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Six Healthcare Trends


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Six Healthcare Trends

  1. 1. SIX HEALTHCARE TRENDS AND WHY USER EXPERIENCE MATTERSPointClear Solutions | March 2012Dawn Nidy, Senior User Experience StrategistRodney M. Hamilton, M.D., Chief Medical Information OfficerTABLE OF CONTENTS Introduction ................................................................................................................... 2 Trend #1: Increased Adoption of Electronic Medical Records ...................................... 4 Trend #2: Increased Level of Patient Engagement ....................................................... 6 Trend #3: Mobile Health Becomes Mainstream ............................................................ 8 Trend #4: Moving Towards Accountable Care ............................................................ 10 Trend #5: The Rise of Retail Health Clinics ................................................................ 12 Trend #6: Increased Care at Home Solutions ............................................................. 13 Conclusion .................................................................................................................. 14 About PointClear Solutions ......................................................................................... 14 References .................................................................................................................. 15
  2. 2.  INTRODUCTION“Usability” has increasingly become a topic of interest in healthcare with the publicationof the NIST guidelinesi for EMR usability and the tie between those guidelines andMeaningful Use Phase 2 requirements. Therefore, usability is no longer a topic that canbe ignored. However, we at PointClear Solutions would like to broaden the discussion toinclude, but not be limited by the term “usability.” We would like to discuss the disciplineand concept of “User Experience” as it relates to current healthcare topics.A great user experience is dependent on a high degree of usability, but it’s also morethan that. Let’s take a look at the definitions from The International Organization forStandardization (ISO):Usability “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” (ISO 9241-11)User Experience “a person’s perceptions and responses that result from the use or anticipated use of a product, system or service.” (ISO 9241-210)Usability testing helps determine the usability of an application. It often measures how auser interface performs in task completion rate (what percentage of users can completea task) or time on task (how long a particular task takes). Experts can also performevaluations against best practices (heuristics). Usability testing is useful as a method ofmeasuring usability and identifying areas to improve.However, if you don’t think about a user-centered approach until usability testing isconducted on a fully built product, you are too late. Usability testing must be performedon a completed design, or at least, a prototype of a design. Usability testing is also oftenperformed in a “usability lab” which takes the user out of their own context; this canaffect the interpretation of found usability issues.User-Centered Design (UCD) is an approach and set of methods that aid userexperience practitioners in creating a usable product and great user experience. InUCD, user research must begin at the start of your project to assess user needs, goals,and workflow. Two methods we use at the beginning of a project are contextual inquiryand task analysis. The outcomes of these methods can inform product decisions alongthe entire software development lifecycle.Contextual inquiry is a master/apprentice model of observing and asking questions tolearn how users go about their work. It involves:Page 2 of 15 PointClear Solutions
  3. 3.   • Context – interviewing users in their own environments using the artifacts that are part of their daily work • Partnership – a tone of collaborative exploration and alternating between observation and discussion • Interpretation – reading between the lines to make connections between behavior, environment, and what users say • Focus – subtle direction of the interview to capture details relevant to designiiTask analysis involves a series of open-ended interviews to develop a detailedunderstanding of how people perform specific tasks. With this method we seek tounderstand: • Why the user is performing the task (goal) • The frequency and importance of the task • Cues – what initiates or prompts the task • Dependencies – what must be in place to perform, and what is dependent on task completion • The people involved – roles and responsibilities • Specific actions performed • Decisions made and information used to support decisions • Errors and exception cases and how they are correctedSimply measuring the usability of tasks in your application, while very important, is notenough. Creating a great user experience requires a deep understanding of the endusers that