Designing Healthcare Technologies:
Motivating Users by Decreasing Cognitive Load
Shannon Halgren, PhD
Julie Rennecker, PhD
HUMAN USE ERROR
 Feeding Tube and Trach Tube
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TubingandLuerMisconnections/ucm313...
EHR Example
Lab Result
 K+
(3.1 mEQ/L)
Dr. A
IV K+ Order 1
(40 meQ over 4 hr)
Dr. A
IV K+ Order 2
(100 meQ addition to ex...
Human use errors are NOT a tiny problem
 Institute of Medicine, 2000, To Err is Human
 44,000 – 98,000 deaths/year
 App...
Human use errors are NOT a tiny problem
 Institute of Medicine, 2012, Best Care at Lowest Cost
 North Carolina: 18% of h...
Why do errors like
these happen?
Designing for the Context of Use
“Standards for drugs and medical devices
concentrate on safe design and production,
with ...
We’re not in Kansas Anymore!
Fear of Litigation
Infection Control
Heavy Regulation
High Risk Tasks
Multi-Tasking
Time Crit...
An inside look at the
healthcare environment…
Trauma Patient Video
What Did You Notice?
What Did You Notice?
 The need for speed
 Frequent interruptions/multi-tasking
 Multiple handoffs
 Multiple, diverse p...
An inside look at the
healthcare environment…
ICU Nurse Video
What Did You Notice?
What Did You Notice?
 The pressure for accuracy
 Frequent interruptions/multi-tasking
 Lots of equipment, all with uniq...
User’s Motivations: Comparison Across Industries
Online Retail Social Media Healthcare
Need for speed Med Med to High Extr...
How do we create
technology for this unique
user group & complex
context?
Cognitive Psychology 101
Cognitive Load
Whitenton, K. (2013). Minimize Cognitive Load to Maximize Usability. Article published online.
Cognitive Lo...
3 Kinds of Cognitive Load
Intrinsic
Load
1 Extrinsic
Load
2 Germane
Load
3
Problem
complexity
- Starting an IV
- Using a
d...
Cognitive Load is Cumulative
+
Intrinsic
Load
Extrinsic
Load
Germane
Load+ =
Total
Cognitive
Load
Cognitive load affects performance
Performance Drop with Cognitive Overload
Mental Capacity
Cognitive Demand
(Total Cognit...
Let me show you
what I mean…
Don’t Try This at Home
Procedural Task
Create a new contact for “Jane Doe”
Phone number: 800-555-9634
Distraction
Don’t Try This at Home
Procedural Task
Create a new contact for “John Doe”
Phone number: 800-555-5678
Cognitiv...
What if these were health care tasks?
Procedural Task
Setup an IV
Cognitive Task
Calculate fluid rate
Answer patient quest...
Humans have limited
cognitive capacity… but
the cognitive demands
on healthcare workers
continue to increase
Capacity
The ...
But what does this
have to do with
product design?
The Resolution
Medical technology must be designed
to require less cognitive overhead.
Design Rules for Reducing Cognitive Load
Be Simple
1
Be Consistent
5
Be a Team Player
6
Be Helpful
2
Intrinsic
Load
Extrin...
Design Rules for Reducing Cognitive Load
Be Simple
1
Be Consistent
5
Be a Team Player
6
Be Helpful
2
Intrinsic
Load
Extrin...
Be Simple
1
The subject matter can be complex, but the UX should not be
 Be Minimal
 Less is more
 Show only what you really need
 Group related information
 Use a clean visual design
Be Si...
Be Simple
1
 Be Minimal
 Be Minimal
 Less is more
 Show only what you really need
 Group related information
 Use a clean visual design
 Be ...
 Be Direct – use obvious alert states
Be Simple
1
FusionCharts Patient Monitoring System
Be Helpful
2
Think guided workflows, not features
 Provide Guidance
 Through the workflow
 Next steps
 Access to help
Be Helpful
2
Be Helpful
2
Before: Where do I start? Where can I get help?
 Provide Guidance - Provide a place to start
On Off
Button B...
Be Helpful
2
After: Guided Workflows, Grouped content
 Provide Guidance - Provide a place to start
 Provide Guidance
 Through the workflow
 Next steps
 Access to help
 Prevent Errors
 Make it obvious
 Make it easy
...
Be Helpful
2
 Prevent Errors – Make it “dummy proof”
Be Helpful
2
 Prevent Errors – Make it “dummy proof”
Designer: Kevin Harald Campean
Design Rules for Reducing Cognitive Load
Be Simple
1
Be Consistent
5
Be a Team Player
6
Be Helpful
2
Intrinsic
Load
Extrin...
Technology should serve as a natural extension of our task
