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Considerations for the Design of a Web-based Clinical Monitoring and Educational System for Elderly Patients

Considerations for the Design of a Web-based Clinical Monitoring and Educational System for Elderly Patients
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  In the last several years, the amount of clinical infor-mation retrievable on the Web has increased, and agreat number of patient education sites have beendeveloped. These allow patients to access informationrelated to their medical conditions but do not provideprotection from misleading or inaccurate data postedfor commercial or other reasons. The Internet can alsoprovide a tool for communication between patientsand health care providers. Message boards and onlinesurveys allow patients to transmit data to providersfor evaluation of their conditions. Online question-naires support the detection of trends in patients’ con-ditions that might require special attention and, in gen-eral, support remote clinical monitoring of signs andsymptoms.Although the Internet seems to have the potential torevolutionize the process of health care delivery andempower patients to become more active in the careprocess, the fastest growing segment of the U.S. pop-ulation—i.e., people over the age of 50 years 1 —are ata disadvantage because designers of both softwareand hardware technology fail to consider them as apotential user group. 2 The design of a usable Web-based information systemfor healthy users who are familiar with computer tech-nology is a challenge. When a system needs to addressage-related constraints and the functional limitationsof inexperienced users, it becomes even more difficult.Designers of a system for elderly patients should aimto increase its functional accessibility. The term “acces-sible design” refers to maximizing the number of potential customers who can readily use a product. 3 A“functional limitation” describes a “reduced sensory,cognitive, or motor capability associated with humanaging, temporary injury, or permanent disability thatprevents a person from communicating, working,playing, or simply functioning in an environmentwhere other people in the population can function.” 3 In this review, we gather published guidelines for thedesign of Web-based clinical systems for elderlypatients, identify literature gaps, and discuss additionalconsiderations. The recommendations are intended toorganize the conception, implementation, and evalua-tion of such Web-based systems and can offer concretesupport for decision making during the design process. Affiliation of the authors: University of Minnesota, Minneapolis,Minnesota.This work was supported in part by grant 27-60-98031 from theTelecommunications and Information Infrastructure AssistanceProgram of the Department of Commerce, and by matching fundsfrom program clinical and industry partners.Correspondence and reprints: George Demiris, PhD, 25 Martiou31, Holargos 155 62, Athens, Greece; e-mail: <>.Received for publication: 11/2/00; accepted for publication: 4/13/01. DEMIRIS ETAL ., Web Design Considerations for the Elderly 468  Review  ■ Considerations for the Designof a Web-based ClinicalMonitoring and EducationalSystem for Elderly Patients A b s t r a c t Designing a Web system for elderly patients requires attention to the users’ functional impairments and inexperience with computers. The authors reviewed published guidelines for the design of Web-based clinical systems for elderly patients and identified additional design considerations that have not been reported in the literature. The resulting recommendations are related to the system interface, the training and support of users, and the content of Web pages. The recommendations can be used as design objectives for Web-based systems for elderly patients, which emphasize system usability and aim to optimize patients’ error-free use of these systems. ■  J Am Med Inform Assoc. 2001;8:468–472. G EORGE D EMIRIS , P H D, S TANLEY M. F INKELSTEIN , P H D, S TUART M. S PEEDIE , P H D Downloaded from gueston 02 March 2018  Background According to the Resource Guide for Accessible Design of Consumer Electronics, 3 the first step in creating an acces-sible design is to get to know the users and their limi-tations. The limitations of elderly persons are function-al impairment due to age or comorbidity (e.g., limita-tions of visual perception, hand–motor function anddexterity, cognitive and perceptual abilities) and inex-perience in the use of computers. Functional Impairment The frequency of functional impairments increaseswith age and with morbidity. 