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  User Training and Skills

  Nov 18, 2020

  Internet-of-Things Skills Among the General Population: Task-Based Performance Test Using Activity Trackers

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  Authors List:

  • Pia S de Boer  
  • Alexander J A M van Deursen  
  • Thomas J L van Rompay  

  Abstract:

  Background: The health internet-of-things (IoT) can potentially provide insights into the present health condition, potential pitfalls, and support of a healthier lifestyle. However, to enjoy these benefits, people need skills to use the IoT. These IoT skills are expected to differ across the general population, thereby causing a new digital divide. Objective: This study aims to assess whether a sample of the general Dutch population can use health IoT by focusing on data and strategic IoT skills. Furthermore, we determine the role of gender, age, and education, and traditional internet skills. Methods: From April 1, 2019, to December 12, 2019, 100 individuals participated in this study. Participants were recruited via digital flyers and door-to-door canvassing. A selective quota sample was divided into equal subsamples of gender, age, and education. Additional inclusion criteria were smartphone possession and no previous experience of using activity trackers. This study was conducted in 3 waves over a period of 2 weeks. In wave 1, a questionnaire was administered to measure the operational, mobile, and information internet skills of the participants, and the participants were introduced to the activity tracker. After 1 week of getting acquainted with the activity tracker, a task-based performance test was conducted in wave 2 to measure the levels of data IoT skills and the strategic IoT skill component—action plan construction. A week after the participants were asked to use the activity tracker more deliberately, a performance test was then conducted in wave 3 to measure the level of the strategic IoT skill component—action plan execution. Results: The participants successfully completed 54% (13.5/25) of the data IoT skill tasks. Regarding strategic IoT tasks, the completion rates were 56% (10.1/18) for action plan construction and 43% (3.9/9) for action plan execution. None of the participants were able to complete all the data IoT skill tasks, and none of the participants were able to complete all the strategic IoT skill tasks regarding action plan construction or its execution. Age and education were important determinants of the IoT skill levels of the participants, except for the ability to execute an action plan strategically. Furthermore, the level of information internet skills of the participants contributed to their level of data IoT skills. Conclusions: This study found that data and strategic IoT skills of Dutch citizens are underdeveloped with regard to health purposes. In particular, those who could benefit the most from health IoT were those who had the most trouble using it, that is, the older and lower-educated individuals.

  • JMIR Hum Factors 2020;7(4):e22532

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  Design and Usability of Websites for...

  Nov 9, 2020

  Young People’s Attitude Toward Positive Psychology Interventions: Thematic Analysis

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  Authors List:

  • Toni Michel  
  • Franziska Tachtler  
  • Petr Slovak  
  • Geraldine Fitzpatrick  

  Abstract:

  Background: Digital instantiations of positive psychology intervention (PPI) principles have been proposed to combat the current global youth mental health crisis; however, young people are largely not engaging with available resources. Objective: The aim of this study is to explore young people’s attitudes toward various PPI principles to find ways of making digital instantiations of them more engaging. Methods: We conducted an explorative workshop with 30 young people (aged 16-21 years). They rated and reviewed 29 common PPIs. Ratings and recorded discussions were analyzed using thematic analysis. Results: Some interventions were conflicting with young people’s values or perceived as too difficult. Participants responded positively to interventions that fit them personally and allowed them to use their strengths. Conclusions: Values, context, strengths, and other personal factors are entangled with young people’s attitudes toward digital instantiations of PPI principles.

  • JMIR Hum Factors 2020;7(4):e21145

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  Design and Usability of Clinical...

  Oct 30, 2020

  A Simulated Graphical Interface for Integrating Patient-Generated Health Data From Smartwatches With Electronic Health Records: Usability Study

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  Authors List:

  • Jordan M Alpert  
  • Naga S Prabhakar Kota  
  • Sanjay Ranka  
  • Tonatiuh V Mendoza  
  • Laurence M Solberg  
  • Parisa Rashidi  
  • Todd M Manini  

  Abstract:

  Background: Wearable technology, such as smartwatches, can capture valuable patient-generated data and help inform patient care. Electronic health records provide logical and practical platforms for including such data, but it is necessary to evaluate the way the data are presented and visualized. Objective: The aim of this study is to evaluate a graphical interface that displays patients’ health data from smartwatches, mimicking the integration within the environment of electronic health records. Methods: A total of 12 health care professionals evaluated a simulated interface using a usability scale questionnaire, testing the clarity of the interface, colors, usefulness of information, navigation, and readability of text. Results: The interface was positively received, with 14 out of the 16 questions generating a score of 5 or greater among at least 75% of participants (9/12). On an 8-point Likert scale, the highest rated features of the interface were quick turnaround times (mean score 7.1), readability of the text (mean score 6.8), and use of terminology/abbreviations (mean score 6.75). Conclusions: Collaborating with health care professionals to develop and refine a graphical interface for visualizing patients’ health data from smartwatches revealed that the key elements of the interface were acceptable. The implementation of such data from smartwatches and other mobile devices within electronic health records should consider the opinions of key stakeholders as the development of this platform progresses.