performance rather than a barrier to overcome.
Be Smart
3
 Be a Natural Extension
… of the user
 Hold information in memory for the user
 Perform calculations for the user
… of ...
Be Smart
3
Lab
 K+
(3.1 mEQ/L)
Dr. A
IV K+ Order 1
(40 meQ over 4 hr)
Dr. A
IV K+ Order 2
(100 meQ addition to existing f...
Be Calm
4
Provide a calm & soothing user experience
 Be Attractive
 Use soothing colors
 Use a neutral color palette
 Provide ample white space
Be Calm
4
“We assume if it...
 Be Attractive – Pay attention to color
Be Calm
4
 Be Attractive – Pay attention to color
Be Calm
4
!
!
!
 Be Attractive
 Use soothing colors
 Use a neutral color palette
 Provide ample white space
 Be Mindful
 Careful use...
 Be Mindful – of audio and animation use
Be Calm
4
Design Rules for Reducing Cognitive Load
Be Simple
1
Be Consistent
5
Be a Team Player
6
Be Helpful
2
Intrinsic
Load
Extrin...
Be Consistent
5
Provide a predictable user experience – routine is important
 Provide simple, consistent workflows
 Within the design
 Across your product line
 Across similar medical devices
 W...
 Within and between your product(s)
Be Consistent
5
Use templates and style guides
 Within and between your product(s)
Be Consistent
5
Inventory interaction behaviors
(alerts, modes, button states, contro...
 With users’ expectations
Be Consistent
5
Measure users’ mental models
 With users’ expectations and needs
Be Consistent
5
Interview and observe users in context
Be a Team Player
6
Recognize that you are part of a technology team…
whether you want to be or not
Be a Team Player
6
The product team’s world view
Our Other
Awesome
Product
ACME
Our Other
Awesome
Product
ACME
Our New Awe...
Our New
Awesome
Product
ACME
Our New
Awesome
Product
ACME
Be a Team Player
6
The user’s world view
Competing
Product
Our O...
 Take a systems engineering perspective
 Avoid local success, global failure
 Consider the other technology being used ...
Be a Team Player
6
then find a way to complement rather than compete
Study competitors, related products, industry standar...
Be a Team Player
6
Be different ONLY if you improve the global user experience.
Don’t be different, just to be different.
Design Rules for Reducing Cognitive Load
Be Simple
1
Be Consistent
5
Be a Team Player
6
Be Helpful
2
Intrinsic
Load
Extrin...
How do I know if my
design’s cognitive load is
manageable?
Evaluating Your Design for Cognitive Load
Common methods used in uncommon ways
 Design Review
 Cognitive Walkthrough
 S...
Evaluating Your Design for Cognitive Load
 Minimalism
 Abbreviation & icon use
 Consistency across screens & workflows
...
Evaluating Your Design for Cognitive Load
 Simple to use
 Easy interpretation of status
 Obvious next steps
 To ensure...
Evaluating Your Design for Cognitive Load
 Task performance in a realistic setting
 Simulation lab in a medical facility...
Evaluating Your Design for Cognitive Load
 Task analysis
 Workflows
 Context analysis
Extrinsic
Load
Germane
Load
Field...
Considering Cognitive Load During Design Validation
Intrinsic
Load
Extrinsic
Load
Germane
Load
Be Simple & Helpful
 Desig...
Sounds good, but how am
I going to remember all
this?
Checklist for Reducing Cognitive Load
Through Design
For a copy, email one of us or
see me after the session.
shannon@sage...
Design can save lives.
The bottom line.
Manageable level of cognitive load
Unmanageable level of cognitive load
THANK YOU!
Julie Rennecker, PhD RN
Principal Consultant
The Management Doc, LLC
Julie@TheManagementDoc.com
Shannon Halgren...
References
 Drews, FA et al (2009). Text messaging during simulated driving behavior. Human Factors, 51: 762-770.
 Eriks...
Designing Healthcare Technologies: Motivating Users by Decreasing Cognitive Load (Julie Rennecker and Shannon Halgren)
Designing Healthcare Technologies: Motivating Users by Decreasing Cognitive Load (Julie Rennecker and Shannon Halgren)
Designing Healthcare Technologies: Motivating Users by Decreasing Cognitive Load (Julie Rennecker and Shannon Halgren)
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Designing Healthcare Technologies: Motivating Users by Decreasing Cognitive Load (Julie Rennecker and Shannon Halgren)

