Serenity Health

Research defines the problem space.

Overview

The Challenge

The 2021 HFES Mobile Applications in Healthcare competition was a four-month competition where student teams worked to develop consumer-facing mobile apps showcasing how human factors research and methodology informed the design process. Early in the competition, our team decided that we wanted to focus on addressing the topic advanced directives and end of life care.

My Role

I worked on all aspects of the design of Serenity Health, from planning and executing the research to the design and testing of the final prototype. Each of the four student members of the development team contributed equally through various steps of the process, however I was the only team member who worked on developing the prototype and running users through testing.

Tools

Figma, Qualtrics

Methods

Exploratory Interviews, Survey Data, Personas, Context Analysis, Competitor Analysis, Prototyping

Defining the Problem Space

As a finished product Serenity Health takes the form of a "personal health records" (PHR) application with special focus on planning for the future and sharing with security, but it didn't start that way! The development process of Serenity Health began as an advanced directives application where users could set up and plan for end of life care for themselves. The project took several twists and turns along its path to being fully-realized, but the journey from research to development can be laid out in three, simple steps: know your user, know your product, and iterate through design and testing.

A full list of methods for this project include: GOMS Task Analysis, Heuristic Evaluations, the System Usability Scale, Cognitive Walk-Through, the creation of Prototype Design Guidelines, a Design Thinking Session, many Sketches, even more Prototyping, and (most importantly) User Testing. 


Understanding the User

Exploratory Interviews and Survey Data

Wanting to better understand the landscape of advanced directives and end of life care, our team conducted five exploratory interviews with people who had experience with advanced directives. After refining our questions and incorporating some feedback, we distributed an online survey on the topic of advanced directives and received 89 responses. Our goal during this early stage of design was to better understand how people think and talk about advanced directives and end of life care.

 

What are Advanced Directives?

An advanced directive is a legal document which outlines a person's wishes for medical treatment in the event that they become incapacitated and may be broad or specific in nature. 

Do you want to have discussions about your expectations for end of life care with your friends or family? 

"... It's something we easily talk about. Death is something we will all experience, so we talk about what our end of life decisions are freely and often."

Why do you think talking about end of life care is so difficult? 

"It's a very emotional topic for all involved. Emotion often supersedes logic for people, but understanding that it's all about what your loved one wants [...] is necessary for understanding and respecting such decisions."

What are your reasons for not creating advanced directives?

"The opportunity hasn't presented itself, and I haven't been motivated to go out of my way to complete one. I do plan on filling out an advanced directive [...] I want to absolve my loved ones from making hard decisions."

Main Persona Creation

Our survey data and interviews reflected a target audience with a wide range of age and experience; our personas varied in their medical and technical knowledge and know-how, and while some were worried about their health and their future, others weren't as worried. Let's meet Sandra, a 37-year-old fourth-grade teacher living in the suburbs.

Sandra S helped us clarify users who are looking to grapple with their own future as well as the future of the people they care about most. Understanding these motivations highlights the importance of a well-organized and easy-to-learn application, as well as the challenge of simplifying the complexity of advanced directives while maintaining their functionality.

User-Generated Insights

Legally Complex

As a legal process, creating advanced directives is complicated an time-consuming: each state in the US has a different set of procedures for filing and ratifying advanced directives, and decisions filed in one state may not be legally binding in another.

Difficult to Discuss

End-of-life care is a difficult topic to discuss with friends or family: the topic of death and dying is anxiety-inducing, and that apprehension prevents many conversations from happening.

Inaccessible to Most

Planning for end-of-life care is important for everyone to consider and discuss: designing accessible solutions allows a wide range of users to utilize these resources to their advantage.

The Problem Space: Are We Designing the Right Solution for the Right Problem?

Our team had a solid understanding of the problems which we wanted to address and the needs of users looking to navigate the space of advanced directives. We also identified the assumption our team had made by assuming that users would already know about advanced directives, or that users would necessarily want to engage with the subject. Our team's next step was to understand our product better: identify critical usability issues and analyze how existing applications approached the same problem.


Understanding the Product

Context Analysis

Context analysis is an expert method wherein critical usability issues are identified in a product's users, involved tasks, technical environment, physical environment, and organizational environment. The output of a context analysis involves specific, expected usability issues and methods for testing and controlling variables which relate to those usability issues. 

In this case our context analysis highlighted that the highly complex nature of creating advanced directives could go wrong at many steps, and we determined that it would be important to develop a formal task analysis. A concrete, textual task analysis would assist us in the evaluation of competitor applications and help us identify mismatches between user's models of a task and the implementations of that task. A formal task analysis is also important for the methods of cognitive walk through and think-aloud user testing procedures.