  • JMIR Hum Factors 2020;7(4):e19769

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  Design and Usability of Clinical...

  Oct 21, 2020

  Characterizing and Visualizing Display and Task Fragmentation in the Electronic Health Record: Mixed Methods Design

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  Authors List:

  • Yalini Senathirajah  
  • David R Kaufman  
  • Kenrick D Cato  
  • Elizabeth M Borycki  
  • Jaime Allen Fawcett  
  • Andre W Kushniruk  

  Abstract:

  Background: The complexity of health care data and workflow presents challenges to the study of usability in electronic health records (EHRs). Display fragmentation refers to the distribution of relevant data across different screens or otherwise far apart, requiring complex navigation for the user’s workflow. Task and information fragmentation also contribute to cognitive burden. Objective: This study aims to define and analyze some of the main sources of fragmentation in EHR user interfaces (UIs); discuss relevant theoretical, historical, and practical considerations; and use granular microanalytic methods and visualization techniques to help us understand the nature of fragmentation and opportunities for EHR optimization or redesign. Methods: Sunburst visualizations capture the EHR navigation structure, showing levels and sublevels of the navigation tree, allowing calculation of a new measure, the Display Fragmentation Index. Time belt visualizations present the sequences of subtasks and allow calculation of proportion per instance, a measure that quantifies task fragmentation. These measures can be used separately or in conjunction to compare EHRs as well as tasks and subtasks in workflows and identify opportunities for reductions in steps and fragmentation. We present an example use of the methods for comparison of 2 different EHR interfaces (commercial and composable) in which subjects apprehend the same patient case. Results: Screen transitions were substantially reduced for the composable interface (from 43 to 14), whereas clicks (including scrolling) remained similar. Conclusions: These methods can aid in our understanding of UI needs under complex conditions and tasks to optimize EHR workflows and redesign.

  • JMIR Hum Factors 2020;7(4):e18484

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  Design and Evaluation of Patient...

  Oct 21, 2020

  New Patient Education Video on Colonoscopy Preparation: Development and Evaluation Study

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  Authors List:

  • Matthew T Bernstein  
  • Jesse Garber  
  • Patrick Faucher  
  • Kristin A Reynolds  
  • Gayle Restall  
  • John R Walker  
  • Harminder Singh  

  Abstract:

  Background: Although several patient education materials on colonoscopy preparation exist, few studies have evaluated or compared them; hence, there is no professional consensus on recommended content or media to use. Objective: This study aims to address this need by developing and evaluating a new video on colonoscopy preparation. Methods: We developed a new video explaining split-dose bowel preparation for colonoscopy. Of similar content videos on the internet (n=20), the most favorably reviewed video among patient and physician advisers was used as the comparator for the study. A total of 232 individuals attending gastroenterology or urology clinics reviewed the new and comparator videos. The order of administration of the new and comparator videos was randomly counterbalanced to assess the impact of presentation order. Respondents rated each video on the following dimensions: information amount, clarity, trustworthiness, understandability, new or familiar information, reassurance, information learned, understanding from the patient’s point of view, appeal, and the likelihood of recommending the video to others. Results: Overall, 71.6% (166/232) of the participants preferred the new video, 25.0% (58/232) preferred the comparator video, and 3.4% (8/232) were not sure. Furthermore, 64.0% (71/111) of those who viewed the new video first preferred it, whereas 77.7% (94/121) of the participants who viewed the new video second preferred it. Multivariable logistic regression analysis also demonstrated that participants were more likely to prefer the new video if they had viewed it second. Participants who preferred the new video rated it as clearer and more trustworthy than those who preferred the comparator video. Conclusions: This study developed and assessed the strengths of a newly developed colonoscopy educational video.

  • JMIR Hum Factors 2020;7(4):e15353

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  Participatory Design and...

