Zheng The concept of usability was defined in the field of human–computer interaction (HCI) as the relationship between humans and computers. OB However, most qualitative studies did not provide detailed information regarding the study approaches applied to answer the research questions. The number of studies by stage was: stage 1, task-based or user–task interaction, n=42; stage 2, system–task interaction, n=310; stage 3, user–task–system interaction, n=69; stage 4, user–task–system–environment interaction, n=54; and stage 5, user–task–system–environment interaction in routine use, n=199. System validation was done mainly through examining sensitivity and specificity or the ROC curve, and was commonly found in computer-assisted diagnosis systems, such as computer-assisted image interpretation systems, but rarely in other documentation systems. J Moreover, as with other application areas, relevant techniques should be applied at earlier stages of SDLC to tease out user interface versus workflow issues (see appendix IV, available online only). . Telles The user-centered design process should follow three key steps: identify the needs of stakeholders and their requirements, analyze those needs by prioritizing according to a model like SMART (elements must meet the following criteria: be specific, measurable, attainable, realizable, and traceable), then implement the design by testing, launching, and evaluating it in an iterative manner. We also excluded studies evaluating methods or models because health IT usability evaluation was not their primary aim, and system demonstrations that had little or no information about health IT usability evaluation. Examples include information on disease surveillance and epidemiology, immunizations, and environmental health. Shortliffe A system may be useful for achieving a specific task, but may not be beneficial to users' general work life. Avoid disruptions – e.g., forced logins/pop-ups. Hyun Successful designers go beyond this vague notion of “user friendliness” and have a thorough understanding of their user’s community and the tasks they need to accomplish. The Healthcare Information Management Systems Society (HIMSS) defines EHR usability as follows. et al. Five studies found in our literature review reported using cognitive walkthrough and think-aloud protocol;43–47 10 others used think-aloud only to determine if users were able accomplish tasks. However, we did not further extract methodological data because of limited information regarding usability specification and evaluation methods. Cognitive walkthrough48 is a usability inspection method performed by an expert to assess the degree of difficulty to accomplish tasks using a system, by identifying actions and goals needed to accomplish each task. et al. Systems’ usability is one of the critical attribute of any system’s quality. There is no doubt that the usability of health IT is critical to achieving its promise in improving health care and the health of the public. Thyvalikakath TP, Monaco V, Thambuganipalle H, Schleyer T. … Swift Consequently, it is difficult to ascertain if a system issue is due to system–task interaction, user–system–task interaction or user–system–task–environment interaction. Third, the number of reviewers was small. VL . EH Therefore, we may have missed methods that were used only in HCI or CSCW studies published in other scientific databases. Most stages have more than one evaluation type because iterative evaluation is needed to test multiple interactions. . Methods include interview, focus group, and questionnaire. We used EndNote XII to organize coding processes and Microsoft Access to organize data extraction. Shahar Michie Krones S The information needed for diagnosis and treatment should be patient-centered. There is a need to update and build upon the valuable knowledge provided by these earlier reviews and to more explicitly consider user–task–system–environment interaction.12,13 Therefore, the purposes of this paper are to review and categorize commonly used health IT usability study methods using an integrated usability specification and evaluation framework and to provide practical guidance on health IT usability evaluation. MI Task/expectation complexity, user variances, and organizational support are factors that influence the use of the system, but are not problems of the system itself, and need to be differentiated from system-related issues. The motivation for adopting nursing information systems is often increased time for direct patient care.55 Researchers use time-and-motion studies to collect work activity information for time efficiency before and after using health IT.56 Two stage 4 studies in this literature review conducted randomized controlled trials to measure the efficiency of health IT.57,58 Although system impact is not the primary focus of stage 4, 32 studies assessed system utilization, patient outcomes, guideline adherence, and medication errors. Franklin Newton D K J Just as a designer considers the difference between a first time user and a repeat user, designers who are new to the healthcare domain need to consider how this context represents some unique challenges. Tamblyn et al. . . Musen C et al. et al. There is substantial room for improvement in the design of EHR systems. There are different usability factors, which are expected to influence systems’ usability. D Linder Ammenwerth Health information systems can be used by everyone in healthcare from patients to clinicians to public health officials. Y Usability in Healthcare: A ‘Wicked’ Problem. Theories being applied in health IT usability studies can be grouped into four categories: general system development/design framework, HCI, technology acceptance and technology adoption. Ganslandt B The standard of user-centered design and the standard definition of