can only be gained through direct observation in the users’ own context.Usability testing will uncover aspects of the execution that should be corrected and helpyou understand the priority of each issue. But usability testing does not replace the needfor a foundation of user understanding built into the product from the start.If you are a vendor, you’ll be glad to know there are intrinsic financial benefits tofollowing a user-centered approach. An ROI analysis by Karat indicated a $10 return oneach dollar invested in usabilityiii. Products that are created with a user-centeredapproach have reduced costs in support, training, and maintenance (fewer changerequests). In addition, the cost to correct a problem increases the further you are in thedevelopment process. A user-centered approach combines up-front user research withusability testing on prototypes rather than fully developed systems, as well as continuedmeasurement and improvement throughout the product lifecycle. Incorporating userexperience design will add value at any point in the process, but the value will diminishthe later it is applied in the project.It costs 10 times as much to fix the same design problem if not found until thedevelopment phase. And it costs a staggering 100 times as more to fix the sameproblem in design if found after deployment. iv Detecting these issues earlier in thePage 3 of 15 PointClear Solutions
  4. 4.  process or preventing them through user-centered design is a cost-effective approach todeveloping products and services.In this paper, we’ll talk about how user-centered design can benefit specific areas of thehealthcare market that are relevant today.TREND #1: INCREASED ADOPTION OF ELECTRONIC MEDICAL RECORDSElectronic Medical Records (EMR) have the potential to transform the healthcareindustry by increasing the access to and exchange of clinical information by medicalproviders and patients. However, there are significant challenges in implementingEMRs. Some of them are directly related to the usability and user experience of thesoftware. “Two of the five major barriers to adoption of healthcare information and communications technology in the US are ‘lack of user friendly, integrated technology solutions’ and ‘lack of end-user acceptance’.” v Creating the right tools for clinicians requires a deep understanding of the mental model of the end users. In 2011, Stead and Linvi evaluated premier EMRs in the United States and concluded that even these systems did not provide the required cognitive support for clinicians (i.e., tools for thinking about and solvinghealth problems). Cognitive support may include designs to provide an overview orsummary of the patient, information “at a glance,” intuitive designs and tailored supportfor clinicians in specific contexts.vii “Designing something requires that you completely understand what a person wants to get done. Empathy with a person is distinct from studying how a person uses something. Empathy extends to knowing what the person wants to accomplish regardless of whether she has or is aware of the thing you are designing. You need to know the person’s goals and what procedure and philosophy she follows to accomplish them.” viiiA typical method that vendors use to understand workflow is to employ a Subject MatterExpert (SME). While this method can add some helpful insight, it can also lead down thewrong path if it’s the only method used. Any SME will have their own biases and anunderstanding that is limited by their own experience. By using methods such ascontextual inquiry and task analysis, as described in the introduction, the product teamwill gain a much richer and broader understanding of the end users. The team will thenbe able to spot patterns across many types of customer segments, but also be able toPage 4 of 15 PointClear Solutions
  5. 5.  understand when something is unique to a particular customer or type. And by involvingproduct team members in the research process, you naturally create many expertsrather than having to rely on a single source.Usability issues can compromise patient safety if the interface does not properly preventerrors, diagnose errors, or allow users to recover from errors. “According to one source, more than one-third of medical device incident reports have been found to involve use error, and more than half of the recalls can be traced to user interface design problems. As a result, the FDA has placed increased emphasis on testing the user interfaces of devices in pre-market approval, as evidenced by recent publication of the agency’s human factors guidance.” ixPoorly designed EMRs create a significant drop in productivity during the learning phase,which then increases costs and reduces profit for practices and hospitals. A recent studyby UC Davis on EMR productivity showed that “it takes approximately 4 to 6 months –called the learning period – for the technology shock to be fully absorbed into thesystem.”x Their study also indicated that some specialties such as family medicine andpediatrics never regained the productivity they had before introducing an EMR. Thislengthy EMR “learning period” is very likely the result of poorly designed software.Products that truly support Meaningful Use must make MU reporting easy to use andeasy to find. And while meeting Meaningful Use requirements is of immediate concernfor most purchasers, it is not a competitive advantage or a sustainable business modelon its own. Smart buyers realize an EMR is a long-term investment. They will belooking at how the EMR supports their workflow, how easy it is to learn, and how easy itis to use. Decision makers who are also end-users will ask questions about how theEMR software solves their practice’s needs overall and evaluate software on thosecriteria.Page 5 of 15 PointClear Solutions
