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JMIR Human Factors
(Re-)designing health care and making health care interventions and technologies usable, safe, and effective
(Toronto, January 13, 2020) We are thrilled to announce that JMIR Human Factors has been accepted for inclusion in Elsevier’s Scopus. A little over 5 years after JMIR Human Factors published its first article, Scopus advised JMIR Publications that the title will be accepted into their database of journals. Other JMIR titles indexed in Scopus include the Journal of Medical Internet Research, JMIR mHealth & uHealth and JMIR Research Protocols; other JMIR titles are still under evaluation. Scopus is used by more than 5,000 institutions worldwide and JMIR Publications is happy to be a part of it. Elsevier is currently setting up the journal and it should be searchable in Scopus shortly.
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.
Background: An increasing number of software companies work according to the agile software development method, which is difficult to integrate with user-centered design (UCD) practices. Log file analysis may provide opportunities for integrating UCD practices in the agile process. However, research within health care information technology mostly has a theoretical approach and is often focused on the researcher’s interpretation of log file analyses.
Objective: We aimed to propose a systematic approach to log file analysis in this study and present this to developers to explore how they react and interpret this approach in the context of a real-world health care information system, in an attempt to answer the following question: How may log file analyses contribute to increasing the match between the health care system and its users, within the agile development method, according to agile team members?
Methods: This study comprised 2 phases to answer the research question. In the first phase, log files were collected from a health care information system and subsequently analyzed (summarizing sequential patterns, heat mapping, and clustering). In the second phase, the results of these analyses are presented to agile professionals during a focus group interview. The interpretations of the agile professionals are analyzed by open axial coding.
Results: Log file data of 17,924 user sessions and, in total, 176,678 activities were collected. We found that the Patient Timeline is mainly visited, with 23,707 (23,707/176,678; 13.42%) visits in total. The main unique user session occurred in 5.99% (1074/17,924) of all user sessions, and this comprised Insert Measurement Values for Patient and Patient Timeline, followed by the page Patient Settings and, finally, Patient Treatment Plan. In the heat map, we found that users often navigated to the pages Insert Measurement Values and Load Messages Collaborate. Finally, in the cluster analysis, we found 5 clusters, namely, the Information-seeking cluster, the Collaborative cluster, the Mixed cluster, the Administrative cluster, and the Patient-oriented cluster. We found that the interpretations of these results by agile professionals are related to stating hypotheses (n=34), comparing paths (n=31), benchmarking (n=22), and prioritizing (n=17).
Conclusions: We found that analyzing log files provides agile professionals valuable insights into users’ behavior. Therefore, we argue that log file analyses should be used within agile development to inform professionals about users’ behavior. In this way, further UCD research can be informed by these results, making the methods less labor intensive. Moreover, we argue that these translations to an approach for further UCD research will be carried out by UCD specialists, as they are able to infer which goals the user had when going through these paths when looking at the log data.
Background: With the advent of electronic health record (EHR) systems, there is increasing attention on the EHR system with regard to its use in facilitating patients to play active roles in their care via secure patient portals. However, there is no systematic review to comprehensively address patient portal interventions and patient outcomes.
Objective: This study aimed to synthesize evidence with regard to the characteristics and psychobehavioral and clinical outcomes of patient portal interventions.
Methods: In November 2018, we conducted searches in 3 electronic databases, including PubMed, EMBASE, and Cumulative Index to Nursing and Allied Health Literature, and a total of 24 articles met the eligibility criteria.
Results: All but 3 studies were conducted in the United States. The types of study designs varied, and samples predominantly involved non-Hispanic white and highly educated patients with sizes ranging from 50 to 22,703. Most of the portal interventions used tailored alerts or educational resources tailored to the patient’s condition. Patient portal interventions lead to improvements in a wide range of psychobehavioral outcomes, such as health knowledge, self-efficacy, decision making, medication adherence, and preventive service use. Effects of patient portal interventions on clinical outcomes including blood pressure, glucose, cholesterol, and weight loss were mixed.
