Towards a New Design Paradigm for Complex Electronic Medical Record Systems: Intuitive User Interfaces

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1 th Hawaii International Conference on System Sciences Towards a New Design Paradigm for Complex Electronic Medical Record Systems: Intuitive User Interfaces Virginia Ilie, Ph.D. California Lutheran University Thousand Oaks, CA, USA Ofir Turel, Ph.D. California State University, Fullerton, CA, USA Paul D. Witman, Ph.D. California Lutheran University Thousand Oaks, CA, USA Abstract Design of usable interfaces has preoccupied information systems researchers for decades however there is still little agreement as to what constitute usable systems. Many complex systems such as electronic medical records (EMR) fail to provide users with an intuitive interface and are not designed for environments where (1) users operate under severe opportunity-cost time pressures and (2) users engage in goal-directed activities to accomplish a task. Under these circumstances, what kind of interface should EMR systems present to clinical users? To answer this question the concept of intuitive interface based on theories of human intuition such as cognitive-experiential self-theory and cognitive neuroscience is first defined. Next interviews with clinical staff at two hospitals uncover various aspects of intuitive EMR interfaces, and point to the need to further study and improve this important issue. Significance of this research as well as future research directions are discussed. 1. Introduction Design of usable interfaces has preoccupied information systems researchers for decades. There is still little agreement among researchers as to what constitute usable systems. Usability remains an elusive concept [42] as it is difficult to design a system to fit everyone s needs [23]. One stream of research relates usability to Web site specific features based on a set of design principles for the Web [34]. These principles provided a framework for many studies investigating usability of e-commerce sites. Another stream of research built on established standards such as Microsoft usability guidelines (MUG) and ISO s Ergonomics of Human System Interaction (ISO ). Researchers developed a set of usability metrics for web-sites based on dimensions such as content, ease of use, promotion, made-for-the-medium and emotion [1, 52]. Despite this important body of research in the human-computer interaction, many complex enterprise systems such as electronic medical records (EMR) fail to provide users with an intuitive interface. Presumably, this is because such systems were not initially designed for environments where there is an opportunity-cost time pressure such as healthcare. In typical healthcare environments, clinical staff works under severe time constraints and conflicting work demands [25]. Current research on decision-making in such circumstances suggests three ways in which individuals respond to decision problems under time pressures. First, individuals tend to accelerate their processing or spend less time processing the information [6]. Second, processing tends to be more selective under time pressures with more focus on the important or negative information about alternatives [53]. Third, decision strategies may shift as a result of time pressures [36]. This view is also supported in EMR studies, showing that physicians act based on a least-effort perspective. When faced with a choice between alternate information sources including the paper chart and electronic medical records, they tended to select and use the one that required least effort [25]. Moreover, the use of complex EMR in healthcare requires increased time efforts from physicians [19]. Research suggests that physicians are reluctant to use EMR because such systems are very time consuming [24]. In addition, the increased time pressures in clinical environments causes new un-intended consequences in the form of new errors introduced in the EMR by incorrect use of the system [7]. Further, EMR systems do not seem to meet the demands of goal-directed activities [24]. A goaldirected activity consists of using a system for its utility such as searching for specific information to accomplish a task. Goal-directed users have clear, well-defined goals and put more effort into reaching their goals rather than undirected exploration [32]. User satisfaction for goal-directed users is maximized at low levels of complexity; medium and high levels /12 $ IEEE DOI /HICSS

2 of perceived complexity distract and frustrate such users. Under these circumstances, a challenging question arises. What kind of user interface should complex EMR systems present to a goal-directed clinical user that operates under opportunity-cost time pressures? The key objective of this manuscript is to develop a preliminary answer to this question. To do so, the manuscript first develops the concept of intuitive interface in design of complex EMR systems. Next, interviews with 45 physicians and 20 nurses are analyzed for detecting key themes of intuitiveness clinical users would like to see in EMR systems. Implications and future research directions are then discussed. 