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Title: North Shore-Long Island Jewish Health System Faculty Practice Plan - Revenue Opportunities


1

Usability of Multi-modal Home Health Monitoring
Devices Used By Older Adults Rita Hubert Pace
University April 12, 2008
2
Essence of the Idea
Usability of Home Health Monitoring Devices Used
by Older Adults
3
Aging Population Statistics
The number of persons age 65 and over is expected
to more than double to 71.5 million by 2030.
Administration on Aging, United States
Department of Health and Human Services, Profile
of Older Americans 2004
4
Care Giver Shortage
Fewer workers will be available to care for the
aging population.
Department of Health and Human Services, The
Future Supply of Long-Term Care Workers in
Relation to the Aging Baby Boom Generation, May
14, 2003.
5
Increased Need for Long Term Health Care Workers
  • It is projected that between 2000 and 2010 there
    will be a need for 70 more health care workers
    in the home health care industry.

Department of Health and Human Services, The
Future Supply of Long-Term Care Workers in
Relation to the Aging Baby Boom Generation, May
14, 2003.
6
United States Healthcare Spending Projections
Medicare spending was 252.2 billion in 2002 and
is projected at more than 500 billion by 2012.
California HealthCare Foundation, Snapshot
Health Care Costs 101, www.chcf.org, 2005
7
United States Health Information Technology
Spending
  • Organization of Economic Co-operation and
    Development (OECD) Statistics for Health
    Information Technology Spending as of 2005
    including
  • Electronic Medical Records
  • Telehealth
  • Electronic Ordering Systems
  • Decision Support Tools
  • Networks and Infrastructure

Health Care Spending and Use of Information
Technology in OECD Countries, Health Affairs, Vol
25, No 3, pp 819-831, 2006
8
Older Adults with Chronic Diseases
  • Chronic Disease examples
  • Heart disease
  • Hypertension
  • Asthma
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Chronic Diseases account for 95 of the health
    care spending for older adults.
  • 80 of older Americans have 1 chronic disease
  • 50 of older Americans have 2 chronic diseases
  • The average person 75 years of age has 3 chronic
    diseases.
  • Chronic Diseases are the leading cause of death
    in America.
  • Diabetes
  • Stroke
  • Arthritis

Centers for Disease Control, Health and Human
Services,The State of Aging and Health in
America 2004, www.cdc.gov/aging/pdf/state_of_Agin
g_and_Health_in_America_2004.pdf
9
Relevance and Significance of the Research
  • Home health monitoring devices will provide older
    adults with the ability to live independently at
    home longer while under the care of the health
    provider.
  • Home health monitoring devices will reduce the
    need for caregivers and reduce costs.
  • The Kaiser Permanente Tele-Home Health Research
    Project found mean cost savings of 726 in the
    home health monitoring group.
  • New England Healthcare Institute and
    Massachusetts Technology Collaborative reports
    that studies show an annual cost reduction of
    7,830 per patient per year for congestive heart
    failure and 747 per patient per year for
    diabetes with the use of home health monitoring
    devices.
  • The Pennsylvania Home Care Association study
    found that with home health monitoring devices,
    each nurse could care for 6 more patients, 17
    rather than 11.

10
Definition Home Health Monitoring
  • Home Health Monitoring or TeleMonitoring
  • the use of technology devices in the home
  • the collection of health parameters by the
    patient
  • the transfer of the data to a remote
    monitoring station
  • healthcare provider review and actions
  • Some devices, not studied in this research, use
    videoconferencing and stethoscopes.

11
Home Health Monitor Measures
  • Weight
  • Device 1 and Device 2 use a scale
  • Blood Pressure/Pulse
  • Device 1 and Device 2 use a Blood Pressure Cuff
    (Device 2 uses a separate machine with a separate
    start button)
  • Temperature
  • Device 1 uses a temperature sensor probe.
  • Device 2 uses manual data entry of temperature
    measure performed with home thermometer
  • Blood Oxygen Saturation
  • Device 1 and Device 2 use a finger sensor clip
  • 6 Health Questions
  • Device 1 uses both visual and auditory
    interaction for the questions.
  • Device 2 uses only visual interaction for the
    questions.

