Literature Review and Environmental Scan: Evaluation of Personal Health Records Pilots for Fee-for-Service Medicare Enrollees. PHR Usability


When deciding whether or not to use a PHR, consumers balance its expected utility with its actual ease of use–or usability. It matters little that something is easy to use if it is not what you want. Similarly, a PHR would offer little value if the system can hypothetically do what you want, but you can’t make it happen because the user interface is too cumbersome or difficult to navigate (e.g., too many mouse clicks moving from screen-to-screen or irrelevant but required data-entry fields).[122] This section defines the term ‘usability’ presents general principles and methods to enhance usability, and reviews what is known about PHR usability from the perspective of consumers. This section emphasizes a user-centered design approach. Although there is some overlap in the techniques for assessing the utility and usability of a product, this section focuses on user-centered design process after it is determined that the PHR offers utility to consumers.

Definition of Usability

Usability is a quality attribute that refers to how well users can learn and use a product to achieve their goals and how satisfied they are with that process. The term usability also refers to methods for improving ease-of-use during the design process.[123] Hess and Shneiderman recommend that usability research be conducted from the user’s perspective. They maintain, however, that proposing and asking the right questions is difficult.

Historically, computer developers have been tempted to ask, ‘What can the computer do?’ New advances in health IT are prompting developers to ask, ‘What can people do?’ To be effective, health IT research should combine best evidence from user sciences (human factors engineering, human-computer interaction, psychology, and usability) with best evidence in medicine.[124]

Each of the usability components below involves the extent and success to which a user can perform tasks at all levels of complexity. When viewed together, the following five components lead to an assessment of consumers’ overall user experience:[125]

  1. Learnability: How easy is it for users to accomplish basic tasks the first time they encounter the design?
  2. Efficiency: Once users have learned the design, how quickly can they perform tasks?
  3. Memorability: When users return to the design after a period of not using it, how easily can they reestablish proficiency?
  4. Errors: How many errors do users make, how severe are these errors, and how easily can they recover from the errors?
  5. Satisfaction: How pleasant is it to use the design?

General Principles and Methods to Enhance Usability

To maximize usability, PHRs must accommodate the needs and characteristics of a range of potential users, follow usability guidelines and checklists for their design, iteratively test and revise the PHR, and monitor usage and usability of the PHR after its release. An important goal of PHRs is to extend the reach of PHRs to diverse beneficiaries in an equitable fashion.

The University of Wisconsin’s Comprehensive Health Education Support System (CHESS) used formative usability testing to help ensure that CHESS is equally accessible to a broad range of users. CHESS is a computer-based system designed to support women with breast cancer. Usability testing and principles were used throughout CHESS’ design. A study demonstrated that underserved women with breast cancer successfully used CHESS as much if not more than their more advantaged counterparts. In addition, access to CHESS was correlated with quality of life improvement and greater participation in the health care system.[126] Usability testing was also examined in a study of the differential effects of online narrative and didactic information on participants by race. This study found that African Americans use and benefit more from online narrative and didactic information than do Caucasians.[127]

Usability guidelines specific to PHRs have not yet been developed. Until such guidelines are developed, basic usability theory and guidelines (often called checklists) can be applied to PHRs. Gary Marchionini believes that once developed, generic PHR guidelines look like basic web usability guidelines (Marchionini himself utilized the National Cancer Institute’s usability guidelines for his own PHR usability studies.) Web usability guidelines have also been written for aged, disabled, and limited literacy populations.[128] These guidelines generally advise that the reading level, content, and format of the IT be designed to be accessible to all potential users. A sample of recommended guidelines suggests the following:[129]

  • Plain and clear language
  • Placement of the most important content at the top of the page
  • 12 or 14 point type size for body text
  • Left justification of text (no right justification)
  • Simple and straightforward organization of website
  • Avoidance of the need for scrolling text

The VHA’s PHR, ‘My HealtheVet’ follows general usability and Federal Section 508 accessibility guidelines for persons with disabilities. According to VHA staff, ‘My HealtheVet’ was designed for the ‘lowest common denominator’ as it serves a wide variety of veterans–young, old, and highly and less highly educated.

Iterative Usability Testing and Revision

User-centered design and usability theory and guidelines recommend that the product (the PHR) be tested again and again throughout the design process, and that prospective users be included in the testing. Usability testing has a number of possible goals and purposes. One of the most important is to discover major problems in the user interface that could result in human error, termination of the interaction, and lead to frustration on the part of the user.[130] Other goals might be to reduce training time, promote performance and efficiency, and increase user satisfaction.[131]

The testing by prospective users should address the following questions:

  • Is the application easy to use and navigate?
  • Is the content appropriate, acceptable, and applicable?
  • Do participants want and choose to use the application?

Usability testing employs representative users who try to do typical tasks with the product, while observers, including the development staff, watch, listen and take notes. Testing may take place in the home or in a testing facility with a two-way mirror or similar observation techniques. Home testing provides the design team with information on the capability of the users’ computer hardware, as well as the ease of use of the program’s features. During the software design stage, successive and iterative rounds of testing by the design team and potential users should continue. Testing and revision should continue until there is little to be learned from additional testing.

After adequate usability testing, alpha and beta tests should be conducted to assess whether the PHR works effectively in a ‘real world’ scenario. Then, major modules or features should be released in phases. This ‘phase in’ allows the PHR vendor or sponsor to isolate problems and correct for them. Whatcom County staff developed and tested its PHR using user-centered design principles, but found that it needed to engage providers in this process and incorporate their needs and workflow as well.

Ongoing Monitoring of PHR Usability

The usability of a PHR should continue to be monitored after the large-scale release. A number of monitoring techniques can be used:

  • Monitor help desk questions, as these questions highlight problems that users experience
  • Conduct satisfaction surveys (online or at a provider’s office) to assess user satisfaction and dissatisfaction with the overall PHR and its specific functions
  • Monitor the number of users and the functions they employ
  • Assess the questions and comments emailed to the webmaster
  • Administer follow-on usability tests (as consumers’ expectations may change)
  • Conduct user research (observing consumers) to assess how the product is used (especially before the product’s second release)

NORC’s discussions with Kaiser Permanente, VHA, Intuit, LifeLedger and Whatcom County staff indicated that they have found these approaches to be effective for uncovering barriers to usability.

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