Six Healthcare Trends

SIX HEALTHCARE TRENDS AND
WHY USER EXPERIENCE MATTERS

PointClear Solutions | March 2012

Dawn Nidy, Senior User Experience Strategist
Rodney M. Hamilton, M.D., Chief Medical Information Officer

TABLE 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

INTRODUCTION
“Usability” has increasingly become a topic of interest in healthcare with the publication
of the NIST guidelinesi for EMR usability and the tie between those guidelines and
Meaningful Use Phase 2 requirements. Therefore, usability is no longer a topic that can
be ignored. However, we at PointClear Solutions would like to broaden the discussion to
include, but not be limited by the term “usability.” We would like to discuss the discipline
and 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 more
than that. Let’s take a look at the definitions from The International Organization for
Standardization (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 a
user interface performs in task completion rate (what percentage of users can complete
a task) or time on task (how long a particular task takes). Experts can also perform
evaluations against best practices (heuristics). Usability testing is useful as a method of
measuring usability and identifying areas to improve.

However, if you don’t think about a user-centered approach until usability testing is
conducted on a fully built product, you are too late. Usability testing must be performed
on a completed design, or at least, a prototype of a design. Usability testing is also often
performed in a “usability lab” which takes the user out of their own context; this can
affect the interpretation of found usability issues.

User-Centered Design (UCD) is an approach and set of methods that aid user
experience practitioners in creating a usable product and great user experience. In
UCD, 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 inquiry
and task analysis. The outcomes of these methods can inform product decisions along
the entire software development lifecycle.

Contextual inquiry is a master/apprentice model of observing and asking questions to
learn how users go about their work. It involves:

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• 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 designii

Task analysis involves a series of open-ended interviews to develop a detailed
understanding of how people perform specific tasks. With this method we seek to
understand:
• 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 corrected

Simply measuring the usability of tasks in your application, while very important, is not
enough. Creating a great user experience requires a deep understanding of the end
users 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 help
you understand the priority of each issue. But usability testing does not replace the need
for 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 to
following a user-centered approach. An ROI analysis by Karat indicated a $10 return on
each dollar invested in usabilityiii. Products that are created with a user-centered
approach have reduced costs in support, training, and maintenance (fewer change
requests). In addition, the cost to correct a problem increases the further you are in the
development process. A user-centered approach combines up-front user research with
usability testing on prototypes rather than fully developed systems, as well as continued
measurement and improvement throughout the product lifecycle. Incorporating user
experience design will add value at any point in the process, but the value will diminish
the later it is applied in the project.

It costs 10 times as much to fix the same design problem if not found until the
development phase. And it costs a staggering 100 times as more to fix the same
problem in design if found after deployment. iv Detecting these issues earlier in the


process or preventing them through user-centered design is a cost-effective approach to
developing products and services.

In this paper, we’ll talk about how user-centered design can benefit specific areas of the
healthcare market that are relevant today.

TREND #1: INCREASED ADOPTION OF ELECTRONIC MEDICAL RECORDS
Electronic Medical Records (EMR) have the potential to transform the healthcare
industry by increasing the access to and exchange of clinical information by medical
providers and patients. However, there are significant challenges in implementing
EMRs. Some of them are directly related to the usability and user experience of the
software.

“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 solving
health problems). Cognitive support may include designs to provide an overview or
summary of the patient, information “at a glance,” intuitive designs and tailored support
for 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.” viii

A typical method that vendors use to understand workflow is to employ a Subject Matter
Expert (SME). While this method can add some helpful insight, it can also lead down the
wrong path if it’s the only method used. Any SME will have their own biases and an
understanding that is limited by their own experience. By using methods such as
contextual inquiry and task analysis, as described in the introduction, the product team
will gain a much richer and broader understanding of the end users. The team will then
be able to spot patterns across many types of customer segments, but also be able to


understand when something is unique to a particular customer or type. And by involving
product team members in the research process, you naturally create many experts
rather than having to rely on a single source.