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Healthcare users are a demanding group. Multiple beeping and blinking devices, frequent interruptions, competing demands, and high-risk tasks overload their cognitive capacity, leaving them with little patience for ambiguity or inefficiency and - more importantly - at risk for making serious errors. We will introduce participants to the factors motivating healthcare technology users by offering a peek into the world of a busy nurse and showing examples of the tragic errors that can result when overload occurs. We then propose six design principles based in cognitive theory and illustrated with real world examples as a framework to help UX designers motivate healthcare technology users by minimizing cognitive load. Participants will leave the session with actionable knowledge they can apply to current projects.

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  • Good morning. Thank you for joining us. When we started designing products for healthcare, several years ago, we quickly realized that what we thought we know about design, didn’t always apply to healthcare. That realization interested us enough to explore this product use environment at a deeper level and to shift our design processes to meet the unique needs of these users. In this talk we’ll share what we’ve learned.


    We’re happy to be here this morning to talk with you about cognitive load—which we refer to as “cognitive overhead”--as it applies to healthcare technology design. We’ll talk about what cognitive overload is, how it affects healthcare workers, and ways that we designers can minimize it through our product designs.


  • I’m going to begin by taking about error.

    We ALL make mistakes. And we know mistakes, or what we in Human Factors call Human Use Errors, are made in the healthcare environment.

    But, what factors affect when and how often human use errors are made?

    How can the design of medical devices and applications minimize human use error?

    These are some questions we’ll be exploring during this presentation.

    Let’s begin by taking a quick look at a few documented human use errors in the use of medical technologies…
  • In healthcare, a common source of human use error are what call fatal tubing mash-ups. This is where a healthcare working connect two tubes together that should not be connected.

    In this case, a feeding tube was accidentally inserted into a trach tube port and milk was delivered to an infants lungs.

    The result was fatal.
  • And, in this example, an unfortunate string of errors related to the use of an Electronic Health Record (EHR) put a patient in serious danger, though he lived.

    It began when
    A gentleman had a low K level, 3.1 mili equivalients. It’s just a little bit low, but does require treatment.
    Dr. A orders a K bolus to be delivered over a short period of time…
    Then he noticed the pt. already has an IV so decides it would be better to add the K to the existing IV fluid for a longer delivery time which results in greater pt. comfort (K sometimes burns).
    He attempted to cancel the first order, but instead cancelled a similar order by mistake.
    Pharm. filled the first order and changed the second order to comply with hospital policy around K treatments, but did fill it.
    Both orders, the bolus and the slower K administration, were carried out by the nurses.
    Shift change: Dr. B sees the 3.1 K level and interprets is as a new, post treatment lab value and treats for low K.
    K now has more than doubled. I very high or low level can stop the heart. They caught this mistake

    The problem wasn’t that these healthcare workers didn’t care or were being careless, it was that the EHR allowed these mistakes to happen. There were several places along the way where the HER could have been more helpful in preventing this series of mistakes.

    “While health IT presents many new opportunities to improve patient care and safety, it can also create new potential hazards.5 …poor user interface design or unclear information displays can contribute to clinician errors.” (ONC, Health IT: Patient Safety Action & Surveillance Report, 2013: p.4)
  • We wish that these errors were isolated incidents, but they’re not--the statistics on healthcare errors are staggering..

    In 2000, the IOM published a study that got a great deal of public attention. In that report, they stated that almost 100,000 people per year died due to preventable medical errors. This is the equivalent of one full 747 crashing every day, which of course, we would hear about.

    This report caused a number of new initiatives, guidelines and regulations designed to prevent human use error.
  • However, fast forward a little more than a decade…
    Subsequent studies published in 2012 and 2013 suggest that the situation has not improved
    Even worse, approximately 86% of adverse events are unreported
    A second study found that the original study may have underestimated the problem by as much as a factor of 4, putting the number of preventable deaths as high as 400,000 per year
    and the incidents of preventable “serious harm” are as high as 2-8 million/year.

    It’s difficult to determine the proportion of these errors due to medical device design, but as designers, we certainly don’t want to worsen the problem.
  • ACT II


  • One recommendation from the original IOM study was that device design needed to pay more attention to the use of devices IN CONTEXT, not just whether they delivered the appropriate fluid or electric current, for example, at the correct rates.

    Through our own research, we’ve seen that a critical component of this “context” is the mental workload of the healthcare user.
  • All of us involved in healthcare know that it’s a complex, high-risk world full of logistical and regulatory challenges just to name a few…

    So it should be no surprise that healthcare workers have a lot on their mind when they’re interacting with the devices you’ve designed.
  • The first follows a trauma patient who arrives in the ER with a head trauma.
    The second will provide a look at one hospital unit through the eyes of an ICU nurse.

    As you watch this first video, notice the wide number of complex micro-environments found within this healthcare facility …
    2 minutes
  • “In this video, we saw a fairly typical trauma patient sequence beginning with the LifeFlight helicopter (or other ambulance) transferring to the ER, on to surgery, and finally to an ICU bed. What did you notice that might be important for you to keep in mind for designing healthcare devices?
  • Here are some things we noticed …
  • The first follows a trauma patient who arrives in the ER with a head trauma.
    The second will provide a look at one hospital unit through the eyes of an ICU nurse.

    As you watch this first video, notice the wide number of complex micro-environments found within this healthcare facility …
    2 minutes
  • As you watch this video, try to keep track of all the different tasks and technologies this nurse works with across a few hours…
    2 minutes

    “Rook” ICU/Post-Op Nurse
    Rook cares for a recovering post-op patient while awaiting another from surgery…
    After working with her own patient, Rook assists in room set-up for a new admit…
    After room setup, Rook gets a call – another patient is arriving from surgery…
    Throughout the day, Rook mentors a novice CTICU nurse…
    After assisting a nurse colleague, Rook’s primary patient is about to arrive…
  • “In just 2 minutes, we saw an ICU nurse perform several tasks:
    Care for/monitor a post-op patient
    Setup for a new admit
    Receive a second post-op patient
    Mentor a novice ICU nurse
    Assist colleague
    Get supplies
    Etc.”



