A glossary of user-centered design strategies for implementation experts

User-centered design (UCD), a discipline that seeks to ground the design of an innovation in information about the people who will ultimately use that innovation, has great potential to improve the translation of evidence-based practices from behavioral medicine research for implementation in health care settings. UCD is a diverse, innovative field that remains highly variable in terms of language and approaches. Ultimately, we produced a glossary of UCD-related strategies specifically for experts in implementation research and practice, with the goal of promoting interdisciplinary collaboration in implementation efforts. We conducted a focused literature review to identify key concepts and specific strategies of UCD to translate into the implementation field. We also categorized the strategies as primarily targeting one or more levels of the implementation process (i.e., interventions, individuals, inner context, and outer context). Ultimately, we produced a glossary of 30 UCD strategies for implementation experts. Each glossary term is accompanied by a short, yet comprehensive, definition. The strategies and their definitions are illustrated, using a hypothetical behavioral medicine intervention as an example, for each of the four levels of the implementation process. This UCD glossary may prove useful to implementation experts who wish to develop effective collaborations and "shared language" with UCD experts to enhance use of behavioral medicine research in health services. Directions for future research are also discussed.

Critiquing the Concept of BCI Illiteracy

Brain-computer interfaces (BCIs) are a form of technology that read a user's neural signals to perform a task, often with the aim of inferring user intention. They demonstrate potential in a wide range of clinical, commercial, and personal applications. But BCIs are not always simple to operate, and even with training some BCI users do not operate their systems as intended. Many researchers have described this phenomenon as "BCI illiteracy," and a body of research has emerged aiming to characterize, predict, and solve this perceived problem. However, BCI illiteracy is an inadequate concept for explaining difficulty that users face in operating BCI systems. BCI illiteracy is a methodologically weak concept; furthermore, it relies on the flawed assumption that BCI users possess physiological or functional traits that prevent proficient performance during BCI use. Alternative concepts to BCI illiteracy may offer better outcomes for prospective users and may avoid the conceptual pitfalls that BCI illiteracy brings to the BCI research process.

Brain Painting: usability testing according to the user-centered design in end users with severe motor paralysis

BACKGROUND

For many years the reestablishment of communication for people with severe motor paralysis has been in the focus of brain-computer interface (BCI) research. Recently applications for entertainment have also been developed. Brain Painting allows the user creative expression through painting pictures.

OBJECTIVE

The second, revised prototype of the BCI Brain Painting application was evaluated in its target function - free painting - and compared to the P300 spelling application by four end users with severe disabilities.

METHODS

According to the International Organization for Standardization (ISO), usability was evaluated in terms of effectiveness (accuracy), efficiency (information transfer rate (ITR)), utility metric, subjective workload (National Aeronautics and Space Administration Task Load Index (NASA TLX)) and user satisfaction (Quebec User Evaluation of Satisfaction with assistive Technology (QUEST) 2.0 and Assistive Technology Device Predisposition Assessment (ATD PA), Device Form).

RESULTS

The results revealed high performance levels (M≥80% accuracy) in the free painting and the copy painting conditions, ITRs (4.47-6.65bits/min) comparable to other P300 applications and only low to moderate workload levels (5-49 of 100), thereby proving that the complex task of free painting did neither impair performance nor impose insurmountable workload. Users were satisfied with the BCI Brain Painting application. Main obstacles for use in daily life were the system operability and the EEG cap, particularly the need of extensive support for adjustment.

CONCLUSION

The P300 Brain Painting application can be operated with high effectiveness and efficiency. End users with severe motor paralysis would like to use the application in daily life. User-friendliness, specifically ease of use, is a mandatory necessity when bringing BCI to end users. Early and active involvement of users and iterative user-centered evaluation enable developers to work toward this goal.

Aligning implementation and user-centered design strategies to enhance the impact of health services: results from a concept mapping study

BACKGROUND

Innovative approaches are needed to maximize fit between the characteristics of evidence-based practices (EBPs), implementation strategies that support EBP use, and contexts in which EBPs are implemented. Standard approaches to implementation offer few ways to address such issues of fit. We characterized the potential for collaboration with experts from a relevant complementary approach, user-centered design (UCD), to increase successful implementation.

METHOD

Using purposive and snowball sampling, we recruited 56 experts in implementation (n = 34) or UCD (n = 22). Participants had 5+ years of professional experience (M = 10.31), worked across many settings (e.g., healthcare, education, human services), and were mostly female (59%) and white (73%). Each participant completed a web-based concept mapping structured conceptualization task. They sorted strategies from established compilations for implementation (36 strategies) and UCD (30 strategies) into distinct clusters, then rated the importance and feasibility of each strategy.

