• Usability
  • What's preventing eHealth adoption in Africa?

    African countries are converging under a common desire: to transform African healthcare through technology. But they also share a common frustration: African healthcare's slow and unsteady embrace of new technology. 

    Why do so many seemingly great technologies fail to penetrate the health care system?

    This was a question I asked myself while undertaking my master’s research. I hope the following answers shed some light on the realities of technology adoption in healthcare. 

    1. Many eHealth innovations don’t address the real problem 

    eHealth innovators start by discovering a useful technology. Later, they figure out how people can use it. eHealth should not only address a problem, but needs to be goal directed. Meaning, innovators should start with the goals of the end-user. The solutions come next. When the order is reversed, the results usually disappoint.

    As an example, the introduction of wearable health tech has excited innovators in the industry. These wristbands, watches, sensors and headsets can obtain and transmit large amounts of data on heart rhythms and blood pressure. However, there’s little evidence those wearing them overcome abnormal heart rhythms or elevated blood pressures better than those who don't. 

    2. No one wants to pay for new technologies 

    Creating an innovative technology to help doctors and patients isn't enough. Patients, doctors, healthcare facilities and insurance companies long for the benefits and value that these technologies provide, however, each thinks someone else should pay for it.

    Furthermore, new technologies that lowers costs and reduce patient visits discourage doctors and healthcare facilities from embracing these technologies because they work on a fee-for-service model instead of a fee-for-value model.

    3. The infrastructure to share information is underdeveloped 

    The introduction of the electronic health record (EHR) allows healthcare providers to share patient information and collaborate across different specialties to provide holistic treatment plans for the patients.  However, in Africa the supporting infrastructure, policies and standards for data sharing across multiple platforms and geographies are lagging.  Several African countries have started investing in strategic working groups to address this challenge.

    4. Technology slows down users

    For many healthcare providers, entering data into an EHR takes longer than keeping a paper record.  The structured format of the EHR also frustrates healthcare provider when the application prevents them from skipping steps or leaving out clinical details. 

    Frustrating as it may be, the added information reduces the risks of medical error, avoids redundant testing, and facilitates easier access to test results.  The benefits to the patient are clear, but less so for the healthcare provider. Getting healthcare providers to embrace these more effective approaches is the next big challenge for innovators to overcome.

  • How can online health information avoid negative results?

    Type “health information” into your favourite search tool.  Then, prepare to scroll through over 2.6 million results. The negative effect of these sources on users hasn’t been examined.  A study led by Reem El Sherif at the Department of Family Medicine at McGill University in Montreal, and published in the Journal of Medical Internet Research (JMIR), aims to deal with it.

    Two goals are:

    Describe negative outcomes in primary careIdentify potential preventive strategies from users, health practitioners and health librarians.

    It found three types of interdependent negative outcomes:

    Internal, such as increased worryingInterpersonal, such as a tension in patient-clinician relationshipsService-related, such as postponing clinical encounters.

    The study links them as:

    Three types of strategies were identified that aim to reduce these negative outcomes. They were:

    Providing users with reliable informationEducating users on how to assess websites that provide health informationHelping users to present and discuss their online information with health professionals, their social networks or librarians.

    These are integrated too:

    Librarians have a core role in minimising negative outcomes. Responsible for providing reliable health information and advocating the advantages of using health websites, they’re well positioned to implement the preventive strategies. Their work with users and health practitioners can integrate them with users’ health information–seeking and ensure the reliability of the information they find and use. Improving health literacy can lead to fewer internal tensions. Librarians can also develop discussions with health practitioners, leading to fewer interpersonal tensions. Their third contribution’s helping users to find relevant information so they can make better health and health care decisions, leading to fewer service-related tensions.

    While this might seem a bit obvious, the researchers identified two barriers that needed overcoming. One’s a lack of awareness of available health librarian services. The other’s a lack of access to health librarians by the public. A possible solution is to train community librarians working in public facilities, such as libraries, on how to provide health information services.

    Africa’s health systems should consider these additional costs of online health information. Without these resources, their investments in online health information may not realise the benefits requires of them, so an inadequate return.

  • Good eHealth content design enables safer care

    Usability’s a vital component of eHealth’s benefits. It can drive utilisation and healthcare quality. Patient safety’s an important part of quality, and the Electronic Health Record Association (EHRA), part of the Health Information and Management Systems Society (HIMSS), has developed and published Electronic Health Record Design Patterns for Patient Safety.