    What did you notice that might be important for you to keep in mind when designing healthcare devices?
    [TAKE THEIR COMMENTS] --- if giving talk to smaller group
  • While the task details might vary from one hospital unit to the next or between hospital units and outpatient clinics, there are several recurring themes that span unit types and facilities…[READ SLIDE]






    Longer version/smaller group
    IF MANY COMMENTS: “Those are great observations—here are a few that we came up with: …”
    IF NONE or FEW COMMENTS: “Here are some things we noticed: …”
  • To appreciate why designing for healthcare is so different, let’s step back and take a look at
    User motivations when performing technology tasks in healthcare compared to performing technology tasks
    in other industries that we as a UX community more frequently support.
  • READ SLIDE

    To answer this question, we’d like to review some basic concepts from cognitive psychology [Click!]
  • Julie: and to do that I’ll turn it over to Shannon, the cognitive psychologist member of our team.

    Shannon:
    Let’s spend a few minutes going back to Cognitive Psych 101
  • You can think of this as how much “brain power” is required to perform a task
  • Intrinsic Load - how complex the problem is All these examples have an intrinsic degree of cognitive demand even when performed on a simulator. Intrinsic load includes things like the number of steps to be remembered to complete the task, information that must be held in memory between steps in a task sequence, or activites/tasks that must be performed simultaneously [e.g., needing to hold down a button while inputting a new setting, needing to press two keys simultaneously, …]

    Extraneous Load - load on working memory unrelated to problem at hand distractions--Audio or visual; information being remembered; participating in conversation with the patient, doctor, or family member

    Germane Load - processing effort going towards the development of schema in LTM (creating connections, sequencing, rehearsing, building scaffolding)
  • As long as the cognitive demand is less than capacity/threshold, then performance is adequate.

    But, the moment the demand exceeds threshold, performance suffers



  • I’m going to ask you to do a little experiment with me so I can demonstrate what it feels like to experience cognitive load.

    For this exercise you’ll need to open the contact list on your mobile phone or tablet .

    Go ahead and pull out your devices now and display your contact list.
  • Now, I’m going to give you a simple procedural task to perform with this device:
    Please create a new contact for Jane Doe and enter her phone number.

    All done? How did that go?
    Most of you probably found it pretty simple to do - it’s something you’ve done a least a few times before.

    ----
    Now, I’m going to ask you to do that same task again, but this time, we’re going to add some cognitive load.

    DON’T start the next task until I tell you to begin.
  • This leads us to a dilemma in healthcare.
  • Product design simply can not be part of the problem. We need to contribute to the solution.
  • We’ve developed a set of SIX design principles addressing the three aspects of cognitive load:
    [Read through list]

    Now, we’ll look more closely at each one.
  • First, we need to address the intrinsic load imposed by whatever device we’re designing.

    The two key principles here are “Be Simple” and “Be Helpful.”
  • [READ SLIDE].

    One key to simplicity is…
  • Read slide
  • Here’s an example: You’re 10 minutes late out the door. Which would you rather use to decide if you need to grab a coat?

    The example on the right is a great example of less is more -
    It provides only what you need

    Even a visual design can be distracting
  • A second key to Being Simple is “Be Direct…”
  • Patient Monitoring System by Fusion Charts

    Status is clear at a glance
    Graphics support rather than distract
    Appropriate visual heirarchy
  • [Read slide]
  • One of the best ways to be helpful is to provide guidance to assist the user during task performance

    [read slide]
  • Here’s a conceptual example from one of our projects:

    If you were a new user, where would you start? How would you get help?
  • Our redesign took a guided workflow approach and provide a clear place to start and immediate access to additional help.
  • Hungarian designer Kevin Harald Campean

    http://designtaxi.com/news/360796/A-Bold-Sleek-Redesign-Of-The-First-Aid-Kit/?goback=%2Egde_63344_member_275785103#%21
  • Hungarian designer Kevin Harald Campean

    http://designtaxi.com/news/360796/A-Bold-Sleek-Redesign-Of-The-First-Aid-Kit/?goback=%2Egde_63344_member_275785103#%21
  • It isn’t enough to only focus on the intrinsic load of our product.

    As we saw in the video, our products will be used in complex environments, so we also need to think about helping users dealing with a heavy extrinsic load.