RESULTS

We used multidimensional scaling techniques to examine patterns in the sorting of strategies. Based on conceptual clarity and fit with established implementation frameworks, we selected a final set of 10 clusters (i.e., groups of strategies), with five implementation-only clusters, two UCD-only clusters, and three trans-discipline clusters. The highest-priority activities (i.e., above-average importance and feasibility) were the trans-discipline clusters plus facilitate change and monitor change. Implementation and UCD experts sorted strategies into similar clusters, but each gave higher importance and feasibility ratings to strategies/clusters from their own discipline.

CONCLUSIONS

In this concept mapping study, experts in implementation and UCD had perspectives that both converged (e.g., trans-discipline clusters, which were all rated as high-priority) and diverged (e.g., in importance/feasibility ratings). The results provide a shared understanding of the alignment between implementation science and UCD, which can increase the impact and sustainability of EBP implementation efforts. Implications for improved collaboration among implementation and UCD experts are discussed.

Complementary approaches to problem solving in healthcare and public health: implementation science and human-centered design

Complementary approaches to problem solving in healthcare and public health: implementation science and human-centered design”: Combining implementation science and human-centered design approaches is novel and these complementary approaches can be applied together to optimize the integration of evidence-based practices within clinical and public health settings.

User-centered design to improve clinical decision support in primary care

BACKGROUND

A growing literature has demonstrated the ability of user-centered design to make clinical decision support systems more effective and easier to use. However, studies of user-centered design have rarely examined more than a handful of sites at a time, and have frequently neglected the implementation climate and organizational resources that influence clinical decision support. The inclusion of such factors was identified by a systematic review as "the most important improvement that can be made in health IT evaluations."

OBJECTIVES

(1) Identify the prevalence of four user-centered design practices at United States Veterans Affairs (VA) primary care clinics and assess the perceived utility of clinical decision support at those clinics; (2) Evaluate the association between those user-centered design practices and the perceived utility of clinical decision support.

METHODS

We analyzed clinic-level survey data collected in 2006-2007 from 170 VA primary care clinics. We examined four user-centered design practices: 1) pilot testing, 2) provider satisfaction assessment, 3) formal usability assessment, and 4) analysis of impact on performance improvement. We used a regression model to evaluate the association between user-centered design practices and the perceived utility of clinical decision support, while accounting for other important factors at those clinics, including implementation climate, available resources, and structural characteristics. We also examined associations separately at community-based clinics and at hospital-based clinics.

RESULTS

User-centered design practices for clinical decision support varied across clinics: 74% conducted pilot testing, 62% conducted provider satisfaction assessment, 36% conducted a formal usability assessment, and 79% conducted an analysis of impact on performance improvement. Overall perceived utility of clinical decision support was high, with a mean rating of 4.17 (±.67) out of 5 on a composite measure. "Analysis of impact on performance improvement" was the only user-centered design practice significantly associated with perceived utility of clinical decision support, b=.47 (p<.001). This association was present in hospital-based clinics, b=.34 (p<.05), but was stronger at community-based clinics, b=.61 (p<.001).

CONCLUSIONS

Our findings are highly supportive of the practice of analyzing the impact of clinical decision support on performance metrics. This was the most common user-centered design practice in our study, and was the practice associated with higher perceived utility of clinical decision support. This practice may be particularly helpful at community-based clinics, which are typically less connected to VA medical center resources.

Effect of a mobile app intervention on vegetable consumption in overweight adults: a randomized controlled trial

Background

Mobile applications (apps) have been heralded as transformative tools to deliver behavioral health interventions at scale, but few have been tested in rigorous randomized controlled trials. We tested the effect of a mobile app to increase vegetable consumption among overweight adults attempting weight loss maintenance.

Methods

Overweight adults (n=135) aged 18–50 years with BMI=28–40 kg/m² near Stanford, CA were recruited from an ongoing 12-month weight loss trial (parent trial) and randomly assigned to either the stand-alone, theory-based Vegethon mobile app (enabling goal setting, self-monitoring, and feedback and using “process motivators” including fun, surprise, choice, control, social comparison, and competition) or a wait-listed control condition. The primary outcome was daily vegetables servings, measured by an adapted Harvard food frequency questionnaire (FFQ) 8 weeks post-randomization. Daily vegetable servings from 24-hour dietary recalls, administered by trained, certified, and blinded interviewers 5 weeks post-randomization, was included as a secondary outcome. All analyses were conducted according to principles of intention-to-treat.