4 Functional limitationsare present in 37.2 percent of persons over 65 years of age and in 73 percent of those over 75 years. 5 In 1995,13 percent of persons 70 to 74 years of age had visualimpairments, compared with 31 percent of persons85 years of age and over. 6 The prevalence of hearingimpairments rose from 26 percent of persons 70 to 74years of age to 49 percent of persons 85 years of ageand over. 6 Nearly 9 percent of non-institutionalizedpersons 70 years of age and over are unable to per-form one or more activities of daily living (ADLs),such as bathing and dressing. 6 Aging can affect the information-processing capacity,reduce the speed of precise movements, and increasethe variance in their timing. 7 It increases the timerequired to retrieve information from memory as wellas the “thinking time” needed to interpret complex dis-play scenarios and to “work out appropriate nextmoves in system control.” 7 It reduces the ability to rap-idly select needed information and may impair the pre-cision with which information can be sought. Agingalso decreases the attention span over long periods of time and “causes qualitative as well as quantitativechanges in the information extracted from displays.” 7 Such impairments limit the ability of elderly personsto use and browse the Web. Reading online informa-tion and selecting links to other Web pages requirevisual and motor coordination that many elderlypatients no longer possess. Computer Inexperience Although the elderly population has the highest pen-etration rate for telephones, it is behind all other agegroups with respect to computer ownership (only25.8 percent of senior households have a computer),and Internet access (14.6 percent of all senior house-holds have Internet access). 8 Manuals are often written for users already familiarwith computer use. Instructions for personal com-puters or videophones with Internet access frequent-ly use such terms as “mouse,” “pointer,” and “dou- ble-click” without further explanation, assuming thatusers are already familiar with such terminology,which is not true for a great proportion of the elderlypopulation in both urban and rural areas.In addition to the limitations of the target population,security and confidentiality are major concerns forevery technology-based system that communicateshealth information and provides medical care.Security is the means for preventing unauthorizedaccess. Confidentiality is the restriction of informa-tion access to only those persons with an appropriatereason for such access. Security and confidentialityrequirements are an essential ingredient of any clini-cal information system, especially when data are being transferred over the Internet. 9,10 Design Recommendations To meet these design challenges, existing guidelinesfor online system design were identified in the litera-ture and other considerations were added to addressliterature gaps. The resulting set of recommenda-tions, which constitute the design objectives for aWeb-based clinical system for elderly persons,addresses four areas—system interface, training andsupport of users, content, and security. System Interface Simple and Clear Web PagesAs described in the Web content accessibility guide-lines, 11 tables should transform gracefully, providecontext and orientation information, and ensure thatdocuments are clear and simple. The language andlayout of the display have to be designed to be assimple as possible to ensure readability and compre-hension by all users.Alternatives for Different TasksAccording to the Resource Guide for Accessible Design of Consumer Electronics, 3 a system should provide alter-native ways to achieve tasks—e.g., use of the mouse orthe keyboard to select links. Online questions should be phrased so that theresponse can be selected, if possible, from multiplechoices. Elements of Proper Visual DisplayIcons should be simple, and concrete symbols should be designed to look like the object they represent and be distinguishable from others. 3 Large buttons 469  Journal of the American Medical Informatics AssociationVolume 8Number 5Sep / Oct2001 Downloaded from gueston 02 March 2018  increase the area that can be selected with the point-er for clicking. Buttons should include large icons aswell as text labels to describe their function. Becauseof a general decline in acuity among elderly persons,the font sizes of a site should be larger (14 points ormore) and have very clear headings. 12 Text placedover even a light or subtly patterned backgroundmay prove troublesome, especially for persons withreduced visual acuity. 