9

Human–Computer Interaction
Gregory L. Alexander

• OBJECTIVES
1. Recognize theoretical underpinnings for Human–Computer Interaction.
2. Discuss Human–Computer Interaction principles.
3. Apply the use of Human–Computer Interaction principles to a healthcare model called Aging in Place.
4. Propose how the application of Human–Computer Interaction principles can improve nurse and patient
outcomes in healthcare.

• KEY WORDS
Human–Computer Interaction
Patient care
Information technology
Patient safety
System design

INTRODUCTION
Human–Computer Interaction (HCI) is broadly defined as an intellectually rich and highly impactful phenomenon
influenced by four disciplines: (1) Human Factors/Ergonomics, (2) Information Systems, (3) Computer Science, and
(4) Library and Information Science (Grudin, 2012). Aspirations of fledgling HCI researchers and practitioners, over
the past 30 years, were to develop better menus, enhance use of graphical user interfaces, advance input devices,
construct effective control panels, and improve information comprehension (Shneiderman, 2012). There are few
fields, like HCI, which can claim such a rapid expansion and strong influence on the design of ubiquitous
technologies including desktops, Web, and mobile devices used by at least 5 billion users around the world
(Shneiderman, 2012). This chapter provides important information for nurses engaged in HCI efforts to improve
healthcare systems and processes. The purpose of this chapter is to elevate nurses’ understanding of theoretical
underpinnings for HCI approaches used to evaluate clinical technologies; to infuse HCI concepts by identifying
important HCI approaches, during this time of rapid and continuous change; and finally, to describe how HCI
evaluation can lead to improved performance and outcomes in nurse-led systems.

HUMAN FACTORS: A BUILDING BLOCK FOR HUMAN–COMPUTER

INTERACTION
Human factors is a discipline that optimizes relationships between technology and humans (Kantowitz & Sorkin,
1983; McCormick & Sanders, 1982). Human factors has been defined in a number of ways by a number of experts
(see Table 9.1). In healthcare, human factors experts attempt to understand relationships between humans, tools they
use (i.e., computers), living and work environments, and tasks they perform (Staggers, 1991; Staggers, 2003;
Weinger, Pantiskas, Wiklund, & Carstensen, 1998). Human factors experts apply information about human
characteristics and behavior to determine optimal design specifications for tools people use in their daily life
(Johnson & Barach, 2007). The goal of a human factors approach in nurse-led systems is to optimize the interactions
between nurses and the tools they use to perform their jobs, minimize error, and maximize efficiency, optimize well-
being, and improve quality of life.

TABLE 9.1 Human Factors Definitions

 HCI, concerned with interactions between people and computers, is an area of study concentrated on by human
factors experts (Staggers, 2002). HCI is defined as the study of how people design, implement, and evaluate
interactive computer systems in the context of users’ tasks and work (Nelson & Staggers, 2014). HCI emerged in the
1980s as an interdisciplinary field incorporating ideals of computer science, cognitive science, and human factors
engineering professionals, but since has grown into a science incorporating concepts and approaches from many
other disciplines. An excellent history of HCI written by Grudin can be found in Human Computer Interaction
Handbook (Grudin, 2012). Some critics believe current descriptions of HCI require broader definitions. Critics
suggest that current definitions do not reflect ubiquitous, pervasive, social, embedded, and invisible user-oriented
technologies (Shneiderman, 2012). Further, some HCI critics want to move beyond computer use to emphasize other
components of HCI including “…user experience, interaction design, emotional impact, aesthetics, social
engagement, empathetic interactions, trust building, and human responsibility” (Shneiderman, 2012).