These highly complex tasks would also have sections which would depend on information from previously completed forms or sections of the same document. Maintaining task flexibility while communicating task requirements was a highlighted usability issue which the team could carry into our competitor analysis. While advanced directives are legal in nature, they also deal with many medical factors which are personal and unique to everyone. Documenting medical history for identifying important forms or sections to complete typically involves memory recall, and making decisions about future care can be a taxing cognitive process on its own. 

GOMS Task Analysis

A formal task analysis assists in evaluating competitor applications and identifying mismatches between the task and a user's models of the task.

Maintain Flexibility

Maintaining task flexibility while communicating task requirements was a highlighted usability issue which the team could carry into our competitor analysis.

Reduce Workload

Recalling information about one's own medical history and making decisions and plans regarding future care can be a taxing cognitive process.

Competitor Analysis

Our team performed competitor analysis on several different applications, spanning the categories of end-of-life care, lifestyle & fitness, and personal health records (PHR).

Our team evaluated two applications aimed at walking users through the process of preparing for their end-of-life care. We used these competitor applications to inform our task analyses, and offered heuristic evaluations of the applications using Nielsen's 10 guidelines for interface design with emphasis (informed by our context analysis) of the importance of task flexibility and mental demands. We modeled our heuristic evaluation from Nielsen's 10 because of the inclusion of "task flexibility" and "low cognitive load" in its scoring system.

From our user-generated insights, we wanted to better understand how existing applications encouraged users to tackle difficult health-related issues. To this end, we performed competitor analysis on three "lifestyle" applications using similar methods to our competitor analysis for end-of-life care applications.

From our context analysis, we also wanted to analyze how existing health applications assisted users in the mentally-taxing task of inputting complex medical data. For this, we performed competitor analysis on three personal health records (PHR) applications using the same methods as we used for our analysis of lifestyle applications.

The Money Behind Advanced Directive Applications

Insurance-driven applications don't communicate peace of mind, and their data practices offer little in regards to security and privacy.

How Lifestyle Applications Make the Daunting, Exciting

Lifestyle applications don't necessarily motivate users to complete tasks they weren't already motivated to do.

The Landscape of PHR Applications

Existing personal health records applications are difficult to navigate and most don't offer the ability to import medical data from external sources.

Critical Point: Redefining Our Problem Space

Our team saw opportunity to feed two birds with one scone: both PHR and end-of-life care apps were difficult to use. The developers and owners of advanced directive apps were insurance companies, which led to an experience which felt motivated by money rather than health. Our team also identified that there could be huge benefit in nesting advanced directives within the framework of a PHR app, helping users approach the topic from a medically-focused state of mind.

Final Design

Our team was able to complete two iterations of clickable prototype for the competition, both developed in Figma. Our first prototype was a clickable, low-fidelity prototype which revolved around proof of concept for planned application layout and overall architecture. A round of testing was performed with users doing concurrent think-aloud procedures. Information gathered during the first round of testing was incorporated into design changes in the final prototype. A link to a clickable version of the final prototype can be found below.

Clear, Distinct Interface Design

The final design for the home screen for Serenity Health. Large icons and high contrast text ensures easy navigation through a clutter-free page.

Low Workload - High Flexibility

Step-by-step guides through sections for advanced directives were incorporated to be cognitively low-workload by presenting one question at a time, and flexible by allowing users to start and stop at any point.

Easy Import - Secure Export


Users are able to send and receive information of their choice over long or short distances, and privacy is protected by an app-specific PIN lock.

What I Learned & Next Steps

Prepare for Stakeholders

While our team didn't have stakeholders to leverage, it's important to consider how things would have changed if our team did have stakeholders. We would have needed buy-in from those stakeholders for the main shift from end-of-life care to a personal health records application, and that likely means more formalized research showing the differences between a stand-alone application and the nested concept we switched to. 

Further, our team would have had to give considerations for the privacy of the information that users would enter into the app as well as concerns about the legality of the documents stored in the application. Those conversations would have happened both with stakeholders as well as subject matter experts for each issue.

Choose a More Simple Problem

The competition prompt asked that teams be able to show improved patient outcomes as a result of application design, and would be difficult to do for Serenity Health on account of both the sensitive nature of the information involved as well as the long time scale that outcomes would be measured on. 

Additionally, the development of a full personal health records application would be a gargantuan task for any team: in the future I would have recognized the difficulty of the task overall and focused mainly on the development of how to effectively nest advanced directives inside a PHR app.

Check Your Assumptions About the Problem Space

I'm happy with how our team performed for the competition, and the amount of work that went into the pre-design stage. We definitely had some important conversations throughout the competition and I walked away knowing that everyone on my team had learned something through the competition.