Results

Daily vegetable consumption was significantly greater in the intervention versus control condition for both measures (adjusted mean difference: 2.0 servings; 95% CI: 0.1, 3.8, p=0.04 for FFQ; and 1.0 servings; 95% CI: 0.2, 1.9; p=0.02 for 24-hour recalls). Baseline vegetable consumption was a significant moderator of intervention effects (p=0.002) in which effects increased as baseline consumption increased.

Conclusions

These results demonstrate the efficacy of a mobile app to increase vegetable consumption among overweight adults. Theory-based mobile interventions may present a low-cost, scalable, and effective approach to improving dietary behaviors and preventing associated chronic diseases.

Trial registration

ClinicalTrials.gov NCT01826591. Registered 27 March 2013.

Know thy eHealth user: Development of biopsychosocial personas from a study of older adults with heart failure

BACKGROUND

Personas are a canonical user-centered design method increasingly used in health informatics research. Personas-empirically-derived user archetypes-can be used by eHealth designers to gain a robust understanding of their target end users such as patients.

OBJECTIVE

To develop biopsychosocial personas of older patients with heart failure using quantitative analysis of survey data.

METHOD

Data were collected using standardized surveys and medical record abstraction from 32 older adults with heart failure recently hospitalized for acute heart failure exacerbation. Hierarchical cluster analysis was performed on a final dataset of n=30. Nonparametric analyses were used to identify differences between clusters on 30 clustering variables and seven outcome variables.

RESULTS

Six clusters were produced, ranging in size from two to eight patients per cluster. Clusters differed significantly on these biopsychosocial domains and subdomains: demographics (age, sex); medical status (comorbid diabetes); functional status (exhaustion, household work ability, hygiene care ability, physical ability); psychological status (depression, health literacy, numeracy); technology (Internet availability); healthcare system (visit by home healthcare, trust in providers); social context (informal caregiver support, cohabitation, marital status); and economic context (employment status). Tabular and narrative persona descriptions provide an easy reference guide for informatics designers.

DISCUSSION

Personas development using approaches such as clustering of structured survey data is an important tool for health informatics professionals. We describe insights from our study of patients with heart failure, then recommend a generic ten-step personas development process. Methods strengths and limitations of the study and of personas development generally are discussed.

Iterative development of Vegethon: a theory-based mobile app intervention to increase vegetable consumption

BACKGROUND

Mobile technology may serve as a cost-effective and scalable tool for delivering behavioral nutrition interventions. This research sought to iteratively develop a theory-driven mobile app, Vegethon, to increase vegetable consumption.

METHODS

Development of Vegethon followed phases outlined by the IDEAS framework: 1) empathize with users (qualitative interviews, n = 18); 2) specify target behavior; 3) ground in behavioral theory; 4) ideate implementation strategies; 5) prototype potential products; 6) gather user feedback (qualitative interviews, n = 14; questionnaire, n = 41); 7) build minimum viable product; and 8) pilot potential efficacy and usability (pilot RCT, n = 17). Findings from each phase informed subsequent phases. The target population that informed intervention development was 18-50 years of age, had BMIs of 28-40 kg/m(2), and lived in the geographical area surrounding Stanford University. A full description of the final version of Vegethon is included in the paper.

RESULTS

Qualitative findings that shaped initial intervention conception were: participants' interests in accountability without judgment; their desire for simple and efficient dietary self-monitoring; and the importance of planning meals in advance. Qualitative findings identified during intervention refinement were the need for a focus on vegetable self-monitoring; inclusion of vegetable challenges; simplification of features; advice and inspiration for eating vegetables; reminder notifications; and peer comparison. Pilot RCT findings suggested the initial efficacy, acceptance, and feasibility of the intervention. The final version of Vegethon enabled easy self-monitoring of vegetable consumption and included a range of features designed to engage the user (e.g., surprise challenges; leaderboard; weekly reports). Vegethon was coded for its inclusion of 18 behavior change techniques (BCTs) (e.g., goal setting; feedback; social comparison; prompts/cues; framing/reframing; identity).

CONCLUSIONS

Vegethon is a theory-based, user-informed mobile intervention that was systematically developed using the IDEAS framework. Vegethon targets increased vegetable consumption among overweight adults and is currently being evaluated in a randomized controlled efficacy trial.

TRIAL REGISTRATION

Clinical Trials.gov: NCT01826591.

Designing the Future of Children's Mental Health Services

Advancements in evidence-based psychosocial interventions, digital technologies, and implementation strategies (i.e., health services research products) for youth mental health services have yet to yield significant improvement in public health outcomes. Achieving such impact will require that these research products are easy to use, useful, and contextually appropriate. This paper describes how human-centered design (HCD), an approach that aligns product development with the needs of the people and settings that use those products, can be leveraged to improve youth mental health services. We articulate how HCD can advance accessibility, effectiveness, and equity, with specific consideration of unique aspects of youth mental health services.