FRAMEWORKS FOR HCI IN NURSING

Early pioneers in nursing informatics set the stage for development of nursing information systems and their use in
storing information, knowledge development, and development of technology in caregiving activities (Graves &
Corcoran, 1989; Schwirian, 1986; Turley, 1996; Werley & Grier, 1981). These early models had several limitations
including a lack of environmental and task-oriented elements, conceptual differences across frameworks, and a lack
of time dimensions; subsequently, nursing frameworks were proposed to illustrate dynamic interactions occurring
between nurses, computers, and enabling elements that optimize a user’s ability to process information via computers
(Staggers & Parks, 1993). These became the early foundations for incorporating human factors approaches into the
design of information technologies used by nurses. However, there were still limitations identified in these early
models because they did not explicitly make the patient part of the model and they didn’t define the context or include
all elements of nursing’s metaparadigm (Effken, 2003). Effken (2003) proposed the Informatics Research Organizing
Model, which emphasized all elements of nursing’s metaparadigm including the system, nurse, patient, and health.
Later, Alexander’s Nurse—Patient Trajectory Framework was proposed (Alexander, 2007, 2011). Alexander’s
framework utilizes nursing process theory, human factors, and nursing and patient trajectories as components of a
framework that can be used to evaluate patient care systems. The midrange framework specifically emphasizes the
use of human factors approaches to link patient care processes, nurse and patient trajectories, and nursing and patient
outcomes. In this discussion, the framework (see Fig. 9.1) has been modified to explore HCI in the context of nurse
and patient trajectories as technology is integrated into nurse-led systems. Examples of HCI design and research
using this model will be used to achieve the objectives.
• FIGURE 9.1. Trajectory HCI. (Reproduced, with Permission, from Gregory L. Alexander, PhD.)
DESIGNING FOR HCI
The discipline of HCI incorporates proponents of interaction design. Interaction designers are concerned with
shaping digital things for people’s use (Lowgren, 2013). Concepts proposed by interaction designers in healthcare
have significant implications for design of pervasive technologies that are being developed and adopted by
healthcare providers and patients. Interaction designers are characterized as shaping and transforming processes
through the use of digital devices; they consider all possible futures for a digital design space; designers frame a
problem at the same time they are creating a solution; and finally, designers address instrumental and technical
aspects of digital media, but also recognize aesthetical and ethical aspects of designs (Lowgren, 2013).

AGING IN PLACE: AN EXAMPLE OF INTERACTION DESIGN

One problem for the millions of older adults who have multiple chronic illnesses is that they want to remain at home
as long as possible. However, at the end of life, these chronic illnesses result in greater frailty, decline in
independent daily activities, and greater safety concerns such as falls. Furthermore, as these conditions progress
often older adults experience reduced mobility with greater isolation from their peers. Solutions to problems faced
by these frail individuals are needed to help them age in place and to have better experiences at the end of their life.
Solutions for these problems are being developed by an interdisciplinary team of software designers at the
University of Missouri in an independent living facility called TigerPlace (Rantz et al., 2013). To maximize efforts,
the formation of an interdisciplinary interaction design team was critical in initial and ongoing stages of developing
solutions for these age-old problems. The multidisciplinary team included nurses, physicians, sociologists, computer
engineers, architectural designers, and informatics specialists. Rich dialog was produced from multiple perspectives
that enhanced our ability to produce a wide variety of solutions, including embedded sensor systems that assisted in
early detection of declining health experienced by older adults living in TigerPlace. While developing these
solutions the design team concurrently considered crucial aspects of HCI design such as aesthetics, ethics, usability,
and user experience (Alexander et al., 2011a). Examples are drawn from these experiences to demonstrate principles
of HCI design.

AESTHETICS IN HCI
Aesthetics has been defined as, “of or relating to beauty”, and “pleasing in appearance: ATTRACTIVE easy to use
keyboards, clear graphics, and other ergonomic and aesthetic features” (Merriam Webster, 2014). Aesthetics
influences cognitive and emotional processes of people who interact with technology and is a strong determinate of
user satisfaction and pleasure, which are important HCI outcome metrics (Tractinsky, 2013). Traditionally, HCI
researchers have emphasized objective performance criteria, such as time to learn, error rates, and task completion
times; other aspects such as aesthetics have been neglected (Lavie & Tractinsky, 2004). In the current context,
aesthetics refers to the beauty and pleasing appearance of technological artifacts designed to solve complex health-
related problems.

