What are Twitter’s Problems?

February 18th, 2010

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by Jim Bradford, MediCHI Consulting


Note: This is the second in a series of 3 twitter articles:

  • Twitter 1: What is Twitter good for?
  • Twitter 2: What are Twitter’s problems?
  • Twitter 3: How could Twitter be improved?

1.      What are Twitter’s problems?

I don’t know who invented the screwdriver but I can easily imagine his or her frustration. Here we have an elegantly simple tool for driving screws. The name says it all. There is no need for a user guide, or online help, or night courses at the local community college. You just buy a screwdriver and a bag of screws and you’re set!

Unfortunately the human race is endlessly inventive. We use screwdrivers to pry open paint cans, to depress those annoyingly recessed valves in pneumatic tires, and occasionally as a weapon during those regrettable domestic disputes that occur while trying to assemble Wal-Mart furniture.

Twitter was built to emulate the text messaging capability of mobile phones. However, over the past few years the Twitter user community has invented all kinds of new ways to use this simple tool. Unlike screwdrivers software systems can grow and evolve. I believe that the time has come for Twitter to do so. This section outlines a few of the major problems that are holding Twitter back.

“Flow By”: You may remember the famous opening scene of the first Star Wars trilogy that features a few lines of text scrolling off  into hyperspace. Imagine that the text was scrolling at twice the Star Wars speed. Imagine the tense concentration you would need to keep up. Now double the scrolling speed again and you will have produced an information processing task roughly equivalent to following the Twitter updates from a couple hundred people. The more people you follow the worse it gets. I call this the “flow by” problem. It is nearly impossible to keep up with the stream of consciousness postings of dozens of people–it simply flows by too quickly. This is of little consequence if the postings concern the dyspeptic ordeals of the family cat but it is a major deficiency if you are using Twitter to debate a political issue or monitor an evolving corporate crisis. Twitter needs to develop tools for keeping track of dialogs, multilogs, and focused discussion.

Dilution: Unless you are very selective in your choice of people to follow you are likely to receive a great deal of trivia about other people’s lives. I call this process, in which informative Tweets are buried in trivia, “dilution.” For example, I collected the following gems from one of my Twitter accounts during a 10 minute period on a Saturday afternoon:

Everything has its beauty but not everyone sees it.
How to Download Music Off You Tube.
Do NOT Pay For White Teeth!
Florida looking good in their second pre-season game against Troy.
Hearing my brother & niece argue about her taking a bath.

When I recall that my primary interest is the design and evaluation of user interfaces for healthcare I.T., these Twitter gems start to look a lot like cubic zirconia.

Is My Targeted Audience Reading Me? If my purpose in sending short segments of text to perfect strangers is to communicate, then it is important that my followers read my Tweets and I read theirs. The “flow by” and “dilution” problems make this hard to do. It is impossible to know who has read a Tweet and fairly difficult to track the responses. This is where the Twitter “text message” model breaks down. Text messages are most often 1-to-1. Dialogs flow naturally out of 1-to-1 interactions. It would be easy to contrast the Twitter dynamic by saying it is many-to-many but it is actually worse than that. Your “many” (consisting of your followers) is not the same as my “many.” Human communication needs a social environment in which there is a reasonable expectation that all parties receive the messages that form the basis of human interaction. In this respect Twitter reminds me of one of those European art films in which  all the characters are talking and nobody is listening.

Hard to Hold a Serious Conversation: The fans of Twitter might argue that the service was never intended to be a discussion list. I’ll concede the point but even though microblogging wasn’t meant to serve as a discussion list its postings often create the desire to discuss. In Twitter there is no capacity to hold a sidebar discussion. I believe that within the Twitter community there is an unmet need for some clever amalgam of microblog + chat room + discussion list. It’s a safe prediction that in the highly entrepreneurial environment of social media, if Twitter doesn’t invent a way to combine microblogging and discussion then someone else will.