    The key principles here are “Be Smart” and “Be Calm.”
  • Let’s take a look at how the EHR could have been more helpful during this series of unfortunate events.
  • Healthcare workplaces are over stimulating and stressful environments
    The technology, in contrast, needs to be “calm”
  • We’ll use the color palette we selected for this presentation as an example. If we did our job right, you didn’t even notice the colors until we pointed them out. Or, if you did notice them, it was because you liked them.
  • Some might feel this color palette is more exciting, but it’s also is more tiring to view over long time periods
  • A subtle color palette allows more attention to be given to alerts. This allows alerts to be less demanding themselves.
  • This color palette demands more vigilance to detect alerts.
  • Finally, we need to recognize the contribution to Germane Load made by each additional device added to the users’ world.
  • Formative research techniques can be used to gather data on user expectations.

    Card sorts can be used to understand users’ mental models …
  • And field research can be used to gain an intimate understanding of users’ environment, tasks, motivations and needs.
  • Beyond consistency within your own product, it is important to recognize that your product is part of a technology team…whether you want to be a team player or not!


    Free clip art
  • Free clip art
  • Free clip art
  • [Ascom could be a good example here: In some facilities, the client uses their entire suite of products; in others, only the handset or only the console, etc.]
  • Evaluating the cognitive load of your design doesn’t require new research methods so much
    as attending to additional aspects of the design while using familiar methods, such as
    Design Reviews, Cognitive Walkthroughs, Usability testing & field research, etc.

    I’ll walk through a few examples to show you what I mean…
  • Real world environment:
    coffee shop; subway; living room

    Modified Research Lab:
    Room setup to mimic patient care setting
    Equipment placement similar to actual use

    Interruptions:
    Answering unrelated questions
    Doctor asking for a new task stat
    Phone call/Text message

    Provide Appropriate Level of Training prior to testing
    Team trainings
    Sales Rep training
    Instructions for Use available
    Consider lag time between training and task performance
  • What you [designers] do matters.
    Medical device design can mean the difference between injury & safety, life & death.
    Your designs can be the difference between a manageable level of cognitive load…
  • … where your users feel like super heroes …
  • … or an unmanageable level of cognitive load which leads to human use error.

  • “We hope this has been helpful. Be well & do good work.”

    …. And now we’ll take any questions.
  • Designing Healthcare Technologies: Motivating Users by Decreasing Cognitive Load (Julie Rennecker and Shannon Halgren)

