define a general hierarchical classification of medical device hazards. This classification is combined with the Trace Intersecting Theory to form a human-machine-environment interaction model. Such a model was applied to the dataset of 2001 to 2017 class I infusion pump recalls extracted from the Food and Drug Administration (FDA) website. This dataset does not include cases involving illegal factors. Results: The proposed model was used for conducting hazard analysis on 70 cases of class I infusion pump recalls by the FDA. According to the analytical results, an important source of product technical risk was that the infusion pumps did not infuse accurate dosage (ie, over- or underdelivery of fluid). In addition, energy hazard and product component failure were identified as the major hazard form associated with infusion pump use and as the main direct cause for adverse events in the studied cases, respectively. Conclusions: The proposed human-machine-environment interaction model, when applied to adverse event data, can help to identify the hazard forms and direct causes of adverse events associated with medical device use.

  • Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Patients’ Experiences of Using a Consumer mHealth App for Self-Management of Heart Failure: Mixed-Methods Study


    Background: To support the self-management of heart failure, a team of hospital clinicians, patients, and family caregivers have co-designed the consumer mobile health app, Care4myHeart. Objective: This research aimed to determine patient experiences of using the app to self-manage heart failure. Methods: Patients with heart failure used the app for 14 days on their own smart device in a home setting, following which a mixed-methods evaluation was performed. Eight patients were recruited, of whom six completed the Mobile Application Rating Scale and attended an interview. Results: The overall app quality score was “acceptable” with 3.53 of 5 points, with the aesthetics (3.83/5) and information (3.78/5) subscales scoring the highest. The lowest mean score was in the app-specific subscale representing the perceived impact on health behavior change (2.53/5). Frequently used features were weight and fluid restriction tracking, with graphical representation of data particularly beneficial for improved self-awareness and ongoing learning. The use of technology for self-management will fundamentally differ from current practices and require a change in daily routines. However, app use was correlated with potential utility for daily management of illness with benefits of accurate recording and review of personal health data and as a communication tool for doctors to assist with care planning, as all medical information is available in one place. Technical considerations included participants’ attitudes toward technology, functionality and data entry issues, and relatively minor suggested changes. Conclusions: The findings from this usability study suggest that a significant barrier to adoption is the lack of integration of technology into everyday life in the context of already established disease self-management routines. Future studies should explore the barriers to adoption and sustainability of consumer mobile health interventions for chronic conditions, particularly whether introducing such apps is more beneficial at the commencement of a self-management regimen.

  • Anesthesia dashboard. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Evaluation of an Anesthesia Dashboard Functional Model Based on a Manufacturer-Independent Communication Standard: Comparative Feasibility Study


    Background: Current anesthesia workspaces consist of several technical devices, such as patient monitors, anesthesia machines, among others. Commonly, they are produced by different manufacturers; thus, they differ in terms of their modus operandi, user interface, and representation of alarms. Merging the information from these devices using a single joint protocol and displaying it in a single graphical user interface could lead to a general improvement in perioperative management. For this purpose, the recently approved and published Institute of Electrical and Electronics Engineers 11073 service-oriented device connectivity standard was implemented. Objective: This paper aims to develop and then evaluate an anesthesia workstation (ANWS) functional model in terms of usability, fulfillment of clinical requirements, and expected improvements in patient safety. Methods: To compare the self-developed ANWS with the conventional system, a pilot observational study was conducted at the University Hospital Aachen, Germany. A total of 5 anesthesiologists were asked to perform different tasks using the ANWS and then the conventional setup. For evaluation purposes, response times were measured and an interaction-centered usability test with an eye-tracking system was carried out. Finally, the subjects were asked to fill in a questionnaire in order to measure user satisfaction. Results: Response times were significantly higher when using the ANWS, but decreased considerably after one repetition. Furthermore, usability was rated as excellent (≥95) according to the System Usability Scale score, and the majority of clinical requirements were met. Conclusions: In general, the results were highly encouraging, considering that the ANWS was only a functional model, as well as the lack of training of the participants. However, further studies are necessary to improve the universal user interface and the interplay of the various networked devices.

  • Physician in operating room. Source: Foter; Copyright: Foter; URL:; License: Public Domain (CC0).

    Anesthesiology Control Tower—Feasibility Assessment to Support Translation (ACTFAST): Mixed-Methods Study of a Novel Telemedicine-Based Support System for...


    Background: Despite efforts to improve patient outcomes, major morbidity and mortality remain common after surgery. Health information technologies that provide decision support for clinicians might improve perioperative and postoperative patient care. Evaluating the usability of these technologies and barriers to their implementation can facilitate their acceptance within health systems. Objective: This manuscript describes usability testing and refinement of an innovative telemedicine-based clinical support system, the Anesthesiology Control Tower (ACT). It also reports stakeholders’ perceptions of the barriers and facilitators to implementation of the intervention. Methods: Three phases of testing were conducted in an iterative manner. Phase 1 testing employed a think-aloud protocol analysis to identify surface-level usability problems with individual software components of the ACT and its structure. Phase 2 testing involved an extended qualitative and quantitative real-world usability analysis. Phase 3 sought to identify major barriers and facilitators to implementation of the ACT through semistructured interviews with key stakeholders. Results: Phase 1 and phase 2 usability testing sessions identified numerous usability problems with the software components of the ACT. The ACT platform was revised in seven iterations in response to these usability concerns. Initial satisfaction with the ACT, as measured by standardized instruments, was below commonly accepted cutoffs for these measures. Satisfaction improved to acceptable levels over the course of revision and testing. A number of barriers to implementation were also identified and addressed during the refinement of the ACT intervention. Conclusions: The ACT model can improve the standard of perioperative anesthesia care. Through our thorough and iterative usability testing process and stakeholder assessment of barriers and facilitators, we enhanced the acceptability of this novel technology and improved our ability to implement this innovation into routine practice. International Registered Report Identifier (IRRID): RR2-10.1186/s40814-018-0233-4

  • Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Interruptive Versus Noninterruptive Clinical Decision Support: Usability Study


    Background: Clinical decision support (CDS) has been shown to improve compliance with evidence-based care, but its impact is often diminished because of issues such as poor usability, insufficient integration into workflow, and alert fatigue. Noninterruptive CDS may be less subject to alert fatigue, but there has been little assessment of its usability. Objective: This study aimed to study the usability of interruptive and noninterruptive versions of a CDS. Methods: We conducted a usability study of a CDS tool that recommended prescribing an angiotensin-converting enzyme inhibitor for inpatients with heart failure. We developed 2 versions of the CDS: an interruptive alert triggered at order entry and a noninterruptive alert listed in the sidebar of the electronic health record screen. Inpatient providers were recruited and randomly assigned to use the interruptive alert followed by the noninterruptive alert or vice versa in a laboratory setting. We asked providers to “think aloud” while using the CDS and then conducted a brief semistructured interview about usability. We used a constant comparative analysis informed by the CDS Five Rights framework to analyze usability testing. Results: A total of 12 providers participated in usability testing. Providers noted that the interruptive alert was readily noticed but generally impeded workflow. The noninterruptive alert was felt to be less annoying but had lower visibility, which might reduce engagement. Provider role seemed to influence preferences; for instance, some providers who had more global responsibility for patients seemed to prefer the noninterruptive alert, whereas more task-oriented providers generally preferred the interruptive alert. Conclusions: Providers expressed trade-offs between impeding workflow and improving visibility with interruptive and noninterruptive versions of a CDS. In addition, 2 potential approaches to effective CDS may include targeting alerts by provider role or supplementing a noninterruptive alert with an occasional, well-timed interruptive alert.

  • An elderly couple using the ColorApp application through a mobile phone. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Usable Mobile App for Community Education on Colorectal Cancer: Development Process and Usability Study


    Background: Participation in colorectal cancer screening is still low among Malaysians despite the increasing trend of incidence, with more than half of the new cases being detected in the advanced stages. Knowledge improvement might increase screening participation and thus improve the chances of disease detection. With the advancement of communication technology, people nowadays prefer to read from their mobile phone using a Web browser or mobile apps compared with the traditional printed material. Therefore, health education and promotion should adapt this behavior change in educating the community. Objective: This study aimed to document the process of designing and developing a mobile app for community education on colorectal cancer and assess the usability of the prototype. Methods: The nominal group technique (NGT) was used for the content development of the mobile app. NGT involving community educationists and clinicians combined with community representatives as the target users identified relevant health information and communication strategies including features for a user-friendly mobile app. The prototype was developed using framework Ionic 1, based on the Apache Cordova and Angular JS (Google). It was published in the Google Play store. In total, 50 mobile phone users aged 50 years and above and who had never been diagnosed with any type of cancer were invited to download and use the app. They were asked to assess the usability of the app using the validated Malay version of System Usability Scale Questionnaire for the Assessment of Mobile Apps questionnaire. The One-sample t test was used to assess the usability score with a cut-off value of 68 for the usable mobile app. Results: The Colorectal Cancer Awareness Application (ColorApp) was successfully developed in the local Malay language. The NGT discussion had suggested 6 main menus in the ColorApp prototype, which are Introduction, Sign and Symptoms, Risk Factors, Preventive Measures, Colorectal Cancer Screening Program, and immunochemical fecal occult blood test kit. A total of 2 additional artificial intelligence properties menus were added to allow user-ColorApp interaction: Analyze Your Status and ColorApp Calculator. The prototype has been published in the Google Play store. The mean usability score was 72 (SD 11.52), which indicates that ColorApp is a usable mobile app, and it can be used as a tool for community education on colorectal cancer. Conclusions: ColorApp mobile app can be used as a user-friendly tool for community education on colorectal cancer.

  • Source: Wikimedia Commons; Copyright: BAXTER CZECH spol. s r.o.; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Uptake and Scalability of a Peritoneal Dialysis Virtual Care Solution: Qualitative Study


    Background: Early research in the area of virtual care solutions with peritoneal dialysis (PD) patients has focused on evaluating the outcomes and impact of these solutions. There has been less attention focused on understanding the factors influencing the uptake, usability, and scalability of virtual care for chronic kidney disease (CKD) patients receiving PD at home. Objective: In this context, a study was undertaken to (1) assess and understand the factors influencing the uptake of a virtual care solution and (2) provide recommendations for the scalability of a virtual care solution aimed at enhancing CKD patients’ outcomes and experiences. Methods: This study used a qualitative design with semistructured interviews and a thematic analysis approach. A total of 25 stakeholders—6 patients and 3 caregivers, 6 health care providers, 2 vendors, and 8 health system decision makers—participated in this study. Results: The following three primary mechanisms emerged to influence the usability of the virtual care solution: (1) receiving hands-on training and ongoing communication from a supportive team, (2) adapting to meet user needs and embedding them into workflow, and (3) being influenced by patient and caregiver characteristics. Further, two overarching recommendations were developed for considerations around scalability: (1) co-design locally, embed into the daily workflow, and deploy over time and (2) share the benefits and build the case. Conclusions: Study findings can be used by key stakeholders in their future efforts to enhance the implementation, uptake, and scalability of virtual care solutions for CKD and managing PD at home.

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