Conclusions: Patient portal interventions were overall effective in improving a few psychological outcomes, medication adherence, and preventive service use. There was insufficient evidence to support the use of patient portals to improve clinical outcomes. Understanding the role of patient portals as an effective intervention strategy is an essential step to encourage patients to be actively engaged in their health care.
Background: Frequent vital sign monitoring during and after transfusion of blood products and certain chemotherapies or immunotherapies is critical for detecting infusion reactions and treatment management in patients. Currently, patients return home with instructions to contact the clinic if they feel unwell. Continuous monitoring of vital signs for hematological patients treated with immunotherapy or chemotherapy or receiving blood transfusions using wearable electronic biosensors during and post treatment may improve the safety of these treatments and make remote data collection in an outpatient care setting possible.
Objective: This study aimed to evaluate patient experiences with the VitalPatch wearable sensor (VitalConnect) and to evaluate the usability of data generated by the physIQ accelerateIQ monitoring system for the investigator and nurse.
Methods: A total of 12 patients with hematological disorders receiving red blood cell transfusions, an intravenous (IV) proteasome inhibitor, or an IV immunotherapy agent were included in the study and wore the VitalPatch for 12 days. Patients completed questionnaires focusing on wearability and nurses completed questionnaires focusing on the usability of the VitalPatch.
Results: A total of 12 patients were enrolled over 9 months, with 4 receiving red blood cell transfusions, 4 receiving IV proteasome inhibitors, and 4 receiving IV immunotherapy. These patients were treated for diseases such as multiple myeloma, myelodysplastic syndrome, and non-Hodgkin lymphoma. Of these patients, 83% (10/12) were aged 60 years and older. A total of 4 patients (4/12, 33%) withdrew from the study (3 because of skin irritation and 1 because of patch connection issues). Patients wore biosensor patches at baseline and for 1-week post administration. Patient-reported outcomes (PROs) were collected at baseline, day 1, day 5, and day 8. No difference in the PRO was observed when nurses or patients applied the patch. PRO data indicated minimal impact on the patient’s life. Ease of use, influence on sleep, impact on follow-up of health, or discomfort with continuous monitoring did not change between baseline and day 8. Changes in PRO were observed on day 5, where a 20% (2/10) increase in skin irritation was reported. Withdrawals because of skin irritation were reported in all cases when wearing the second patch. Nurses reported the placement of the VitalPatch to be easy and felt measurements to be reliable.
Conclusions: Generally, the VitalPatch was well tolerated and shown to be an attractive device because of its wearability and low impact on daily activities in patients, therefore making it suitable for implementation in future studies.
Background: In recent years, interest in digital technologies such as electronic health, mobile health, telemedicine, big data, and health apps has been increasing in the health care sector. Acceptance and sustainability of these technologies play a considerable role for innovative health care apps.
Objective: This study aimed to identify the spread of and experience with new digital technologies in the medical sector in Germany.
Methods: We analyzed the acceptance of new health care technologies by applying the Technology Acceptance Model to data obtained in the German ePatient Survey 2018. This survey used standardized questionnaires to gain insight into the prevalence, impact, and development of digital health applications in a study sample of 9621 patients with acute and chronic conditions and healthy users. We extracted sociodemographic data and details on the different health app types used in Germany and conducted an evaluation based on the Technology Acceptance Model.
Results: The average age of the respondents was 59.7 years, with a standard deviation of 16 years. Digital health care apps were generally accepted, but differences were observed among age groups and genders of the respondents. Men were more likely to accept digital technologies, while women preferred coaching and consultation apps. Analysis of the user typology revealed that most users were patients (n=4041, 42%), followed by patients with acute conditions (n=3175, 33%), and healthy users (n=2405, 25%). The majority (n=6542, 68%) discovered coaching or medication apps themselves on the internet, while more than half of the users faced initial difficulties operating such apps. The time of use of the same app or program ranged from a few days (n=1607, 37%) and several months (n=1694, 39%) to ≥1 year (n=1042, 24%). Most respondents (n=6927, 72%) stated that they would like to receive customized health care apps from their physician.
