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Reference 9 - correction
- Gunther Eysenbach (13 May 2004)
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Three barriers to effective electronic information systems: Usability, usability, usability
- Douglas S Badenoch, Andre Tomlin (17 May 2004)
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Computer Generated Patient Interviewing
- Richard O Sills (19 May 2004)
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E-learning for medical students
- Robert W Marshall (19 May 2004)
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Utilizing the potential of the humble mobile phone
- Anatole S Menon-Johansson, Frances McNaught, Ann K. Sullivan (3 June 2004)
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Potential reasons for lack of health outcome measures
- Laura A. O'Grady (17 June 2004)
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Gunther Eysenbach, Editor, Journal of Medical Internet Research Toronto
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Reference 9 is inaccurately cited. The correct reference is
Skinner H, Biscope S, Poland B, Goldberg E Competing interests: None declared |
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Douglas S Badenoch, Development Manager Minervation Ltd, Oxford Business Park North, Oxford, OX4 2JZ, UK, Andre Tomlin
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Sir, We welcome your editorial celebrating "the return of the human" to health informatics. Human-Computer Interaction (HCI) professionals have been arguing for sociotechnical systems for decades now (e.g. 1,2); it’s good to see that the message is finally getting through to the broader community. The question is not whether we need to merge human-centred and technology- centred approaches; the question is how to do it. If electronic resources are to improve health, they have to be accessible, reliable and usable. Currently, over 80% of web sites are inaccessible [3], including, our own research would suggest, most Primary Care Trust and health care Charity sites [4]; few electronic resources are subject to the methodological rigour we would expect of reliable, evidence -based publications; and many of the high quality resources that do exist are prohibitively difficult to use in everyday practice [4]. Improving accessibility is largely a technical issue: by improving infrastructure and coding practices we can ensure that our audience can get access to the information they need when they need it. Reliability is mostly determined by the quality of the content management process that sits behind the system (the old IT systems adage “garbage in, garbage out” applies here). Usability is a more complex question which straddles technical and social issues. Put simply, usability concerns whether the information system is designed and structured so that users can get an answer to fit their purpose [5]. For too long now in health care the technology tail has been wagging the functionality dog, with projects being led by technology enthusiasts while the rest of us struggle to adapt our tasks to yet another way of doing them. We know how to solve this problem: it’s called “user-centred design” [6]. So why isn’t it happening in health care? Some believe that there is still an argument to be won over its cost- effectiveness. In spite of considerable evidence from the IT literature that user-centred design results in cost savings downstream [7,8], and a clear need to assess the usability of information systems [9], there remains a perception that it is too time-consuming and costly. User involvement, if it happens at all, takes place AFTER we have defined and piloted our technology, by which time it is too late to make fundamental changes to the application. A good first step is the creation of effective tools which help us assess rapidly the usability of electronic resources [10]. We need these to show where the limitations are in resources which already exist. Once we have identified and defined the usability problem and educated the audience to expect better from IT systems, we can create real momentum towards genuinely high quality electronic information systems. References: 1 Schneiderman B. Designing the User Interface: Strategies for Effective Human-Computer Interaction. Addison-Wesley, 1988 (1st Edition; 4th Edition 2004) 2 Badenoch DS. Grounded Information Systems. In W Cronin (ed) Information Management: from strategies to action 2. Aslib, 1992. 3 Disability Rights Commission. The Web: Access and Inclusion for Disabled People. London:TSO, 2004. http://www.drc- gb.org/publicationsandreports/report.asp (checked 17th May 2004) 4 Minervation Limited. In-house survey of health care web sites and electronic resources using the LIDA tool. Minervation 2004. Data can be provided on request from accessibility@minervation.com. 5 Badenoch DS, Tomlin A, Hunt D, Massart R. What is Usability? Minervation, 2004. http://www.minervation.com (accessed 17th May 2004) 6 Nielsen J. Designing Usability. Academic Press 1994. 7 Neal D. Good design pays off. IT Week . 2003. 19-5-2003. 8 Bias RG, Mayhew DJ. Cost-justifying Usability. Academic Press, 1994. 9 Kushniruk AW, Patel VL. Cognitive and usability engineering methods for the evaluation of clinical information systems. J Biomed Inform 2004; 37(1):56-76 10 The LIDA Tool. Minervation 2004. http://www.minervation.com/downloads.html (accessed 17th May 2004) Competing interests: The authors work for Minervation Ltd, a company specialising in accessible, usable and reliable information resources for health care. |