The Rise of Twam: Our capitalist economy finds its most uncouth expression in the phenomenon of Internet spam. At first examination it might seem that Twitter has a natural immunity to Twam (Twitter spam). Each user explicitly selects those accounts that he or she will “follow.” Unfortunately a social etiquette has evolved within the Twitter community that encourages you to follow those users who have opted to follow you. This reciprocity has opened the door to Twam. In the past year or so a substantial percentage of Tweets are created by software programs known as “bots” (“bot” is short for “robot”–a program that imitates the behavior of humans in chat environments such as the venerable IRC, “Internet Relay Chat”–one of the earliest social media systems). Within the Twitter community these bot-driven accounts are known as “zombies.” Recent studies have suggested that up to a quarter of all postings on Twitter comes from zombies ["Twitter Zombies: 24% of Tweets Created by Bots", http://mashable.com/2009/08/06/twitter-bots/ ]. So far the Twitter support team has been losing the intellectual arms race with the Twammers but rumblings within the community suggest that people are becoming more selective in choosing who they will “follow back.”

Nice to Meet You: For a service that is categorized as a “social media” Twitter is surprisingly bad at building relationships between people. For reasons outlined earlier in this article, it is hard to react and respond to specific postings and have others react and respond to yours. Of the several metaphors that can be used to describe the Tweeting experience one that emphasizes Twitter’s failures as a social medium is that it is like giving a speech to a group of people who are themselves in the process of giving speeches. Everyone is in the process of sending out “one to many” communications. The most frequent result is that people talk past each other and this is antithetic to forming meaningful (or even casual) relationships.

2.      Summary

In my examination of Twitter’s shortcomings I found 6 major deficiencies:

  • Flow By
  • Dilution
  • Cannot discover if messages have been read
  • Hard to hold a conversation
  • Twam
  • Poor at creating and building relationships

The next article in this series will offer some suggestions for improving Twitter (including a focus on some of the underlying user interface issues).

Posted in Twitter, Usability | 1 Comment »

Should we leave tweeting to the birds?

December 28th, 2009

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by Jim Bradford, MediCHI Consulting


Note: This is the first in a series of 3 twitter articles:

  • Twitter 1: What is Twitter good for?
  • Twitter 2: What are Twitter’s problems?
  • Twitter 3: How could Twitter be improved?

1.       Twitter Overview

If you have been living in a cave for a few years you may not have heard about the Twitter phenomenon. The service was developed in 2006 by Jack Dorsey. Twitter was inspired by cell phone text messaging which had already gained enormous popularity among teens. The idea was to send short message service (SMS) text messages via the Internet for free (a big win for the parents of text-addicted teens). Although there is no technical reason to adhere to the 140 character limit for text messages, Twitter limits message length to maintain the feel of texting. The original Twitter prototype was developed in about 2 weeks and from a usability perspective, it shows.

In the past 18 months Twitter use has grown explosively attracting approximately 1 million users who post about 3 million messages a day. The original teen users have largely been lost in a crowd of doctors, CEO’s, teachers and scientists. The key question “Is Twitter a passing fad (the digital equivalent of the pet rock) or a technology that is becoming a fixture of our technocivilization?” has yet to be answered.

2.      What is Twitter good for?

The original intent of the Twitter design was to create an online infrastructure to support teen texting. I left my teen years behind four decades ago but I imagine the great issues of teendom haven’t changed (boys, girls, who likes/dislikes who, and various answers to the perennial “Wazzup?”). As the user population has evolved so have the applications. In the recent contretemps following the Iranian presidential election, protesters used Twitter to keep the world informed of their struggle after the government ejected most professional journalists.

In my personal observation of Twitter traffic over the past two years (as well as several suggestions by Patricia Anderson at the University of Michigan) there are 8 areas in which Twitter has proved useful: social grooming (explained below), contact with the flock, news gathering, marketing, opinion sampling, topic-based research, crisis response, and ask-your-peers information gathering.