Aesthetics for Aging in Place Technologies

Referring back to our Aging in Place HCI model, our team has found that aesthetic design features influence the
adoption of technologies by patients who want to age in place; additionally, aesthetics are important to healthcare
providers whose healthcare decisions are influenced during interactions with the technology (Demiris et al., 2004).
As an example of aesthetic appeal, we will use descriptions of the functional components of our IT system used by
patients and providers who live and work, respectively, with our sensor system. Aesthetic design has important
ramifications for patient and provider trajectories in Alexander’s framework illustrated in Fig. 9.1. The influence of
aesthetic appeal for our users has important implications for technology acceptance in the lived environments of our
patients and for providers (Venkatesh, Morris, Davis, & Davis, 2003).
Information about how the TigerPlace sensor system operates can be found in past publications (Rantz et al.,
2013). We will provide a brief description here. TigerPlace residents who consent to have sensor systems have the
option of having motion sensors placed throughout their apartment that detect motion, location, and functional activity
levels in each room and in certain places, such as opening the refrigerator or turning on the stove. Another option, for
TigerPlace residents, is to have a water-filled sensor installed under their mattress on their bed that detects bed
restlessness, breathing patterns, and heart rate, while they are lying on the bed. Another option, for residents, is
technology that captures gait parameters including most used walking paths and fall detection images. All of these
data are collected in a secure server, accessed only by research staff with proper authorization. The data can be
viewed via a computer interface which we have developed with HCI methods (Alexander et al., 2011a).
Residents, who live at TigerPlace, have expressed aesthetic concerns about the technology, which have influenced
our product design and implementation in residents’ apartments. In the initial stages of product development, the
design team made a conscious decision to make all the technologies as noninvasive to the users as possible,
including deploying technologies that are not worn by end users. The design team decided that technologies that are
worn may infringe on the independence of the older adults, and furthermore, could contribute to the stigma of frailty
that older adults may experience. Older adults at TigerPlace expressed that they felt safer living with the technology,
but they did not want the technology to stand out (Demiris, 2009). The invisibility of the technology was an important
aesthetic design factor the team had to consider as we developed the product. HCI metrics that help us understand the
perceptions of noninvasiveness and invisibility have been rarely measured, but are important considerations for
prevailing IT systems that will be embedded where people live.
TigerPlace providers, nurse care coordinators who care for TigerPlace residents, want a system that can
contribute to earlier detection of health decline for residents who are aging in place. However, a sensor system that
captures activity data around the clock, 24/7, can be daunting to search through in order to make appropriate
decisions about care coordination. One problem that designers faced was how to develop an interface that supports
proper data visualization, of this big data, with good aesthetic appeal for end users. Using an interactive, iterative
HCI process, the design team worked together with care coordinators to discuss concerns about the early illness
warning system and suggest solutions (Alexander et al., 2011a). Figure 9.2 illustrates the outcome of this critical
work engaging end users and software developers in the design process of an interface for our sensor system.
• FIGURE 9.2. Sensor–System Interface.

The design teams worked to incorporate colors along a longitudinal graph for each hour of each day, which we
call a motion density map, to help providers easily detect resident activity level change. More vivid blues and
yellows on the motion density map indicate greater activity levels, which are easily detectable, compared to the
duller hues. Additionally, the design layout expedited the ability to detect important activity changes at different times
of the day, such as during the nighttime when residents should be sleeping (yellow and gray hues between midnight
and 6:00 AM). Design aesthetics incorporated into longitudinal data, as illustrated in Fig. 9.2, is being used by
healthcare providers to detect patient decline. The aesthetic design of these interfaces is crucial to facilitate proper
use and detection of early illness decline experienced by residents and observed for by providers.

