1. Usability and Human Factors
People and Technology, Studies of Technology
Welcome to Usability and Human Factors, People and Technology, Studies of Technology. This is Lecture a, the introductory lecture on usability and human factors.
The first unit consists of 3 parts. In the first unit, we characterize the cognitive consequences of health technologies in the context of health care. We also introduce the concept and principles of human computer interaction and human factors. In particular, we elaborate on the concept of usability and usability principles. The class subsequently focuses on issues of patient safety in the context of health technologies, a matter of growing concern. The unit also briefly addresses user-centered design and describes sound design principles.
Lecture a
This material (Comp 15 Unit 1) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC This material was updated by The University of Texas Health Center at Houston under Award Number 90WT0006.
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit
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2. People and Technology, Studies of Technology Lecture a – Learning Objectives
Explain the importance of technology in health (Lecture a)
Describe the contributions of Human-Computer interaction to the Health field (Lecture a)
Define the concept of system usability (Lecture a)
By the end of this lecture students should be able to:
Explain the importance of technology in health.
Describe the contributions of Human-Computer interaction to the Health field
Define the concept of system usability

3. Human Factors & Health Care
Health Devices
Electronic Health Record Systems
Technology is central to the healthcare system. In fact, it is involved in every single interaction we have in the context of healthcare. Technology in healthcare can include devices or health information systems. Devices in healthcare include, for example, glucose meters used by patients with diabetes, infusion pumps, and telemedicine systems that may be used to talk to patients in their homes. Health information systems, such as electronic health records, are increasingly prevalent and show a remarkable diversity and level of complexity. Human factors is a discipline devoted to the study of technology systems and how people work with them.
Health Devices
(Kaufman, )
Electronic Health Record Systems
(Kaufman, )
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4. People and Technology Clipart Microsoft
Most of us genuinely love and value our technology but we all experience moments of great frustration with it. By the way this picture is meant to be merely illustrative. It's not recommended that you try this at home or at the office.
Clipart Microsoft

5. Transformative Nature of Technology
Technologies have enormous social and cognitive impact
Precipitates large scale societal changes
Technological changes have positive and negative consequences
Technologies do not just enable us to perform certain kinds of functions. They often also have a transformative nature. Technologies throughout history have had enormous social and cognitive impact and they certainly continue to do so. They have precipitated large-scale societal changes. We have some interesting cases throughout history. Technological changes invariably have both positive and negative consequences. We can find ways to promote the positive elements of technology and reduce the negative ones, to improve user satisfaction with the technology and ultimately to improve usability and productivity. Usability is the study of the ease with which people can employ a tool or technology to achieve a particular goal, which we will discuss in greater depth later in this unit.
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6. Transformative Technologies
Here are a few interesting examples of transformative technologies. They've had long trajectories over many decades, sometimes over a century in which they have greatly changed shape, form, and function. Telephones are an interesting case in point. The initial design for a phone was that there would be one and only one phone for a single town. Penetration of the consumer market was remarkably slow and it wasn't until the introduction of a long cord that allowed housewives to talk on the phone while doing household chores that the phone became a common household technology. The vacuum cleaner is a technology with something of a surprisingly controversial history. Initially it was expected to free women from tedious and labor-intensive housework, and it did that to a certain degree. On the other hand, it greatly raised the expectations of cleanliness of the house and to some extent this actually increased the amount of daily housework. Similarly, electronic health records were designed to make the practice of medicine much easier by providing ready access to information to physicians. However, the reality is that it greatly increases the amount of time they spend documenting patient information. These are all unintended consequences of new technology. It is important to realize that all technologies have unintended consequences.
Dulaunoy, 2007, CC BY-NC-SA 2.0
Casonato, 2008, CC BY-NC-SA 2.0

7. Modern Technologies CC BY-NC-SA 2.0
These are example of modern transformative technologies. They look rather different from the old telephones that you've seen and other technologies from the previous slide. They are slicker and in many respects easier to use, though sometimes that is somewhat deceptive. And they're so deeply ingrained and such a central part of our lives that we really don't question their benefits. And of course this won't be the case for all health information technologies. Many of them are still in a transition period. One technological advancement, the electronic health record system, is in the process of transitioning to the point where it's becoming increasingly central in all facets of healthcare, but doesn't yet have the widespread acceptance of, for example, something like the cell phone or an iPad.
CC BY-NC-SA 2.0