Social Grooming: Many higher primates (chimpanzees, gorillas, telemarketers) live in tribal groups. Group affiliation and status are maintained through grooming behavior in which one primate will pick parasites out of the fur of another tribal member. Since humans are embarrassingly short of fur our species has invented social chatter to take the place of primate grooming. This is close to the original intent of Twitter. The content of the messages is largely irrelevant – it is the contact and its acknowledgment that serve the essential social processes.

Contact with the Flock: Our political leaders (at all levels) tend to live busy lives. Nevertheless the average citizen has little contact with the people we elect. The sophisticated technology users on the Obama team began a quiet revolution in the way our leaders interact with their various flocks. Social networking sites have played a major role in this new outreach. A number of national figures (Senator McCain, Secretary Clinton and of course, the White House) have used Twitter to share a kind of public diary of their activities (Senator McCain’s postings are by far the most interesting–it has been fascinating to see how much minutiae a national leader must deal with). I suspect that Tweets between our leaders and their constituents tend to be one-directional because technology has yet to find a way to facilitate a meaningful dialog involving hundreds of thousands of people.

News Gathering: The news business has seen a lot of change in recent years. Cable news channels, the struggle of print media, the blurring line between entertainment and news, the politicization of news, the importance of news aggregators (such as the Drudge Report) and the rise of the blogging community have opened the door to all kinds of news gathering innovation. One of these is the use of “citizen reporters.” In a world of “sound bite news” Twitter is the perfect medium. Short, on-the-scene observations from ordinary people have proved a compelling supplement to professional reporting. In addition, more and more celebrities have begun to tweet. These 140 character glimpses into the lives of the rich, the beautiful and the famous are closely monitored by news organizations in the hope of being the first to report on breaking news.

Marketing: The vast and growing population of Twitter users is a very tempting target for marketers. It is very easy to subscribe to a user as a “follower.” Twitter etiquette encourages users to return the favor. This opens the door for the “follower account” to send unsuspecting users an endless stream of “Twam” (my term for Twitter spam). It is not clear whether Twamming generates much revenue. As a usability and medical systems consultant I aggregate news items of interest to my prospective clients and post them on my website. I then Twam my Twitter followers with the news item headline and the address of my website. The technique certainly drives up traffic to my site but I am not convinced that it is generating any useful business. The jury is still out.

Opinion Sampling: If you have a decent number of followers (at least 100) then you can usually post a question and get a useful answer. You must, of course, actually find the Tweets containing replies from a much larger flow of Tweets on other topics (Twitter provides a messaging capability but it is common for people to reply to questions with Tweets of their own). I have used Twitter to find new academic reference material for my research and to get quick, “straw vote” reactions to design ideas. It would be fairly easy to enhance Twitter to provide polling and sampling utilities. It is easy to imagine politicians soliciting feedback this way and news organizations using real time Twitter polls to engage with their audiences.

Topic-Based Research: Hashtags are used to tag Twitter postings as relevant to one or more topics. For example, in my postings on Electronic Medical Record systems I tag the post with #emr. Other Twitter users can search for recent posts on any given hashtag (a directory of hashtags can be found at: http://hashtags.org/). Twitter’s search function (currently found in the right margin of a Twitter screen) can be used to follow all posts containing a given hashtag. For example, searching on #emr will bring up all posts containing this tag displayed in chronological order. The list of postings can be used to find users with similar interests who can then be followed on Twitter. This is inarguably the most powerful way to network on Twitter. The network you create can serve as a powerful research resource. Remember that there is no rule against creating multiple Twitter identities. It is often useful to devote a particular identity to a specific interest.

Crisis Response: There are two kinds of crisis for which Twitter has proved useful. One is the “violent event” category (hurricanes, earthquakes, terrorist attacks). Even supposing that the technical infrastructure that supports Twitter (Internet servers, cell phone towers, etc.) remain intact, the kind of reporting possible through Twitter is more suited to news gathering than it is to coordinating relief efforts.