Conclusions: The acceptance of digital technologies in the German health care sector varies depending on age and gender. The broad acceptance of medical digital apps could potentially improve individualized health care solutions and warrants governance.
Background: Human-centered design is a methodology that applies an iterative participatory process that engages the end-user for whom an innovation or intervention is designed for from start to end. There is general evidence to support the use of human-centered design for development of tools to affect health behavior, but specifically for family planning provision. This study is part two of a three-phase study that uses a user-centered design methodology which uses the findings from Phase I to design, develop, and test a digital health solution to support follow-up after an induced surgical abortion. Objective: The objectives for this study were to: (1) develop a web-based intervention based on preferences and experiences of women who underwent an abortion as measured in the formative phase of the Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care Study; (2) conduct usability testing of the intervention to determine user-friendliness and appropriateness of the intervention; and (3) finalize a beta version of the web-based intervention for pilot testing. Methods: The study design was based on the “development-evaluation-implementation” process from the Medical Research Council Framework for Complex Medical Interventions. This study is in Phase II of III and is based on user-centered design methodology. Phase I findings demonstrated that women engage with technology to assist in clinical care and they preferred a comprehensive website with email or text notifications to support follow-up care. In Phase II we collaborated with family planning experts and key stakeholders to synthesize evidence from Phase I. With them and a development partner we built a prototype. Usability testing was completed with 9 participants using a validated System Usability Scale. This was then used to refine the intervention for Phase III pilot study. This study was approved by the local Ethics board. Results: We developed a comprehensive web-based tool called myPostCare.ca, which includes: Post-Procedure Care, Emotional Well-Being Tool, Contraception Explorer, Sexual Health, Book an Appointment, and Other Resources. Additionally, over the course of a month after the procedure, automatic email notifications were sent to women as a form of virtual follow-up support, directing them to myPostCare.ca resources. The web-based tool was refined based on usability testing results. Conclusions: This study demonstrated that user-centered design is a useful methodology to build programs and interventions that are women-centered, specifically for abortion care.
Background:
Digital data collection has the potential to reduce participant burden in research projects that require extensive registrations from participants. To achieve this, a digital data collection tool needs to address potential barriers and motivations for participation.
Methods:
The study was designed as a sequential mixed-methods study with 3 phases. In phase 1, 15 semistructured interviews were conducted in a Danish population of individuals with MS. Interview guide frameworks were based on dimensions from the electronic health literacy framework and the Health Education Impact Questionnaire. Data from phase 1 were analyzed in a content analysis, and findings were used to inform the survey design in phase 2 that validates the results from the content analysis in a larger population. The survey consisted of 14 items, and it was sent to 1000 individuals with MS (response rate 42.5%). In phase 3, participants in 3 focus group interviews discussed how findings from phases 1 and 2 might affect motivation for participation and adoption of the digital tool.
Results:
The following 3 categories related to barriers and incentives for participation were identified in the content analysis of the 15 individual interviews: (1) life with MS, (2) use of technology, and (3) participation and incentives. Phase 1 findings were tested in phase 2’s survey in a larger population (n=1000). Majority of participants were comfortable using smartphone technologies and participated actively on social media platforms. MS symptoms did cause limitations in the use of Web pages and apps when the given pages had screen clutter, too many colors, or too small buttons. Life with MS meant that most participants had to ration their energy levels. Support from family and friends was important to participants, but support could also come in the form of physical aids (walking aids and similar) and digital aids (reminders, calendar functions, and medication management). Factors that could discourage participation were particularly related to the time it would take every day. Biggest motivations for participation were to contribute to research in MS, to learn more about one’s own MS and what affects it, and to be able to exchange experiences with other people with MS.
Conclusions:
MS causes limitations that put demands on the tool developed for digital data collection. A digital data collection tool can increase chances of high adoption rates, but the tool needs to be supplemented with clear and simple project design and continuous communication with participants. Motivational factors should be considered for both study design and the development of a digital data collection tool for research.