    1. 1. Designing Healthcare Technologies: Motivating Users by Decreasing Cognitive Load Shannon Halgren, PhD Julie Rennecker, PhD
    2. 2. HUMAN USE ERROR
    3. 3.  Feeding Tube and Trach Tube http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TubingandLuerMisconnections/ucm313275.htm Fatal Tubing Mash-Ups
    4. 4. EHR Example Lab Result  K+ (3.1 mEQ/L) Dr. A IV K+ Order 1 (40 meQ over 4 hr) Dr. A IV K+ Order 2 (100 meQ addition to existing fluid) Dr. A Attempted to cancel first order (cancelled a similar order by mistake) Pharmacy Filled Order 1 Changed Order 2 (too much K+, used 80 meQ) Nurse(s) Carried out Order 1 Carried out Order 2 (40 meQ IV bolis and 80 meQ/L drip started} Dr. B Mistakes low K + lab result as NEW Treats for low K+ Patient  K+ (7.8 mEQ/L, normal = 3.7-5.2 mEQ/L) Shift Change 36 hours later ! ! ! ! ! (ONC, Health IT: Patient Safety Action & Surveillance Report, 2013: p.4)
    5. 5. Human use errors are NOT a tiny problem  Institute of Medicine, 2000, To Err is Human  44,000 – 98,000 deaths/year  Approximately one full 747 crashing every day
    6. 6. Human use errors are NOT a tiny problem  Institute of Medicine, 2012, Best Care at Lowest Cost  North Carolina: 18% of hospital patients are harmed  Medicare: 14% of hospital patients harmed  Classen et al: 33% of hospital patients harmed  Estimated 86% of adverse events are unreported!  James, 2013, Journal of Patient Safety  New estimate of preventable deaths: 210,000 – 400,000/year  Preventable incidents of “serious harm”: 2 – 8 million/year
    7. 7. Why do errors like these happen?
    8. 8. Designing for the Context of Use “Standards for drugs and medical devices concentrate on safe design and production, with less attention to their safe use [in context].” - Institute of Medicine, To Err is Human,1999
    9. 9. We’re not in Kansas Anymore! Fear of Litigation Infection Control Heavy Regulation High Risk Tasks Multi-Tasking Time Critical Tasks Mistakes = Lives High Accountability Sleep Deprivation Complicated Technology Multi-Disciplinary Teams
    10. 10. An inside look at the healthcare environment… Trauma Patient Video
    11. 11. What Did You Notice?
    12. 12. What Did You Notice?  The need for speed  Frequent interruptions/multi-tasking  Multiple handoffs  Multiple, diverse players  Lots of equipment, all with unique UIs  The pressure to get it right
    13. 13. An inside look at the healthcare environment… ICU Nurse Video
    14. 14. What Did You Notice?
    15. 15. What Did You Notice?  The pressure for accuracy  Frequent interruptions/multi-tasking  Lots of equipment, all with unique UIs  Multiple, diverse players  Training during task performance
    16. 16. User’s Motivations: Comparison Across Industries Online Retail Social Media Healthcare Need for speed Med Med to High Extremely High Need for accuracy Med to High Low Extremely High Consequence of slow response Low Low to Med Med to Extremely High Consequence of error Med Low to Med Med to Extremely High User stress level Low Low to Med Med to Extremely High Environmental distractions Low to Med Low to Med Med to Extremely High Variety of technology Low Low Extremely High
    17. 17. How do we create technology for this unique user group & complex context?
    18. 18. Cognitive Psychology 101
    19. 19. Cognitive Load Whitenton, K. (2013). Minimize Cognitive Load to Maximize Usability. Article published online. Cognitive Load: The amount of mental resources required to operate the system
    20. 20. 3 Kinds of Cognitive Load Intrinsic Load 1 Extrinsic Load 2 Germane Load 3 Problem complexity - Starting an IV - Using a defibrillator - Conducting robotic surgery Unrelated working memory load - Distractions - Mental notes - Conversation Processing memory going towards building LTM schema - How is this IV pump different from the one I just used next door? - How do I hold this transducer at each stage of insertion
    21. 21. Cognitive Load is Cumulative + Intrinsic Load Extrinsic Load Germane Load+ = Total Cognitive Load
    22. 22. Cognitive load affects performance Performance Drop with Cognitive Overload Mental Capacity Cognitive Demand (Total Cognitive Load) Performance Drews, FA et al (2009). Text messaging during simulated driving behavior. Human Factors, 51, 762-770. Pashler, HE (1984). Processing stages in overlapping tasks: Evidence for a central bottleneck. J of Experimental Psychology: Human Perception and Performance, 1, 395-403. Wickens, CD (1991). Processing resources and attention. In D. Damos (ed.), Multiple-task performance, p3-34. London, UK: Taylor & Francis.
    23. 23. Let me show you what I mean…
    24. 24. Don’t Try This at Home Procedural Task Create a new contact for “Jane Doe” Phone number: 800-555-9634
    25. 25. Distraction Don’t Try This at Home Procedural Task Create a new contact for “John Doe” Phone number: 800-555-5678 Cognitive Task Count by 2s
    26. 26. What if these were health care tasks? Procedural Task Setup an IV Cognitive Task Calculate fluid rate Answer patient questions Distraction Child crying Overhead page
    27. 27. Humans have limited cognitive capacity… but the cognitive demands on healthcare workers continue to increase Capacity The Conflict
    28. 28. But what does this have to do with product design?
    29. 29. The Resolution Medical technology must be designed to require less cognitive overhead.
    30. 30. Design Rules for Reducing Cognitive Load Be Simple 1 Be Consistent 5 Be a Team Player 6 Be Helpful 2 Intrinsic Load Extrinsic Load Germane Load Be Smart Be Calm 4 3
    31. 31. Design Rules for Reducing Cognitive Load Be Simple 1 Be Consistent 5 Be a Team Player 6 Be Helpful 2 Intrinsic Load Extrinsic Load Germane Load Be Smart Be Calm 4 3
    32. 32. Be Simple 1 The subject matter can be complex, but the UX should not be