  6. 6.  TREND #2: INCREASED LEVEL OF PATIENT ENGAGEMENTA recent Pew Internet study showed that 80% of Internet users gather health informationonline.xi Another recent study showed that patients pay more attention and becomemore engaged in their healthcare when they have easy access to their medicalinformation online.xii Patients are increasingly adopting digital health tools such aspatient portals and Personal Health Records (PHRs). Two notable successes are KaiserPermanente, which reported in 2010 that over 3 million of their patients are registered fortheir My Health Manager, and Geisinger Health in Pennsylvania which reported a 25%registration rate for myGeisinger as of 2010.xiii What  health  information  do  people  look  for  online?   Information about a specific 66! disease or medical problem! Information about a certain 56! medical treatment or procedure! Information about doctors or 44! other health professionals! Percentage of Internet Users! Information about hospitals or 36! other medical facilities! Information related to health 33! insurance! 0   20   40   60   80   xivData from the Pew Internet & American Life ProjectIncreased patient engagement can be a key driver in creating a more educated, healthypatient population. Patient technology tools have the promise of creating a better patientexperience while reducing the administrative overhead for practices. However, carefulattention must be paid to the practice workflow integration points as they relate to patientself-service options.For example, if patients are able to send and receive secure messages, that feature hasthe potential to increase practice efficiency and increase patient satisfaction. But what ifthe system requires the practice staff to log into a separate tool outside their EMR inorder to retrieve messages? Or what if there is no way of easily knowing when a newmessage is waiting? Then the workflow breaks down and the potential benefits to bothpatients and practices are lost.In order for patients to adopt and use patient portals, they must feel confident that theself-service option is equally or more reliable, trustworthy and efficient than picking upPage 6 of 15 PointClear Solutions
  7. 7.  the phone and calling. Thoughtful design and a transparent approach can help reassureusers into feeling more confident about using the application.Here are some thoughts to consider when developing patient-friendly technology tools: • Use patient-friendly language and presentation. The solution should not simply spit data out of the EMR in the same terminology or format as viewed by clinicians. • Minimize data entry for patients. Patients will be frustrated and may abandon when asked to re-enter information they have already provided to their doctor’s office. • Data is a make or break aspect of the patient experience. The data must be accurate, meaningful, and complete. Sharing data across entities is very important for patient experience. • Balance privacy and security concerns with considerations for ease of use. Patients appreciate the need for data protection, but they will abandon if what you are asking is unreasonable or unattainable. • Carefully consider your requirements for password creation, how often users have to change their password, and how they recover from forgotten user IDs or passwords. Again, balance security concerns with ease of use. • Consider staged authentication. If there are pieces of functionality that have lower risk for a patient to access, such as scheduling an appointment, then reduce the barriers to use that feature. • Consider what can be accessed without any authentication. Users should be able to understand the value of your offering before having to register. There may be some tools that should not require registration at all. • Consider patient workflow. For example, if your patient has to receive a passcode in the mail or in person before they can use your online tools, it will have a negative impact on adoption. Going offline to go online is not in their workflow. • Deliver what’s important to patients. What is their intrinsic motivation to use your tools? Discover what will deliver value for patients through user research rather than going off your own assumptions. • Consider what will make a compelling experience that will make patients want to continue to use your product. What will make it engaging, sticky and perhaps even fun (where appropriate)? You must understand your users’ goals and align them to the design of the product.Page 7 of 15 PointClear Solutions