User-Centered Design Groups to Engage Patients and Caregivers with a Personalized Health Information Technology Tool

Health information technology (IT) has opened exciting avenues for capturing, delivering and sharing data, and offers the potential to develop cost-effective, patient-focused applications. In recent years, there has been a proliferation of health IT applications such as outpatient portals. Rigorous evaluation is fundamental to ensure effectiveness and sustainability, as resistance to more widespread adoption of outpatient portals may be due to lack of user friendliness. Health IT applications that integrate with the existing electronic health record and present information in a condensed, user-friendly format could improve coordination of care and communication. Importantly, these applications should be developed systematically with appropriate methodological design and testing to ensure usefulness, adoption, and sustainability. Based on our prior work that identified numerous information needs and challenges of HCT, we developed an experimental prototype of a health IT tool, the BMT Roadmap. Our goal was to develop a tool that could be used in the real-world, daily practice of HCT patients and caregivers (users) in the inpatient setting. Herein, we examined the views, needs, and wants of users in the design and development process of the BMT Roadmap through user-centered Design Groups. Three important themes emerged: 1) perception of core features as beneficial (views), 2) alerting the design team to potential issues with the user interface (needs); and 3) providing a deeper understanding of the user experience in terms of wider psychosocial requirements (wants). These findings resulted in changes that led to an improved, functional BMT Roadmap product, which will be tested as an intervention in the pediatric HCT population in the fall of 2015 (ClinicalTrials.govNCT02409121).

BMT Roadmap: A User-Centered Design Health Information Technology Tool to Promote Patient-Centered Care in Pediatric Hematopoietic Cell Transplantation

Health information technology (HIT) has great potential for increasing patient engagement. Pediatric hematopoietic cell transplantation (HCT) is a setting ripe for using HIT but in which little research exists. "BMT Roadmap" is a web-based application that integrates patient-specific information and includes several domains: laboratory results, medications, clinical trial details, photos of the healthcare team, trajectory of transplant process, and discharge checklist. BMT Roadmap was provided to 10 caregivers of patients undergoing first-time HCT. Research assistants performed weekly qualitative interviews throughout the patient's hospitalization and at discharge and day 100 to assess the impact of BMT Roadmap. Rigorous thematic analysis revealed 5 recurrent themes: emotional impact of the HCT process itself; critical importance of communication among patients, caregivers, and healthcare providers; ways in which BMT Roadmap was helpful during inpatient setting; suggestions for improving BMT Roadmap; and other strategies for organization and management of complex healthcare needs that could be incorporated into BMT Roadmap. Caregivers found the tool useful and easy to use, leading them to want even greater access to information. BMT Roadmap was feasible, with no disruption to inpatient care. Although this initial study is limited by the small sample size and single-institution experience, these initial findings are encouraging and support further investigation.

User-centered design in brain-computer interfaces-a case study

OBJECTIVE

The array of available brain-computer interface (BCI) paradigms has continued to grow, and so has the corresponding set of machine learning methods which are at the core of BCI systems. The latter have evolved to provide more robust data analysis solutions, and as a consequence the proportion of healthy BCI users who can use a BCI successfully is growing. With this development the chances have increased that the needs and abilities of specific patients, the end-users, can be covered by an existing BCI approach. However, most end-users who have experienced the use of a BCI system at all have encountered a single paradigm only. This paradigm is typically the one that is being tested in the study that the end-user happens to be enrolled in, along with other end-users. Though this corresponds to the preferred study arrangement for basic research, it does not ensure that the end-user experiences a working BCI. In this study, a different approach was taken; that of a user-centered design. It is the prevailing process in traditional assistive technology. Given an individual user with a particular clinical profile, several available BCI approaches are tested and - if necessary - adapted to him/her until a suitable BCI system is found.

METHODS

Described is the case of a 48-year-old woman who suffered from an ischemic brain stem stroke, leading to a severe motor- and communication deficit. She was enrolled in studies with two different BCI systems before a suitable system was found. The first was an auditory event-related potential (ERP) paradigm and the second a visual ERP paradigm, both of which are established in literature.

RESULTS

The auditory paradigm did not work successfully, despite favorable preconditions. The visual paradigm worked flawlessly, as found over several sessions. This discrepancy in performance can possibly be explained by the user's clinical deficit in several key neuropsychological indicators, such as attention and working memory. While the auditory paradigm relies on both categories, the visual paradigm could be used with lower cognitive workload. Besides attention and working memory, several other neurophysiological and -psychological indicators - and the role they play in the BCIs at hand - are discussed.