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Richard O Sills, Private Plymouth / Cornwall
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I am sorry that I did not see the original editorial calling for submissions. Computer-generated patient interviewing has a 30 year history and there is a great deal written about it in the literature. Dr John Bachman, Professor of Family Medicine at the Mayo Clinic,has written an excellent literature review of the subject which speaks for itself. This can be found at the following URL: http://www.medicalhistory.com/articles.htm Dr Charles Zelnic has written an article recently detailing his own experiences using Instant Medical History in his extensive US family practice. This article can be found at: http://www.crmef.org/Curriculum/IMH%20Review/IMH_MSR.htm I believe that these articles speak for themselves. Competing interests: I am doing some work in association with Primetime Medical Software |
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Robert W Marshall, Specialist Registrar in Rheumatology Queen Alexandra Hospital, Cosham, Portsmouth, PO6 3LY
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I read with interest your May 15th edition devoted to electronic communication. One area that was noticeable by its absence, however, was the use of e-learning for undergraduate medical students. These are a group of individuals who often have a lust for knowledge, along with the skills and opportunities to use information technology. Furthermore, as the doctors of the future they will be increasingly involved with technology in their professional practice. Past experience developing e-learning packages for students at the University of Bristol [1] has shown them to be powerful tools for learning, as there are exciting opportunities for the use of images, videos, and links to external sites of relevance. However, they are extremely labour-intensive to set up, and unless created judiciously can lead to information overload. Further, whilst they are valuable for developing learning in the cognitive domain, they are less useful for improving interpersonal skills and changing attitudes. The best balance seems to be reached by providing small-group sessions with a facilitator to consolidate the subject, and to place it within the correct clinical context. Further, involvement of the students in the production of e-learning packages helps to impart a sense of ownership to the students, and to overcome any resistance to the use of alternative teaching methods. GMC guidance on reducing the amount of information imparted to students [2] must be squared with the ever increasing amount of information freely available on the internet. Human contact is vital for this. [1] Marshall RW, Kirwan JR. Development of e-learning tutorials in Rheumatology - experience from the University of Bristol. Rheumatology 43 (Supp 2) 2004. OP40 (p ii17) [2] General Medical Council. Tomorrow's Doctors. Recommendations on undergraduate medical education. London. 2003 Competing interests: None declared |
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Anatole S Menon-Johansson, Specialist Registrar Chelsea and Westminster Hospital, London, SW10 9NH, Frances McNaught, Ann K. Sullivan
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Dear Sir, We read with interest the themed edition on Electronic communication and health care. Novel text message language was alluded to in the Editorial by Jadad and Delamothe (1) and the latest mobile phone, complete with handheld computer capabilities, was illustrated in Mohammad Al- Ubaydli’s article, (2) however we were surprised that mobile phone and text messaging services were not discussed in this issue. Sexual health clinics see 1.3 million patients per year in the United Kingdom and there is considerable pressure to see and treat patients as soon as possible (3). A significant amount of clinic time is spent providing results in person or by phone. In order to evaluate our patients’ experience, views and access to technology we gave questionnaires to 300 consecutive patients. Three quarters of respondents were aged between 20 and 35 years, and 98% of respondents had mobile phones (4). An extended pilot of text message results within our GU service is currently underway at the John Hunter Clinic. Multiple messages about results, including recall, can be sent simultaneously using web based software. No specific results are sent via text. Unlike letters, our software informs us if the address (i.e. number) is wrong or the message was not received and unlike conventional telephones, it is significantly less time intensive. If the text message is not delivered, the software resends on three consecutive days before reporting it as undeliverable. Within the pilot we have found a high uptake rate in those patients with a mobile phone. There has been a rapid response to messages, with some patients returning the same day for treatment, and many within 3 days, reducing the period of infectivity, and allowing more timely partner notification. Even though we appreciate the utility and power of handheld computer technology it seems to us that we have yet to fully utilize the potential of the humble mobile phone. Even though some individuals may not carry a mobile phone (5) many of our patients could benefit from inventive use of text message technology. References 1.Alejandro R Jadad and Tony Delamothe. What next for electronic communication and health care? BMJ, 2004; 328: 1143 - 1144. 