Usability issues can compromise patient safety if the interface does not properly prevent
errors, 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.” ix

Poorly 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 study
by 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 the
system.”x Their study also indicated that some specialties such as family medicine and
pediatrics never regained the productivity they had before introducing an EMR. This
lengthy 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 and
easy to find. And while meeting Meaningful Use requirements is of immediate concern
for most purchasers, it is not a competitive advantage or a sustainable business model
on its own. Smart buyers realize an EMR is a long-term investment. They will be
looking at how the EMR supports their workflow, how easy it is to learn, and how easy it
is to use. Decision makers who are also end-users will ask questions about how the
EMR software solves their practice’s needs overall and evaluate software on those
criteria.


TREND #2: INCREASED LEVEL OF PATIENT ENGAGEMENT
A recent Pew Internet study showed that 80% of Internet users gather health information
online.xi Another recent study showed that patients pay more attention and become
more engaged in their healthcare when they have easy access to their medical
information online.xii Patients are increasingly adopting digital health tools such as
patient portals and Personal Health Records (PHRs). Two notable successes are Kaiser
Permanente, which reported in 2010 that over 3 million of their patients are registered for
their 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

xiv
Data from the Pew Internet & American Life Project

Increased patient engagement can be a key driver in creating a more educated, healthy
patient population. Patient technology tools have the promise of creating a better patient
experience while reducing the administrative overhead for practices. However, careful
attention must be paid to the practice workflow integration points as they relate to patient
self-service options.

For example, if patients are able to send and receive secure messages, that feature has
the potential to increase practice efficiency and increase patient satisfaction. But what if
the system requires the practice staff to log into a separate tool outside their EMR in
order to retrieve messages? Or what if there is no way of easily knowing when a new
message is waiting? Then the workflow breaks down and the potential benefits to both
patients and practices are lost.

In order for patients to adopt and use patient portals, they must feel confident that the
self-service option is equally or more reliable, trustworthy and efficient than picking up


the phone and calling. Thoughtful design and a transparent approach can help reassure
users 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.


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
www.lukew.com has coined the
term “mobile first” – meaning he believes you should design new applications for mobile
before 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 and
more than 30 percent are using iPads for clinical purposes.xvi Mobile clinical solutions
make perfect sense for physicians because they are highly mobile, constantly moving
between exam rooms or medical facilities. However, most of the largest EMR vendors
still do not offer native mobile solutions for their EMRs. They instead offer remote
access into the regular version of desktop EMR or they direct users to their regular web
application. What’s required is a solution that is designed specifically for touch
interactions and keeps in mind the context of use: mobile.

Designing great mobile solutions requires a thoughtful approach to the mechanics of
touch-based interfaces. The interaction model on a touch device has some fundamental
differences from a desktop solution that uses an external keyboard and mouse. The
finger is not as precise in pointing as a mouse. The Apple iOS interface guidelines
recommend a target no less than 44 x 44 pixels for accuracy of selection – a size that by
desktop proportions could be considered quite large for something like a button. Typing
on a mobile device is much more cumbersome and should be limited to the bare
minimum. And when typing is required, mobile solutions should be coded so that they


switch to the most appropriate keyboard automatically. For example, if requiring a
phone number input, the mobile app should switch the user to the numeric keyboard
entry automatically. They should also include smart defaults for the most common
options and auto-complete options when typing, especially for difficult terminology such
as prescription drug names.

Applications designed for desktop have limitations when used on mobile devices, such
as no access to right-click options and a significantly smaller screen size. Also, many
desktop web products have not been thoroughly tested on mobile browsers and
therefore are prone to bugs or features not working properly.

Designing for mobile requires a deep understanding of context: what goals and tasks do
your users need to accomplish on mobile? There may be specific features that are more
important on a mobile device and those should be available and prominent. Users will
have some of the same goals as when using your product in other platforms. But often
there are unmet needs that can be addressed and new business opportunities to exploit
by 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 context
and easy to use – otherwise users will abandon. You add little value by simply having a
mobile 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 be
designed 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 phone
platforms that you may not want to exclude. You may need some combination of native
apps for specific platforms and a mobile web solution that can work on any mobile
browser-enabled device. You’ll need to weigh the pros and cons of native and mobile
web approaches from a cost and functionality perspective. Keeping a pulse on what
your target audience is using is critical and can be achieved through using analytics
tools.