8. Early Medical Technologies
Many of the earliest medical technologies were met with great skepticism. The stethoscope is an interesting case in point. Everybody can recognize a stethoscope as being symbolic of the practice of medicine. However, there was a time when it was viewed with great skepticism, and many practitioners thought this technology had the potential to cloud their judgments about patients. It also had the potential to come between them and their patients. One could chart a dramatic cultural change over time, as the stethoscope became increasingly accepted and more widely adopted.
Early technologies are often quite difficult to use, but some demonstrate instrumental value. The iron lung, which was a critical technology, was developed in the 1920s. It’s the equivalent of today's respirator and it kept many patients alive during polio epidemics. It was an incredibly difficult system to use and it has given rise to many successive iterations in development resulting in today's modern respiratory and pulmonary management systems. The key point is that technologies evolve over time, as does their acceptance among practitioners.
Curious Expeditions, 2008, CC BY-NC-SA 2.0
Emmalouise99, 2007, CC BY-NC-SA 2.0

9. What is Usability?
Usability means how useful, usable, and satisfying a system is for the intended users to accomplish goals in the work domain by performing certain sequences of tasks 
(Zhang & Walji, 2011)
“Usable” has three subcomponents:
Learnability 
Efficiency 
Error tolerance 
(National Center for Cognitive Informatics and Decision Making. ”What is Usability?”, n.d.)
What do we mean by usability? It reflects the quality of a user's experience when interacting with the product or a system and that we can enumerate several factors that affect the user's experience.
Usability means how useful, usable, and satisfying a system is for the intended users to accomplish goals in the work domain by performing certain sequences of tasks
The scientists at the National Center for Cognitive Informatics and Decision Making (NCCD) have given a lot of thought to this definition. Let’s look at those three key concepts - useful, usable, and satisfying - that make up usability for an electronic health record (EHR).
Useful – How well does the system support the work you’re trying to do? A system is useful if it can perform the functions necessary to get the job done. It’s that simple. 
Usable – Is it easy to learn, easy to use, and error-tolerant? You’d expect “usable” to be a part of Usability, right? But in this case, usable is a measurable concept and each of the subcomponents can be measured precisely:
Learnability – Ease of learning is important. Can a new user learn the system quickly and easily? Some technologies are merely walk up and learn technologies, the classic case being an ATM machine. However, most medical systems, medical devices, and complicated software have a learning curve.
Efficiency – how fast can a new user complete a task with the system?
Error tolerance – how well does the system help users avoid and recover from errors?
Satisfying – No, not the satisfaction you get from eating a good meal, but the satisfaction of a job well done. This is a subjective feeling, admittedly, but very important if an EHR is to succeed in the workplace. Does the user like using the system? Does he or she feel that it’s a useful tool for their daily work? Or do they just dread having to enter data in the EHR? If so, it won’t be a satisfying experience – and no one would say that EHR was usable.