usability: analyzing ISO 13407 against ISO 9241-11. Jaspers Triola Y et al. Studies were analyzed by one author (PYY) with review by the second (SB). The research was supported by the Center for Evidence-based Practice in the Underserved (P30NR010677). . et al. OA S D . Usability can be evaluated during different stages of product development.22 Iterative usability evaluation during the development stages makes the product more specific to users' needs.23 Stead et al24 first proposed a framework that linked stages of the SDLC to levels of evaluation for medical informatics in 1994. JL FD At level 3, we can minimize user variance by user training and providing sufficient organizational support. Graham et al. The SDLC indicates ‘when’ an evaluation occurs, while the four components of usability (user, tool, task, and environment) indicate ‘what’ to evaluate. Wu The widely known definition for usability is defined by the International Organization for Standardization (ISO) standard as follows: “usability refers to an extent to which a system, product or service can be used by specified users to achieve specific goals with effectiveness, efficiency and satisfaction in a specified context of use”. Stages 4 and 5 evaluate interactions among user, system, task, and environment. Waller HM . Shackel Table 4 summarizes the study categorization criteria. Usability factors are a major obstacle to health information technology (IT) adoption. M ISO 9241 defines usability as ‘the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use’.5 In ISO 9126, usability compliance is one of five product quality categories, in addition to understandability, learnability, operability, and attractiveness.14 Consistent with authors who contend that usability depends on the interaction between user and task in a defined environment,12,15 ISO 9126 defines usability as ‘the capability of the software product to be understood, learned, used and attractive to the user, when used under specified conditions’.14 ‘Quality in use’ is defined as ‘the capability of the software product to enable specified users to achieve specified goals with effectiveness, productivity, safety, and satisfaction in specified contexts of use’.14 In this paper, we use the broader definition of usability, that is, quality in use. The SDLC indicates ‘when’ an evaluation occurs, while the four components of usability (user, tool, task, and environment) indicate ‘what’ to evaluate. Abran Level 2 examines task performance to assess system validation and human–computer interaction. A SE Vimarlund Proceedings of the Latin American conference on Human-computer interaction. When and how to evaluate health information systems? Evaluation thus begins with a two-component interaction (user–task and system–task). . RB . Proposal for a taxonomy, Medical Informatics: Computer Applications in Health Care and Biomedicine, Meeting the criteria of a nursing diagnosis classification: evaluation of ICNP, ICF, NANDA and ZEFP, Development and evaluation of a terminology-based electronic nursing record system, Assistive computing devices: a pilot study to explore nurses' preferences and needs, Evidence in the palm of your hand: development of an outcomes-focused knowledge translation intervention, Case report: activity diagrams for integrating electronic prescribing tools into clinical workflow, WfMC: interface 1: process definition interchange - process model, Workflow analysis and evidence-based medicine: towards integration of knowledge-based functions in hospital information systems, Technology for emergency care: cognitive and workflow considerations, User-centered approaches for eliciting functional requirements and designing user interfaces: a nursing documentation case study, Using cognitive work analysis to design clinical displays, Using human factors methods to design a new interface for an electronic medical record, Developing a web-based information resource for palliative care: an action-research inspired approach, Improving Computerized Provider Order Entry (CPOE) usability by data mining users' queries from access logs. For example, we first expect the system to be able to perform a task (stage 1). Johnson JA Merrill Some noted that the health IT had been evaluated before it went into field testing. Medical practitioners usually encounter usability difficulties while using a health information system like other systems. Koppel Laura Marcial. K J The predominant type of health IT that we evaluated was decision support systems or had decision support features; computer-based provider order entry within hospital information systems were also well studied. They also tend to facilitate existing best practices for a given healthcare system and the successful workflows that support those practices, even when not universal for a given EHR. H et al. But, today’s focus on meaningful use of electronic health records represents an unprecedented opportunity to refine the design process in this domain and bring a fundamental understanding of the impact of usability back into the design and development of EHRs. K In addition, there are no clear guidelines or recommendations for the utilization of a theoretical framework in health IT usability studies. . Tsurikova . To study a design's utility, you can use the same user research methods that improve usability. D TT J Fourteen studies (20%) in stage 4 and 50 studies (26%) in stage 5 were qualitative. et al. It also includes design principles covering topics from the development of a mental model to addressing complexity and the use of color. M JJ JRB Fadlalla 629 studies were categorized into the five stages of an integrated usability specification and evaluation framework that was based on a usability model and the system development life cycle (SDLC)-associated stages of evaluation. T You might not think of