  8. 8.  TREND #3: MOBILE HEALTH BECOMES MAINSTREAM “We don’t merely adopt mobile devices; we marry them” -B.J. Fogg, Stanford Persuasive Technology Lab As of October 2011 there were 250 million iOS devices activated (e.g. iPhone, iPad, iPod Touch). And the rapidly growing Google Android platform reported in February 2012 that there are over 300 million Android devices worldwide and 850,000 are being activated daily.xv As of February 2012, there are about 7,500 apps in the medical, health and fitness categories on iTunes. Luke Wroblewski at has coined theterm “mobile first” – meaning he believes you should design new applications for mobilebefore desktop web. Here’s why: • Mobile usage is exploding • Mobile forces you to focus & prioritize. There isn’t room on a 320x480 screen for extraneous information or unnecessary elements. • Mobile extends your capabilities. Web browsers are limited in their functionality and mobile allows you to harness the power of GPS, camera, accelerometer, multi-touch inputs and more.Recent surveys have indicated more than 80 percent of physicians have an iPhone andmore than 30 percent are using iPads for clinical purposes.xvi Mobile clinical solutionsmake perfect sense for physicians because they are highly mobile, constantly movingbetween exam rooms or medical facilities. However, most of the largest EMR vendorsstill do not offer native mobile solutions for their EMRs. They instead offer remoteaccess into the regular version of desktop EMR or they direct users to their regular webapplication. What’s required is a solution that is designed specifically for touchinteractions and keeps in mind the context of use: mobile.Designing great mobile solutions requires a thoughtful approach to the mechanics oftouch-based interfaces. The interaction model on a touch device has some fundamentaldifferences from a desktop solution that uses an external keyboard and mouse. Thefinger is not as precise in pointing as a mouse. The Apple iOS interface guidelinesrecommend a target no less than 44 x 44 pixels for accuracy of selection – a size that bydesktop proportions could be considered quite large for something like a button. Typingon a mobile device is much more cumbersome and should be limited to the bareminimum. And when typing is required, mobile solutions should be coded so that theyPage 8 of 15 PointClear Solutions
  9. 9.  switch to the most appropriate keyboard automatically. For example, if requiring aphone number input, the mobile app should switch the user to the numeric keyboardentry automatically. They should also include smart defaults for the most commonoptions and auto-complete options when typing, especially for difficult terminology suchas prescription drug names.Applications designed for desktop have limitations when used on mobile devices, suchas no access to right-click options and a significantly smaller screen size. Also, manydesktop web products have not been thoroughly tested on mobile browsers andtherefore are prone to bugs or features not working properly.Designing for mobile requires a deep understanding of context: what goals and tasks doyour users need to accomplish on mobile? There may be specific features that are moreimportant on a mobile device and those should be available and prominent. Users willhave some of the same goals as when using your product in other platforms. But oftenthere are unmet needs that can be addressed and new business opportunities to exploitby leveraging the unique capabilities of mobile devices, such as the integrated phone,camera, accelerometer or GPS.Users have an expectation for mobile apps; they should be purposeful, useful in contextand easy to use – otherwise users will abandon. You add little value by simply having amobile version of your product. The value is added in the execution. Through user-centered design and research, these needs can be uncovered and applications can bedesigned for maximum engagement.Designing for mobile also requires you to make decisions about your platform strategy.While iOS and Android dominate today’s market, there are many emerging smart phoneplatforms that you may not want to exclude. You may need some combination of nativeapps for specific platforms and a mobile web solution that can work on any mobilebrowser-enabled device. You’ll need to weigh the pros and cons of native and mobileweb approaches from a cost and functionality perspective. Keeping a pulse on whatyour target audience is using is critical and can be achieved through using analyticstools.You will also need to consider form factor when deciding on which platforms to develop.The portability and ubiquity of a smart phone makes it useful in many situations,however, data-rich or image-heavy apps could benefit from the greater screen realestate on an iPad or other tablet, provided a tablet device makes sense in the context ofuse. When designing a tablet solution it is best to have a different user interface fromboth your smart phone and desktop web applications. You should design a tabletinterface that is uniquely suited for the combination of the tablet screen size and touchinterface.Using a design technique called Experience Journey Maps, you can visualize the entireexperience your users have with your products and services. This technique can beuseful to identify gaps where you’re not serving users well, and also highlightopportunities for new solutions, such as in mobile.Page 9 of 15 PointClear Solutions
