Introduction

The shift from institutional to home care is one of the most significant trends in health care today. In 1991, 23 percent of Americans reported needing home medical care for themselves or a family member during the preceding 5 years—a percentage that has probably risen since the 1991 data were collected by the National Association for Medical Equipment Services.

As part of the national trend toward home care, a growing number and variety of medical devices have become available for use in the home. They range in sophistication from wheelchairs, walkers, and basic mobility aids; to patient monitors, glucose meters, and ventilators; to high-technology infusion, dialysis, and respiration devices.

INCENTIVES FOR HOME CARE

Multiple factors are fueling the growth in home health care and home medical equipment. Advances in medical technology have enabled people to consider home care for chronic illnesses and disabilities that would have kept them in a hospital or a nursing home in the past. Mounting pressures to contain health care costs have created economic incentives for home care. And with the number of Americans age 65 and over expected to double in the next 45 years, the need for health care in all settings will continue to rise.

Patient preference is another important factor. Most people (72 percent of respondents in a 1991 survey by the American Association of



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Safe, Comfortable, Attractive, and Easy to Use: Improving the Usability of Home Medical Devices Introduction The shift from institutional to home care is one of the most significant trends in health care today. In 1991, 23 percent of Americans reported needing home medical care for themselves or a family member during the preceding 5 years—a percentage that has probably risen since the 1991 data were collected by the National Association for Medical Equipment Services. As part of the national trend toward home care, a growing number and variety of medical devices have become available for use in the home. They range in sophistication from wheelchairs, walkers, and basic mobility aids; to patient monitors, glucose meters, and ventilators; to high-technology infusion, dialysis, and respiration devices. INCENTIVES FOR HOME CARE Multiple factors are fueling the growth in home health care and home medical equipment. Advances in medical technology have enabled people to consider home care for chronic illnesses and disabilities that would have kept them in a hospital or a nursing home in the past. Mounting pressures to contain health care costs have created economic incentives for home care. And with the number of Americans age 65 and over expected to double in the next 45 years, the need for health care in all settings will continue to rise. Patient preference is another important factor. Most people (72 percent of respondents in a 1991 survey by the American Association of

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Safe, Comfortable, Attractive, and Easy to Use: Improving the Usability of Home Medical Devices Retired Persons) prefer home care over hospital or nursing home care. They like the privacy, autonomy, and sense of control that home care gives them. They like being in a familiar, comfortable environment, in which they can interact with family and friends and retain their sense of identity. CAREGIVER NEEDS AND DEMANDS In order to go home, patients must be in good enough shape to take care of themselves or, more likely, must have someone available to take care of them—a spouse, a family member, a companion, or a home care professional or paraprofessional. About two-thirds of all home care in the nation comes from family caregivers, and the rest is provided by nurses, therapists, technicians, home care attendants, and the patients themselves. About 18 to 25 million people in the United States are family caregivers. The estimated market value of their services exceeds $190 billion a year. A typical family caregiver is a married woman in midlife who has been caring for her husband for 8 years and expects to do so for the rest of his life. According to a member survey by the National Family Caregivers Association, 81 percent of caregivers are female; 68 percent are between the ages of 40 and 60, and 79 percent are married (see Table 1). Most have a part-time or full-time job outside the home. Many feel frustrated, depressed, overworked, and isolated, and most would like more help from others. Using home medical equipment places serious responsibilities on caregivers and patients. Equipment failures and operator errors can be fatal or can put the patient back in the hospital. Caregivers must make very complex judgments about such factors as oxygen levels and fluid balance. They must take care of cleaning and maintenance chores. In short, they must be able to use home medical equipment safely, effectively, and with a minimum of discomfort. TABLE 1 Family Caregivers—A Demographic Profile Characteristic Percentage Sex   Female 81 Male 16 Age   30-39 9 40-59 68 60-69 13 70+ 7 Marital Status   Married 79 Single, Widowed, Divorced 19 Education   High School Graduate 36 Associate - 4-Year Degree 39 Masters/Doctorate 19 Source: Caregiver Member Survey Report, Executive Summary, May 1994.

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Safe, Comfortable, Attractive, and Easy to Use: Improving the Usability of Home Medical Devices HUMAN FACTORS AND HOME MEDICAL EQUIPMENT Human factors research provides a systematic approach to helping people use devices with greater safety, satisfaction, accuracy, and comfort. Drawing on a body of scientific knowledge about human capabilities and limitations as well as objective data about human interaction with equipment, human factors specialists design ways to improve work environments and make equipment more usable. An expanding field that includes ergonomics and usability engineering, human factors science has examined such issues as why power plant workers make errors, how furniture movers can avoid injury, and how people interact with computers and other forms of automation. Although human factors research is just beginning to be systematically used by the home medical device industry, we believe it holds great promise for the improvement of both equipment design and user training. Good design is especially critical for home medical equipment because users may have infirmities, high stress, limited training, and inadequate sources of advice and support. Applying human factors research to the design and manufacture of home medical equipment can reduce the burdens of caregivers; increase safety, dexterity, and comfort; make devices easier to use and maintain; and lower costs. Failing to consider human factors can lead to dissatisfaction, more human errors, and potentially dangerous consequences for users. One example of this kind of failure is a blood glucose monitor with tiny, insertable reagent strips that are difficult to manipulate; another is an infusion pump on which the numbers can easily be misread when viewed from various angles. In studying home medical equipment, human factors researchers ask such questions as: Are the controls, displays, and instructions understandable? How easily can the equipment be moved? How much force is needed to turn the dial, and can an impaired or elderly person do it? Can people hear the beeps or alarms? Can they read the instructions if their vision is diminished? PURPOSE OF THE WORKSHOP The purposes of the workshop were to elicit information about the home medical equipment industry, discuss the potential contributions and major challenges of applying human factors research to it, initiate dialogue and share perspectives among the different groups concerned, and help shape the future work of the committee and the human factors field in this area.

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Safe, Comfortable, Attractive, and Easy to Use: Improving the Usability of Home Medical Devices The workshop included 14 presentations by representatives of groups with an interest in home medical equipment (see the appendix for the full agenda). Each presentation was followed by questions from and discussion with the workshop participants. The day concluded with a whole-group discussion of the major issues raised during the workshop. This report summarizes the workshop presentations and discussion of caregivers, manufacturers, suppliers, regulatory agencies, and human factors specialists. The next section presents the perspectives of the major groups with an interest in home medical equipment and human factors. The final section synthesizes the issues from the workshop and presents the committee's observations.