There is however, a different kind of crisis for which Twitter can be very useful. Poisoned peanuts, poisoned pet food, and products with manufacturing defects all represent crises to companies and  even entire industries. Twitter is the ultimate vox populi (voice of the people). Corporate crises tend to surface on Twitter long before they make the news. Major corporations should monitor hashtags associated with their name and the names of their products as a matter of routine.

Once a crisis response has been initiated Twitter can also offer a useful window on how the public is responding. Of course, Twitter is one tool out of many but it is one that risk management executives should take seriously.

Ask-Your-Peers Information Gathering: Once your list of followers is big enough Twitter is a pretty good resource for “neighbors chatting over the fence” interactions. My daughter has a dog that seems to have only a couple of functioning neurons. The intellectually challenged pooch has a thing for skunks. My daughter was at her wit’s end trying to deodorize her pet. I posted a quick question on Twitter and within a few moments I had lots of things to try (one of them even worked). As long as your questions are appropriate for  your follower demographics Twitter can serve as a kind of real time Wikipedia.

3.      Summary

In my examination of the ways that Twitter is used, I found 8 major areas of application:

  • Social Grooming
  • Contact with the Flock
  • News Gathering
  • Marketing
  • Opinion Sampling
  • Topic-Based Research
  • Crisis Response
  • Ask-Your-Peers Information Gathering

The list is surprisingly long and it is a tribute to human ingenuity. This is particularly true when we consider Twitter’s many limitations. These will be covered in my next article, “What are Twitter’s problems?”

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Posted in Twitter, Usability | 2 Comments »

New Workshop from MediCHI: Your patient has a pulse, does your software?

December 10th, 2009

Learn more at the The Defensive Buying Workshop

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Defensive Buying – Your Key to Selecting the Best Medical Software

December 9th, 2009

Just published, “Defensive Buying – Your Key to Selecting the Best Medical Software” in HCPLive, http://tinyurl.com/y9q65xj

Posted in General Human Factors | No Comments »

Guest Article: Coping with Stress of Senior Home Care

December 8th, 2009

Senior home care is making the decision to care for your aging parents or loved ones in their home or in your home allowing them their independence but taking on the responsibility of their being the caregiver.  Caring for aging parents or loved ones carries a lot of responsibility and a range of emotions.  No matter how much love in your heart, carrying the load of caring for your loved one will leave you drained physically, emotionally and possibly financially.    Coping with the stress of senior home care has to be managed or you will not be able to be an effective caregiver.

Managing the stress of senior home care is all about taking charge.  Take charge of your thoughts, your emotions, your schedule, your environment and the way you deal with problems and unexpected situations.  The ultimate goal of coping with the stress of senior home care is to achieve a balanced life.

How to reduce, prevent, and cope with the stress of senior home care:

Senior home care requires organization – Organize your time and your schedule.  Write everything down so that you or another family member has reference to phone numbers, doctors, medications, in home senior care providers, important insurance and financial numbers.

Start a personal journal- Share your feelings about the stress of senior home care.  Writing down your thoughts will help you to take charge of your emotions.

Prioritize your health and well-being.   Nurturing yourself is a necessary not a luxury.  Healthy ways to relax and recharge:

  • Go for a walk
  • Call a good friend
  • Sweat out the tension with a good workout
  • Write in your journal
  • Curl up with a good book
  • Take a long bath
  • Eat healthy and exercise regularly
  • Play with your pet
  • Work in your garden
  • Listen to music
  • Savor a cup of warm coffee or tea

Give yourself a break – Enlist the help of a professional senior home care provider. Senior home care providers such as Visiting Angels can provide daily or weekly help to everyday chores, errands, hygiene, meals or transportation needs just to name a few.  Senior home care providers can also provide a respite to you responsibilities with as little as 15 minute notice to avoid unnecessary stress if your schedule needs help.

Coping with the stress of senior home care is the only possible way to be an effective caregiver to your loved ones.  Your mental and physical health must take priority or you will not be able to manage what needs to be done.  Take advantage of these tips.  Organize yourself, express yourself, nurture yourself and help yourself by arranging for assistance with a senior home care provider.