12
Schema and Positioning of Telemedicine Segments
adapted from Dan and Luprano, 2003
Teleoperation
High
Telediagnostic
Teleconsulting
Medical Complexity
E-learning
Telemonitoring
Tele- meeting
Low
Research
Development
Commercial
Technology Maturity Level
13
Definition Usability
  • Usability is the study of the interaction between
    a computer-based device and the user of the
    device.
  • ISO 9241 Usability Standard - Usability is the
    effectiveness, efficiency and satisfaction.
  • Jakob Nielsen considers usability characteristics
    as being easy to use, easy to learn and easy to
    remember.

14
Home Health Monitor Device Multi-modal Usability
Factors
  • Multi-modal Usability Factors
  • Audio
  • Male or Female voice
  • Volume adjustable
  • Languages available
  • Visual
  • Text size
  • Color
  • Contrast
  • Button size
  • Button spacing

15
Usability Methods According to Jakob Nielsen
Method Name Users Needed Main Advantage Main Disadvantage
Observation 3 or more Ecological validity reveals users real tasks. Suggests functions and features. Appointments hard to set up. No experimenter control.
Questionnaire At least 30 Finds subjective user preferences. Easy to repeat. Pilot work needed (to prevent misunderstandings).
Interview 5 Flexible, in-depth attitude and experience probing. Time consuming. Hard to analyze and compare.
Focus Group 6-9 per group Spontaneous reactions and group dynamics. Hard to analyze. Low validity
Nielsen, Jakob, Usability Engineering, Morgan
Kaufman, Academic Press, 1993
16
Healthcare Monitoring Usability Studies
  • Telephone-Linked Care for Diet Adherence in
    Dyslipidemia (2004)
  • Method telephone interviews and laboratory
    observation
  • Sample size 8
  • Home Asthma Telemonitoring System (2004)
  • Method telephone interviews and home-based
    field observation
  • Sample size 5
  • Informatics for Diabetes Education and
    Telemedicine (2003)
  • Method cognitive walkthrough and home-based
    field study observation
  • Sample size for the field study observation 25
  • Diabetes Glucometer (2001)
  • Method Survey and laboratory observation
  • Sample size 26 for the survey and 6 for the
    observation

17
Lessons Learned From Older Adult Research
  • Use individual interviews, rather than paper
    questionnaires or focus groups.
  • Eliminate the use of dont know .
  • Obtain Qualitative data via open ended questions
    about feelings, problems and experiences with
    technology.
  • Conduct in-home interviews to learned the most
    and see how the technology fits into home.
  • Older Adults are concerned about user
    friendliness of devices.
  • Use a video and audio tape recorder to record the
    tester using the device because it is easier to
    do transcripts from audio tape recordings
  • Let seniors try technology and ask questions in a
    supported environment
  • In-home studies provide a realistic setting for
    testing home health monitoring devices

18
Technology and Older Adult Research -
Representative Sample Size
Experienced Computer Users Inexperienced Computer Users
Technology Accepting Users Will provide informed and constructive responses. Should result in useful ideas for improving service based on users previous experience. 10 Participants Will provide ideas of how inexperienced consumers will react when they first acquire a product. 5 Participants
Technology Resistant Users Will highlight concerns from a technical perspective and which features are of value, even to technology resistant users. 2 Participants Will identify concerns of the wider consumer population. Useful if aim is to launch a simple service of interest to mass market. 4 Participants
Syme, Audrey and Roos Eisma, How Representative
is Your Older Adult Sample?, HCI and the Older
Population, Leeds, UK, September 7, 2004.
19
Research Study Phases
Phase 1
  • Semi-structured Telephone Interviews
  • 21 experienced Participants

Phase 2
  • Audio and Video Recording Observations for Device
    1 Usage
  • 7 Experienced Participants
  • 10 Inexperienced Volunteers

Phase 3
  • Audio and Video Recording Observations for Device
    1 and 2 Usage
  • 10 Volunteers

20
Study Audience
  • Older Adults between 50 and 88 years of age.
  • Both males and females.
  • Older adults living in rural New Hampshire.
  • The Test Group
  • 21 current and former Visiting Nurse Association
    patients who used a home health monitoring device
    for more than 7 days.
  • The Control Group
  • 10 volunteers with no previous experience using
    home health monitoring devices.