10. Usability Principles Visibility of system status
Match between the system and the real world
User control and freedom
Consistency and standards
Error prevention
Recognition rather than recall
Flexibility and efficiency of use
Aesthetic and minimalist design
Help users recognize, diagnose, and recover from errors
Help and documentation
This list illustrates a set of widely accepted usability principles for evaluating the usability of a system. These principles were proposed by Jakob Nielsen, a highly regarded authority on usability, and they are used in a particular method of usability assessment know as the Heuristic Evaluation. We will be talking more about this method on the lecture on usability evaluation. I will briefly talk about a few of the principles.
Visibility of system status refers to how easily one can determine what state the system is in at a given moment in time. For example, if you just clicked on a link on a web page and it’s taking a long time to load, you should be able to tell whether the server is slow or overloaded or whether the page is no longer accessible.
Recognition rather than recall suggests that a user should not have to memorize complex command sequences to use an application. A system that provides multiple cues in text or icons to guide the user will diminish memory load. When memory load is reduced, a user can devote more of their energy to the task at hand.
Errors are inevitable, but a good system should allow a user to recover from an error without the risk of disastrous consequences such as loss of data.
Consistency and standards refers to the fact that a system should adhere to widely acceptable standards and that there should be a measure of consistency across all displays.
Finally, an application that is engaging and pleasurable to use will likely be more widely adopted than one that is not.
("10 Heuristics for User Interface Design: Article by Jakob Nielsen", n.d.)
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11. Human Computer Interaction (HCI) and Human Factors
Basic & Applied Discipline
Study of people using computers to work
People, systems, tasks
Ergonomics & Human Factors
User performance in context of any system
Computer, mechanical or manual
Understanding
Humans in relation to their use of technologies
Human computer interaction or HCI and human factors are sister disciplines, though human factors has been around many more years. It dates from the turn of the 20th century. Some of the earliest work was applied to productivity of workers in factory settings. For example, they would experiment with different kinds of environmental variables such as temperature and lighting, to see how it affected the productivity of workers. Human computer interaction is a more recent discipline dating from the early 1980s. Human computer interaction is focused on the study of people using computers in the context of work. The focus is on people, systems, and tasks. This emphasizes a particular kind of systems approach and, so problems are never purely attributed to a system. It's really an interaction between an individual's skills and the resources provided by a system.
Tasks provide a convenient way to conceptualize the things that people do. So, for example, on using an electronic health record system you could characterize any number of tasks related to retrieving particular kinds of information to make judgments about a patient or documenting certain findings. For example, if a physician recently performed a physical examination, a task would be to use the electronic health record system to document the results of the exam.
Human factors involve a broader study of user performance not only in the context of computing systems but really with any system, whether that be computer, mechanical, or manual. It also has for the present purposes a strong focus on the workplace and the study of workflow. Both disciplines involve understanding humans in relation to the use of technologies.
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12. HCI and Health Information Technologies
Enormous advances in health information technologies in the last decade
Potential for improved healthcare
Clinicians & patients employ health information technologies
Current designs are suboptimal
Increasingly, there are more options
There have been enormous advances in health information technologies in the past 15 years. There is tremendous potential for improved healthcare if we are able to harness these technologies and use them productively. Increasingly, clinicians and patients will be expected to employ health information technology. In fact, clinicians are routinely required to use many of these health information technologies. Although patients are a little bit behind the curve, that's beginning to change and there will increasingly be demands upon patients to be involved in their own healthcare; for example, using personal health records and understanding their health status on the basis of information available in these health information technologies. We also know that current designs are frequently suboptimal. Some systems are more or less optimal depending on a particular population of users and depending on a particular context. If you're somebody involved in the purchase of these technologies, or if you're a stakeholder of any kind, it's important to know that increasingly there are more and more options available to you.
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13. Why it May Matter to You
Technology is a potential source of error and can compromise patient safety
Position to make a difference in product selection
The best technologies have some deficiencies
Better and worse choices
So, why may it matter to you? Well, technology for one is a potential source of error and we know it can compromise patient safety. Potentially at some point, either now or at some point in your career, you'll be in a position to make a difference in product selection. It may vary depending on the kind of position that you have. You may be in a leadership position or you might be a user of said technology, and to the extent that you could understand and communicate and persuade people, you can potentially make a difference. It's important to know that even the best technologies have some deficiencies, and every single setting and context is somewhat different. There are always better and worse choices, whether you are purchasing a system from a vendor or whether you are developing one in-house, and usability and human factors should play an important role in that process.

14. People and Technology, Studies of Technology Summary – Lecture a
Social and cognitive consequences of new technologies
Usability and usability principles
Human computer interaction and human factors as a discipline
Why these disciplines matter in the context of health information technologies
NEXT: Patient safety, introduction to design and user-centered design
This concludes Lecture a of People and Technology, Studies of Technology. This introductory lecture introduced issues pertaining to the social and cognitive consequences of new technologies, especially in the context of health care. The lecture also introduced the disciplines of human computer interaction and human factors. This lead us to the very important concept of usability and why it may matter in the context of health information technologies. In the next lecture, we will focus on the subject of patient safety, a matter of growing importance and introduce the method of user-centered design.