Bio:  Linda Dunkelberger is a freelance writer and editor.  “Coping with Stress of Senior Home Care” shares tips for coping with the stress of senior home care.  Visiting Angels is a senior home care provider that helps seniors with everyday tasks, errands, meals, transportation, just to name a few services.  For more information on Visiting Angels in your area, see www.Visitingangels.com.

Posted in General Human Factors | 1 Comment »

Inhuman Factors–Producing Virtuoso Users

July 16th, 2009

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by Jim Bradford, MediCHI Consulting

For many years universities have taught computer science students more than they ever wanted to know about Human Factors (Human Factors is the art and science of creating software that is intuitive and easy-to-use). Inevitably or in some cases, eventually, these students graduate and go to work for companies that create “feature driven” products in preference to “usability driven” products. Most computer science graduates have the knowledge they need to do good design work but they are rarely asked to apply this knowledge.

So, after a quarter century as a usability evangelist, I am throwing in the towel. If you can’t beat ‘em, join ‘em as my grandfather used to say. In the next paragraph or two I am going to define a new discipline that I am calling “Inhuman Factors.” Inhuman Factors acknowledges that many products are complex, hard to understand, and never reach the point of being fully debugged. Inhuman Factors takes the view that difficult to use products will be the norm for the foreseeable future.

To illustrate the argument let’s pick on Microsoft for a moment. The Microsoft Office suite had humble beginnings. Their word processor was originally intended to replace the typewriter. Their presentation system (PowerPoint) was offered as a replacement for transparencies and overhead projectors. Their spreadsheet application was built to replace the bookkeeper’s humble ledger. In just a little over a decade these applications have grown to such monstrous feature-driven complexity that the company now oversees a certification process to identify those hardy souls who have actually managed to figure things out. Talk about making a virtue of necessity! This is the most brazen spin for bad design since Heinz claimed that their ketchup was hard to pour because it was “rich.”

One of the classic signs of a poorly designed user interface is a wide disparity between experts (power users) and the rest of the user population. Many years ago I worked in the R&D division of a large telecommunications company (now bankrupt – not my fault). I was part of a department that developed a very complicated in-house computer aided design tool. We did an after-the-fact usability assessment for this system and discovered that the most productive user was nearly 20 times as productive as the least productive user (a 2,000% difference – the least productive user took nearly a month to do what the most productive user managed in a day).

This is where Inhuman Factors comes in. Through a process of task and workflow analysis, through the development of meaningful cognitive models, and through the creation of useful exemplars, Inhuman Factors will do formally what that high performing user did intuitively. Inhuman Factors will deploy many of the same tools as traditional Human Factors but with a contrarian goal – the creation of virtuoso users who can take existing software applications to the heights of productivity that the sales force originally promised.

Please check back in the coming months as I elaborate on the theme of Inhuman Factors. Comments and suggestions are welcome.

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Posted in General Human Factors, Interface Design, Usability | No Comments »

What Is Usability and How to Recognize It

January 27th, 2009

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by Jim Bradford, MediCHI Consulting

This article was originally published on the prominent healthcare blog, HIStalk

From time to time when I use a new application I seem to develop a kind of Tourette’s Syndrome characterized by teeth grinding, fist clenching, and dark mutterings. As I struggle through yet another badly designed, user-unfriendly system, I find myself wishing fervently that Bill Gates had finished college.

Technically, the user friendliness of a system is known as “usability.” There is an entire academic discipline (variously called “Human Factors” or “Ergonomics”) that is devoted to the study of usability. But if you don’t happen to have a Ph.D. in Ergonomics how do you recognize a well designed, highly usable system?

Mental Models and the Psychology of Geeks

The human brain constantly monitors the environment and creates models about it. This allows us to think about our environment and make predictions about what will happen next. We carry over this natural tendency to model things into our interaction with computers.

Not all models are created equal however. I have a friend who believes that if you set a thermostat as high as it will go, it will warm up the house faster. It is not an unreasonable model-it just doesn’t happen to be right.