ETHICS IN HCI
For a long while, perceptions have been that information technology can help improve diagnostic accuracy, make
information more accessible, and can improve the representation of facts in medical records (Miller, Schaffner, &
Meisel, 1985; Staggers, Thompson, & Snyder-Halpern, 2001). However, with the everywhereness of technology
embedded throughout our world and the robust forms of technology being used, ethical considerations for HCI are
becoming paramount. For instance, consider the example of designing for mobile platforms, three main problem
areas of design have been proposed for these types of devices including use of screen space, interaction mechanisms,
and design of mobile user interfaces (Nilsson, 2009). Designers assume great responsibility to address these
problems by designing in solutions that optimize use of these platforms, while minimizing potential pitfalls of HCI
design problems (Association for Computing Machinery, 2014). Mobile healthcare platforms, such as telemonitoring
equipment, Web-based support systems, or bedside clinical decision support systems to help frontline nurses manage
critical symptom changes are a few examples (van der Krieke, Emerencia, Aiello, & Syteme, 2012; Winkler et al.,
2011; Yuan, Finley, Long, Mills, & Johnson, 2013). Designers assume an ethical responsibility to test these platforms
using HCI methods not only in controlled settings during early stages of development life cycles but also at periods
of implementation in the field where unintended consequences can occur (Ash, Berg, & Coiera, 2004).

Ethics for Aging in Place Technologies

The sensor technologies being used at TigerPlace have been incorporated into the living environments of residents
choosing to age in place at this facility. Future use of these sensors includes possible interactions with other types of
users, such as families, physicians, nurses. So, their input into the development of this technology is critical during
all stages of development and implementation.
In order to meet ethical obligations to the public who will eventually use these sensor systems, the design team
incorporated multiple HCI methodologies to examine user’s perceptions of the interface and to examine the
functionality of the interface. For instance, our team conducted many key informant interviews with residents living
with sensors to explore their lived experiences with the sensor systems (Demiris et al., 2004). Finally, we conducted
task-oriented usability assessments that were electronically documented with usability software, called Morae, with
each type of end user (residents, families, nurses, physicians) (Alexander et al., 2011b). Through these usability
assessments the design team identified potential problem areas encountered during interactions for each user type.
Again, these findings were used by software designers to improve the functionality, aesthetics, and appearance of the
sensor interface. Usability methodologies are important to meet ethical obligations of software design.

USABILITY IN HCI
Usability evaluation determines the extent that a technology is easy and pleasurable to use by determining if it is well
adapted to users, their tasks, and that negative outcomes are minimized as a result of use (Bastien, 2010). Usability
evaluation has been a staple of HCI researchers for the past 30 years and continues to grow in prominence as
technology advances have been made around the world. HCI designers have proposed that usability is inherently
measureable in all electronic technologies, that usability evaluation determines if an interactive system is usable, and
if a system is usable, then usability evaluation can determine the extent of usability using hardy usability metrics, and
finally, that usability evaluation is an accessible form of analysis and easy enough to learn about in HCI literature
(Cockton, 2013). There are a large number of methods available for designers to use to assess the usefulness of a
piece of medical technology. Table 9.2 provides a comparison of HCI methods for capturing user requirements to
help interested readers in selecting some appropriate HCI methods.