  10. 10.  Joyce Hostyn wrote an excellent blog article called “Visualizing the customer experienceusing customer experience journey maps.” In her article she compiled examples fromvarious companies who used this technique to evolve their user experience. Here shetalks about the benefits of this technique: “Journey maps are a tool to help bring the outside world into an organization. They can help bring customer stories to life. An entire story; not just one silo or function... And as we map out the customer’s story, our organization’s own story becomes visible. And often what’s revealed is an incomplete fractured story.”Before embarking on a mobile app design, redesign, or mobile strategy, here are somequestions you should answer through user research and analytics: • How are my users’ goals different on mobile than when using desktop? • What is the context of use for a mobile solution (as opposed to desktop)? • How do mobile applications fit into the entire user journey? • What user needs are being currently unmet on desktop that can be solved through mobile? • What device capabilities will help my users achieve their goals? • What new opportunities does mobile afford my business? • What devices, browsers and platforms are my audience using (in percentages)?TREND #4: MOVING TOWARDS ACCOUNTABLE CAREHow many times have you gone to a doctor’s office WHAT IS AN ACO?and filled out the same health questions on the paperclipboard? Asking patients to provide the same An ACO is a network ofinformation over and over again is not only inefficient doctors and hospitals thatbut also prone to errors and omissions. Also, why is shares responsibility forthis information not available to other physicians, like providing care to patients.specialists, when patients are referred for additional These programs reward ACOcare? Clearly, our healthcare system in the United participants that lower theirStates is not really a “system” at all. However, new growth in healthcare costsmodels of healthcare delivery are emerging rapidly. while meeting performance standards on quality of careThe Patient Protection and Affordable Care Act of and service.2010 established the concept of an Accountable CareOrganization (ACO). These organizations give There are ACO programsproviders financial incentives to provide better sponsored by CMS and alsocoordinated care for patients. The intent of ACOs is to by commercial payers. Manyshift the incentives so that providers are rewarded for of these programs are still invalue – not volume. the pilot stage as of the first quarter of 2012.Page 10 of 15 PointClear Solutions
  11. 11.  In order to achieve its goals, an ACO will require an increased exchange of informationand robust technology tools, some of which may not exist today. These tools will needto be built with clinical safety, workflow, and efficiency in mind.Because accountable care organizations are a new concept with very fewimplementations live, the exact operational constructs are still evolving. No doubt, therewill be new workflows defined and existing workflows redefined. Appropriate userresearch and usability testing will be essential to ensuring that modification to existingsoftware and the creation of new software meet the needs of this new healthcaredelivery model.The table below describes the types of competencies that ACO organizations will needto have and the technology tools they will need to support them. These tools will need tobe integrated in a coherent way if there is any hope of having a highly effective andusable system for ACOs. And some of these tools will certainly require mobile support.Competency Software RequirementsCross Continuum Management HIE; Provider Messaging; Workflow Management; Shared Care plans; Referral Tracking; Clinical Decision SupportPopulation Health Management Health Risk Assessment; Predictive Modeling & Analytics tools; Workflow Management; Registries; Clinical Decision SupportPatient Engagement Mobile Health; Telehealth; PHRs, Patient Portals; SurveysQuality & Performance Reporting Business Information / Analytics tools; DashboardsAdministrative and Financial Risk Risk Modeling Tools; Complex CaseManagement Systems Management; BenchmarkingCore Infrastructure Identity Management; Semantic Interoperability; Security Framework; Patient Consent Framework; Controlled TerminologyPage 11 of 15 PointClear Solutions
