The Role of Human Factors in Home Health Care Workshop Summary (2010) / Chapter Skim
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6 The Health Care Challenge: Matching Care to People inTheir Home Environments--Neil Charness
6 The Health Care Challenge: Matching Care to People inTheir Home Environments--Neil Charness
Pages 73-116
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examine data on their capabilities; (3) assess their attitudes and how these might be expected to impact successful interaction with current and future home health care technology; (4)
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(Those with chronic conditions also experience disproportionate treatment for acute conditions.) The definition of chronic diseases by the Centers for Disease Control and Prevention is that they are "noncommunicable illnesses that are prolonged in duration, do not resolve spontaneously, and are rarely cured completely." The five most costly ones in 2006 were (1)
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, will also increase demands on the health care system. The future population of home health care users is already in place: it is the current U.S.
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In addition, many of those who have chronic conditions now (e.g., spinal cord injuries, diabetes) will continue to consume home health care services as their general health deteriorates and as comorbidities develop.
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THE PERSON-ENVIRONMENT FIT FRAMEWORK I consider health care somewhat broadly to include not only treatment of acute or chronic disorders but also such processes as information seeking and advice provision for health-related activities (e.g., exercise and diet) that might occur through a search of the Internet.1 A useful framework for envisioning how best to match care to people in their home environments is that of capability-demand fit.
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As another example, think of some of the demands made by newer mobile vital sign monitoring devices now entering the home health care market. Consider a wristwatch-like device that, in the presence of a wireless network in the home, streams information, such as the user's temperature, location, and potential falls (via an embedded accelerometer)
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For most health self-care, the proximal environment includes the home, its residents, and health care devices. In the United States, some relevant characteristics of households for the noninstitutionalized civilian population are shown in Table 6-1 and Figure 6-4.
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and instrumental activities of daily living (IADLs) and, more specifically, with health technology products.
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A more inclusive definition of the health care environment would consider other providers outside the home (physicians, nurses, formal and informal caregivers) , including health care staff or advisors associated with schools and workplaces as well as other service providers who enter the home (e.g., to prepare meals, help with bathing)
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For example, for people ages 65+, only about 5 percent live in congregate housing settings, although percentages rise steeply with age. DEMOGRAPHICS OF HEALTH CARE uSERS Every member of the population is a potential home health care user.
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is beyond the scope of this chapter. However, given that those with chronic conditions incur about 90 percent of the health care expenditures, they are the primary focus of this review.
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SOURCE: Based on data from U.S. Census Bureau (2010)
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Finally, the types of disability in veteran populations are likely to differ from those in the civilian population and have implications for home health care system design. Given the very high prevalence of musculoskeletal and hearing problems, health care device manufacturers need to pay heed to ease of manipulation (for example, permit one-handed operation of devices similar
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I briefly review some of those changes, at the general population level, as they pertain to health care utilization and, when information is available, to health technology use. What becomes obvious for each category is that there is enormous diversity in the United States, making the tasks of designing home health care devices and training challenging ones.
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For four or more years of college, there was a sixfold increase, from 5 to over 30 percent. Part of the increase in attainment may be attributed to a concomitant increase in cognitive ability worldwide (measured with intelligence tests,
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, comprehend complex instructions when given in English (listening comprehension skills) , or be able to use a health care device like a glucose meter when provided with written English instructions (reading comprehension skills)
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SOURCE: U.S. Census Bureau, Population Projections of the United States by Age, Sex, Race, Hispanic Origin, and Nativity: 1999 to 2100.
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although video demonstrations of the use of some health care devices are already available on the Internet in languages other than English (e.g., a glucose meter with Spanish instructions on YouTube)
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Thus, one must consider the person-environment fit for any home health care device and system, and this leads to the first commandment of human factors and ergonomics, sometimes phrased as "Honor thy user" or "Know thy user." PERCEPTuAL, COGNITIVE, AND PSYCHOMOTOR CAPABILITIES OF uSERS I now briefly review some of the normative changes with age (and disability) that can affect interactions with home health care technology, giving some examples for such abilities as perception, cognition, and psychomotor ability, and anthropometrics.