Background: There is limited published data on variation in physician usage of electronic health records (EHRs), particularly after hours. Research in this area could provide insight into the effects of EHR-related workload on physicians. Objective: This study sought to examine factors associated with after-hours EHR usage among primary care physicians. Methods: Electronic health records usage information was collected from primary care pediatricians in a large United States hospital. Inclusion criteria consisted solely of being a primary care physician who started employment with the hospital before the study period, so all eligible primary care physicians were included without sampling. Mixed effects statistical modeling was used to investigate the effects of age, gender, workload, normal-hour usage, week to week variation, and provider to provider variation on the after-hour usage of EHRs. Results: There were a total of 3498 weekly records obtained on 50 physicians, of whom 22% were male and 78% were female. Overall, more EHR usage during normal work hours was associated with decreased usage after hours. The more work relative value units generated by physicians, the more time they spent interacting with EHRs after hours (β=.04, P<.001) and overall (ie, during normal hours and after hours) (β=.24, P<.001). Gender was associated with total usage time, with females spending more time than males (P=.03). However, this association was not observed with after-hours EHR usage. Provider to provider variation was the largest and most dominant source of variation in after-hour EHR usage, which accounted for 52% of variance of total EHR usage. Conclusion: The present study found that there is a considerable amount of variability in EHR use among primary care physicians, which suggested that many factors influence after-hours EHR usage by physicians. However, provider to provider variation was the largest and most dominant source of variation in after-hours EHR usage. While the results are intuitive, future studies should consider the effect of EHR use variations on workload efficiency.
Background: Injury care involves the complex interaction of patient, physician, and environment that impacts patient complications, level of harm, and failure to rescue (FTR). FTR represents the likelihood of a hospital to be unable to rescue patients from death after in-hospital complications. Objective: This study aimed to hypothesize that error type and number of errors contribute to increased level of harm and FTR. Methods: Patient information was abstracted from weekly trauma performance improvement (PI) records (from January 1, 2016, to July 19, 2017), where trauma surgeons determined the level of harm and identified the factors associated with complications. Level of harm was determined by definitions set forth by the Agency for Healthcare Research and Quality. Logistic regression was used to determine the impact of individual factors on FTR and level of harm, controlling for age, gender, Charlson score, injury severity score (ISS), error (in diagnosis, technique, or judgment), delay (in diagnosis or intervention), and need for surgery. Results: A total of 2216 trauma patients presented during the study period. Of 2216 patients, 224 (224/2216, 10.10 %) had complications reported at PI meetings; of these, 31 patients (31/224, 13.8 %) had FTR. PI patients were more likely to be older (mean age 51.3 years, SE 1.58, vs 46.5 years, SE 0.51; P=.008) and have higher ISS (median 22 vs 8; P<.001), compared with patients without complications. Physician-attributable errors (odds ratio [OR] 2.82; P=.001), most commonly errors in technique, and nature of injury (OR 1.91; P=.01) were associated with higher levels of harm, whereas delays in diagnosis or intervention were not. Each additional factor involved increased level of harm (OR 2.09; P<.001) and nearly doubled likelihood of FTR (OR 1.95; P=.01). Conclusions: Physician-attributable errors in diagnosis, technique, or judgment are more strongly correlated with harm than delays in diagnosis and intervention. Increasing number of errors identified in patient care correlates with an increasing level of harm and FTR.