CONCLUSION

The user's performance on the first BCI paradigm would typically have excluded her from further ERP-based BCI studies. However, this study clearly shows that, with the numerous paradigms now at our disposal, the pursuit for a functioning BCI system should not be stopped after an initial failed attempt.

Availability of researcher-led eHealth tools for pain assessment and management: barriers, facilitators, costs, and design

INTRODUCTION

Numerous eHealth tools for pain assessment and management have been developed and evaluated with promising results regarding psychometric properties, efficacy, and effectiveness. Although considerable resources are spent on developing and evaluating these tools with the aim of increasing access to care, current evidence suggests they are not made available to end users, reducing their impact and creating potential research waste.

METHODS

This study consisted of 2 components: (1) a systematic review of eHealth tools for pediatric pain assessment and/or management published in the past 10 years, and (2) an online survey, completed by the authors of identified tools, of tool availability, perceived barriers or facilitators to availability, grant funding used, and a validated measure of user-centeredness of the design process (UCD-11).

RESULTS

Ninety articles (0.86% of citations screened) describing 53 tools met inclusion criteria. Twenty-six survey responses were completed (49.06%), 13 of which (50.00%) described available tools. Commonly endorsed facilitators of tool availability included researchers' beliefs in tool benefits to the target population and research community; barriers included lack of infrastructure and time. The average cost of each unavailable tool was $314,425.31 USD ($3,144,253.06 USD total, n = 10). Authors of available tools were more likely to have followed user-centered design principles and reported higher total funding.

CONCLUSION

Systemic changes to academic and funding structures could better support eHealth tool availability and may reduce potential for research waste. User-centered design and implementation science methods could improve the availability of eHealth tools and should be further explored in future studies.

Clinicians and patients perspectives on follow-up care and eHealth support after allogeneic hematopoietic stem cell transplantation: A mixed-methods contextual analysis as part of the SMILe study

PURPOSE

We report on our contextual analysis's methodology, as a first step of an implementation science project aiming to develop, implement, and test the effectiveness of an integrated model of care in SteM-cell transplantatIon faciLitated by eHealth (SMILe).

METHODS

We applied an explanatory sequential mixed-methods design including clinicians and patients of the University Hospital Freiburg, Germany. Data were collected from 3/2017 to 1/2018 via surveys in 5 clinicians and 60 adult allogeneic stem-cell transplantation patients. Subsequently, we conducted 3 clinician focus groups and 10 patient interviews. Data analysis followed a 3-step process: (1) creating narrative descriptions, tables, and maps; (2) mapping key observational findings per dimension of the eHealth-enhanced Chronic-Care Model; (3) reflecting on how findings affect our choice of implementation strategies.

RESULTS

Current clinical practice is mostly acute care driven, with no interdisciplinarity and weak chronic illness management. Gaps were apparent in the dimensions of self-management support and delivery-system design. Health behaviors that would profit from support include medication adherence, physical activity and infection prevention. The theme "being alone and becoming an expert" underpinned patients need to increase support in hospital-to-home transitions. Patients reported insecurity about recognizing, judging and acting upon symptoms. The theme "eHealth as connection not replacement" underscores the importance of eHealth augmenting, not supplanting human contact. Synthesis of our key observational findings informed eight implementation strategies.

CONCLUSION

Stakeholders are willing towards a chronic care-focused approach and open for eHealth support. The contextual information provides a basis for the SMILe model's development and implementation.

Harmonizing evidence-based practice, implementation context, and implementation strategies with user-centered design: a case example in young adult cancer care

BACKGROUND

Attempting to implement evidence-based practices in contexts for which they are not well suited may compromise their fidelity and effectiveness or burden users (e.g., patients, providers, healthcare organizations) with elaborate strategies intended to force implementation. To improve the fit between evidence-based practices and contexts, implementation science experts have called for methods for adapting evidence-based practices and contexts and tailoring implementation strategies; yet, methods for considering the dynamic interplay among evidence-based practices, contexts, and implementation strategies remain lacking. We argue that harmonizing the three can be facilitated by user-centered design, an iterative and highly stakeholder-engaged set of principles and methods.

METHODS

This paper presents a case example in which we used a three-phase user-centered design process to design and plan to implement a care coordination intervention for young adults with cancer. Specifically, we used usability testing to redesign and augment an existing patient-reported outcome measure that served as the basis for our intervention to optimize its usability and usefulness, ethnographic contextual inquiry to prepare the context (i.e., a comprehensive cancer center) to promote receptivity to implementation, and iterative prototyping workshops with a multidisciplinary design team to design the care coordination intervention and anticipate implementation strategies needed to enhance contextual fit.