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 real
estate on an iPad or other tablet, provided a tablet device makes sense in the context of
use. When designing a tablet solution it is best to have a different user interface from
both your smart phone and desktop web applications. You should design a tablet
interface that is uniquely suited for the combination of the tablet screen size and touch
interface.

Using a design technique called Experience Journey Maps, you can visualize the entire
experience your users have with your products and services. This technique can be
useful to identify gaps where you’re not serving users well, and also highlight
opportunities for new solutions, such as in mobile.


Joyce Hostyn wrote an excellent blog article called “Visualizing the customer experience
using customer experience journey maps.” In her article she compiled examples from
various companies who used this technique to evolve their user experience. Here she
talks 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 some
questions 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 CARE
How many times have you gone to a doctor’s office WHAT IS AN ACO?
and filled out the same health questions on the paper
clipboard? Asking patients to provide the same An ACO is a network of
information over and over again is not only inefficient doctors and hospitals that
but also prone to errors and omissions. Also, why is shares responsibility for
this information not available to other physicians, like providing care to patients.
specialists, when patients are referred for additional These programs reward ACO
care? Clearly, our healthcare system in the United participants that lower their
States is not really a “system” at all. However, new growth in healthcare costs
models of healthcare delivery are emerging rapidly. while meeting performance
standards on quality of care
The Patient Protection and Affordable Care Act of and service.
2010 established the concept of an Accountable Care
Organization (ACO). These organizations give There are ACO programs
providers financial incentives to provide better sponsored by CMS and also
coordinated care for patients. The intent of ACOs is to by commercial payers. Many
shift the incentives so that providers are rewarded for of these programs are still in
value – not volume. the pilot stage as of the first
quarter of 2012.


In order to achieve its goals, an ACO will require an increased exchange of information
and robust technology tools, some of which may not exist today. These tools will need
to be built with clinical safety, workflow, and efficiency in mind.

Because accountable care organizations are a new concept with very few
implementations live, the exact operational constructs are still evolving. No doubt, there
will be new workflows defined and existing workflows redefined. Appropriate user
research and usability testing will be essential to ensuring that modification to existing
software and the creation of new software meet the needs of this new healthcare
delivery model.

The table below describes the types of competencies that ACO organizations will need
to have and the technology tools they will need to support them. These tools will need to
be integrated in a coherent way if there is any hope of having a highly effective and
usable system for ACOs. And some of these tools will certainly require mobile support.

Competency Software Requirements

Cross Continuum Management HIE; Provider Messaging; Workflow
Management; Shared Care plans; Referral
Tracking; Clinical Decision Support

Population Health Management Health Risk Assessment; Predictive
Modeling & Analytics tools; Workflow
Management; Registries; Clinical Decision
Support

Patient Engagement Mobile Health; Telehealth; PHRs, Patient
Portals; Surveys

Quality & Performance Reporting Business Information / Analytics tools;
Dashboards

Administrative and Financial Risk Risk Modeling Tools; Complex Case
Management Systems Management; Benchmarking

Core Infrastructure Identity Management; Semantic
Interoperability; Security Framework;
Patient Consent Framework; Controlled
Terminology


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 treat
low severity illnesses such as colds. These services are short in duration and the
patient 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 setting
expectations 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 patients
to easily find a nearby clinic location and schedule an appointment are necessary to
support the immediacy of these types of health conditions.

