E-health: the importance of usability and accessibility

21 April 2016

Websites, apps, and smart devices are slowly changing the face of healthcare. E-health is making patients more independent, care more affordable, and processes more efficient. But this is no easy feat: those who develop digital healthcare solutions have to contend with specific target groups and sensitive personal information. Developing sites and apps for the healthcare sector requires a focus on accessibility and usability. This article discusses some of these points in more detail.

Follow the standards

Many healthcare sites and apps are geared towards an older target group that requires more care than the rest of the population. If the people in your target group have trouble seeing or trouble operating devices like smartphones, tablets, or laptops, accessibility becomes even more important. "If the people in a target group have trouble seeing or trouble operating devices like smartphones, tablets, or laptops, accessibility becomes even more important."

Web guidelines

For the Web, you can use the international guidelines WCAG 2.0 is based on four principles: perceivable, operable, understandable, and robust. Guidelines have been developed for each principle that explain how you can make your website or application more accessible. These are divided into three levels: A, AA, and AAA. Think carefully about which level you want to support; supporting the highest level can be extremely difficult and not always necessary, as level AA is often sufficient. The European Union is drafting new legislation that takes WCAG 2.0 level AA as its starting point.

There's also a Dutch version of these web guidelines, known as web guidelines version 2. These guidelines contain the international text and a fifth principle, known as the universal principle, which describes the guidelines for creating content that is accessible, exchangeable, meaningful, and durable for everyone. Examples include using clear headers and separating content and presentation so you can present your content in a different context.

iOS and Android guidelines

Are you developing an app? Apple (iOS Human Interface Guidelines) and Google (Material Design) have established guidelines on designing the best app. Applying these standards will help you ensure that the integrated accessibility settings, such as voice-over and dictation features, actually work. It also gives users the option of changing the contrast and font size. Another advantage is that you can make good use of the design conventions that users are familiar with from other apps.

Knowing when to deviate...

In some situations, it's not possible to apply the standards. Ultimately, it all comes down to usability. With the iOS interface, for example, the font size in the navigation bar and the tab bar can't be changed. Is the tab bar really necessary? Or is there another design option available? Is deviating from the standards a good idea? Changes often have to be developed for each specific resolution. Given the high development costs, it's worth considering whether this is the best option.

As Nielsen Norman Group demonstrated in a  study, these standards are not sacrosanct. The company questioned the effectiveness of hidden content that can only be accessed by swiping and the form submit button at the top of a page. They also advise against the standard "+" icon.

Use clear and accessible language

Whether you're university-educated, non-university educated, a Dutch native or a foreigner: everyone gets sick. There are huge differences in language proficiency in a target group, so be sure to avoid complex language if you can. The Council of Europe created a useful tool that distinguished between six language levels (from A1 to C2). A good starting point is level B1, which can be considered "simple Dutch". A glossary has been compiled for each level. A good example is the word "symptoms," which does not meet the B1 level requirements. Instead, you should use the word "complaints," if the context allows. Consult the Dutch website  Zoekeenvoudigewoorden.nl to check whether a word meets the B1 language requirements.

Identify the client and patient journeys

E-health often requires you to deal with a range of stakeholders and target groups. Make sure you identify the journey each target group embarks on when they first discover your product or service. What do people think and how do they feel? What are their concerns or objections? "Make sure you identify the journey each target group embarks on when they first discover your product or service."

Patients may be the end users of your site or app, but they're not necessarily the client. A product or service will never be successful just because patients recognize their value. You'll have to convince the healthcare provider of the importance of change in order to achieve real success. A customer journey can help you identify the key decision-making moments.

In some cases, your product will be used by friends or family members, simply because the patient is unable to use it. You might want to think about creating a separate channel for these caregivers. Watch the video below for a short introduction on creating customer journey maps.

Security should never be at the expense of usability.

Security and privacy is an important consideration in e-health. But how do you prevent security from becoming a barrier to usability? Below are a few tips:

  • If users are logged out automatically after each session, make sure the authentication process is easy. Banks are particularly good at this and use a simple PIN code or a fingerprint scanner for new iPhones (TouchID). Another option is two-factor authentication, which requires two separate login factors (e.g. a text message).
  • If you decide to set password restrictions make sure users know what these restrictions are and offer feedback if the password wasn't entered correctly (e.g. a check mark next to the input field). Password length is one of the most important security factors. Other factors, like special characters, don't make the password more secure, but they do make things harder for users.
  • Give users the ability to designate certain devices, such as laptops, tablets, or smartphones as trusted devices. This will allow you to set extra login requirements when a user logs in from an unknown location. Notifying users by e-mail gives them the opportunity to intervene in the event of an unknown login attempt.
  • Be transparent about who has access to personal information. For each account, indicate which systems or organizations have access to the information provided and give users the option of restricting or revoking this access.
  • If you are unable to determine who opened an account on your website or app, send ageneral notificationwhen someone attempts to register with an existing e-mail address. This notification could include something like: "further instructions have been sent to your e-mail address". You can then notify the individual that someone attempted to create an account using their e-mail address. The same method applies when someone forgets their password.

Wearables and other resources

Monitoring your heart rate while exercising, tracking the number of steps you take on a daily basis, or monitoring your sleep patterns: there are plenty of wearables on the market that can track these events. In addition to consumer wearables, there are also medical devices on the market that you can link to your tablet or smartphone via Bluetooth. These allow you to monitor blood pressure, heart rate, and oxygen levels. User experience is extremely important for devices like these. The interface, paired with an app or website, makes for a more complex interaction. Be sure to think carefully about how the device will be used in practice.

Develop efficient user flows

"As wearables and other device make interaction more complex, user flows can be a very useful tool." A user flow is the sequence of steps that a user follows in order to perform a task. As wearables and other devices make interaction more complex, user flows can be a very useful tool. For example, the sequence of actions can differ per patient. If someone is tracking their weight, he or she may start by using a smart bathroom scale instead of your application. Ideally, they should be able to record their weight measurement in your app. Give patient the ability to submit their measurements or take new measurement. You should also think about solutions to possible problems (e.g. manually entering a weight measurement).

Ask patients about the context

Whether you work with medically-approved devices or consumer electronics, it's always important to know your patient's situation at the time of the measurement. A high blood pressure reading may be because the patient just vacuumed the house. Give patients the opportunity to comment on their measurements. If a patient can vacuum, it means they're active!

Test with end users

You'll have carry out several end user tests to determine the usability of your app or website. There's no need for a finished product; an accessible prototype is all you need to carry out a usability test. Start small and create a testing ground. Many usability problems can be observed with groups of ten users or fewer. It's better to carry out four tests with five users than one test with twenty users.

Websites and apps aren't the only examples of successful e-health applications. E-health brings about an organizational change and a different way of thinking for patients and healthcare providers. It requires considerable research, like the PhD research conducted by Martine Breteler on the impact of digitization in healthcare. Usability and accessibility are important pillars in all areas of e-health. In fact, all digital solutions should be user-friendly and accessible to everyone.

Arnoud works at One Shoe and helps organization develop the user experience that matches their online ambitions. He advises, creates, and designs user experiences for mobile and web-based applications. He has a strong affinity with e-health. Clients include the Nederlandse Huisartsen Genootschap (NHG), thuisarts.nl, FocusCura, UMC Utrecht, the Landelijke Huisartsen Vereniging, and organizations outside the e-health discipline, such as ING, NCRV, GroenLinks, and Utrecht University.

This blog post was previously published on Frankwatching.