RESULTS

Our user-centered design process resulted in the Young Adult Needs Assessment and Service Bridge (NA-SB), including a patient-reported outcome measure and a collection of referral pathways that are triggered by the needs young adults report, as well as implementation guidance. By ensuring NA-SB directly responded to features of users and context, we designed NA-SB for implementation, potentially minimizing the strategies needed to address misalignment that may have otherwise existed. Furthermore, we designed NA-SB for scale-up; by engaging users from other cancer programs across the country to identify points of contextual variation which would require flexibility in delivery, we created a tool intended to accommodate diverse contexts.

CONCLUSIONS

User-centered design can help maximize usability and usefulness when designing evidence-based practices, preparing contexts, and informing implementation strategies-in effect, harmonizing evidence-based practices, contexts, and implementation strategies to promote implementation and effectiveness.

Development of an integrated e-health tool for people with, or at high risk of, cardiovascular disease: The Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) web application

BACKGROUND

Cardiovascular disease is the leading killer globally and secondary prevention substantially reduces risk. Uptake of, and adherence to, face-to-face preventive programs is often low. Alternative models of care are exploiting the prominence of technology in daily life to facilitate lifestyle behavior change.

OBJECTIVE

To inform the development of a web-based application integrated with the primary care electronic health record, we undertook a collaborative user-centered design process to develop a consumer-focused e-health tool for cardiovascular disease risk reduction.

METHODS

A four-phase iterative process involved ten multidisciplinary clinicians and academics (primary care physician, nurses and allied health professionals), two design consultants, one graphic designer, three software developers and fourteen proposed end-users. This 18-month process involved, (1) defining the target audience and needs, (2) pilot testing and refinement, (3) software development including validation and testing the algorithm, (4) user acceptance testing and beta testing. From this process, researchers were able to better understand end-user needs and preferences, thereby improving and enriching the increasingly detailed system designs and prototypes for a mobile responsive web application.

RESULTS

We reviewed 14 relevant applications/websites and sixteen observational and interventional studies to derive a set of core components and ideal features for the system. These included the need for interactivity, visual appeal, credible health information, virtual rewards, and emotional and physical support. The features identified as essential were: (i) both mobile and web-enabled 'apps', (ii) an emphasis on medication management, (iii) a strong psychosocial support component. Subsequent workshops (n=6; 2×1.5h) informed the development of functionality and lo-fidelity sketches of application interfaces. These ideas were next tested in consumer focus groups (n=9; 3×1.5h). Specifications for the application were refined from this feedback and a graphic designer iteratively developed the interface. Concurrently, the electronic health record was linked to the consumer portal. A written description of the final algorithms for all decisions and outputs was provided to software programmers. These algorithmic outputs to the app were first validated against those obtained from an independently programmed version in STATA 11. User acceptance testing (n=5, 2×1.0h) and beta testing revealed technical bugs and interface concerns across commonly-used web browsers and smartphones. These were resolved and re-tested until functionality was optimized.

CONCLUSION

End-users of a cardiovascular disease prevention program have complex needs. A user-centered design approach aided the integration of these needs into the concept, specifications, development and refinement of a responsive web application for risk factor reduction and disease prevention.

User-centered development of a smart phone mobile application delivering personalized real-time advice on sun protection

Smart phones are changing health communication for Americans. User-centered production of a mobile application for sun protection is reported. Focus groups (n = 16 adults) provided input on the mobile application concept. Four rounds of usability testing were conducted with 22 adults to develop the interface. An iterative programming procedure moved from a specification document to the final mobile application, named Solar Cell. Adults desired a variety of sun protection advice, identified few barriers to use and were willing to input personal data. The Solar Cell prototype was improved from round 1 (seven of 12 tasks completed) to round 2 (11 of 12 task completed) of usability testing and was interoperable across handsets and networks. The fully produced version was revised during testing. Adults rated Solar Cell as highly user friendly (mean = 5.06). The user-centered process produced a mobile application that should help many adults manage sun safety.

Development and validation of a patient decision aid for prostate Cancer therapy: from paternalistic towards participative shared decision making

BACKGROUND

Patient decision aids (PDAs) can support the treatment decision making process and empower patients to take a proactive role in their treatment pathway while using a shared decision-making (SDM) approach making participatory medicine possible. The aim of this study was to develop a PDA for prostate cancer that is accurate and user-friendly.

METHODS

We followed a user-centered design process consisting of five rounds of semi-structured interviews and usability surveys with topics such as informational/decisional needs of users and requirements for PDAs. Our user-base consisted of 8 urologists, 4 radiation oncologists, 2 oncology nurses, 8 general practitioners, 19 former prostate cancer patients, 4 usability experts and 11 healthy volunteers.