TABLE 9.2 Comparison of Methods for Capturing User Requirements

Contextual Inquiry
Contextual inquiry is qualitative in nature. This methodology is derived from ethnography, which focuses on
scientific descriptions and illustrations of social groups and systems. Contextual inquiry is usually conducted in the
field using extensive, well-designed, systematic observations to capture how people interact with technology in real-
world settings. Through this method the researcher becomes immersed in the group or system to understand how
interactions take place. This method provides rich data that can be voluminous depending on number of settings
involved, time spent in the settings, and the number of observations captured in the setting. Typically, sample subjects
are key informants who have specialized knowledge, status, or skills which are of interest to the researcher.
Oftentimes one, two, or more subjects can be observed individually or in dyads over periods of time to understand
how interactions take place or how technology may influence interactions. Decisions about the sample and settings
also have impacts on costs of conducting contextual inquiry research, which can be high. Researchers using
contextual inquiry methods use their interpretations of observations as a source to answer important questions about
social groups or systems. In many studies, other methods are used concurrently with contextual inquiry, such as focus
groups in order to validate researchers’ interpretations of phenomenon observed in the field.
Cognitive Task Analysis
Cognitive research is used to describe psychological processes associated with the acquisition, organization, and use
of knowledge (Hollnagel, 2003). Cognitive processes in human–machine interactions are complex and involve
continuous exchanges of information between operators and the machines they use, which is a type of shared
cognition. For example, nurses and physicians work in tandem to deliver optimal care for each patient. The design of
human–machine interfaces such as nursing and physician interfaces used for documentation and medical record
review must consider the nature of interdisciplinary work. Unfortunately, studies typical of evaluating nursing
workflow disruption have not been a focus in similar studies assessing physician workflow; for instance,
investigating how nursing roles and activities are affected by physician orders when implementing a clinical
information system would provide valuable design input for electronic medical record designs (Lee & McElmurry,
2010). Medical devices are also an important human–machine interface which are sometimes shared and need to be
tested collaboratively by interdisciplinary healthcare teams, but these evaluations are limited, such as evaluations
including both nurses and pharmacists should provide important design considerations for computerized provider
order entry for pharmacy and medication administration systems to ensure safe execution of orders and delivery of
medications (Alexander & Staggers, 2009).
Cognitive processes in human–machine systems involve the operator providing input to the machine, the machine
acting on the input, and displaying information back to the operator; the operator processes information through
sensing mechanisms such as visual, auditory, somatosensory, and vestibular systems; and finally, the operator
determines if the information from the machine is accurate, providing correct communication, decides what actions to
take, and provides new input to the machine (Proctor & Proctor, 2006). Attempts to understand and exploit human
capabilities and strengths within the area of human cognitive ability are critical to the safe design of technology. Safe
design includes responses to human stress and is an important variable in HCI research. For example, the ability of a
nurse to make timely and accurate decisions and to be vigilant of machine alarms during periods of sleep deprivation
while working several 12-h night shifts in a row is a common work scenario that is worthy of attention in HCI
research. Furthermore, human factors experts in nursing have begun using mapping techniques called link analysis to
map the cognitive processes of nursing work to understand what stresses or interruptions nurses encounter during
work, which contribute to cognitive delay. For example, nonlinearity of nursing work, which requires frequent shifts
in the process of delivering care results in interruptions and delays in care that contribute to unsafe environments
(Potter et al., 2004). Understanding cognitive abilities of operators in the healthcare sector provides better
understanding of physical and operational structures that affect clinical decision-making and clinical reasoning that
may lead to potential system failures.
Cognitive task analysis used to evaluate task load has been used in healthcare settings. These type of analyses are
typically qualitative in nature and involve interactions with “real” users to inform the design of new devices, which
have usability outcomes already established (Martin, Norris, Murphy, & Crowe, 2008). Examples of CTA, in health
care research, include the identification of potential errors performed with computer-based infusion devices used for
terbutaline administration in preterm labor; to evaluate cognitive and physical burdens during period of high
workload and stress while using computer-based physiological monitoring systems in cardiac anesthesia; and to gain
new perspectives in the work of nursing processes to understand how disruptions can contribute to nursing error in
acute care environments (Cook & Woods, 1996; Obradovich & Woods, 1996; Potter et al., 2004).

Usability Tests
The International Organization for Standardization’s definition of usability is “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/IEC, 1998). Usability evaluations are viewed as a critical component to inform all stages of
medical device product development from initial concepts through evaluation. The potential impacts of well-
designed usability studies for medical devices are reduced user errors and intensification of patient safety efforts.
For example, the National Institute of Standards and Technology in the U.S. Department of Commerce issued a report
describing why usability of electronic medical records is critical (Lowry et al., 2012). In the report, the authors
outline a three-step process for electronic health record evaluation and human user performance testing including the
following: (1) During the electronic health record design stage, users, work settings, and workflows are documented
to determine possible system usability problems and to develop a working model that minimizes potential safety
risks; (2) conduct an expert analysis comparing the prototype interface designs to rigorously established design
standards, such as heuristics discussed next in order to establish estimates of effectiveness, efficiency, and potential
risks; and finally (3) examine critical tasks to be performed with real users documenting objective performance
measures, such as task completion times, number of errors, and failures. Additionally, subjective measures are
important to identify, such as mismatches between user expectations identified during periods when users are
encouraged to think aloud about their experiences. Subject measures can be measured with simple usability scales, as
the System Usability Scale, which is freely available for researchers. These processes, if conducted in a rigorous
way, could be applied to any medical device usability evaluation, not just electronic health records.
Usability studies are often conducted in labs during early conceptual and prototype stages of a project. However,
usability studies should also be conducted through to final evaluation stages in the field. This is important because
field experiments can bring about unintended consequences due to workflows and processes encountered by users
during interactions with devices. There is evidence in the literature that field studies are not conducted as often as
they should be for crucial medical devices being implemented in patient care settings (Alexander & Staggers, 2009).
Reasons for a lack of usability studies in the field could be increased costs and disruptions to services from
excessive time commitments required for these types of assessments.