Here’s a fictional scenario to depict what a successful retail clinic experience might look
like:

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 clinic


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 to
have the right tools for patients to get efficient quality care, tools that set the right
expectations and provide appropriate notifications, and to apply a thoughtful integration
of 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.”xvii

TREND #6: INCREASED CARE AT HOME SOLUTIONS
The 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 never
used before. Telehealth is still a novel concept to most patients, and even fewer have
actual experience with this model. Care at home will require highly intuitive tools that
patients can easily learn on the fly; even patients with low technical skills. These tools
will 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 to
follow doctor’s orders and allow them to track their progress. And attention will need to
be 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 be
useful to help visualize workflow in the Care at Home model. The experience map
would include all the constituents, how their workflow overlaps and where there are
dependencies between parties. It should also include which tools are used for each task
and how those tools support the users’ goals.


Another method that could be leveraged to test new workflow and care models is
bodystorming.xviii This technique is a way of physically prototyping how a solution will
work in the real world. This model could be used throughout the process to test how the
solution will work for all constituents. It could start early in the design process to include
paper prototypes of the interface or leveraging existing video conferencing tools like
Skype. The goal would be to test out the workflow and tools needed to support Care at
Home. Real patients with little clinical knowledge should be included in this type of
physical prototype. Through these types of bodystorming exercises, the workflow and
user interface could be rapidly tested and iteratively designed before the technology
solutions are fully developed: saving time, money and ultimately creating a better
product.

CONCLUSION
It’s an exciting time in both healthcare and technology. Delivering higher quality, lower
cost 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 that
support ease of use, user satisfaction and clinical safety, and promote adoption by
patients and providers. The convergence of technology advances, healthcare reform,
and patient engagement all create a perfect storm of opportunity. But capitalizing on
opportunity requires innovation. And innovation requires a deep understanding of what’s
important to your end users and delivering that in your offering.

A committed, strategic focus on User Experience will make the difference between
marginal and break-out growth for vendors in the healthcare industry in the next few
years 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 Jobs

ABOUT POINTCLEAR SOLUTIONS
PointClear's focus is on transforming healthcare delivery through technology innovation
that improves user experience. Our competencies lie at the intersection of product
strategy, technology and user experience. Our user-centered approach to software
development assures that our solutions are accessible, relevant and actionable - driving
user adoption, promoting human-centered delivery of professional healthcare, and
ultimately creating business value for our clients. We serve provider, payer,
pharmaceutical, public health organizations and the technology market that supports
them.


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. http://en.wikipedia.org/wiki/Contextual_inquiry
iii
Karat C. Iterative testing of a security applications. Paper presented at: Proceedings of the
Human 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. Current
Challenges and Opportunities for Better Integration of Human Factors Research with
Development of Clinical Information Systems. IMIA Yearbook of Medical Informatics, (2009).
vi
Stead W, Linn H. Computational Technology for Effective Healthcare: Immediate Steps and
Strategic Directions. Washington, D.C.: National Academies Press; (2009).
vii
Promoting Usability in Health Organizations: Initial Steps and Progress Toward a Healthcare
Usability Maturity Model (HIMSS EMR Usability Task Force). Health Information Management
Systems Society. (2011)
viii
Young, I. Mental Models. Rosenfeld Media. (2008)
ix
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National Institute of Standards and Technology (NIST), (2012).
x
Bhargava, Hemant K. and Mishra, Abhay, Electronic Medical Records and Physician
Productivity: Evidence from Panel Data Analysis (2011).
xi
Fox, Susannah. Pew Internet & American Life Project. Health Topics. (2011).
http://www.pewinternet.org/Reports/2011/HealthTopics.aspx
xii
Lake Research Partners, funded by California HealthCare Foundation. Consumers and Health
Information Technology: A National Survey. (2010).
xiii
Fox, Susannah. Pew Internet & American Life Project. Measuring the Impact of Patient
Portals: What the Literature Tells Us. (2011).
xiv
Fox, Susannah. Pew Internet & American Life Project. September 2010 - Health Tracking.

(2010). http://www.pewinternet.org/Shared-Content/Data-Sets/2010/September-2010--
Health.aspx

xv
Information Week. “Android's Success: By The Numbers” Feb 28, 2012.
http://www.informationweek.com/news/mobility/smart_phones/232601613
xvi
http://www.mhimss.org/news/mhimss-tracks-himss12-attract-large-audiences
xvii
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: case
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