  Oct 15, 2020

  Privacy Perceptions and Concerns in Image-Based Dietary Assessment Systems: Questionnaire-Based Study

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  Authors List:

  • Aakash Sharma  
  • Katja P Czerwinska  
  • Lars Brenna  
  • Dag Johansen  
  • Håvard D Johansen  

  Abstract:

  Background: Complying with individual privacy perceptions is essential when processing personal information for research. Our specific research area is performance development of elite athletes, wherein nutritional aspects are important. Before adopting new automated tools that capture such data, it is crucial to understand and address the privacy concerns of the research subjects that are to be studied. Privacy as contextual integrity emphasizes understanding contextual sensitivity in an information flow. In this study, we explore privacy perceptions in image-based dietary assessments. This research field lacks empirical evidence on what will be considered as privacy violations when exploring trends in long-running studies. Prior studies have only classified images as either private or public depending on their basic content. An assessment and analysis are thus needed to prevent unwanted consequences of privacy breach and other issues perceived as sensitive when designing systems for dietary assessment by using food images. Objective: The aim of this study was to investigate common perceptions of computer systems using food images for dietary assessment. The study delves into perceived risks and data-sharing behaviors. Methods: We investigated the privacy perceptions of 105 individuals by using a web-based survey. We analyzed these perceptions along with perceived risks in sharing dietary information with third parties. Results: We found that understanding the motive behind the use of data increases its chances of sharing with a social group. Conclusions: In this study, we highlight various privacy concerns that can be addressed during the design phase. A system design that is compliant with general data protection regulations will increase participants’ and stakeholders’ trust in an image-based dietary assessment system. Innovative solutions are needed to reduce the intrusiveness of a continuous assessment. Individuals show varying behaviors for sharing metadata, as knowing what the data is being used for, increases the chance of it being shared.

  • JMIR Hum Factors 2020;7(4):e19085

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  Participatory Design and...

  Sep 30, 2020

  A Novel Auditory-Cognitive Training App for Delaying or Preventing the Onset of Dementia: Participatory Design With Stakeholders

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  Authors List:

  • Emily Frost  
  • Talya Porat  
  • Paresh Malhotra  
  • Lorenzo Picinali  

  Abstract:

  Background: Multiple gaming apps exist under the dementia umbrella for skills such as navigation; however, an app to specifically investigate the role of hearing loss in the process of cognitive decline is yet to be designed. There is a demonstrable gap in the utilization of games to further the knowledge of the potential relationship between hearing loss and dementia. Objective: This study aims to identify the needs, facilitators, and barriers in designing a novel auditory-cognitive training gaming app. Methods: A participatory design approach was used to engage key stakeholders across audiology and cognitive disorder specialties. Two rounds, including paired semistructured interviews and focus groups, were completed and thematically analyzed. Results: A total of 18 stakeholders participated, and 6 themes were identified to inform the next stage of app development. These included congruence with hobbies, life getting in the way, motivational challenge, accessibility, addictive competition, and realism. Conclusions: The findings can now be implemented in the development of the app. The app will be evaluated against outcome measures of speech listening in noise, cognitive and attentional tasks, quality of life, and usability.

  • JMIR Hum Factors 2020;7(3):e19880

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  Design of Processes and Workflows

  Sep 28, 2020

  Document-Engineering Methodology in Health Care: An Innovative Behavioral Science–Based Approach to Improve Patient Empowerment

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  Authors List:

  • Bernd Pohlmann-Eden  
  • Silke C Eden  

  Abstract:

  Engaging patients in their treatment and making them experts of their condition has been identified as a high priority across many medical disciplines. Patient empowerment claims to improve compliance, patient safety, and disease outcome. Patient empowerment may help the patient in shared decision making and in becoming an informed partner of the health care professional. We consider patient empowerment to be in jeopardy if written medical information for patients is too complex and confusing. We introduce document-engineering methodology (DEM) as a new tool for the health care industry. DEM tries to implement principles of cognitive science and neuroscience-based concepts of reading and comprehension. It follows the most recent document design techniques. DEM has been used in the aviation, mining, and oil industries. In these very industries, DEM was integrated to improve user performance, prevent harm, and increase safety. We postulate that DEM, applied to written documents in health care, will help patients to quickly navigate through complex written information and thereby enable them to better comprehend the essence of the medical information. DEM aims to empower the patient and help start an informed conversation with their health care professional. The ultimate goals of DEM are to increase adherence and compliance, leading to improved outcomes. Our approach is innovative, as we apply our learning from other industries to health care; we call this cross-industry innovation. In this manuscript, we provide illustrative examples of DEM in three frequent clinical scenarios: (1) explaining a complex diagnosis for the first time, (2) understanding medical leaflet information, and (3) exploring cannabis-based medicine. There is an urgent need to test DEM in larger clinical cohorts and for careful proof-of-concept studies, regarding patient and stakeholder engagement, to be conducted.