15. People and Technology, Studies of Technology References – Lecture a
Horsky, J., Kaufman, D.R., Oppenheim, M.I. & Patel, V.L. (2003). A framework for analyzing the cognitive complexity of computer-assisted clinical ordering. Journal of Biomedical Informatics, 36, 4-22.
Kaufman, D. R., Pevzner, J., Rodriguez, M., Cimino, J. J., Ebner, S., Fields, L., et al. (2009). Understanding workflow in telehealth video visits: Observations from the IDEATel project. Journal of Biomedical Informatics, 42(4),
Kaufman, D.R. & Starren, J. B. (2006). A methodological framework for evaluating mobile health devices. In the Proceedings of the American Medical Informatics Annual Fall Symposium. Philadelphia: Hanley & Belfus. 978
Kaufman, D.R., Patel, V.L., Hilliman, C., Morin, P.C., Pevzner, J, Weinstock, Goland, R. Shea, S. & Starren, J. (2003). Usability in the real world: Assessing medical information technologies in patients’ homes. Journal of Biomedical Informatics, 36,
National Center for Cognitive Informatics and Decision Making in Healthcare. What is Usability. Retreived from
Nielsen, J. (1993). Usability engineering. Boston: Academic Press.
Norman, D. A. (1986). Cognitive engineering. In D. A. Norman & S. W. Draper (Eds.). User centered system design: New perspectives on human-computer interaction (pp ). Hillsdale, NJ: Lawrence Erlbaum Associates.
Zhang, J. & Walji, M. (2011). TURF: Toward a unified framework of EHR usability. Journal Of Biomedical Informatics, 44(6),
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16. People and Technology, Studies of Technology References – Lecture a (Cont’d – 1)
Images
Slide 3: Clockwise from the bottom left-hand corner
Kaufman, D.R. & Starren, J. B. (2006). A methodological framework for evaluating mobile health devices. In the Proceedings of the American Medical Informatics Annual Fall Symposium. Philadelphia: Hanley & Belfus. 978
Kaufman, D.R., Pevzner, J, Hilliman, C., Weinstock, R.S., Teresi, J. Shea, S. & Starren, J. (2006). Re-designing a telehealth diabetes management program for a digital divide seniors population. Home, Healthcare, Management & Practice. 18:
Infusion Pump—unpublished work (2002) with Patel, Kubose and Kaufman
Kaufman, D. R., Pevzner, J., Rodriguez, M., Cimino, J. J., Ebner, S., Fields, L., et al. (2009). Understanding workflow in telehealth video visits: Observations from the IDEATel project. Journal of Biomedical Informatics, 42(4),
Horsky, J., Kaufman, D.R., Oppenheim, M.I. & Patel, V.L. (2003). A framework for analyzing the cognitive complexity of computer-assisted clinical ordering. Journal of Biomedical Informatics, 36, 4-22.
Kaufman, D.R., Patel, V.L., Hilliman, C., Morin, P.C., Pevzner, J, Weinstock, Goland, R. Shea, S. & Starren, J. (2003). Usability in the real world: Assessing medical information technologies in patients’ homes. Journal of Biomedical Informatics, 36,
eClinicalWorks screen. Unpublished usability analysis of eClinicalWorks (2008) with Kaufman & Hripcsak
Slide 4: Clipart. Image Courtesy of Microsoft.
Slide 6: Very old telephone. Retrieved on August 3rd, 2010 from
Old poster advertisement for an Electro Lux vacuum with a woman using it. Retrieved on August 3rd, 2010 from
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17. People and Technology, Studies of Technology References – Lecture a (Cont’d – 2)
Images
Slide 7:Various new technologies such as Blackberry, GPS, iPhone, iPad and iPods. Retrieved on August 3rd, 2010 from:
Slide 8:
Ancient Doctor's Tools. Retrieved on August 3rd, 2010 from
Ancient Egyptian stethoscope carved in stone. Retrieved on August 3rd, 2010 from
Ancient Enemas. Retrieved on August 3rd, 2010 from
Mechanical Therapy (hand drawn picture of a man sitting on a complex machine). Retrieved on August 3rd, 2010 from
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18. Usability and Human Factors People and Technology, Studies of Technology Lecture a
This material was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC This material was updated by The University of Texas Health Center at Houston under Award Number 90WT0006.
No Audio.
Health IT Workforce Curriculum Version 4.0