Usability and cognitive load in the design of a personal health record

Highlights

• We created and tested usability of a new personal health record pre-visit form.

• Using the NASA Task Load Index, we show that some pages induce higher cognitive load.

• Recall of health information is one of the ways the system creates cognitive load.

• Our system achieved a high degree of usability based on the SUS scale.

Abstract

While personal health records (PHRs) carry an array of potential benefits such as increased patient engagement, poor usability remains a significant barrier to patients’ adoption of PHRs. In this mixed-methods study, we evaluate the usability of an important PHR feature, a patient intake form called the pre-visit summary, from the perspective of cognitive load using real cardiovascular patients in vivo. A validated measure for cognitive load, the NASA Task Load Index, was used along with retrospective interviews to identify tasks within the pre-visit summary that were more mentally challenging for patients. Participants experienced higher cognitive load on the Medications, Immunizations, Active Health Concerns, and Family History pages because these pages required a higher recall of personal health information and due to some user interface design issues. This research is significant because it uses validated measures of cognitive load to study real patients interacting with a PHR in vivo.

Introduction

Health information technology (HIT) use in clinical practice is growing and the extensive use of electronic health records (EHRs) has increased in response to the financial incentives promised by Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) [1] The Health Information Technology for Economic and Clinical Health (HITECH) Act supports the use of EHRs in a way that adds value to patient care through a three-stage incentive program; Meaningful Use [2]. Stage 3 of Meaningful Use aims to boost health information exchange between providers and encourage patient engagement by offering patients secure online access to their personal health information (PHI) [2]. Personal health records (PHRs) are private, secure, and confidential electronic applications that allow patients to access, manage, and share their PHI [3]. PHRs tethered to their healthcare providers’ EHRs, also known as patient portals, provide patients online access to their most up-to-date PHI, including laboratory results, medication lists, immunization histories, and more [4]. PHRs are patient-centered nature have the potential to increase patient engagement and enhance the healthcare decision-making process [3,[5], [6], [7].

Aside from viewing PHI, the PHR allows patients to update their PHI, make payments, download educational materials, schedule or view upcoming clinic visits, and complete intake forms [8]. One such intake form is the pre-visit summary. The pre-visit summary engages patients in reflecting on their medical history and identifying new health concerns before their clinic visit. The pre-visit summary promotes the accurate update of information within the EHR and reduces the time required of clinical staff to update patients’ records before their clinic visit [5]. The in-person clinic visit is then focused on interpreting, discussing, and responding to the information [9].

Several barriers impede PHR adoption, which include the "digital divide," and data accuracy and integrity [3,[10], [11], [12], [13]. One of the main challenges for PHR adoption is poor system usability [11,14,15]. Inefficient, ineffective, and complicated designs lead to dissatisfied users who abandon such PHRs despite their beneficial features [16]. Cognitive load is another challenge associated with PHR adoption. While cognitive load has been studied extensively in healthcare providers [e.g., [17], [18], [19], studies on patient cognitive load are challenging to find.

The TURF (task, user, representation, function) framework was developed specifically to understand and evaluate the usability of EHR systems. According to the TURF framework, the term usability is defined as how “useful, usable, and satisfying a system is for the intended users to accomplish goals in the work domain” [20]. A system is said to be “useful” if it fully incorporates domain functions essential for work. The system is “usable” if it is easy to learn, efficient to operate, and error-tolerant. The system is “satisfying” when it considers the system's likeability. The TURF framework guided this study's methodology. Formal usability evaluation of HIT solutions is a crucial step to HIT's success [14]. There is a gap in the literature concerning in vivo PHR usability evaluations with patients using their PHI to perform tasks. We address this gap by conducting an in vivo usability assessment with real patients completing an online pre-visit summary using their PHI to identify usability issues and cognitive load experienced during use.

Cognitive Load Theory was developed to optimize information presentation and design to promote mental performance [21]. Cognitive load is “the load that performing a task imposes on the cognitive system of a learner” [22]. Cognitive load theory divides cognitive load into three components: intrinsic, extraneous, and germane [23]. The complexity of the task causes intrinsic cognitive load, while poor presentation or design causes extraneous cognitive load. Germane cognitive load is caused by the mental load of converting learned information into a mental schema. Reducing extraneous cognitive load creates more usable systems by easing the cognitive burden of completing a task. The TURF framework refers to two competitive forces: intrinsic complexity and extrinsic difficulty. A well-designed system reduces extrinsic difficulty through simplified representations for the tasks at hand [20].

While there is currently no consensus or “gold standard” for measuring cognitive load, utilization of both objective and subjective measures provides a more accurate measurement of cognitive load [24], [25], [26], [27], [28], [29]. Cognitive load is measured objectively with performance-based or physiological measurements [20,22,[30], [31], [32], [33]. Subjective measures of cognitive load assume that subjects can report their cognitive processes through introspection [22,33].

The purpose of this study is to measure cognitive load to test the usability of an online pre-visit summary. A convergent mixed methods design was used to evaluate cardiovascular patients’ cognitive load using validated measures. We asked the following research question to guide our methodology and analysis:

Which tasks within the pre-visit summary induce an increased cognitive load upon patients completing the form?