  12. 12.  TREND #5: THE RISE OF RETAIL HEALTH CLINICS The demand for primary care services in the US outmatches the availability of primary care physicians. At the same time, there is an exponential increase in healthcare costs and high percentage of under-insured patients. This climate has created a demand from patients for lower cost care and more convenient access. Retail health clinics are one solution. Walgreens, CVS and Wal-Mart are the top three providers, offering clinics in many of their stores.Retail clinics typically offer basic preventative care services such as flu shots and treatlow severity illnesses such as colds. These services are short in duration and thepatient volume fluctuates and is unpredictable because patients can walk-in.Technology tools are required that help the staff manage this type of schedule.A positive patient experience in the retail clinic is dependent on accurately settingexpectations of wait times, creating easy to use self-service tools, and creating an in-store experience that supports the retail clinic. And mobile solutions that allow patientsto easily find a nearby clinic location and schedule an appointment are necessary tosupport the immediacy of these types of health conditions.Here’s a fictional scenario to depict what a successful retail clinic experience might looklike: Jane goes to her local pharmacy to pick up a prescription on her way home from work. The cashier at the pharmacy counter asks Jane if she’s had her flu shot yet. “It only takes a few minutes,” he says. Jane has been meaning to get one. She decides to give it a try if it won’t take too long. She walks to the clinic area and checks herself in at the kiosk by answering a few simple questions. The kiosk directs Jane to hold her insurance card under its built-in camera. The kiosk takes a picture of the insurance card, converts the image to text via OCR (optical character recognition) and performs a real-time eligibility check. Jane gets back a message that says her insurance plan covers preventative care at 100%, including flu shots. Then the kiosk displays a confirmation message, “Thank you. We’ll be ready for you in about 5 minutes. We’ll send you a text message when it’s time. You can also track your wait time on the monitor.” The monitor, which is viewable from practically any part of the store, shows the patient’s first name and last initial, how many people are ahead of them and their remaining wait time. Jane decides to shop for a few household items while she waits. She receives the text message five minutes later as expected. She walks to the clinicPage 12 of 15 PointClear Solutions
  13. 13.   area where there’s a dedicated place for her to leave her basket outside the exam room. The shot only takes a minute, and then she’s able to finish her shopping and head home.This is just one possible scenario of many. However, it’s important for retail clinics tohave the right tools for patients to get efficient quality care, tools that set the rightexpectations and provide appropriate notifications, and to apply a thoughtful integrationof the retail experience. “Viewed in isolation, market trends such as the rise of retail and worksite clinics, the expansion of home-based care, and the proliferation of information and communication technologies can seem unrelated. However, when viewed holistically, these trends demonstrate that the landscape of primary care appears to be undergoing a significant transformation.”xviiTREND #6: INCREASED CARE AT HOME SOLUTIONSThe increasing trend towards medical care in the home requires the assistance of new technologies that are designed to support new care models. Clinical and administrative workflow will have to be reimagined. This will require close collaboration between clinical experts and user experience designers. Mobile technologies will need to play a significant role for clinicians and administrative staff who are operating in this model, either traveling from site to site or delivering care from remote locations.In addition, patients will be required to interact with new technologies they have neverused before. Telehealth is still a novel concept to most patients, and even fewer haveactual experience with this model. Care at home will require highly intuitive tools thatpatients can easily learn on the fly; even patients with low technical skills. These toolswill need to inspire confidence with patients that may be nervous about this type of care.The tools will need to clearly guide patients on what steps they need to take in order tofollow doctor’s orders and allow them to track their progress. And attention will need tobe paid to patients with short and long-term disabilities to make these tools accessible.Experience journey mapping, a method discussed in the mobile trend section, could beuseful to help visualize workflow in the Care at Home model. The experience mapwould include all the constituents, how their workflow overlaps and where there aredependencies between parties. It should also include which tools are used for each taskand how those tools support the users’ goals.Page 13 of 15 PointClear Solutions