2. Theoretical Background 2.1 Current Information Systems Research on Interface Design and Usability The views on usability are rather diverse in IS research [23, 42]. In investigating the usability of a Web-site, researchers used various frameworks and constructs. One stream of research relates usability to site-specific features based on a set of design principles for the Web [34]. These principles were organized around four main categories namely, content, navigational structure, response time and credibility [34]. Navigational structure is perhaps one dimension that has been widely investigated in studies evaluating Web-site quality and usability. Navigation is defined as the sequencing of pages, well-organized layout and consistency of navigation protocols [35] as well as the number of links per page and their hierarchical structure (depth and breadth) [14]. A well-designed navigational structure is crucial in order to prevent disorientation [3, 43] which occurs when users do not know their present location in the system relative to the display structure [55] and feel lost in the hyperspace [54]. Other authors used the notion of response time or download delay [40] when evaluating site usability. This construct refers to the initial speed of download of a page or speed of display between pages [35]. Speed of download is an important usability consideration as most users do not tolerate much inactive time. Studies showed that the maximum tolerable time during online waits varies between two seconds [33] and ten seconds [18] before users switch to a different site. Various authors incorporated download delay in their usability studies [15, 35, 47, 48]. Other system features such as system availability, customization and personalization [47,48] and feedback mechanisms [35] have been considered in assessing usability. In particular, customization and personalization enable interactivity between users and the Web-site [35] and provide flexibility and control for users to organize the desired information [23]. Another stream of research built on established standards such as Microsoft usability guidelines (MUG) and ISO s Ergonomics of Human System Interaction (ISO ). Researchers that used the Microsoft guidelines developed a set of usability metrics for Web-sites based on dimensions such as content (including relevance, multimedia, depth and breadth and information quality), ease of use, promotion, made-for-the-medium and emotion [1, 52]. Results from these studies suggest that the salience of usability characteristics vary, depending on the user task and industry. They also reveal that among all dimensions of usability, content is the dominant factor for Web-sites visitors. Other authors [16, 37] used ISO s definition for usability and developed and tested a usability scale with five dimensions. In their view, usability is defined as the extent to which a site can be used by specified users to achieve specific goals with effectiveness, efficiency, engagement, error tolerance and ease of learning in a specified context of use (ISO ). The instrument was found to have acceptable nomological validity; however it explained only a very small proportion (2.8%) of the variance in intention to transact on a Web-site and 12.3% of the intention to return to a site [16]. The authors concluded that either the instrument did not encompass all dimensions of usability or usability is not as an important factor for retaining customers as thought [16, p.69). Thus, despite the large body of IS literature related to user interfaces, there is little agreement as to what constitute usable systems. Thus, this study proposes looking at system interfaces based on a fundamental human characteristic: intuition. The section below reviews relevant literature related to human intuition. 2.2 Theories of Human Intuition In understanding the bases for intuitive interfaces, this study turns to behavioral science theories of human intuition [8,31,41,51] and cognitive psychology theories such as cognitiveexperiential self-theory [11,12], associative and rulebased processing theory [45,46] and cognitive neuroscience theories [28,29]

3 Intuition is defined as affectively charged judgments that arise from rapid, non-conscious and holistic associations [8, p.40]. Intuition is conceptualized in the management literature in two main ways, as a holistic hunch and as automated expertise [31]. As a holistic hunch, intuition corresponds to judgment or choice made through a subconscious process involving (a) synthesis of information drawn from diverse experiences, (b) novel combination of information and (c) strong feelings of being right [31]. Information stored in memory is subconsciously combined in complex ways leading to judgments or choices that feel right [31, p.21]. The final choice is made based on a gut feeling or inner vision [51] sometimes despite potential rational evidence of the contrary. Intuition as automated expertise corresponds to a recognition of a familiar situation and the straightforward but partially subconscious application of previous learning related to that situation [31]. Thus type of intuition develops over time based on (a) past situation-specific experiences, as relevant experiences are accumulated in a particular domain, (b) a replay of past learning and (c) a feeling of familiarity of the situation [31]. The ability to intuit is acquired through experience and learning and relies upon pattern-recognition processes held in long-term memory [2,26]. For example, when an experienced physician examines a patient for an illness, s/he may immediately recognize a pattern and set an initial diagnosis based on past accumulated expertise. Overall, the key to automated expertise lies in a person s capacity to identify a familiar situation and subsequently apply automatic, stored knowledge related to that situation. Instead of relying on explicit analysis to identify and process key factors, the accumulated expertise or the familiarity of the situation leads to some steps in the analysis being dropped while some others are completed in a rapid, subconscious fashion. From a neurological standpoint, this represents shifting activity from the prefrontal cortex which processes logical considerations to the striatum which retrieves automated behavioral responses [9]. Similarly, cognitive-experiential self-theory [10,11] posits two parallel interactive models of information processing which are served by two cognitive systems, a rational and an experiential system. The rational system operates at the conscious level and is analytic, verbal and relatively affect-free. This system enables information to be acquired through intentional engagement in deliberative analyses [22]. The experiential system is believed to be the older of the two systems; it operates on an automatic, pre-conscious basis and it is primarily non-verbal in nature. The experiential system is emotionally driven [11] and it is basically based on intuition. Generally, individual action is based on the interaction between these two systems which may also sometimes lead to conflicts between the heart and the head [12, p.671]. Other researchers distinguish between associative processing and rule-based processing as two parallel systems of information processing [45,46]. The associative mode operates preconsciously (e.g. intuitively), to the extent individuals are only aware of the outcome and not the process itself [5]. Rule-based processing uses symbolically represented knowledge and it is based on causal, logical and analytical reasoning [22]. Recent research in cognitive neuroscience [28,29] used functional magnetic resonance imaging (fmri) to identify two cognitive processing systems [27] namely the intuitive, reflexive system or the Xsystem and the analytic, reflective system or the Csystem. The X-system is older and entails the use of non-reflective consciousness based on parallel processing; it is fast operating, slow learning and spontaneous [27]. The X-system s intuitively-based knowledge is located in neural substrates that are slow to form, slow to change and relatively insensitive to explicit feedback from others [22,27,28]. This system operates without effort, intention or awareness [22] and it leads to judgments based on accumulated experience, without explicit evaluation of evidence. The C-system is younger and entails the use of reflective consciousness based on serial processing; it is slow operating, fast learning and intentional [28]. This system relies on explicit evidence organized into propositions and processed serially in the memory [22]. The C-system responds flexibly when habits and instinct are ill-suited for the task at hand. Overall, there are several defining characteristics of intuitive processing. First, such processing involves a process in which environmental stimuli are matched with some deeply held non-conscious category, pattern or feature [8]. Second, intuitive processing has speed when compared to rational decision-making processing. This is the reason why, intuitive judgments are believed to be more effective to a rational analysis, especially as a problem becomes less structured [8]. Third, intuitive processing involves synthesis of information drawn from various experiences [31]. Intuition is a choice that feels right based on application of previous learning related to that situation

4 2.3 Importance of Intuitive System Interfaces The importance of an intuitive interface in complex system design is currently underestimated in Information Systems (IS) research. Various researchers in IS [e.g., 38,29,50] noted however that the design of present-day system interfaces demands that users are consciously aware of both the task at hand as well as the current system state. In addition, many user interfaces come with their own customs and habits [38, p.99] and the habitual modus operandi learned in system A may not apply to system B [38]. Thus, the logic and methods a user may try to apply while using system A may not necessarily apply while using system B. Under these circumstances, user s attention will be displaced from the current task to the system interface itself. The user will then have to refocus attention from the interface back to the task at hand, having lost precious time and often also the train of thought. This idea is also corroborated by studies in experimental psychology [4] that show that individuals can consciously pay attention to only one activity at any given time and all other parallel activities are automatic or subconscious. Errors are also deemed to be a consequence of human s single locus of attention [38]. Thus, it is suggested that a central goal of interface design is to allow users to make their own tasks the exclusive locus of attention while reducing the interface to habitual operation [38]. It is proposed that intuitive interfaces can achieve this goal. An intuitive interface is defined as an interface that is perceived as being familiar to the user based on pattern-recognition processes held in the longterm memory; i.e., an interface that resembles something the user has already learned or interacted with [39,50]. Consistent with theories of human intuition, intuitive interfaces should rely on a person s capacity to identify a familiar situation and subsequently apply automatic, stored knowledge related to that situation rather than rely on explicit or conscious analysis or reasoned thinking. Intuitive interfaces thus are immediately understandable and users feel comfortable and at ease while navigating through the interface. Intuitive interfaces make use of humans automatic cognitive processes or the experiential rather than the rational system [10,11,12]. For instance, consider a car rental scenario. Once an individual rents a car, she knows immediately how to proceed, start the car, fasten the seatbelt, set the car in Drive and drive away. Provided the driver has a license and knows how to drive, most automatic cars are intuitive regardless of model or capacity. There is very less explicit thinking or rational