    It deals with the relationships between usability and patient safety and set out design patterns that increase EHRs’ consistency and safety. Its principles can be applied to all eHealth, such as ePrescribing and mHealth. Its standards can help Africa’s health systems design and specify safer eHealth and provide content for their eHealth regulation.

    The guidance is sets of does and don’ts, and extends over five components:

    MedicationsAlert fatigueLab resultsNumeric displayDisplaying text.

     Avoiding confusion with drugs with similar names, it recommends avoiding azetazolamide and azetohexmide and using azetaZOLAMIDE and azetoHEXMIDE to emphasise the difference. Another example’s using propoanolol 20g, with spacing, instead of risking misreading propoanolol20g as 120g. Avoiding abbreviations is important too.

    Critical and non-critical alerts need different standards too. Treating eHealth systems displays the same for both adds to alert fatigue. Drug interaction alerts must contain sufficient data for users to perceive and interpret correctly as a critical alert. There’s advice on this too.

    For lab results, the principles include:

    ·       Display numeric and text results clearly

    o   Keep multi-component test results together when they’re displayed with other results

    o   Display result in columns wide enough for users to see the full value and abnormality levels without adjusting displays

    o   Keep information for clinical judgment on the same page and avoid horizontal scrolling to see critical information

    o   When screens can’t display a full message, ensure its easy to read it all, such as dragging a scroll bar or clicking an arrow to expand panels

    o   Show changed test results after initial reports clearly.

    ·       Distinguish new results from previous results, such as using icons, layout sections or notifications

    ·       Use consistent format for abnormal results, regardless of source

    ·       Ensure that graphical displays of results over time cannot be misinterpreted, such as;

    o   Include patient identifying information with the graph

    o   Include the reference range provided by the laboratory for each variable

    o   Always provide the precise value of each data point. 

    For numeric data, examples of effective standards include using a comma to separate groups of three digits, always using zero with fractional numbers, so 0.5, never .5, and making all numbers in columns right justified to make it easy to see the differences in scale.

    EHRA says its guidance is an evolving document. From its solid, constructive foundation, Africa’s health systems can use the process to adopt its standards and ensure their eHealth services to maximise usability and patient safety.

  • Health websites need to show their providences

    As the Internet’s used more by people wanting information about their health and illnesses, it’s essential that they can see and know the reliability and constraints of the sources. A study by a UK team in the Journal of Medical Internet Research (JMIR) says the wide range of sources of health information on websites from different organisations and people need to enable users to evaluate and select the sources they want to use. They should be able to use this to assess the sites’ credibility and trustworthiness. The findings provide important information for Africa’s health systems in developing their health websites. 

    The team reviewed four multi-disciplinary and four health-oriented databases described in empirical studies on both trust and credibility and identified factors that affect judgments on both. It also analysed demographic factors affecting trust. This helped to identify gaps in current knowledge and construct proposals for future research.

    Data from 3,754 unique records were allocated to one of three categories:

    Using trust or credibility as a dependent variableUsing trust or credibility as an independent variableStudies of the demographic factors that influence the role of trust or credibility for health websites.

    Findings were:

    Website design, clear layout, interactive features, and the authority of the owner provide a positive effect on trust or credibilityAdvertising has a negative effectOn content, authors’ authority, ease of use and content have a positive effect on trust or credibilityAge, gender, and perceived health status are demographic factors influencing trust.

    More research’s needed on the interaction between variables associated with health information seeking, increased consistency of trust and credibility measurement and more emphasis on specific health website sources. The effect of demographic variables and how the enhance understanding of the impact on trust and credibility judgments need more research too. There’s no need for Africa’s health systems to wait for these before using the first set of research findings.

  • Is Africa's eHealth usability at risk?

    As Africa moves ahead on using EHRs, regulation, usability and procurement will converge. Usability’s an essential component of benefits, and regulation’s essential to setting EHRs’ and other eHealth usability standards and supplier certification. Procurement’s where these are applied. Africa’s health systems have a few challenges.

    Their eHealth regulations are well behind good practice. A study of eHealth regulation in Sub-Saharan African countries by South Africa’s Greenfield Management Solutions found that specific eHealth regulations are minimal, with reliance on general regulations such as data protection and telecommunications regulations. This status provides no basis for setting User-Centred Design (UCD) standards for usability for eHealth vendors to apply. Two main sources for these are one generic and one for EHRs.

    ISO 9241-210:2010 is generic. It has six core design principles for usability where design’s:

    Based on an explicit understanding of users, tasks and environments Users are involved throughout design and development Driven and refined by user-centred evaluation An iterative process It addresses the users’ whole experience Dealt with by multidisciplinary teams with an appropriate range of skills and perspectives.