  • JMIR Hum Factors 2020;7(3):e19196

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  Design and Usability of Medical Devices

  Sep 17, 2020

  Embedding the Pillars of Quality in Health Information Technology Solutions Using “Integrated Patient Journey Mapping” (IPJM): Case Study

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  Authors List:

  • Stephen McCarthy  
  • Paidi O'Raghallaigh  
  • Simon Woodworth  
  • Yoke Yin Lim  
  • Louise C Kenny  
  • Frédéric Adam  

  Abstract:

  Background: Health information technology (HIT) and associated data analytics offer significant opportunities for tackling some of the more complex challenges currently facing the health care sector. However, to deliver robust health care service improvements, it is essential that HIT solutions be designed by parallelly considering the 3 core pillars of health care quality: clinical effectiveness, patient safety, and patient experience. This requires multidisciplinary teams to design interventions that both adhere to medical protocols and achieve the tripartite goals of effectiveness, safety, and experience. Objective: In this paper, we present a design tool called Integrated Patient Journey Mapping (IPJM) that was developed to assist multidisciplinary teams in designing effective HIT solutions to address the 3 core pillars of health care quality. IPJM is intended to support the analysis of requirements as well as to promote empathy and the emergence of shared commitment and understanding among multidisciplinary teams. Methods: A 6-month, in-depth case study was conducted to derive findings on the use of IPJM during Learning to Evaluate Blood Pressure at Home (LEANBH), a connected health project that developed an HIT solution for the perinatal health context. Data were collected from over 700 hours of participant observations and 10 semistructured interviews. Results: The findings indicate that IPJM offered a constructive tool for multidisciplinary teams to work together in designing an HIT solution, through mapping the physical and emotional journey of patients for both the current service and the proposed connected health service. This allowed team members to consider the goals, tasks, constraints, and actors involved in the delivery of this journey and to capture requirements for the digital touchpoints of the connected health service. Conclusions: Overall, IPJM facilitates the design and implementation of complex HITs that require multidisciplinary participation. Trial Registration:

  • JMIR Hum Factors 2020;7(3):e17416

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  Focus Groups and Qualitative Research...

  Sep 17, 2020

  Understanding the Attitudes of Clinicians and Patients Toward a Self-Management eHealth Tool for Atrial Fibrillation: Qualitative Study

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  Authors List:

  • Boon Piang Cher  
  • Gayatri Kembhavi  
  • Kai Yee Toh  
  • Jananie Audimulam  
  • Wei-Yan Aloysius Chia  
  • Hubertus JM Vrijhoef  
  • Yee Wei Lim  
  • Toon Wei Lim  

  Abstract:

  Background: Atrial fibrillation (AF) is the most common heart rhythm disorder and poses a growing disease burden worldwide because of an aging population. A multidisciplinary approach with an emphasis on patient education and self-management has been demonstrated to improve outcomes for AF through the engagement of patients in their own care. Although electronic tools (e-tools) such as apps have been proposed to provide patient education and facilitate self-management, there have been few studies to guide the development of these tools for patients with AF. Objective: This study aims to explore the perceptions of patients and health care providers (HCPs) and their attitudes toward the use of e-tools for the self-management of AF. It also seeks to elicit the factors that contribute to these attitudes. Methods: Semistructured qualitative interviews with HCPs and patients were conducted to understand the interpretations and expectations of an e-tool that would be used for the self-management of AF. Interview data were analyzed using an exploratory thematic analysis approach to uncover emergent themes and infer ideas of preferred features in a device. A modified technology acceptance model was developed as a framework to help interpret these findings. Data from the HCPs and patients were compared and contrasted. Results: Both patients and HCPs thought that an e-tool would be useful in the self-management of AF. Although both groups favored educational content and monitoring of blood pressure, patients expressed more passivity toward self-care and an ambivalence toward the use of technology to monitor their medical condition. This appears to be related to factors such as a patient’s age, social support, and their attitudes toward technology. Instead, they favored using the app to contact their HCPs. Conclusions: This study provides insights into significant differences in the attitudes of patients and HCPs toward the use of e-tools for self-care against their priorities. Understanding patients’ motivations and their needs are key to ensuring higher acceptance of such tools.