Background: Smoking rates of Australians with severe mental illness (SMI) are disproportionately higher than the general population. Despite the rapid growth in mobile health (mHealth) apps, limited evidence exists to inform their design for SMI populations. Objective: This study aimed to explore the feasibility, acceptability, and utility of adapting a novel smoking cessation app (Kick.it) to assist smokers with SMI to prevent smoking relapse and quit. Methods: Using co-design, two in-depth interviews with 12 adult smokers and ex-smokers with SMI were conducted in this qualitative study. Stage 1 interviews explored participants’ smoking-related experiences and perceptions of social support for smoking cessation, informed the development of the stage 2 interview schedule, and provided context for participants’ responses to the second interview. Stage 2 interviews explored participants’ perceptions of the feasibility, utility, and acceptability of the app features for SMI populations. Results: People with SMI perceived mHealth interventions to support their quit smoking attempts as feasible, acceptable, and useful. Key emerging themes included personalization of the app to users’ psychosocial needs, a caring app to mediate self-esteem and self-efficacy, an app that normalizes smoking relapse and multiple quit attempts, a strong focus on user experience to improve usability, and a social network to enhance social support for smoking cessation. Conclusions: This study gained an in-depth understanding of the lived experiences of smoking and quitting among people with SMI and their perception of the Kick.it app features to help inform the tailoring of the app. Specific program tailoring is required to assist them in navigating the complex interactions between mental illness and smoking in relation to their psychosocial well-being and capacity to quit. This study describes the adaptations required for the Kick.it app to meet the specific needs and preferences of people with SMI. Results of this study will guide the tailoring of the Kick.it app for SMI populations. The study findings can also inform a co-design process for the future development and design of smoking cessation apps for SMI populations.
Background: Alarm fatigue commonly leads to a reduced response to alarms. Appropriate and timely response to intravenous pump alarms is crucial to infusion continuity. The difficulty of filtering out critical short half-life infusion alarms from nonurgent alarms is a key challenge for risk management for clinicians. Critical care areas provide ample opportunities for intravenous medication error with the frequent administration of high-alert, critical short half-life infusions that require rigorous maintenance for continuity of delivery. Most serious medication errors in critical care occur during the execution of treatment, with performance-level failures outweighing rule-based or knowledge-based mistakes. Objective: One objective of this study was to establish baseline data for the types and frequency of alarms that critical care clinicians are exposed to from a variety of infusion devices, including both large volume pumps and syringe drivers. Another objective was to identify the volume of these alarms that specifically relate to critical short half-life infusions and to evaluate user response times to alarms from infusion devices delivering these particular infusions. Methods: The event logs of 1183 infusion pumps used in critical care environments and in general care areas within the European region were mined for a range of alarm states. The study then focused on a selection of infusion alarms from devices delivering critical short half-life infusions that would warrant rapid attention from clinicians in order to avoid potentially harmful prolonged infusion interruption. The reaction time of clinicians to infusion-interruption states and alarms for the selected critical short half-life infusions was then calculated. Results: Initial analysis showed a mean average of 4.50 alarms per infusion in the general critical care pump population as opposed to the whole hospital rate of 1.39. In the pediatric intensive care unit (PICU) group, the alarms per infusion value was significantly above the mean average for all critical care areas, with 8.61 alarms per infusion. Infusion-interruption of critical short half-life infusions was found to be a significant problem in all areas of the general critical care pump population, with a significant number of downstream (ie, vein and access) occlusion events noted. While the mean and median response times to critical short half-life infusion interruptions were generally within the half-lives of the selected medications, there was a high prevalence of outliers in terms of reaction times for all the critical short half-life infusions studied. Conclusions: This study gives an indication of what might be expected in critical care environments in terms of the volume of general infusion alarms and critical short half-life infusion alarms, as well as for clinician reaction times to critical short half-life infusion-interruption events. This study also identifies potentially problematic areas of the hospital for alarm fatigue and for particular issues of infusion and infusion-line management. Application of the proposed protocols can help create benchmarks for pump alarm management and clinician reaction times. These protocols can be applied to studies on the impact of alarm fatigue and for the evaluation of protocols, infusion-monitoring strategies, and infusion pump-based medication safety software aimed at reducing alarm fatigue and ensuring the maintenance of critical short half-life infusions. Given the frequency of infusion alarms seen in this study, the risk of alarm fatigue due to the white noise of pump alarms present in critical care, to which clinicians are constantly exposed, is very high. Furthermore, the added difficulties of maintaining critical short half-life infusions, and other infusions in specialist areas, are made clear by the high ratio of downstream occlusion to infusion starts in the neonatal intensive care unit (NICU). The ability to quantitatively track the volume of alarms and clinician reaction times contributes to a greater understanding of the issues of alarm fatigue in intensive care units. This can be applied to clinical audit, can allow for targeted training to reduce nuisance alarms, and can aid in planning for improvement in the key area of maintenance of steady-state plasma levels of critical short half-life infusions. One clear conclusion is that the medication administration rights should be extended to include right maintenance and ensured delivery continuity of critical short half-life infusions.