RESULTS

Informational needs for patients centered on three key factors: treatment experience, post-treatment quality of life, and the impact of side effects. Patients and clinicians valued a PDA that presents balanced information on these factors through simple understandable language and visual aids. Usability questionnaires revealed that patients were more satisfied overall with the PDA than clinicians; however, both groups had concerns that the PDA might lengthen consultation times (42 and 41%, respectively). The PDA is accessible on http://beslissamen.nl/ .

CONCLUSIONS

User-centered design provided valuable insights into PDA requirements but challenges in integrating diverse perspectives as clinicians focus on clinical outcomes while patients also consider quality of life. Nevertheless, it is crucial to involve a broad base of clinical users in order to better understand the decision-making process and to develop a PDA that is accurate, usable, and acceptable.

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults

BACKGROUND

Mobile health technology can improve medication safety for older adults, for instance, by educating patients about the risks associated with anticholinergic medication use.

OBJECTIVE

This study's objective was to test the usability and feasibility of Brain Buddy, a consumer-facing mobile health technology designed to inform and empower older adults to consider the risks and benefits of anticholinergics.

METHODS

Twenty-three primary care patients aged ≥60 years and using anticholinergic medications participated in summative, task-based usability testing of Brain Buddy. Self-report usability was assessed by the System Usability Scale and performance-based usability data were collected for each task through observation. A subset of 17 participants contributed data on feasibility, assessed by self-reported attitudes (feeling informed) and behaviors (speaking to a physician), with confirmation following a physician visit.

RESULTS

Overall usability was acceptable or better, with 100% of participants completing each Brain Buddy task and a mean System Usability Scale score of 78.8, corresponding to "Good" to "Excellent" usability. Observed usability issues included higher rates of errors, hesitations, and need for assistance on three tasks, particularly those requiring data entry. Among participants contributing to feasibility data, 100% felt better informed after using Brain Buddy and 94% planned to speak to their physician about their anticholinergic related risk. On follow-up, 82% reported having spoken to their physician, a rate independently confirmed by physicians.

CONCLUSION

Consumer-facing technology can be a low-cost, scalable intervention to improve older adults' medication safety, by informing and empowering patients. User-centered design and evaluation with demographically heterogeneous clinical samples uncovers correctable usability issues and confirms the value of interventions targeting consumers as agents in shared decision making and behavior change.

An analysis of usability evaluation practices and contexts of use in wearable robotics

BACKGROUND

User-centered design approaches have gained attention over the past decade, aiming to tackle the technology acceptance issues of wearable robotic devices to assist, support or augment human capabilities. While there is a consensus that usability is key to user-centered design, dedicated usability evaluation studies are scarce and clear evaluation guidelines are missing. However, the careful consideration and integration of user needs appears to be essential to successfully develop an effective, efficient, and satisfactory human-robot interaction. It is primarily the responsibility of the developer, to ensure that this users involvement takes place throughout the design process.

METHODS

Through an online survey for developers of wearable robotics, we wanted to understand how the design and evaluation in actual daily practice compares to what is reported in literature. With a total of 31 questions, we analyzed the most common wearable robotic device applications and their technology maturity, and how these influence usability evaluation practices.

RESULTS

A total of 158 responses from a heterogeneous population were collected and analyzed. The dataset representing contexts of use for augmentation (16.5%), assistance (38.0%), therapy (39.8%), as well as few other specific applications (5.7%), allowed for an insightful analysis of the influence of technology maturity on user involvement and usability evaluation. We identified functionality, ease of use, and performance as the most evaluated usability attributes and could specify which measures are used to assess them. Also, we could underline the frequent use of qualitative measures alongside the expected high prevalence of performance-metrics. In conclusion of the analysis, we derived evaluation recommendations to foster user-centered design and usability evaluation.

CONCLUSION

This analysis might serve as state-of-the-art comparison and recommendation for usability studies in wearable robotics. We believe that by motivating for more balanced, comparable and user-oriented evaluation practices, we may support the wearable robotics field in tackling the technology acceptance limitations.

Interfacing brain with computer to improve communication and rehabilitation after brain damage

Communication and control of the external environment can be provided via brain-computer interfaces (BCIs) to replace a lost function in persons with severe diseases and little or no chance of recovery of motor abilities (ie, amyotrophic lateral sclerosis, brainstem stroke). BCIs allow to intentionally modulate brain activity, to train specific brain functions, and to control prosthetic devices, and thus, this technology can also improve the outcome of rehabilitation programs in persons who have suffered from a central nervous system injury (ie, stroke leading to motor or cognitive impairment). Overall, the BCI researcher is challenged to interact with people with severe disabilities and professionals in the field of neurorehabilitation. This implies a deep understanding of the disabled condition on the one hand, and it requires extensive knowledge on the physiology and function of the human brain on the other. For these reasons, a multidisciplinary approach and the continuous involvement of BCI users in the design, development, and testing of new systems are desirable. In this chapter, we will focus on noninvasive EEG-based systems and their clinical applications, highlighting crucial issues to foster BCI translation outside laboratories to eventually become a technology usable in real-life realm.