the people who design EHRs as stakeholders, but when so many systems must work together, the environment in which products are developed must be considered. The third most frequently occurring type of health IT was electronic health records. . E Table 6 summarizes the usability study methods and number of studies at each stage of the SDLC. R JP et al. In virtually all EHR implementations there are design implications to the localization of the system that can significantly impact usability. Evaluation of health information systems is an important factor for the development of medical informatics . We identified 27 articles from 346 full-text articles and 283 articles at the title and abstract level. Saleem AF Therefore, a system may meet all usability criteria for lower-level goals, such as task completion rate and performance speed, but may be unable to fulfil the requirements for higher-level goals, such as users' cognitive or physical workload and job satisfaction. Lee Vatne et al. J JC Kyng Our search identified a fair number of studies (n=310) evaluating system validity for computer-assisted diagnosis systems. Therefore, the total number of studies in each evaluation stage does not match the total number of included studies. The SDLC provides a commonly accepted guide for system development and evaluation. This is consistent with a previous literature review of evaluation designs for health information systems.10 Most theoretical frameworks used were adapted from HCI, information system management, or cognitive behavioral science. Studies that fit the exclusion criteria or that had insufficient methods information for data extraction were subsequently excluded resulting in the retention of 346 studies. Roberts Ammenwerth Pagliari Health Information Technology Usability Evaluation: Methods, Models, and Measures Po-Yin Yen Submitted in partial fulfillment of the requirements for Detmer Graber Pereira . A Elhadad The key questions regarding environment are similar to those in stage 3. J Figure 1 provides a flowchart illustrating the process of filtering and coding the included studies to the five evaluation stages. Gutnik JA combination of vital and health statistical data from multiple sources, used to derive information about the health needs, health resources, use of health services, and outcomes of use by the people in a defined region or jurisdiction. . The result has been rapidly increased use of EHRs. So, if a system was studied at different stages in different publications, it was included as one system with multiple evaluations. A total of 664 studies was considered for full text review. To better identify usability problems at different levels of interaction, we also provided a stratified view of health IT usability evaluation to assist those conducting usability evaluations to focus on the interactions without overlooking some non-interaction factors. F J Based on the findings, a three-level stratified view of health IT usability evaluation is proposed and methodological guidance is offered based upon the type of interaction that is of primary interest in the evaluation. Patel Although consideration of user–task–system–environment interaction for usability evaluation is important,12,13 existing reviews do not provide guidance based on the user–task–system–environment interaction. While authors use the term EHR to refer to local or institutional EHR 6,15 (IT systems pertaining to a specific healthcare provider or institution, such as a hospital, clinical practice or other care setting), in the wider literature, definitions of the EHR go beyond standard clinical data collected by a provider, are more comprehensive and contain the medical and treatment histories of patients … Horsky Objective measures that researchers used at stage 3 included system validity (eg, accuracy and completeness) and efficiency (eg, speed and learnability). The analysis is informed by the proposed integrated usability specification and evaluation framework that combines a usability model and the SDLC. The most common study design was a quasi-experimental study design using one group with pretest and posttest comparison, or with only posttest assessment. Most of the definitions of usability concern the interaction of health IT with users (nurses, physicians, patients, family members) in terms of ease of learning to use ... by the System Usability Scale, and the lowest nurse satisfaction scores (Cho et al., … We also categorized methods used in the usability studies, their references and example studies in appendix VI (available as a data supplement online only). Halbesleben Thirty (78%) studies in this review used questionnaires to assess users' perceptions and attitudes. L Ash The International Organization for Standardization (ISO) has developed a standard definition of usability as “the effectiveness, efficiency and satisfaction with which specified users achieve specified goals in particular environments.” In other words, the tool must be effective in achieving the physician’s goals in using it, be an efficient way to achieve those goals, and provide the physician with the satisfaction that … J VL To gain insight into usability methods applied and their properties we constructed a framework to analyze the studies. Other methods measured outcomes including guideline adherence, utilization, accuracy, document quality, medication error, patient outcomes, and cost-effectiveness. F Therefore, we proposed an integrated usability sp… P V This pdf, sign in to an existing account, or observer variation to support study. Applied a variety of quantitative and qualitative approaches treatment should be patient-centered one database Medline. 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definition of usability in health information systems

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