thought processes related to how to approach driving; it is rather intuitive. Clearly, if the car is manual and involves a stick shift, the car would not be intuitive to drive and would require a certain amount of learning and accommodation. Further, consider familiar icons such as the home or print buttons on most computer screens. They are universally recognized features on most interfaces/browsers. They are intuitive to the extent they draw from the physical environment users are typically already accustomed with. In other words, intuitive interfaces make use of pre-existent routines and socially-acquired know-how. Intuitive interfaces may also encompass human-like perceptual capabilities such as speech-recognition (which is highly desirable in healthcare as physicians are already accustomed to dictation). Many EMR interfaces however are not intuitive. Anecdotal evidence suggests that designers have focused on creating many different icons on EMR interfaces which clinical users do not understand. One such example is a yellow light bulb which was connecting a physician order to the pharmacy. It is not intuitive for a physician to know (or even remember based on training) the fact that the light bulb must be pressed to save an order and send it to pharmacy. In addition, EMR interfaces tend to distribute the information which used to be in one place in the paper chart and make it available in multiple places. Consider a physician needs to get access to his/her patient list. A paper list contains three important pieces of clinical information: patient name, room number, reason why patient is in the hospital. The patient list in many EMRs only contains the first two elements while the third one is to be found in another place called Clinical Inbox within the EMR. Such non-intuitive design elements can add to the time it takes to use EMR and also contribute to usability errors in EMR from physicians overlooking a test result or not saving the clinical record. The next section describes a preliminary examination of EMR interfaces from an intuitiveness standpoint, in two large hospitals in the US. This exploratory study involved an analysis of interviews with 45 physicians and 20 nurses. 3. Intuitive Interfaces: Tales from Two Hospitals In order to understand the concept of intuitive interfaces for complex systems such as electronic medical records (EMR), interviews were conducted with physicians practicing in two large hospitals in

5 the US. The first hospital (Hospital A) was a large acute-care community hospital system, part of a billion-dollar, not-for-profit health system in the Southern US. This system operates seven different campuses throughout a major metropolitan area in the southern US and a total of 1,767 beds. The second hospital (Hospital B) was a teaching hospital with 620 beds, part of an academic medical center in the Midwest US. Each hospital had implemented its own unique EMR system acquired from different vendors. Thus, this study considered two different EMR systems. A total of 45 physicians and 20 nurses were interviewed with respect to electronic medical record s interface. Interviews lasted between 15 and 25 minutes. All interviews were recorded using a digital recorder and transcribed. Interviews were conducted to the point of redundancy [30, p. 202] or, until no new information emerged. During all formal interviews, participants were asked two main open ended questions: Do you find the EMR interface intuitive to use? and What makes the EMR interface intuitive for you? These questions were followed by probing questions depending on a participant s answer. Hierarchical coding based on classification was in this study. This type of coding involves preliminary text-based coding followed by subsequent grouping of codes into higher-level categories (more abstract). Interview data was analyzed by categorizing small segments of text into meaningful codes (themes). Preliminary results from the data analysis as well as the main themes that emerged from the interviews are reported in the next section. Theme 1: Intuitive interfaces are familiar According to clinicians, an intuitive EMR interface is an interface that somehow links to something you re used to do. For instance, one physician describe intuitive systems as follows: we all know when you use a mouse and you double click on an icon it opens; well, you should be able to do the same in all your other programs. Other physicians noted that when we go to an Internet site and we want to look at the past history bar everybody knows to use the drop down box to get all your past history, all Websites you ve gone to. In other words, intuitive EMR interfaces are similar to other computer interfaces users have worked with whether basic Microsoft products, financial systems (e.g. online banking) or other EMR systems. Unfortunately, physicians in both hospitals also noted that current EMR systems are not very intuitive. For instance when you want to change dates for the clinical documents, you a have to physically input a date otherwise the default date is one week old and they don t have a drop down box that lets you change the date from one week to six months ago. Another non-intuitive item on EMR interfaces is related to the OK button which some physicians metaphorically referred to as the curse of the OK button. Physicians have to acknowledge their decision on several different screens before they can enter a medical order in the system which is perceived as very time consuming and non-intuitive. As one physician in Hospital A noted, you know I push ok to continue, well if I ok-ed it before why am I going to push ok to continue again? Further, the fact that it takes multiple clicks to enter a clinical result aggravates