Background: There are several social cognitive theories (SCTs) and models that support platform design in electronic health (eHealth) promotion trials. The rationale for this scoping review was to determine how social design features (informational aid, expressive support, gaming, and tailored content) are used to promote self-efficacy, engagement, knowledge, and behavior change. Objective: This study aimed to review a broad spectrum of digital health interventions in the literature seeking trials that use SCTs for the design of eHealth applications. Methods: The author conducted a systematic scoping review of 161 Web-based health interventions from published randomized clinical trials using 1 or more tools to address the social cognitive determinants in their website design from January 2006 to April 2016. An iterative approach was used in the selection of studies and data extraction. The studies were analyzed for quality and coded for type of social design features employed. Results: Expressive interaction tools were found in 48.6% (54/111) of studies categorized as a strong recommendation by the Joanna Briggs Institute criteria. Overall, less than half of the studies addressed participant social support and motivational needs (43.8%). The vast majority of studies (100%) relied on the use of the Web for delivery of informational aid and tailored content for the individual participant (75.9%). Conclusions: This review fills a research gap by linking social theory to Web strategy to improve the impact and sustainability of eHealth interventions. A Digital Health Intervention Model was developed to provide a framework to enhance future Web-based health intervention design and execution.
Background: Redesigning electronic medical record (EMR) systems is needed to improve their usability and usefulness. Similar to other artifacts, EMR systems can evolve with time and exhibit situated roles. Situated roles refer to the ways in which a system is appropriated by its users, that is, the unintended ways the users engage with, relate to, and perceive the system in its context of use. These situated roles are usually unknown to the designers as they emerge and evolve as a response by the users to a contextual need or constraint. Understanding the system’s situated roles can expose the unarticulated needs of the users and enable redesign opportunities. Objective: This study aimed to find EMR redesign opportunities by understanding the situated roles of EMR systems in prenatal care settings. Methods: We conducted a field-based observational study at a Japanese prenatal care clinic. We observed 3 obstetricians and 6 midwives providing prenatal care to 37 pregnant women. We looked at how the EMR system is used during the checkups. We analyzed the observational data following a thematic analysis approach and identified the situated roles of the EMR system. Finally, we administered a survey to 5 obstetricians and 10 midwives to validate our results and understand the attitudes of the prenatal care staff regarding the situated roles of the EMR system. Results: We identified 10 distinct situated roles that EMR systems play in prenatal care settings. Among them, 4 roles were regarded as favorable as most users wanted to experience them more frequently, and 4 roles were regarded as unfavorable as most users wanted to experience them less frequently; 2 ambivalent roles highlighted the providers’ reluctance to document sensitive psychosocial information in the EMR and their use of the EMR system as an accomplice to pause communication during the checkups. To improve the usability and usefulness of EMR systems, designers can amplify the favorable roles and minimize the unfavorable roles. Our results also showed that obstetricians and midwives may have different experiences, wants, and priorities regarding the use of the EMR system. Conclusions: Currently, EMR systems are mainly viewed as tools that support the clinical workflow. Redesigning EMR systems is needed to amplify their roles as communication support tools. Our results provided multiple EMR redesign opportunities to improve the usability and usefulness of EMR systems in prenatal care. Designers can use the results to guide their EMR redesign activities and align them with the users’ wants and priorities. The biggest challenge is to redesign EMR systems in a way that amplifies their favorable roles for all the stakeholders concurrently.