13 Color should be used conservatively. Sufficient brightness contrast should be used so that the coloritself is not the only source of information. Weale 14 determined that the amount of perceived light is 50percent less at age 50 years than at age 20 years; thisreduction increases to 66 percent at age 60 years.Therefore, it is important to provide high contrast between darker and lighter colors. Fluorescent colorshave a very intense effect that can be exhausting tothe eye, especially if the viewer has visual disabili-ties, 13 and should therefore be avoided. With age, the ability to discriminate colors on the basis of hue, lightness, and saturation is reduced. 15 Hue is the perceptual attribute associated with ourability to identify basic colors such as blue, green,yellow, red, and purple. 15 Saturation refers to theintensity of the color, 16 and lightness to the level of light reflected from a color. 16 Designers can helpcompensate for deficits by making colors differ moredramatically in all three attributes. 15 Since yellowingof the eye lens causes less violet light to be registered by the eye, the ability to see certain colors such as blues, greens, and violets diminishes with aging.Thus, viewing a page through a piece of yellow cel-lophane gives an idea of how an elderly viewermight perceive the page. 16 Help Features and Constructive Error MessagesA site should feature a help menu with several meansof obtaining assistance. Context-sensitive help pre-vents the user from having to search through severalitems. Error messages should offer constructiveadvice and provide suggestions. The message shouldnot only report the occurrence of an error but alsoprovide an explanation of its cause and offer possiblesolutions.Clear Navigation Mechanisms 11 A copy of the keyboard, including a description of function keys that assist the navigation process,should be given to every user. Function keys thathelp the user navigate back to the personal homepage are recommended.Avoidance of Sound EffectsAging affects the hearing function as well as the abil-ity to concentrate on audio and text at the same time.Therefore, avoidance of sound effects is recommend-ed unless a specific application requires their use.Elimination of Distracting FeaturesFeatures that could distract the user from a certaintask should be avoided, as should the use of “pop-up” windows that appear while the content of a pageis being read and interfaces that require immediateresponse. Aging affects the reaction time to environ-mental stimulation and increases the time required toprocess displayed information. Therefore, featureslike pop-up windows and animated banners can bedistracting and should be avoided.Inclusion of Users in the Design PhaseThe targeted users of the system can provide usefulfeedback not only after its completion but also duringits design and development. They can point out fea-tures they perceive as undesirable for such a systemand redirect the design efforts. Training and Support Sufficient TrainingAlthough evidence suggests that older people havethe capacity and the desire to learn to use technolo-gy, 17,18 learning becomes more difficult with age. 19 This factor, however, can be addressed by sufficienttraining. The learning process can be enhanced by adetailed manual that explains in simple text, with thehelp of graphs and images, the function and use of thesystem. Such a manual should include examples andscreen shots. It is helpful if a patient is introduced to the new systemand receives training in its use over a period of sever-al days. A reiteration of the material discussed at eachsession is also helpful. Edwards and Engelhardt 20 found that introducing the technology “in a highlyinteractive and understandable manner” was one fac-tor that was likely to “influence the receptivity of sen-iors toward computers.”Personalized TrainingNot all elderly home care patients have the samefunctional limitations or level of experience withcomputers. Therefore, training sessions shouldaddress the needs of individual users and enablethem to overcome the specific barriers to system uti-lization that they face. DEMIRIS ETAL ., Web Design Considerations for the Elderly 470 Downloaded from gueston 02 March 2018  Education about Online InformationAlthough the links to educational material that areincluded on a Web page can be selected and filtered,it is not possible to predict which pages a user willvisit when browsing the Web. Therefore, it is crucialto explain and emphasize to patients that, althoughthe Internet offers access to a wealth of worldwidemedical information and resources, it does not neces-sarily provide only accurate information. Patientsshould always exercise caution when viewing mate-rial on Web sites and should consult with their healthcare provider regarding both online diagnostic