Design and evaluation of a mobile application to assist the self-monitoring of the chronic kidney disease in developing countries

Background

The chronic kidney disease (CKD) is a worldwide critical problem, especially in developing countries. CKD patients usually begin their treatment in advanced stages, which requires dialysis and kidney transplantation, and consequently, affects mortality rates. This issue is faced by a mobile health (mHealth) application (app) that aims to assist the early diagnosis and self-monitoring of the disease progression.

Methods

A user-centered design (UCD) approach involving health professionals (nurse and nephrologists) and target users guided the development process of the app between 2012 and 2016. In-depth interviews and prototyping were conducted along with healthcare professionals throughout the requirements elicitation process. Elicited requirements were translated into a native mHealth app targeting the Android platform. Afterward, the Cohen’s Kappa coefficient statistics was applied to evaluate the agreement between the app and three nephrologists who analyzed test results collected from 60 medical records. Finally, eight users tested the app and were interviewed about usability and user perceptions.

Results

A mHealth app was designed to assist the CKD early diagnosis and self-monitoring considering quality attributes such as safety, effectiveness, and usability. A global Kappa value of 0.7119 showed a substantial degree of agreement between the app and three nephrologists. Results of face-to-face interviews with target users indicated a good user satisfaction. However, the task of CKD self-monitoring proved difficult because most of the users did not fully understand the meaning of specific biomarkers (e.g., creatinine).

Conclusion

The UCD approach provided mechanisms to develop the app based on the real needs of users. Even with no perfect Kappa degree of agreement, results are satisfactory because it aims to refer patients to nephrologists in early stages, where they may confirm the CKD diagnosis.

Human factors in the design of medical devices - Approaches to meeting international standards in the European Union and USA

This paper focuses on the challenges of meeting agency requirements as it pertains to the application of human factors in the medical device development (MDD) process. Individual case studies of the design and development process for 18 medical device manufacturers located in the US and EU were analyzed and compared using a multiple case study design. The results indicate that there are four main challenges in implementing international standards. These include a lack of direct access to users for the purposes of device development; a lack of understanding by users with regards to the impact of their feedback on the development process; contract formalities limiting user exchanges; and the attitude of clinical users directly impacting on the device developer's invitation to participate in the development processes. The barriers presented in this research have the potential to be resolved but only with greater commitment by both medical device users and developers.

Pilot testing an app-based stress management intervention for cancer survivors

Psychosocial eHealth intervention programs for cancer survivors are still in their infancy, with inconsistent findings so far in the scientific literature. The aim of this study was to explore system use, usefulness, ease of use, and preliminary effects of Stress Proffen, an app-based cognitive-behavioral stress management intervention for patients with cancer. A feasibility pilot project tested the intervention with cancer survivors (N = 25). The intervention contained (a) one face-to-face introduction session, (b) 10 app-based modules with stress management educational material and exercises, and (c) one follow-up phone call. Post-intervention interviews were conducted and user log-data were extracted. Outcome measures-Perceived Stress Scale (PSS), Anxiety and Depression (Hospital Anxiety and Depression Scale [HADS]), Health-Related Quality of Life (HRQoL; SF-36), and Self-Regulatory Fatigue (SRF-18)-were completed at baseline and post-intervention. Participants were primarily women (84%), age 34-71 (mean 48) and represented a variety of cancer diagnoses (majority breast cancer: 40%). Twenty-two participants completed all (pre-post) questionnaires. Sixteen participants (67%) completed at least 7 of 10 modules within the 8-week study period. Post-intervention interviews described StressProffen as providing a new, appreciated, and easily accessible stress management tool for the cancer survivors. Dependent/paired t-tests showed significant pre-post intervention effects with significant decrease in stress (p = .008), anxiety (p = .019), and self-regulatory fatigue (p = .025), and improved HRQoL (Role Physical, General Health, Vitality, and Role Emotional, all p's <.01). App-based stress management interventions such as StressProffen can provide appreciated support for cancer survivors, should be easy to use, can provide significant stress reduction, and improve emotional well-being. Further testing in a randomized controlled trial is warranted and is in progress. Clinicaltrials.gov: NCT0293961.