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Such guidelines are often violated with printed medication information, as seen in Figure 6-10, in part due to constraints of packaging. Prescription drug containers are now often accompanied by page-sized instruction sheets that do use larger print (although that information may easily become separated from the pill container)
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. Thus, when needing to learn to use a new home health care device from instructional materials, both very young children and older adults are likely to be disadvantaged, as will be those with poor English comprehension skills and veterans with closed head injuries (increasingly common for recent veterans because of roadside bomb incidents)
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Although knowledge tends to increase with age, there are major individual differences in knowledge in the population (e.g., as a function of education) and particularly in knowledge about health, termed health literacy (e.g., in the ability to comprehend written health instructions, see Benson and Forman, 2002; measured in national surveys, see National Center for Education Statistics, 2006)
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uSER AND PROVIDER ATTITuDES TOWARD HEALTH CARE AND HEALTH CARE TECHNOLOGY Attitudes are frequently invoked as an important factor in health care utilization, although most studies provide associations. General attitudes toward health and health care may constrain utilization and treatment
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. Here I focus primarily on the narrower case of attitudes that may influence home health care technology use.
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SOURCE: Pew Internet and American Life Project trend data for "usage over time." Available: http://www.pewinternet.org/Trend-Data/Usage-Over-Time.aspx [accessed August 2010]
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; economically disadvantaged groups, who are also the most likely to be in poorer health (e.g., Marmot and Shipley, 1996; Crimmins, Kim, and Seeman, 2009) , are the least able to access health care information and services in this way.5 Survey research suggests that attitudes toward health care and health care technology are related to a number of factors, including age, gender, and ethnicity.
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. So there is reason to be optimistic that those with negative attitudes toward health care technology might change in a positive direction if the equipment is well designed and well supported.
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representative sample of Americans in the Pew Internet and American Life Project and found that, although Internet users have a strong stated preference for privacy when they go online, their risky behavior online does not match their stated concerns (19 percent reported credit card or identity theft, although only 8 percent of those cases involved online theft)
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is feasible for that group, assuming that people can be convinced to adopt smart phone technology and adopt data plans that provide Internet access from the phone. However, at present, such devices represent a small percentage of overall mobile phone use in the United States (about 25 percent of mobile phone users; see http://news.cnet.
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. elsewhere, except for controversies over how to access such services with mobile phone technology.
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, showing significant clinical benefits for management of chronic conditions, including hypertension and AIDS, with less evidence of efficacy for diabetes. A quick review by the author of studies conducted subsequent to those reports indicates that cost-effectiveness was shown for management of congestive heart failure, although in a very small sample (Lehmann, Mintz, and Giacini, 2006)
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for a discussion of human factors issues in designing handheld digital devices. Personal anecdotes also underline the need for a better personenvironment fit for mobile phone use at the level of device design and particularly for instructional support (which is often sparse for mobile phones)
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The level of decomposition depends on the goals of the analysis as well as the type of device or environment. For an example, see the task analysis of using a blood glucose meter by Rogers and colleagues (2001)
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to predict how long tasks would take for different user groups or different devices. Such simulation techniques can uncover design flaws in devices (e.g., inadequate time-out intervals for input on some mobile phones; Jastrzembski and Charness, 2007)
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Knowledge of user Attitudes There is a lack of representative data on attitudes toward health care technologies (e.g., privacy concerns and trust) , health care technology adoption, and, more importantly, technology abandonment.
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Given the importance of access to health care information, coupled with the rapid movement of such information to the Internet, having highspeed Internet access in households is becoming more of a necessity than a luxury. Telehealth applications to homes, including diagnosis, treatment, and rehabilitation, would be facilitated by such access.
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Too little is known about the most effective techniques to instruct and train the use of home health care devices and how to search for and evaluate health care information (e.g., from the web) in the increasingly diverse population of home health care users.
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. Chronic conditions: Making the case for ongoing care.
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. Comprehension of written health care information in an affluent geriatric retirement community: Use of the Test of Functional Health Literacy.
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. New York: Lawrence Erlbaum Associates.
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Wash ington, DC: Pew Internet and American Life Project. Available: http://www.pewinternet.
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. Health care expenses for adults with chronic conditions, 200.
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. Correlates of health literacy in patients with chronic heart failure.
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Journal of the American Geriatric Society, 2, 989-994. Suggested General Readings Carayon, P., and Friesdorf, W
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