The best system designers work hard to give you many clues about how a system works. This allows your brain to make a good model that produces accurate predictions about system behavior. When you encounter such a system you begin to feel that the system is natural, intuitive and easy to use.

Unfortunately geek psychology doesn’t often lead to this kind of design process. In 1971 Gerald Weinberg published his (now classic) book, The Psychology of Computer Programming. To boil a long tome down to its essence, the kind of person attracted to computer programming is frequently the type of person the media would characterize as a “troubled loner.”  Unfortunately the design of usable systems requires a well developed ability to understand how people think, feel and react when confronted with a complex system. As a rule, troubled loners are not good at this.

As a consequence, human factors experts are often drawn from the “touchy feely” disciplines (i.e., anything other than engineering or computer science). They are often brought in to fix computer systems that are so horribly hard to use that almost no one can make them work. This strategy is akin to bringing in a doctor only after the patient has died. The usability specialist does what he or she can but the result is usually a system that has evolved from being impossible to use to the point where it is merely frustrating to use.

The traditional approach to developing computer software (design-code-fix) is pretty well entrenched. Thirty years of preaching from academia has not noticeably improved the usability of computer systems. The key to usability, I believe, is an informed and demanding consumer. This is rooted in a fundamental property of a free market economy-if people stop buying poorly designed products, companies will eventually stop making them.

The Informed Consumer-How to Recognize Usability

Affordance: This design principle dictates that the appearance of things should provide a strong hint about how they are used. A hammer looks like it would be good for driving nails. A screw driver suggests how screws should be managed. An espresso machine, .. well . . not so much. Hammers and screw drivers have good affordance and espresso machines have poor affordance. When you look at the user interface of a new piece of software, do the commands, buttons, menus and other gizmos give you a good idea of how to use the system? If they don’t, it’s strike one against the designer.

Prescriptive Feedback: When using complex systems people will make mistakes and this provides the acid test for usability. Have you ever encountered an error message that says something like, “Illegal command or filename”? Good grief! Which is it, the command I just used or the file I just named? What law did I break? What makes a command illegal? Why can’t I call a file anything I want?

Can you imagine if other products were designed like software? Can you imagine a dashboard trouble indicator saying, “Illegal battery voltage or engine temperature”? If software doesn’t help you fix mistakes then it is strike two against the designer.

Task Fit: Software is a tool. Some software is a tool for creating documents, other software helps manage your finances and still other software exists purely to entertain you. Well designed software should focus on doing a small number of distinct tasks (a half dozen at most) and it should be obvious how the controls of the user interface help you do each task. Unfortunately many software companies prefer a “one size fits all” approach to development and end up creating a “one size fits nobody” product. If it’s not obvious how a software application’s capabilities relate to the task you have in mind, then it is strike three against the designer.

The Bottom Line

In recent years the nature of our daily lives has changed to such an extent that many of us spend the majority of our working and private lives sitting at a keyboard. Usability has become an important determiner of the quality of life for citizens of the twenty-first century. If the software you use is not intuitive, if it is not helpful, and if it doesn’t fit the tasks you want to do then walk away .. just walk away.

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Making Medical Device Interfaces More User-Friendly

January 2nd, 2009

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by Jim Bradford, MediCHI Consulting