21
Qualitative Research Methods
  • Usability Method
  • Semi-structured Telephone Interview
  • Qualitative Measures
  • Satisfaction
  • Comments
  • Sample size
  • 21

22
Quantitative Research Methods
  • Usability Method
  • Field Study Observation in the Older Adult Home
    using audio and video recording
  • Quantitative Measures
  • Time to complete each task
  • Time to complete each sub-task
  • Number of Errors
  • Sample size
  • 19
  • Study group 7
  • Control group 12

23
Institutional Review Board (IRB) Process
  • Definition
  • An institutional review board (IRB) is a
    Committee that has been formally designated to
    approve, monitor, and review biomedical and
    behavioral research involving humans with the
    alleged aim to protect the rights and welfare of
    the research subjects. An IRB performs critical
    oversight functions for research conducted on
    human subjects that are scientific, ethical, and
    regulatory. Wikipedia
  • Pace University IRB Approval is required before
    beginning any Research with Human Subjects.
  • Obtain Certificate on Human Subjects Research
    History, Ethics and Requirements
  • Complete the IRB Form
  • Obtain IRB Approval
  • Update IRB and obtain Approval for any Changes in
    Research and Subjects
  • Close IRB for your Research

24
Phase 1 - Participant Statistics
  • Phase 1 Home Health Monitoring Study
    Semi-structured Telephone Interview
  • Study Statistics
  • Ages Number Gender
  • 50-59 6 4F 2M
  • 60-69 2 2F
  • 70-79 8 2F 6M
  • 80-89 5 3F 2M
  • 11 Females 10 Males
  • Total 21 Participants
  • 21 participants or 100 wear glasses
  • 2 participants or 9.5 wear hearing aid

25
Phase 1 - Satisfaction with Home Health Monitor
Device 1 Used by Patients
  • Overall Satisfaction with the home health
    monitoring device by Patients
  • Response Percentage
  • Very satisfied 16 76
  • Satisfied 4 19
  • Dissatisfied 0
  • Very dissatisfied 1 5

26
Phase 2 - Satisfaction with Home Health Monitor
Device 1 Used by Volunteers
  • Overall Satisfaction with the home health
    monitoring Device 1 by Volunteers
  • Number Percentage
  • Very satisfied 8 80
  • Satisfied 2 20
  • Dissatisfied 0
  • Very dissatisfied 0

27
Phase 3 - Satisfaction with Home Health Monitor
Device 2 Used by Volunteers
  • Overall Satisfaction with the home health
    monitoring Device 2
  • Number Percentage
  • Very satisfied 5 50
  • Satisfied 4 40
  • Dissatisfied 1 10
  • Very dissatisfied 0

28
Phase 1 Device 1 Visual and Button Comments
  • Button on top would be better. (T4)
  • Can not read text but do by color. (T6)
  • Buttons are too close together. Sons finger
    pushes two buttons at a time. (T7)
  • Buttons are flat and too close together. Unable
    to feel different buttons. Need texture on some
    buttons to differentiate. Need better contrast,
    such as black machine and white buttons. (T10)
  • When you push the button you need to feel the
    push, so you know if you pushed enough. Display
    not large enough to see clearly. (T17)
  • Buttons difficult to use with long finger nails.
    Raised button would be better to use rather than
    flat button. (T18)
  • The buttons are difficult to push on front of
    machine, must put hand on top and push button.
    (T20)