    The USA has specific requirements. It’s National Institute of Standards and Technology has adopts NISTIR 7741 NIST Guide to the Processes Approach for Improving the Usability of Electronic Health Records. It’s principles are:

    Understand user needs, workflows and work environments Engage users early and often Set user performance objectives Design the user interface from known human behaviour principles and familiar user interface models Conduct usability tests to measure how well the interface meets user needs Adapt the design and iteratively test with users until performance objectives are met.

    It has six types of compliance:

    0 – Incomplete, so unable to carry out the process

    1 – Performed, where individuals carry out the process

    2 – Managed, where quality, time and resource requirements for the process is known and controlled

    3 – Established, where the process is carried out as specified by an organisation, and resources are defined

    4 – Predictable, where the performance of the process is within predicted resource and quality limits

    5 – Optimising, where an organisation can reliably tailor the process to particular requirements.

    By including these usability standards in eHealth regulations, health systems can expect vendors to comply with good practice, leading to good benefit’s realisation. Health systems can also check how far vendors comply with the standards. This is the crunchy bit.

    A team, led by Dr Raj M. Ratwani of MedStar Health, Washington, DC, has written a research letter to the Journal of the American Medical Association (JAMA). It says that many EHR vendors don’t comply with the usability standards. It’s an important finding because many EHRs have poor usability.

    The team reviewed documentation of 41 of the 50 certified vendors:

    34% failed to state their UCD process 46% used an industry UCD standard 15% used an internally developed UCD process 63% used less than the standard of 15 participants 22% percent used at least 15 participants with clinical backgrounds One vendor used no clinical participants 17% used no physician participants 5% used their own employees 12% lacked enough detail to determine whether physicians participated 51% didn’t provide the required demographic details.

    This poor compliance occurred in a highly regulated system, and was revealed. With African countries limited regulation, they’re more vulnerable to eHealth usability limitations, leading to reduced benefits and wasted resources. The next step’s simple: enhanced eHealth regulation for procurement. 

  • What do users think of their EHRs?

    Market research company Research Now, Software Advice has completed its latest annual EHR surveyin the USA. Nearly 600 people responded. The results provide a valuable profile for health systems embarking on such a big scale investment. The three high-level findings are:

    Mobile users have levels of satisfaction and fewer challenges with their EHR than non-mobile users Investing more in patient portals was a top priority, partially because of the need to improve patient engagement More than half the users said it was difficult integrating data from external systems with their EHRs.

    There’s a considerable range of other data from the survey, including.

    26% of users use a tablet or smartphone, 76% use a desktop or laptop, including people who use a combination 58% of users using a mobile device for access were very satisfied, 28% using non-mobile devices were not 39% of mobile users said learning to use their EHRs was challenging, compared to 58% using non-mobiles who did 73% said EHRs decreasing productivity wasn’t a challenge, compared to 42% non-mobile users 28% of users said they will increase their EHR software investment, 54% said it’ll be the same,5% said it’ll drop 36% want more spending on patient portals, with ePrescribing and HIE in second and third place 56% said integrating their EHRs with other information systems is a major or moderate challenge, 49% said EHRs constrain productivity 87% said the main benefit is easy access to records 43% of small-practices are very satisfied with their EHRs, 31% of large practices are.

    Using the whole survey results provides a clear profile of many features needed in an EHR project to improve its chances of success. They also apply to many other types of eHealth. As you move towards your big scale eHealth project, many of the findings highlight good practices for African countries.

  • Poor usability limits eHealth impacts

    Poor usability inhibits eHealth in the USA, according to survey of EHR users and other experts by Black Book. It says that 88% of vendors will falter because they push usability to the back burner.

    eHealth usability is one of the crucial components needed to secure the high levels of information utilization needed to realize the benefits from eHealth.

    For the scale and effort of eHealth for African countries, it is critical to avoid this situation. FierceHealthIT reports three ways to secure usability from Mike Butler’s blog, a healthcare consultant at Hayes Management Consulting:

    System design – to create systems that interact easily. He writes that this is the “foundation of usability“, ensuring that electronic health record design helps to minimize medical errors while improving the quality of care. Screen displays – to make user interaction “clear and intuitive“. He explains that patients who cannot understand system outputs such as care plans or visit summaries can’t help to validate data accuracy and contribute additional information. Workflow – to keep it simple while maintaining flexibility and efficiency. He explains that simple tasks such as logging into and out of patient records should be easily accomplished.

    Detailed system requirements agreed with stakeholders and enforced through procurement are essential.