    33. 33.  Be Minimal  Less is more  Show only what you really need  Group related information  Use a clean visual design Be Simple 1
    34. 34. Be Simple 1  Be Minimal
    35. 35.  Be Minimal  Less is more  Show only what you really need  Group related information  Use a clean visual design  Be Direct  Careful use of abbreviations  Careful use of icons  Make alert states obvious Be Simple 1
    36. 36.  Be Direct – use obvious alert states Be Simple 1 FusionCharts Patient Monitoring System
    37. 37. Be Helpful 2 Think guided workflows, not features
    38. 38.  Provide Guidance  Through the workflow  Next steps  Access to help Be Helpful 2
    39. 39. Be Helpful 2 Before: Where do I start? Where can I get help?  Provide Guidance - Provide a place to start On Off Button Button Button Button Button Complex Information Display StatusDisplay ON ON ON ON StatusDisplay ON ON Link Link Link Link
    40. 40. Be Helpful 2 After: Guided Workflows, Grouped content  Provide Guidance - Provide a place to start
    41. 41.  Provide Guidance  Through the workflow  Next steps  Access to help  Prevent Errors  Make it obvious  Make it easy  Make it “dummy-proof”  Prevent omissions Be Helpful 2 “When you are stressed out, [making it] dummy proof is better.” – OR Nurse
    42. 42. Be Helpful 2  Prevent Errors – Make it “dummy proof”
    43. 43. Be Helpful 2  Prevent Errors – Make it “dummy proof” Designer: Kevin Harald Campean
    44. 44. Design Rules for Reducing Cognitive Load Be Simple 1 Be Consistent 5 Be a Team Player 6 Be Helpful 2 Intrinsic Load Extrinsic Load Germane Load Be Smart Be Calm 4 3
    45. 45. Technology should serve as a natural extension of our task performance rather than a barrier to overcome. Be Smart 3
    46. 46.  Be a Natural Extension … of the user  Hold information in memory for the user  Perform calculations for the user … of the task  Providing the right tools at the right time  Recognize errors or alert conditions  Be easy to ignore when not needed  Be difficult to ignore when there’s danger Be Smart 3
    47. 47. Be Smart 3 Lab  K+ (3.1 mEQ/L) Dr. A IV K+ Order 1 (40 meQ over 4 hr) Dr. A IV K+ Order 2 (100 meQ addition to existing fluid) Dr. A Attempted to cancel first order (cancelled a similar order by mistake) Pharmacy Filled Order 1 Rejected Order 2 (too much K+, suggested 80 meQ) Nurse(s) Carried out Order 1 Carried out Order 2 (80 meQ/L drip and 40 meQ IV bolis started} Dr. B Mistakes lab result as NEW Treats for low K+ Patient  K+ (7.8 mEQ/L) Normal K+ Level: 3.7-5.2 mEQ/L Shift Change 36 hours later ! ! ! ! ! EHR: - Recognize patient already has fluids and suggest Order 2 to reduce pain. EHR: - Recognize unsafe levels of K+ EHR: - Recognize unsafe levels of K+ EHR: - Recognize unsafe levels of K+ EHR: - Better shift change updates & alerts - Improved usability around date & time on lab results - Recognize unsafe levels of K+
    48. 48. Be Calm 4 Provide a calm & soothing user experience
    49. 49.  Be Attractive  Use soothing colors  Use a neutral color palette  Provide ample white space Be Calm 4 “We assume if it looks nice, it’s a good product.” - OR Nurse
    50. 50.  Be Attractive – Pay attention to color Be Calm 4
    51. 51.  Be Attractive – Pay attention to color Be Calm 4 !
    52. 52. ! !
    53. 53.  Be Attractive  Use soothing colors  Use a neutral color palette  Provide ample white space  Be Mindful  Careful use of animation  Pay attention to use of audio  Avoid causing “alarm fatigue” Be Calm 4
    54. 54.  Be Mindful – of audio and animation use Be Calm 4
    55. 55. Design Rules for Reducing Cognitive Load Be Simple 1 Be Consistent 5 Be a Team Player 6 Be Helpful 2 Intrinsic Load Extrinsic Load Germane Load Be Smart Be Calm 4 3
    56. 56. Be Consistent 5 Provide a predictable user experience – routine is important
    57. 57.  Provide simple, consistent workflows  Within the design  Across your product line  Across similar medical devices  With users’ expectations Be Consistent 5
    58. 58.  Within and between your product(s) Be Consistent 5 Use templates and style guides
    59. 59.  Within and between your product(s) Be Consistent 5 Inventory interaction behaviors (alerts, modes, button states, controls, feedback, etc.)
    60. 60.  With users’ expectations Be Consistent 5 Measure users’ mental models
    61. 61.  With users’ expectations and needs Be Consistent 5 Interview and observe users in context
    62. 62. Be a Team Player 6 Recognize that you are part of a technology team… whether you want to be or not
    63. 63. Be a Team Player 6 The product team’s world view Our Other Awesome Product ACME Our Other Awesome Product ACME Our New Awesome Product ACME Competing Product Competing Product Competing Product Competing Product Competing Product Related Product Related Product Related Product Related Product
    64. 64. Our New Awesome Product ACME Our New Awesome Product ACME Be a Team Player 6 The user’s world view Competing Product Our Other Awesome Product ACME Related Product Related Product Related Product Competing Product Competing Product Unrelated Product Unrelated Product Unrelated Product Unrelated Product Unrelated Product Our Other Awesome Product ACME Related Product Unrelated Product Unrelated Product Unrelated Product Unrelated Product Unrelated Product Unrelated Product Unrelated Product Unrelated Product Unrelated Product Policy Safety Patient Management Stress Management Accuracy Efficiency Protocols Regulation Interpersonal Relationships Risk Record Keeping Fatigue Human Emotions Distractions Quality