29
Phase 2 Device 1 Volunteer Visual and Button
Comments
  • Move buttons on top of machine (V9)
  • Pushing the Start BP button with blood pressure
    cuff on one arm and oxygen sensor on the finger
    of the other hand is difficult. Move buttons to
    top of machine. (V1)
  • Angle of display is difficult. (V5)
  • Do not like looking down on screen. Did not like
    the colors, they were hard to read. Suggest
    black buttons on white background. (V4)
  • The angle of the screen on front of the machine
    is difficult. LED is easier to read. (V6)

30
Phase 3 Device 2 Visual and Button Comments
  • Start BP button easy (V10)
  • Circular buttons are easy. Separate button for
    BP is confusing. (V11)
  • Clear visual screen. Directions are simple to
    follow. (V12)
  • Selection buttons are easy. (V5)
  • Buttons are easy. (V3)
  • Easy visible screen and buttons. (V7)
  • Button and the meaning of the scroll on the side
    of screen is difficult. Circular scrolling with
    arrow buttons should be provided. (V9)
  • Not separate start BP reading button. (V8)
  • Cancel and OK buttons use is difficult. (V3)
  • Reading screen is easy. (V6)

31
Hypothesis
  • 1. Previous computer experience will decrease
    task time, regardless of age.
  • 2. Previous computer experience will decrease
    error rate, regardless of age.
  • 3. Persons with previous experience using the
    device will have faster task times than new
    users.
  • 4. User device satisfaction ratings will be high
    for devices with low task times.
  • 5. User device satisfaction ratings will be high
    for devices with low button press error rates
  • 6. Discomfort with computers and technology
    results in longer performance task times for
    older adults.
  • 7. Participants less than 65 years of age require
    less time to complete 6 health related questions
    than the participants over age 65

32
Phase 2 Patients versus Volunteer Using Device
1 Summary Results
Device 1 Results Number/Gender Average Time for 6 Questions (Average) Button Presses for 6 questions (Average) Button press errors (Average) Device Satisfaction (Average on scale of 1-4) Button easy to use Satisfaction (Average on scale of 1-4)
Patients 6 Female 26.4 sec 6.3 presses 0.3 presses 1.7 rating 1.7 rating
Volunteers 6 Female 4 Male 34.6 sec 6 presses 0 presses 1.2 rating 1.4 rating
33
Phase 3 Volunteers Using Device 1 and Device 2
Summary Results
Device 1 and Device 2 Results Number/Gender Average Time for 6 Questions (Average) Button Presses for 6 questions (Average) Button press errors (Average) Device Satisfaction (Average on scale of 1-4) Button easy to use Satisfaction (Average on scale of 1-4))
Device 1 Volunteers 6 Female 4 Male 30.1 sec 6 presses 0 presses 1.2 scale 1.4 scale
Device 2 Volunteers 6 Female 4 Male 71.1 sec 12.2 presses 0.7 presses 1.6 scale 1.6 scale
34
Hypothesis 1 Previous computer experience will
decrease task time responding to questions,
regardless of age.
  • Using Device 1 the average time for responding to
    6 health related questions for test and control
    group participants
  • The computer experienced group completed the task
    an average of 24 faster than the computer
    inexperienced group.
  • The chi-squared test shows no significant
    difference between the computer experience and no
    computer experience group.
  • p0.293763221

Average Task Time responding to 6 questions in seconds
Experienced Group (Patients) N6 26.4 seconds
Inexperienced Group (Volunteers) N10 34.6 seconds
35
Device 1 More Experienced versus Less
Experienced Test Group Task Time Comparison
Summary The most experienced persons were 21
and 33 seconds. The most inexperienced person
was the longest with 49 seconds. A larger
sample size is needed to evaluate the
statistical significance.
36
Hypothesis 2 Previous computer experience will
result in a decreased error rate, regardless of
age.
  • Summary One experienced computer user had 11
    errors and the remaining 5 computer users had a
    total of 8 errors.
  • A larger sample size is recommended to more
    accurately consider the comparison for this
    hypothesis.