Bradford says: Some surprisingly simple changes can often make large improvements to medical device interfaces.

~~~~~~~~~~~~~~~~~~~~~~~~~~

Citation: “Making Medical Device Interfaces More User-Friendly,” by Michael E. Wiklund, Medical Device & Diagnostic Industry Magazine, 1988, pp 177–182.

People who should read this: (1) the engineers and computer programmers who design medical devices, and (2) administrators responsible for buying new medical devices.

The Context: Medical devices are often designed by people with little understanding of human factors and user interface design principles.

Review:  At first I hesitated to review this article because it is two decades old. As I read it however, I realized that some advice is timeless.

Michael Wiklund has written extensively on medical human factors including three books on the topic:

  • Handbook of Human Factors in Medical Device Design (available, 2009)
  • Designing Usability Into Medical Products (2004)
  • Medical Device and Equipment Design: Usability Engineering and Ergonomics (1995)

In this article Wiklund revisits many of the standard best practices in user interface design but adapts them to the specific context of medical device design. He provides advice on:

  • Crowded display screens
  • Navigation issues (i.e., how a user moves from screen to screen)
  • Layout and hierarchies
  • Aesthetics
  • Typography and descriptive language
  • Effective use of icons
  • Consistency (one of the golden rules of interface design)

Even nontechnical readers (and perhaps nontechnical readers in particular!) will get a great deal of value from this article.

Human Factors has been an active discipline since the mid 1940’s [1]. During most of that time it has been an uphill battle to convince developers of the importance of human factors. After 65 years of experience many technical people still consider good interface design an optional, value-added feature. In my opinion we will only see developers taking human factors (and usability) seriously when customers become informed about the many benefits of a well-designed interface. Wiklund’s article serves as a model of the kind of writing human factors evangelists should be producing.

- – - – - – -
[1] The History of Human Factors and Ergonomics, by David Meister, CRC, 1999, 400 pg.

The bottom line: Physicians and medical administrators need to know that some comparatively simple design practices can make all the difference between a good and bad medical user interface.

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Posted in Interface Design, Medical Human Factors | No Comments »

The Relationship of Usability to Medical Error

November 20th, 2008

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by Jim Bradford, MediCHI Consulting

Posted: November 20, 2008

Bradford says: Devices with very small screens such as PDA’s and smartphones should not be considered as an input device for prescriptions or other medical note-taking.

~~~~~~~~~~~~~~~~~~~~~~~~~~

Citation: “The Relationship of Usability to Medical Error: An Evaluation of Errors Associated with Usability Problems in the Use of a Handheld Application for Prescribing Medications,” by Andre Kushniruk, Mark Triola, Ben Stein, Elizabeth Borycki, and Joseph Kannry, Medinfo 2004, pp 1073-1076.

People who should read this: (1) Physicians considering using handheld terminals, and (2) medical administrators concerned with the safety implications of handheld terminals

The Context: Using Personal Digital Assistants (PDA’s & smartphones) for writing prescriptions.

Review: Illegible handwritten prescriptions have produced safety concerns for over a century. As we enter the twenty-first century sophisticated new handheld devices hold the promise addressing this problem while simultaneously streamlining the way prescriptions are managed and monitored.

This paper evaluates a prescription writing system that replaces the traditional prescription pad with a Handspring Visor Pro personal digital assistant (PDA). The researchers recruited a group of ten volunteers all of whom were Internal Medicine physicians from the Mount Sinai School of Medicine. Each physician was given several medical scenarios and was asked to prescribe the appropriate medication and dosage using the handheld device.  The doctors were asked to verbalize the diagnostics thinking leading to a particular prescription.

The physicians were videotaped as they used the device. In addition, a record was made of the actual interaction with the PDA. A list of slips and errors were compiled across all ten physicians (a slip is a small mistake-equivalent to a typo; an error is a larger mistake-generally based on a misunderstanding of device operation).

A subsequent analysis of the video revealed a number of usability errors in the design of the prescription software. The researchers then used a tabular method based on a timeline to correlate user slips and errors with usability problems. They reached the (not unreasonable) conclusion that the usability problems contributed to the medical errors. Most of the time, these errors involved dosage problems rather than the prescription of the wrong medicine.

The experiment revealed two problems that were common to almost all of the participants.  The first related to the extremely small display area available on a handheld device.  When a significant part of the available screen “real estate” was given over to the menu system needed to operate the device, insufficient space was left to show all of the actual prescription. The researchers believed that many of the dosage errors that occurred derived from the fact that the physicians could not see the entire prescription at a glance.

The second major usability problem contributing to the observed medical errors, was the fact that many of the default values for the prescriptions were wrong from the physicians point of view.