    65. 65.  Take a systems engineering perspective  Avoid local success, global failure  Consider the other technology being used in conjunction with yours  Competitors’ products  Other products from your company  Non-related technology (smart phones, tablets, medical devices, EHRs, patient monitors, etc.)  Each technology might have their own unique  Workflows  Audio sounds  Visual alerts  Icon sets & color palette How will your product fit in with the existing technology? Be a Team Player 6
    66. 66. Be a Team Player 6 then find a way to complement rather than compete Study competitors, related products, industry standards, and the use environment…
    67. 67. Be a Team Player 6 Be different ONLY if you improve the global user experience. Don’t be different, just to be different.
    68. 68. Design Rules for Reducing Cognitive Load Be Simple 1 Be Consistent 5 Be a Team Player 6 Be Helpful 2 Intrinsic Load Extrinsic Load Germane Load Be Smart Be Calm 4 3
    69. 69. How do I know if my design’s cognitive load is manageable?
    70. 70. Evaluating Your Design for Cognitive Load Common methods used in uncommon ways  Design Review  Cognitive Walkthrough  Simulated Use Usability Testing  Field Research  Competitive Product Review  Direct Observation
    71. 71. Evaluating Your Design for Cognitive Load  Minimalism  Abbreviation & icon use  Consistency across screens & workflows Intrinsic Load Extrinsic Load Germane Load Design Reviews Cognitive Walkthrough  Guided workflows  Paths for novice v. expert users  Contextually-specific use cases (e.g., surgery, ER, home care) Intrinsic Load
    72. 72. Evaluating Your Design for Cognitive Load  Simple to use  Easy interpretation of status  Obvious next steps  To ensure workflows and content are accurate and useful  To test audio and animation use  To ensure product is usable when used in conjunction with other technology  To ensure product is easy to learn when experienced with other brands or past versions Extrinsic Load Germane Load Simulated Usability Testing Intrinsic Load
    73. 73. Evaluating Your Design for Cognitive Load  Task performance in a realistic setting  Simulation lab in a medical facility  Research lab modified to mimic use setting  Real world environment  With a realistic level of cognitive load  Distractions  Ambient Noise  Interruptions (major and minor)  Multi-tasking  Finger or foot tapping while performing task  Reading the time from a wall clock when each step of task is performed  With appropriate pre-use training Intrinsic Load Extrinsic Load Germane Load Simulated Usability Testing
    74. 74. Evaluating Your Design for Cognitive Load  Task analysis  Workflows  Context analysis Extrinsic Load Germane Load Field Research: Pre-design Competitive Product & Regulation Review  Industry standards  Regulatory guidelines
    75. 75. Considering Cognitive Load During Design Validation Intrinsic Load Extrinsic Load Germane Load Be Simple & Helpful  Design Walkthrough / Heuristic Evaluation  Cognitive Walkthrough  Iterative Usability Testing Be Smart & Calm  Field Research  Task Analysis  Iterative Usability Testing Be Consistent & a Team Player  Competitive Product Review  Regulation and Guidance Review  Design Review  Simulated Use Usability Testing  Direct Observation
    76. 76. Sounds good, but how am I going to remember all this?
    77. 77. Checklist for Reducing Cognitive Load Through Design For a copy, email one of us or see me after the session. shannon@sage-research.com julie@themangementdoc.com
    78. 78. Design can save lives. The bottom line.
    79. 79. Manageable level of cognitive load
    80. 80. Unmanageable level of cognitive load
    81. 81. THANK YOU! Julie Rennecker, PhD RN Principal Consultant The Management Doc, LLC Julie@TheManagementDoc.com Shannon Halgren, PhD Chief HF/UX Consultant Sage Research & Design, LLC Shannon@sage-research.com
    82. 82. References  Drews, FA et al (2009). Text messaging during simulated driving behavior. Human Factors, 51: 762-770.  Eriksen, CW & Eriksen, BA (1974). Effects of noise letters upon the identification of a target letter in a non-search task. Perception and Psychophysics, 16: 143-149.  Gasper, JG et al (2014). Are Gamers Better Crossers? An Examination of Ation Video Game Experience and Dual-task Effects in a Simulated Street Crossing Task. Human Factors, 56(3): 443-452.  Horsky, J et al (2003). A framework for analyzing the cognitive complexity of computer-assisted clinical ordering. J of Biomedical Informatics, 36: 4-22.  Institute of Medicine (2000). To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, LT Kohn, JM Corrigan, & MS Donaldson (eds). Washington, DC: National Academies Press.  Institute of Medicine (2012). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. M Smith et al (eds.), Committee on the Learning Health Care System in America. Washington, DC: National Academies Press.  James, JT (2013). A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. J of Patient Safety, 9: 122- 128.  Katidioti, I and Taatgen, NA (2014). Choice in Multitasking: How Delays in the Primary Task Turn a Rational into an Irrational Multitasker. Human Factors, 56(4): 728-736.  Kalyuga, S (2011). Informing: A Cognitive Load Perspective. Informing Science: the Int’l J of an Emerging Transdiscipline, 14: 33-45.  Pashler, HE (1984). Processing stages in overlapping tasks: Evidence for a central bottleneck. J of Experimental Psychology: Human Perception and Performance, 10: 395-403.  Pashler, HE et al (2001). Attention and Performance. Ann Rev Psychology, 52: 629-651.  Posner, MI & Petersen, SE (1990). The Attention System of the Human Brain. Ann Rev Neurosci, 13:25-42.  Wickens, CD (1991). Processing resources and attention. In D. Damos (ed.), Multiple-task performance, p3-34. London, UK: Taylor & Francis.  Wicklund, M., Kendler, J. and Strochlic, A. (2011). Usability Testing of Medical Devices. CRC Press, Taylor & Francis Group, Boca Raton, FL.

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