Heuristics
This type of HCI evaluation involves a small group of experts, who evaluate quantitatively how well a device meets
established design standards, called heuristics (Sharp, Rogers, & Preece, 2008). Procedures for a heuristic
evaluation are part of an iterative design process that enables identification and, hopefully, elimination of potential
risks that may cause dangerous outcomes. For example, designers of the Aging in Place sensor system, discussed
throughout this chapter, supported an extensive heuristic analysis of the sensor data display using three outside
experts who were trained in HCI methods. The sensor data display was evaluated against 16 heuristics, which
included 96 heuristic criteria in total, during the conceptual phase, before it was deployed in the clinical setting
where care coordinators use the sensor interface to coordinate care. The assessment was conducted in a usability lab
where the expert reviewers could interact with the sensor interface. Many recommendations were made by reviewers
to the design team to improve the sensor data interface, which were incorporated into the subsequent interface
designs.
The heuristic evaluation resulted in 26 recommendations for design change. Findings were classified according to
their importance, the most important being heuristic criteria that were not met. The most important design changes
that were not met included flexibility and efficiency of use of the interface due to lack of functional descriptions of
interface components provided, help and frequently asked question (FAQ) documentation that were provided to
users, lack of the interface to support all skill levels of users, and poor navigational issues related to lack of
feedback about where users were located in the system during interactions. Positive ratings were given heuristic
criteria related to aesthetic appeal of the interface and minimalist design (Alexander et al., 2008). Through this
process the design team was able to identify weaknesses in system design prior to implementation, responded by
redesigning the interface to strengthen support of these established criteria, and reducing the risk of potential negative
outcomes of use of the system.

Cognitive Walkthrough
Similar to heuristic evaluation, cognitive walkthrough is conducted using expert evaluators who are not necessarily
part of the population of end users of a technological device (Martin et al., 2008). Cognitive walkthrough evaluations
are task-specific, as compared to heuristic evaluation, which provides a holistic view of the interface and system
features. To be successful an investigator conducting a cognitive walkthrough must be aware of who are the systems
users, what tasks are to be analyzed, and sequences of tasks to be conducted, and that evaluators must know how the
interface functions (Unknown, 2014). This means that evaluators must be familiar with tasks, their composition, how
tasks are allocated, and feedback given in response to tasks.
Tasks. Tasks involve interplay between physical and cognitive activities and may be considered to follow a
continuum between nearly pure physical tasks, such as transporting a patient to an X-ray to nearly pure cognitive
tasks such as assessing hemodynamic status. Tasks tend to describe discrete, detailed behaviors needed to carry out
functions and functions tend to describe continuous, macro-level behaviors, such as analyzing or detecting (Sharit,
1997).

Task Composition. A task or action sequence starts with a goal, then steps are initiated based upon user intentions,
followed by the sequence of actions to be performed or intended to be performed, and the steps in the execution of
the task. After tasks are executed they are evaluated based on user perception, interpretation, and evaluation of the
interpretations of the actions. Task structures may be shallow, narrow, wide, and deep. Most everyday tasks, which
occupy most of a human’s time, are considered shallow, narrow structures that are opportunistic in nature, requiring
little complexity in analysis and minimal conscious activity. In shallow and narrow structures, humans need only
examine alternative actions and act; alternatively, wide and deep structures require a considerable amount of
conscious planning and thought, and usually require deliberate trial-and-error functions (Norman, 2002).