2.Mohammad Al-Ubaydli. Handheld computers. BMJ 2004;328:1181-1184 3.The National Strategy for Sexual Health and HIV http://www.doh.gov.uk/nshs/bettersexualhealth.pdf 4.Anatole S Menon-Johansson, Abigail Kingston and Ann K Sullivan. Putting sexual health in context. Prize winning presentation to the British Association of Sexual Health and HIV, Royal Society of Medicine, 27th February, 2004. 5.Richard Smith. Can IT lead to radical redesign of health care? BMJ 2004; 328 Editorial Competing interests: None declared |
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Laura A. O'Grady, PhD Candidate University of Toronto M5S 1V6
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I read with interest Jadad and Delamothe's editorial (1), in which the authors state: "Our original editorial solicited articles that shed light on how new electronic applications could improve people's health—yet many of the submissions reported process measures far removed from health outcomes". I believe the cause for lack of research focusing on health outcomes for e-health interventions has a two-fold origin. One reason may be that many of these interventions have poor usability (concisely outlined in Badenoch's comment found above). Very few sites or interfaces are well designed. In my own research on consumer learning in web-based health care interventions, study participants repeatedly focus on issues related to interface usability (to be submitted for publication), despite the research focus being elsewhere. In addition to usability problems hampering use of content, I also suspect comments of this nature are because participants are well seasoned consumers of other, more perfected and polished means of information dissemination such as print or television. Further, even if a consumer can successfully negotiate a web site to find the desired content, issues may arise in its presentation, which render the material incomprehensible or requiring assistance for personal application. Making content palatable to consumers, presenting it in a fashion that promotes learning, is imperative. Only when usability studies are routinely conducted on web interfaces and content is presented in a way that supports learning can we begin to measure health outcomes. The second, and perhaps overriding, reason is that many of those responsible for providing information in an electronic format such as the web are not required to present information that would be evaluated in terms of health outcome measures. When the Internet, in particular, the World Wide Web, became a prolific source for distribution of health content, many sites were developed by non-profits, governments and even individuals. The goal of these endeavours was often to provide treatment information designed to support and inform decision making by consumers. Many of those conducting process or outcome evaluations on these web sites would have research questions that are not based on health outcomes, but rather correlate directly to the mandate of the organization. Since few health care web sites designed to provide consumer treatment information now available are created by medical doctors or hospitals, few may require outcome measures such as improvements in health. In my research I do not consider conducting health outcome measures, as I believe it to be premature. I cannot begin to measure it unless the site is usable. Further such measures might be invasive, require chart summaries or other means of measure beyond my expertise. I have no knowledge of the nature of submissions for this issue that Jadad and Delamothe have referred to in their editorial. I can only surmise that perhaps some authors of these studies are social scientists such as myself and simply do not measure health outcomes. An understanding that health outcome measures must first be preceded by usability studies focusing on interface design, then implementation of best practices to promote learning, is imperative. Only when these issues have been addressed can measures pertaining to health improvements be measured. This is best accomplished when social scientists partner with medical research professionals in this field. Sincerely, Laura O'Grady PhD Candidate OISE / University of Toronto Toronto, ON, Canada References 1.Alejandro R Jadad and Tony Delamothe. What next for electronic communication and health care? BMJ, 2004; 328: 1143 - 1144. Competing interests: None declared |
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