andtreatment information. Content Links should be provided to sites that provide educa-tional materials that meet the following criteria: ■ The links are compatible with the system’s browser. ■ The material is written in simple and clear lan-guage aimed at the patient. ■ The sites do not endorse a commercial product (toavoid bias of the information provided). ■ The patient’s identification is not required.The final selection of sites must be reviewed byhealth care providers for readability, accuracy, andappropriateness of content. Site reviews at regularintervals are necessary to ensure that the Web pagesare still available and that their updated versionsmeet the requirements mentioned above.Avoidance of Deep Hierarchy in the Information Structure According to Mead et al., 21 the success of older usersat finding information declines significantly whenthey have to follow more than three hyperlinks to getto the information they seek. This decline occurs because older users tend to have greater difficultyremembering their location within a site, because of adecrease in working memory efficiency. 21 Therefore,the structure and representation of informationshould not have a deep hierarchy.Appropriate Electronic CommunicationBetween Patient and ProviderIf a Web-based system enables patients to communi-cate with their providers using e-mail or message- board features, the AMIA Guidelines for the Clinical Useof Electronic Mail with Patients 22 should be followed.Thus, a turnaround time for messages should be estab-lished, patients should be informed about privacyissues, and messages should be printed out and includ-ed in the patients’ charts. 22 Patients must be warnednot to use the online mode of interaction in an emer-gency and should be aware of all recipients of theirmessages as well as general privacy issues. Security Security can be accomplished by utilizing encryptingtechniques and disabling the execution of arbitraryprograms or shell commands on the server 23  by net-work users. Common gateway interface (CGI) scriptsmust either perform the expected function or returnan error message. To achieve these goals, a series of steps have to be taken, such as disabling automaticdirectory listings, configuring the server to allowonly CGI scripts from a particular directory con-trolled by the staff, and preventing general access tothe server log files. Discussion The use of telecommunication and networking tech-nologies can improve access to medical care. Low-cost monitoring devices, broad bandwidths, and hightransmission rates can enable the assessment and fol-low-up of patients’ clinical conditions and their edu-cation. Such systems are believed to enable patientempowerment, which can be defined as “the increas-ing ability of patients to actively understand, partici-pate in, and influence their health status.” 24 Patientsare viewed as consumers of health care who can par-ticipate in their own care through prevention andtreatment. Education assumes a major role in thisprocess, and the Internet can provide a wealth of medical information. Technology can facilitate the involvement of patientsin their own medical care, but it can also become a barrier if they cannot easily and effectively use it tomeet their needs. According to a model outlined byMackie and Wylie, 25 a user’s acceptance of technolo-gy is affected by the user’s awareness of the technol-ogy and its purpose; the extent to which the featuresof the technology are consistent with the user’sneeds; the user’s experience with the technology;and the availability of support, such as documenta-tion and training. Therefore, the emphasis should beon system usability and design interfaces that opti-mize patients’ abilities to accomplish their tasks with-out errors in a reasonable time, so they perceive thesystem as a useful tool. Elderly people who go online to send e-mail or playgames actually show improvement in activities of  471  Journal of the American Medical Informatics AssociationVolume 8Number 5Sep / Oct2001 Downloaded from gueston 02 March 2018  daily living, as shown in a study by Mercer et al. 26 With the increasing role of the Internet in severalaspects of medical information and care, it is only nat-ural to attempt to ensure accessibility for elderlypatients. The success of a monitoring and educationalsystem depends on how well it serves the needs of thetarget population. Thus, crucial characteristics of theusers must be defined and addressed. Unlike electronic system intended for users who arefamiliar with computer technology, the considerationspresented here are meant for elderly patients whohave functional limitations and little or no experiencein the use of