Feedback. Conditions that have been found to hinder feedback in healthcare environments include incomplete
awareness that system failures have occurred, time and work pressures, delays in action or outcome sequences, case
infrequence, deficient follow-up, failed communication, deficient reporting systems, case review biases, shift work
and handoffs (Croskerry, 2000). Feedback is an important element that may be derived from display information in
human–computer interactions and is important in the perception, implementation, and evaluation of tasks. Not all
system feedback mechanisms are technical in nature, sometimes feedback mechanisms are created through human
quality audits, peer reviews, and data mining. Emotional risks associated with the failure to provide feedback
include loss of confidence, uncertainty about performance, and increased stress.
Feedback mechanisms have been recognized as important components in nurse–computer interactions.
Improvements have been recognized in the visibility and standardization of coordination of care mechanisms in
wireless computerized information systems in nursing home information systems. In these settings, improved
feedback mechanisms positively affected staff documentation and communication patterns in automated wireless
nursing home environments where mobile devices were used by nurse assistants to document activities of daily
living as they occurred; simultaneously, nurses were able to see what cares had been completed and outcomes related
to the care. This seamless transition resulted in better quality and efficiency of patient care (Rantz et al., 2010). In
other reports evaluations of response times to critical laboratory results using automated feedback mechanisms
resulted in decreased response times following an appropriate treatment order (Kuperman et al., 1999). Information
technologies that facilitate transmission of important patient data can improve the quality of care.

Focus Groups
Focus groups are an excellent method to cumulate rich qualitative descriptions of how people interact with
technological systems. These are low costs methodologies that require little overhead to conduct, but can provide a
significant amount of information about usefulness of technologies, system processes, and satisfaction of people using
technology. Focus groups methodologies can be used throughout all product design stages and usually involve small
groups of users being interviewed by researcher who is interested in a specified phenomenon familiar to the users
(Krueger, 1994). Focus groups are usually conducted in a controlled environment to avoid distraction, such as a
conference room, where people can feel free to share openly about their experiences. Typically, focus groups are
conducted using well-thought-out questions, which are used by researchers to maintain some methodological
consistency. Taking time to think about these questions ahead of time will enhance reliability and reduce bias that
could be introduced by randomly questioning participants. Data from multiple focus groups are usually analyzed for
emerging themes that help support the research question. Data are analyzed until data saturation is reached and all
themes are realized from the data.

Delphi Technique
The Delphi technique is used to gain consensus from experts on a subject. This method uses multiple rounds of data
collection from experts, with each round using data from previous rounds. The questions posed focus on the opinions,
forecasts, and judgments of experts on a specific topic. Each round of questions completed is analyzed, summarized,
and returned to the experts with a new questionnaire. With each round of questions experts look over previous
information provided by the group and formulate opinions based on the whole group’s feedback until a consensus is
reached. This process of response, feedback, and response is usually repeated at least three times, or until a general
group consensus is obtained. Benefits of this methodology is acquiring input from multiple experts who may be
geographically dispersed, further, overhead and costs are generally low to conduct the method. Some limitations to
this method is that it can be time consuming and cooperation of consensus panel members might be reduced over the
length of the study.

OUTCOMES IN HCI
Traditional outcomes associated with HCI methods are efficiency, effectiveness, and satisfaction, which, as stated,
are highly related to how usable a piece of technology is. These outcomes have been a long-standing, central feature
of HCI for many years. With current emphasis by national institutes, such as National Institute of Standards and
Technology, on incorporating HCI methodologies into the life cycle of developing technologies, HCI principles and
methods will continue to grow in importance. Theoretical frameworks or models of clinical care using any form of
technology should incorporate HCI outcomes related to both the clinician and the patient. For example, satisfaction
with particular technologies will differ depending on whether the interaction being evaluated is between a patient
and a computer or a nurse and a computer. In the examples used throughout this chapter, the patients who are aging in
place, living with sensor systems have a very different set of expectations, compared to nurses who are using the
sensor system for early detection of health decline and care coordination. Patients claim they feel safer living with
the technology, but they are not necessarily interested in seeing or using the data being collected by the sensors.
Nurses have shown that the sensor data are useful in helping to predict early illness decline, but tracking big data
longitudinally presents some unique challenges in data visualization and prediction of health events. As new forms of
technologies evolve, traditional HCI outcomes may require updating to keep pace with development.

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