  14. 14.  Another method that could be leveraged to test new workflow and care models isbodystorming.xviii This technique is a way of physically prototyping how a solution willwork in the real world. This model could be used throughout the process to test how thesolution will work for all constituents. It could start early in the design process to includepaper prototypes of the interface or leveraging existing video conferencing tools likeSkype. The goal would be to test out the workflow and tools needed to support Care atHome. Real patients with little clinical knowledge should be included in this type ofphysical prototype. Through these types of bodystorming exercises, the workflow anduser interface could be rapidly tested and iteratively designed before the technologysolutions are fully developed: saving time, money and ultimately creating a betterproduct.CONCLUSIONIt’s an exciting time in both healthcare and technology. Delivering higher quality, lowercost care will require new approaches to technology as well as care delivery. A user-centered design approach is required in order to create the most effective tools thatsupport ease of use, user satisfaction and clinical safety, and promote adoption bypatients and providers. The convergence of technology advances, healthcare reform,and patient engagement all create a perfect storm of opportunity. But capitalizing onopportunity requires innovation. And innovation requires a deep understanding of what’simportant to your end users and delivering that in your offering.A committed, strategic focus on User Experience will make the difference betweenmarginal and break-out growth for vendors in the healthcare industry in the next fewyears to come. “In most people’s vocabularies, design means veneer. It’s interior decorating. It’s the fabric of the curtains or the sofa. But to me, nothing could be further from the meaning of design. Design is the fundamental soul of a human-made creation that ends up expressing itself in successive outer layers of the product or service… Design is how it works.” – Steve JobsABOUT POINTCLEAR SOLUTIONSPointClears focus is on transforming healthcare delivery through technology innovationthat improves user experience. Our competencies lie at the intersection of productstrategy, technology and user experience. Our user-centered approach to softwaredevelopment assures that our solutions are accessible, relevant and actionable - drivinguser adoption, promoting human-centered delivery of professional healthcare, andultimately creating business value for our clients. We serve provider, payer,pharmaceutical, public health organizations and the technology market that supportsthem.Page 14 of 15 PointClear Solutions
  15. 15.  REFERENCES                                                                                                                i Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records,National Institute of Standards and Technology (NIST), (2012).ii Wikipedia entry on Contextual Inquiry. Karat C. Iterative testing of a security applications. Paper presented at: Proceedings of theHuman Factors Society, (1989).iv Marcus A. Return on Investment for Usable User-Interface Design: Examples and Statistics.Berkeley, CA; (2004).v Saleem, J. J., Russ, A. L., Sanderson, P., Johnson, T. R., Zhang, J., & Sittig, D. F. CurrentChallenges and Opportunities for Better Integration of Human Factors Research withDevelopment of Clinical Information Systems. IMIA Yearbook of Medical Informatics, (2009).vi Stead W, Linn H. Computational Technology for Effective Healthcare: Immediate Steps andStrategic Directions. Washington, D.C.: National Academies Press; (2009).vii Promoting Usability in Health Organizations: Initial Steps and Progress Toward a HealthcareUsability Maturity Model (HIMSS EMR Usability Task Force). Health Information ManagementSystems Society. (2011)viii Young, I. Mental Models. Rosenfeld Media. (2008)ix Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records,National Institute of Standards and Technology (NIST), (2012).x Bhargava, Hemant K. and Mishra, Abhay, Electronic Medical Records and PhysicianProductivity: Evidence from Panel Data Analysis (2011).xi Fox, Susannah. Pew Internet & American Life Project. Health Topics. (2011). Lake Research Partners, funded by California HealthCare Foundation. Consumers and HealthInformation Technology: A National Survey. (2010).xiii Fox, Susannah. Pew Internet & American Life Project. Measuring the Impact of PatientPortals: What the Literature Tells Us. (2011).xiv  Fox, Susannah. Pew Internet & American Life Project. September 2010 - Health Tracking.(2010).  xv Information Week. “Androids Success: By The Numbers” Feb 28, 2012. Primary Care, Everywhere: Connecting the Dots Across the Emerging Health Landscape.Jane Sarasohn-Kahn for the California HealthCare Foundation (2011).xviii Oulasvirta, A., Kurvinen, E., & Kankainen, T. Understanding contexts by being there: casestudies in bodystorming. Personal Ubiquitous Computing., 7(2), 125-134. (2003).  Page 15 of 15 PointClear Solutions