the perception that EMR is not intuitive you have to go through 7-10 screens to get to a result; this is the most horrible design interface I have seen! Theme 2: Intuitive interfaces are transparent Intuitive interfaces make clinical information easily accessible. Intuitive interfaces should allow clinicians to easily (and naturally) get access to clinical information without much rational thought. In a 2009 usability report [21], the Healthcare Information and Management Systems Society (HIMSS) noted that during their use, EMR should not create too many intrusive thoughts for the user like How do I?, What does this do? or Where is...? In other words, the user should not have to think too much about the application itself, the system should be transparent- i.e., a source of assistance and not a stressor. Physicians in Hospital A did not find their EMR to be transparent and they felt they had to gather the necessary information regarding their patient list from many different areas in EMR. For instance, when you click patient list it ll show all your patients, and it ll show the room number and it ll show the attending physician but it doesn t show the reason why the patient is there. A doctor can t afford to go through every chart and read everything to find out what s going on. I want everything at one glance. I need to know what my day is going to be like. Currently, in both hospitals, there are multiple ways to access information and/or document a clinical note such that clinicians may easily miss a result. As one nurse in Hospital B noted there are so many ways of doing things or accessing information I literally feel there is no way to make sure I've covered my bases or documented all I should have

6 Honestly don't even know what it is that I don't know! Another nurse noted that there are way too many places to document the same clinical information which is deemed to be very confusing. For example, she explained there is a lot of double charting in EMR, you have to chart your assessment on urine (color, quality, etc.) three times in different places in order to complete a full assessment. Doing this three times a day on multiple patients gets very tedious. Other physicians in Hospital B shared their frustration with a non-transparent EMR interface there are too many tabs/alternative ways to look up items/areas of notes so it makes things confusing. Ultimately, physicians in both hospitals pointed out that the EMR system is very fragmented such that the information seems so choppy and spread out and you have to know where to look. As a result, clinical information may get missed or many times you come up with completely different information than the person sitting next to you. Theme 3: Intuitive interfaces follow clinicians logic Intuitive interfaces must follow clinicians thinking process. Physicians and nurses in both hospitals felt that EMR systems were designed by technical programmers alone with very less clinician input, which in turn made them perceive the EMR as being non-intuitive to use. For instance, one physician in Hospital B noted that it makes no sense to have the assessment and plan precede the data. Logically, one does not generate a plan before going through the data on which the plan is based. As one nurse in Hospital B put it EMR is not intuitive, it is simply a storage system for information; the system is not built to think logically like a nurse. The thing about programming is they can make it do almost anything. So why aren't the programmers listening to the nurses who are using the system? We are drowning out here, bogged down in computer overtime. Interestingly, in theory, both hospitals had a wide representation of physicians and nurses in the development team working closely with the vendor in customizing the EMR system. However, many clinicians in Hospital A were asking the same question if they have over 200 people on their development team, why haven t they found this problem before? Finally, as one physician in Hospital B noted only an MD who wants to spend all of his time on a computer instead of interacting with patients could love this system (and that describes the person who designed it). Theme 4: Intuitive interfaces reflect automation of improved clinical work processes Intuitive interfaces should have the ability to provide clinicians with many automated functions and reduce the number of manual operations physicians used to do in the paper world. But, the processes should also be improved. This idea is similar to business process reengineering, as opposed to simply automating existing paper-based processes. This theme is very important; intuitive EMR systems should go above and beyond simply automating existing processes, they should provide clinicians with new and improved functionality based on improving current clinical processes. One physician in Hospital A used an analogy to explain the intuitiveness of EMR when you hook up a new hard drive, it picks it up automatically. You don t have to manually configure it. Right now, they re just reproducing the paper to the electronic chart that s a problem. For instance, some nurses in Hospital B pointed out that when new results are available, it would be nice if the system automatically took you to the new results instead of having to hunt for them and I would like a flag showing me when meds were coming up on their due time - and then the flag could change to an overdue flag if I missed giving something on time. Other physicians in hospital B also complained about the inability of the software to do basic math. Several subject matter expert physicians that participated in EMR interface design sessions clashed upon the ideas of reengineering versus enhancements. One physician noted: I don t want the computer to align out a order. I want to do it myself. Another physician had a different view on the topic: that s what we re doing now. You want to duplicate what we re doing now in the EMR? We pose that in order for EMR interfaces to be perceived as intuitive, certain work processes must be reengineered. Such reengineering efforts may also have impacts in turn on reducing complexity and enhancing clinician work efficiency. Theme 5: Intuitive interfaces are adaptable Intuitive interfaces should adapt to users needs. For instance, as some physicians in Hospital A noted if you log in based on your specialty general surgery then you see a certain menu - you know, the things you are interested in. Other physicians in Hospital B made similar comments to the extent that I would like to alter/make my own smart-lists. Specifically, the drop-down menu for our airway exam is insufficient and EMR needs to be modified

7 for various areas of the hospital. Further, nurses from Hospital B noticed that many times, while changing the due time of drugs, EMR is rather inflexible, currently EMR only allows you to change due times on a group of medications if it is within the next hour. I would like to be able to change due times on groups of medications for the entire day at the beginning of my shift. Theme 6: Intuitive interfaces reduce documentation time and contribute to enhanced patient care Finally, the last way to characterize interface intuitiveness is through its outcomes. Intuitive interfaces should reduce the time to retrieve/enter clinical information as well as enhance patient care. Unfortunately, these outcomes are not yet realized, at least in the two hospitals we studied. In fact, EMR were perceived by the interviewees to increase the time spent on the computer and decrease the time spent with the patient. Many physicians and nurses at both hospitals made similar observations and felt that they spend their shifts caring for a computer instead of a patient. Other physicians in hospital B noted that the amount of time I spend on EMR each day is quite excessive and takes away from patient care while nurses in the Intensive Care Unit (ICU) indicated that EMR just takes so much time away from the patient and that fact has never changed from day one. Finally, one nurse from Hospital B concluded that I love being a nurse, but the direction of the care I give has been away from holding the hand of the patient and straight to holding the keyboard of the computer which is deemed to be very, very sad. 5. Implications This study makes several important contributions. First, results from this research can guide EMR designers and system implementers in their efforts to design usable interfaces that do not require extra effort to use. Second, results from this research can resolve one important issue in healthcare IT implementations today: what kind of system interfaces can actually reduce the time it takes to use EMR? Time is one important resource in a clinical setting and most EMR systems today have negatively impacted this precious resource [19, 25]. Based on theories mentioned above and results of preliminary research, it appears that intuitive interfaces based on human automatic cognitive processing are at least part of the answer. Third, recent research in medical informatics found that EMR introduced new, unintended errors in the provision of clinical care [7]. This study found that when busy clinicians could not find the correct data location in EMR, they tended to enter the data where it might fit thus introducing errors in the patient s record. Interviews with physicians in two large hospitals revealed the same pattern. They tended to select the diagnosis that was close to the actual diagnosis but not the exact one. Long drop-down menus in the EMR interface led clinicians to act based on least-effort perspective [17] and selected the diagnosis closest to the top of the list. This study claims that intuitive interfaces can reduce this risk and the overall risk of new types of errors due to using the EMR system itself. Fourth, intuitive interfaces can help with training in a healthcare environment. Training is challenging in healthcare as it is difficult to gather most physicians in a classroom for training. Many times training programs are very short and generic and even with significant training, physicians do not remember many system features. Intuitive interfaces can potentially lead to fewer and more efficient training sessions. Finally, intuitive EMR interfaces can work naturally for users that are goal-oriented and use the system for its utility such as searching for specific information to accomplish a task as opposed to undirected exploration. 5. Future Research The findings of this study are rather exploratory. Future research should supplement and enhance them with confirmatory approaches including testing of various EMR user interfaces using design templates in laboratory settings. Scales for capturing interface intuitiveness and its outcomes should be developed and tested in clinical and/or experimental settings. Further research would also compare the relative efficacy of different EMR interfaces on clinical decision time, decision quality and time-efficiency gains. 6. Summary This research made first strides toward characterizing problems with the interface design of complex systems, and specifically EMR systems, as well as toward suggesting that the increased intuitiveness of such interfaces should be improved. To this end, dozens of interviews were conducted with clinical stuff, which pointed to various intuitiveness dimensions and to potential areas for improvement in complex system interface design

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