  • JMIR Hum Factors 2020;7(3):e15492

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  Usability Evaluation Case Studies

  Sep 14, 2020

  Mobile App for Monitoring 3-Month Postoperative Functional Outcome After Hip Fracture: Usability Study

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  Authors List:

  • Merle A J Geerds  
  • Wieke S Nijmeijer  
  • J H Hegeman  
  • Miriam M R Vollenbroek-Hutten  

  Abstract:

  Background: As a result of an aging population, there has been an increasing incidence of hip fractures worldwide. In the Netherlands, in order to improve the quality of care for elderly patients with hip fractures, the multidisciplinary Centre for Geriatric Traumatology was established in 2008 at the Department of Trauma Surgery at Ziekenhuisgroep Twente hospital (located in Almelo and Hengelo in the Netherlands). Objective: Though the Dutch Hip Fracture audit is used to monitor the quality of care for patients with fractures of the hip, only 30.7% of patients complete registration in the 3-month follow-up period. Mobile apps offer an opportunity for improvement in this area. The aim of this study was to investigate the usability and acceptance of a mobile app for gathering indicators of quality of care in a 3-month follow-up period after postoperative treatment of hip fracture. Methods: From July 2017 to December 2017, patients who underwent surgical treatment for hip fracture were recruited. Patients and caregivers, who were collectively considered the participant cohort, were asked to download the app and answer a questionnaire. Participants were divided into two groups—those who downloaded the app and those who did not download the app. A telephone interview that was based upon the Unified Theory of Acceptance and Use of Technology was conducted with a subset of participants from each group (1:1 ratio). This study was designated as not being subject to the Dutch Medical Research Involving Human Subjects Act according to the appropriate medical research ethics committees. Results: Of the patients and caregivers who participated, 26.4% (29/110) downloaded the app, whereas 73.6% (81/110) did not. Telephone interviews with the subset of participants (n=24 per group) revealed that 54.0% (13/24) of the group of participants who did not download the app had forgotten the study. Among the group who downloaded the app, 95.8% (23/24) had the intention of completing the questionnaire, but only 4.2% (1/24) did so. The reasons for not completing the questionnaire included technical problems, cognitive disorders, or patient dependency on caregivers. Most participants in the group who downloaded the app self-reported a high level of expertise in using a smartphone (22/24, 91.7%), and sufficient facilitating conditions for using a smartphone were self-reported in both groups (downloaded the app: 23/24, 95.8%; did not download the app: 21/24, 87.5%), suggesting that these factors were not barriers to completion. Conclusions: Despite self-reported intention to use the app, smartphone expertise, and sufficient facilitating conditions for smartphone use, implementation of the mobile app was infeasible for daily practice. This was due to a combination of technical problems, factors related to the implementation process, and the population of interest having cognitive disorders or a dependency on caregivers for mobile technology.

  • JMIR Hum Factors 2020;7(3):e16989

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  Design and Usability of Consumer...

  Sep 4, 2020

  Embodied Conversational Agent Appearance for Health Assessment of Older Adults: Explorative Study

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  Authors List:

  • Silke ter Stal  
  • Marijke Broekhuis  
  • Lex van Velsen  
  • Hermie Hermens  
  • Monique Tabak  

  Abstract:

  Background: Embodied conversational agents (ECAs) have great potential for health apps but are rarely investigated as part of such apps. To promote the uptake of health apps, we need to understand how the design of ECAs can influence the preferences, motivation, and behavior of users. Objective: This is one of the first studies that investigates how the appearance of an ECA implemented within a health app affects users’ likeliness of following agent advice, their perception of agent characteristics, and their feeling of rapport. In addition, we assessed usability and intention to use. Methods: The ECA was implemented within a frailty assessment app in which three health questionnaires were translated into agent dialogues. In a within-subject experiment, questionnaire dialogues were randomly offered by a young female agent or an older male agent. Participants were asked to think aloud during interaction. Afterward, they rated the likeliness of following the agent’s advice, agent characteristics, rapport, usability, and intention to use and participated in a semistructured interview. Results: A total of 20 older adults (72.2 [SD 3.5] years) participated. The older male agent was perceived as more authoritative than the young female agent (P=.03), but no other differences were found. The app scored high on usability (median 6.1) and intention to use (median 6.0). Participants indicated they did not see an added value of the agent to the health app. Conclusions: Agent age and gender little influence users’ impressions after short interaction but remain important at first glance to lower the threshold to interact with the agent. Thus, it is important to take the design of ECAs into account when implementing them into health apps.

  • JMIR Hum Factors 2020;7(3):e19987

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