Device 1 Button Press Errors Device 2 Button Press Errors
Computer Experienced 0 Errors N7 19 Errors N6
Computer Inexperienced 3 Errors N9 19 Errors N6
37
Hypothesis 3 Computer Experience versus Computer
Inexperience
Average Task Time
Computer Experience N6 32.5 sec
Computer In-experienced N10 30.1 sec
  • Persons with experience using the device will
    have faster task times than inexperienced users.
  • The similarity of the task times shows that the
    usability of Device 1 is good because responding
    to 6 health related questions for Device 1 is
    easy to learn and use.

38
Hypothesis 4 User Overall satisfaction ratings
will be high for devices with low task times
  • The task time in seconds to respond to 6 health
    related questions by 12 volunteers. Ten
    volunteers used Device 1 and ten volunteers used
    Device 2
  • Chi squared show significant differences at p
    value of less that 0.01
  • Task time in seconds for the same 8 volunteers
    using Device 1 and
  • Chi squared show significant differences at p
    value of less that 0.01
  • Overall Device Satisfaction of the participants
    with Device 1 and Device 2
  • There is no statistical significance and the
    results are therefore similar.
  • Although the Device 2 participants required
    significantly longer times to complete the
    responses to 6 health related questions, their
    satisfaction ratings show similar ratings.

Average Task Time for 6 Questions Average Task Time for measures Device Satisfaction
Device 1 30.1 29.6 1.2
Device 2 71.1 72.3 1.6
39
Hypothesis 5 User Button Ease of use satisfaction
is high for devices with low button error rates.
  • Comparing Device 1 and Device 2 total button
    press error rate for volunteers using vital signs
    and 6 health related questions.
  • The person with 11 button press errors indicated
    the buttons were easy to use. The person with 7
    button press errors indicated the buttons were
    very easy to use. The person with 4 button press
    errors indicated the buttons were difficult to
    use.
  • The CHI-squared comparison of the button press
    errors is highly significant p less than 0.01
  • The comparison of the responses of the button
    ease of use question shows no significance.

Button Press Errors User Satisfaction
Device 1 0-1 9Very Easy 4Easy
Device 2 2-11 2Very Easy 4Easy 1Difficult
40
Hypothesis 6 Computer Comfortable versus
Computer Uncomfortable Participant Task Time
Comparison
Computer Comfort Comparison Task time range Average Task time for 6 health related questions
Computer Comfortable N9 21-49 seconds 31 seconds
Computer Uncomfortable N7 28-36 seconds 31 seconds
Summary A larger sample size is needed to
evaluate the statistical significance.
41
Hypothesis 7 Younger versus Older Groups Task
Time Comparison
Age Group Task time range Average Task time for 6 health related questions
50-65 N6 21-32 seconds 27.5 seconds
65-80 N10 23-49 seconds 33.1 seconds
Summary The range of the results and average
task time are lower for the less than 65 age
group in comparison to the greater than 65 age
group. However, a larger sample size is needed
to evaluate the statistical significance.
42
Device 1 - Recommendations
  • Good use of bright primary colors
  • Good use of multi-modal visual and auditory
    interaction
  • Move buttons to the top of the device
  • Use more spaces between the buttons
  • Use raised buttons with different textures
  • Use raised buttons with louder auditory feedback
    when pressing
  • Use thicker high contrast letters and numbers on
    the monitor screen

43
Device 2 - Recommendations
  • Good screen location and angle for viewing
  • Good primary Button location, size and spacing
  • Button color should use bright primary colors
  • Contrast should be improved on the monitor,
    especially the number pad (gray background with
    gray buttons)
  • Use raised buttons with different textures
  • Use raised buttons with louder auditory feedback
    of pressing
  • Use thicker high contrast letters and numbers on
    the monitor screen
  • Add auditory reading for the health questions, in
    addition to visual question on screen
  • Use more auditory directions, if no patient
    response
  • Repeat messages several times, if no patient
    response