computers. We are currently testing, withelderly home care patients at the TeleHomeCareProject at the University of Minnesota, a system thatreflects these considerations. This project used low-cost, commercially available video-conferencing,Internet-access, and monitoring devices to providecommunication between home care patients andproviders. The formative evaluation of the system willassess the effects of the presented recommendations. References  ■ 1.The Older Population in the United States: March 1999. U.S.Department of Commerce, Economics and StatisticsAdministration, Washington, DC: US Census Bureau, 2000.Report P20-532.2.Parsons H, Terner J, Kearsley G. Design of remote controlunits for seniors. Exp Aging Res. 1994;20:211–8.3.Resource guide for accessible design of consumer electronics—linking product design to the needs of people with functional lim-itations: a joint venture of the electronic industries alliance and theelectronic industries foundation. Telecommunications IndustryAssociation Web site. Available at: Accessed Aug 15, 2000.4.Lussier YA, Kukafka R, Cimino JJ. Overcoming the barriers of Web-based interventions for elderly patients: enabling strate-gies for the MI HEART clinical trial. Proc AMIA Annu Symp.1999:1110.5.National Center for Health Statistics. Current estimates fromthe National Health Interview Survey, 1995. Series 10, no. 199.Hyattsville, Md.: NCHS, 1998. DHHS publication (PHS) 98-1527.6.National Center for Health Statistics. Health, United States1999, with Health and Aging Chartbook. Hyattsville, Md.:NCHS, 1999. DHHS publication (PHS) 99-1232.7.General issues regarding ageing and technology. INCLUDEProject Web site. Available at: Accessed Nov 1, 2000.8.National Telecommunications and Information Admin-istration. Falling through the Net: defining the digital divide.A report on the telecommunications and information technol-ogy gap in America. Washington DC: NTIA, 1999.9.Barrows RC, Clayton PD. Privacy, confidentiality and elec-tronic medical record. J Am Med Inform Assoc. 1996;3:139–48.10.Computer Science and Telecommunication Board. For theRecord: Protecting Electronic Health Information.Washington, DC: National Academy Press, 1997.11.Web content accessibility guidelines 1.0. W3C recommendation.May 5, 1999. W3C Web site. Available at: Accessed Aug 15, 2000.12.Hartley J. Designing instructional text for older readers: a lit-erature review. Br J Educ Technol.1994;25(3):172–88.13.SPRY Foundation. Older adults and the World Wide Web: aguide for Web site creators. Washington, DC: SPRY, 1999.14.Weale R. Retinal illumination and age. Trans IlluminatingEngineering Soc. 1961;26:95.15.Arditi A. Effective color contrast: designing for people withpartial sight and color deficiencies. Lighthouse InternationalWeb site. Available at: Accessed Feb 2001.16.Spiezle CD. Effective web design considerations for olderadults. Redmond, Wash.: Microsoft, 1999.17.Irizarry C, Downing A. Computers enhancing the lives of older people. Aust J Ageing. 1997;16(4):161–5.18.Dyck JL, Smither JA. Age differences in computer anxiety: therole of computer experience, gender and education. J EducComput Res. 1994;10(3):239–48.19.Irizarry C, Downing A, Elford C. Seniors-on-line: introducingolder people to technology. Aust Phys Eng Sci Med.1997;20(1):39–43.20.Edwards R, Englehardt KG. Microprocessor-based innovationsand older individuals: AARP survey results and their implica-tions for service robotics. Int J Technol Aging. 1989;2:56–76.21.Mead SE, Spaulding VA, Sit RA, Meyer B. Effects of age andtraining on World Wide Web navigation strategies. ProcHuman Factors and Ergonomics Soc. 1997;41:152–6.22.Kane B, Sans D. Guidelines for the clinical use of electronicmail with patients. J Am Med Inform Assoc. 1998;5(1):104–11.23.Garfinkel S, Spafford G. Practical Unix and Internet Security.2nd ed. Sebastopol, Calif.: O’Reilly & Assoc, 1996.24.Bruegel R. Patient empowerment: a trend that matters. JAHIMA. 1998;69(8):30–3.25.Mackie RR, Wylie CD. Factors influencing acceptance of com-puter-based innovations. In: Helander M (ed). Handbook of Human–Computer Interaction. New York: Elsevier, 1988:1081–106.26.Mercer Z, Chiriboga D, Sweeny MA. Using computer technol-ogy with older adults: a pilot study. Gerontol Geriatr Educ.1997;18:61–76.27.Health Care Financing Administration. A profile of medicarehome health. Baltimore, Md.: HCFA, Aug 1999. PublicationHCFA-10138.28.Finkelstein SM, Speedie SM, Hoff M, Demiris G. Tele-HomeCare: telemedicine in home health care. Proc IEEE EngMed Biol Soc. 1999:681. DEMIRIS ETAL ., Web Design Considerations for the Elderly 472 Downloaded from gueston 02 March 2018
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