Conclusions: The problem with the small screen size is a serious issue. It is something that is not easily corrected by changing the user interface design. It became very clear during the experiment that physicians (with many demands on their attention) needed to review their notes (in their entirety) at a glance. This is something that physicians and administrators need to consider before adopting handheld devices. A careful tradeoff needs to be made between portability and usability.

Fortunately, the second major usability problem relating to dosage defaults can be corrected fairly easily by ensuring that developers consult with physicians when setting up the system defaults.

The bottom line: Devices with very small screens such as PDA’s and smartphones should not be considered as an input device for prescriptions or other medical note-taking.

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Posted in Medical Human Factors, Usability and Medical Error | 2 Comments »

5 Exceptional Things about Medical I.T.

November 15th, 2008

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by Jim Bradford, MediCHI Consulting

Posted: November 15, 2008

The goal of human factors is to make complex computer systems easy to understand and simple to use. Unfortunately, computer systems are usually created by engineers and computer programmers. Throughout the development cycle, those who create computer systems tend to use themselves as a model for the user population. The result is often a system that is frustratingly difficult to use.

Computer systems fall into two broad categories. Many systems are developed for the general population (for example: word processors and spreadsheets). Other systems are developed to support particular industries (for example: banking, the airline industry or the medical profession). Each industry has its own special requirements and the medical profession is no exception. The following lists five major reasons why the human factors associated with medical information systems are a special case.

#1. Do No Harm: If someone makes a mistake while using a word processor it can be annoying but a mistake using a medical information system could cost someone their life. The design of a user interface can either increase or decrease the likelihood of error. The human factors expert must use what is known about human performance to minimize the risk of medical mistakes.

#2. Doctors are Always Busy: Programmers create medical information systems in the quiet of their cubicles, but physicians use these systems in environments that are anything but quiet. From the assembly line environment of a busy medical practice to the controlled chaos of an emergency room, physicians must retrieve information, make decisions, and update records with an absolute minimum of time and attention available for system interaction. A skilled human factors practitioner uses workflow analysis to create or select a user interface that meets the demands of a busy doctor or nurse.

#3. Adapt the Interface, Not the Physician: Organizations and professions frequently have a set way of doing things. This is often called “business process” or “professional protocol.” Software designers usually have little knowledge of the business processes their software serves. The skillfully designed user interface must ask the right question at the right time and must provide the correct information just when it is needed. The human factors expert is responsible for analyzing the business processes of a user population to make sure that the software serves the processes and not the other way around.

#4. When in Rome, Speak as the Romans Do: Few professions have such a distinct professional vocabulary as does medicine. Medical information systems must use the language of medicine and not require medical staff to learn a new set of terms specific to the software. It is the responsibility of the human factors expert to devise and conduct field studies with an actual user population to ensure that the medical information system uses the correct terms in the correct way.

#5. A House Divided Cannot Function: the issue of “cognitive load” is frequently important in the design of information systems. Can a person drive a car down a busy freeway while simultaneously talking on a mobile phone? Not everybody can. When a person’s attention is divided between several tasks, the possibility of catastrophic error can arise. There are few application areas where this is more critical than in the case of medical information systems. The concepts of “simple and intuitive” are most important when a medical practitioner should be devoting most of his or her attention to medical issues. The human factors expert must identify these critical areas of high cognitive load during the “requirements specification” phase of a system’s development and confirm that the designers succeeded in addressing these issues during the post-development field testing phase.

At a time when many medical practices are replacing paper-based record keeping with electronic medical records systems, the art and science of medical human factors has never been more important.

We are entering an era when hospitals, clinics, laboratories, insurers, and individual medical practices will need to communicate seamlessly with one another through computerized medical information systems. If the human factors is done right, we can expect to see physician productivity go up and the frequency of medical error go down. If the human factors are not done right, we will see productivity go down and the frequency of medical errors go up.

The key to realizing the potential of medical systems is to include human factors in the development cycle and to make extensive use of human factors when medical information systems are selected. Indeed the latter guarantees the former.

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