44
Summary Button Recommendations
  • Button Location/Spacing
  • On top of machine or on an angle screen rather
    than on the front of the machine
  • Space between buttons to avoid double button
    press or incorrect button press
  • Button visual-
  • Button color bright colors
  • Button contrast - high contrast with background
    color
  • Button text color color bright
  • Button text contrast high contrast with
    background color
  • Button Auditory
  • Button auditory feedback for button pressing
  • Button Tactile
  • Button texture different for each button for
    visually limited persons to differentiate buttons
    by texture
  • Button tactile feedback upon pressing
  • Raised button to differentiate from device
  • Button Operations
  • Minimize the number of buttons
  • Minimize the number of button presses

45
Future Work
  • Larger Sample Size
  • Include more Males in the Observational group.
  • Inclusion of more Home Health Monitoring Devices
  • Conduct Satisfaction Rating and Device Interview
    after all Devices are Tested
  • Interview Home Health Monitoring Nurses
  • Interview Physicians who recommend patients for
    Home Health Monitoring
  • Setup Camera on Tripod in Home and ask Patients
    to do their own recording.

46
Experience-Based Recommendations
  • Keep Focused on your Research
  • Ask
  • If you need IRB Approval, Apply ASAP
  • Apply and Present at a Conference Doctorial
    Consortium
  • Set and Meet Short-term Goals
  • Push Yourself
  • It is definitely worth the effort

47
References
  • 1 Dan, Jean-Pierre and Jean Luprano, Homecare
    A Telemedicine Application Medical Device
    Technology, December 2003, www.medicaldevicesonlin
    e.com, pp.25-27.
  • 2 Farzanfar, Ramesh, Joseph Fingelstein, Robert
    Friedman, Testing the Usability of Two Automated
    Home-based Patient-Management Systems, Journal
    of Medical Systems, Vol 28, No 2, April 2004, pp.
    143-153.
  • 3 Goodman, Joy, Stephen Brewster, and Philip
    Gray, Older People, Mobile Devices and
    Navigation, HCI and the Older Population, Leeds,
    UK, September 7, 2004, www.acs.gla.ac.uk/utopia/wo
    rkshop/.
  • 4 Health Care Spending and Use of Information
    Technology in OECD Countries, Health Affairs, Vol
    25, No 3, pp 819-831, 2006
  • 5 Home Care Automation Report, Telemedicine
    Leaders Recognize Home Telehealth, vol 10, no 8,
    pp. 5-6, August 2005
  • 6 Johnston, B, L Wheeler, J Deuser, and K
    Sousa, Outcomes of the Kaiser Permanente
    Tele-home Health Research Project, Archives of
    Family Medicine, vol 9, no 1, 2000, pp 40-45.
  • 7 Kaufman, David, Vimla Patel, Charlyn
    Hilliman, Philip Morin, Jenia Pevzner, Ruth
    Weinstock, Robin Goland, Steven Shea, and Justin
    Starren, Usability in the real world assessing
    medical information technologies in patients
    homes, Journal of Biomedical Informatics, vol
    36, pp 45-60, 2003.
  • 8 Klecun-Dabrowska, Ela and Tony Cornford,
    Evaluation and Telehealth-An Interpretative
    Study, Proceedings of the 34th International
    Conference on System Sciences, pp 1-10, 2001.New
    England
  • 9 Healthcare Institute, Advanced Technologies
    to Lower Health Care Costs and Improve Quality,
    Massachusetts Technology Collaborative,
    http//www.nehi.net/, Fall 2003.
  • 10 Oorni , Kai, What do we Know about
    Usability Evalation? A Critical View,
    www.student.oulu.fi/koorni/digilib2003.pdf, 2003
  • 11 Pennsylvania Homecare Association and
    Pennsylvania State University, The Financial
    Viability of Telehealth and Telehealths Impact
    on Home Health Nurses Telehealth Project
    Evaluation Year 3, September 1, 2004 August
    31, 2005.
  • 12 Rogers, Wendy, Amy Mykityshyn, Regan
    Campbell and Arthur Fisk, Analysis of a Simple
    Medical Device, Egonomics in Design, (Winter
    2001) 6-14.
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