Usability and functionality

Running head: TRADEOFFS BETWEEN USER-CENTERED DESIGN AND FUNCTIONALITY

1

Tradeoffs Between User-Centered Design and

System Functionality/ Interoperability

Jessica Smail

University of Utah

TRADEOFFS BETWEEN USER- CENTERED DESIGN AND FUNCTIONALITY 2

Background

The question of usability versus functionality is one of the most important issues

facing software developers and designers today. The reason for this is simple: in order for

any system to achieve its full potential, it must first be accepted and used by its intended

audience and user group. The system can have the most advanced software engineering

and be highly functional, but if it is not usable, it will not be attractive to users and will

essentially render itself useless (Buschmann, 2011).

Any computerized system can be conceptualized as having two distinct

components: the user interface (front-end) and the system functionality (back end). As

the user of a system, your entire exposure is to the front-end interface. What most users

care about is how fast the system is, how easy and intuitive it seems, how well it

navigates between pages or sections, whether it has the information you are looking for,

and whether it is aesthetically pleasing. The back end of a system is the system’s “guts”-

the interfaces, code, and configuration of the system. These are the parts that make the

software work properly, but are not typically seen by users. When viewed in this manner,

computer systems are much like cars: users can be thought of as drivers with little

mechanical knowledge- they just want to get in to the car, have it feel comfortable, and

have it work properly. The back end of a system is like the mechanical parts to the car

that are “under the hood”- mechanics will see these parts, and the mechanical aspects and

processes have to work together properly for the driver to enjoy their experience, but

most drivers never see them (nor do they care to).

There are many examples of electronic and/or computerized systems in use in

healthcare today. This includes a wide spectrum of things from simple IV pumps, to


“smart” pumps and glucometers, to computerized provider order entry systems, to fully

interoperable electronic medical records. As any healthcare professional with experience

can attest, some of these are very good, and some are not so good. But what makes a

system a good one? Is it the user interface, system functionality, or both? Can you truly

have a system with both a fantastic user interface and a streamlined, well-designed back

end?

One of the greatest challenges in software design and development is determining

the requirements for the software. This includes technical and functional requirements as

well as user-centered ones such as usability and reliability. Unfortunately, these are often

difficult to quantify and may interact in competing ways (Gross & Yu, 2001). Designers

must contend with these requirements and consider the tradeoffs in the software design.

The primary question to be answered by this paper is: what are the tradeoffs

between user-centered design and system functionality/ interoperability, especially as

related to healthcare systems? Corollary questions include: how does one balance user

centered design with system functionality and interoperability? Is one more important

than the other? What are the barriers to having a system with user centered design? What

is the ideal balance between the two?

Search Strategy

In this paper, I will first explore basic heuristics for evaluation of any system, and

identify things that both users/ usability professionals and designers of software systems

think are most important (aspects of a system that have the most value to them). I will

then explore the importance and challenges of usability and user- centered design,

especially as these concepts apply to healthcare systems. I have chosen to examine the


Agile software development methodology in particular, as it is one of the most popular

methodologies practiced today, and will include an evaluation of its potential barriers

with respect to user- centered design. I will evaluate the interplay between system design

and user- centered design, and discuss how user- centered design has been utilized by

software designers and developers. Finally I will provide recommendations as to

combining user- centered design and the Agile development methodology.

Search terms included the following:

• Heuristic evaluation usability

• Usability system functionality

• Usability software functionality or interoperabilty

• Healthcare software usability

• User-centered design

• “User-centered design” and functionality

• “User- centered design” and “software development”

• “User- centered design” and theory

• “User- centered design” and Agile

• Agile software development

• “Usability engineering”

• “Software design” and theory

I conducted a search of the general library index at the University of Utah, which

includes multiple databases at all four of the University of Utah’s online libraries

(Marriott, Quinney, Eccles, and McKay), as well as the online database of Google

scholar. Searches were expanded to include articles referenced by material found in


primary and secondary searches. The search was limited to articles written in English and

published within the last fifteen years. The search was not limited to healthcare-related

articles only, and included textbooks and University course materials.

Theoretical and Conceptual Framework

Definitions of Usability and User- Centered Design

This project is guided by usability and user-centered design as the

theoretical/conceptual framework. A primary concept to understand in the approach to

this problem is the definition of usability. Usability itself has been a rather elusive and

difficult concept to define as it may have multiple meanings dependent on the situation to

which it is applied. The term usability has been applied to software and systems in terms

of the ease with which a user can learn the system, the extent to which a user can utilize

the system to achieve his or her desired goals, and the ease with which a user can

interpret system outputs (Seffah & Metzker, 2004). Dr. Jakob Nielsen, considered by

many to be one of the leaders in the field of usability and user-centered design, stated that

usability is defined by five quality components: learnability, efficiency, memorability,

errors (as in low error rate), and satisfaction (Mchome, Sachdeva, & Bhalla, 2010;

Nielsen Norman Group, 2012). For the purposes of this paper, Nielsen’s definition will

be used as a framework for usability.

Additionally, the concept of user-centered design has been given multiple

definitions by various organizations. The intent of user-centered design is to focus on the

needs of end users and allow that focus to guide the design and development of software

solutions (Lai, Honda, & Yang, 2010). Mao, Vrendenberg, Smith, and Carey (2005)

offered a definition of user-centered design as “the practice of the following principles:


the active involvement of users for a clear understanding of user and task requirements,

iterative design and evaluation, and a multi-disciplinary approach” (p. 106). User-

centered design is considered by many to be a key component in achieving product

usability and usefulness.

User- centered design methods typically involve user interviews or

questionnaires, scenarios, and prototypes. Specialists in this field use these methods to

better understand the users, the tasks they perform, and the environment in which they

perform them (Xiong & Wang, 2010). An additional benefit to a user- centered design

approach is the incorporation of “user advocates” during the design process, aiding the

development team in meeting the user’s needs (Siricharoen, 2011).

Multiple experts have identified usability and user-centered design as key

elements and important components of software design; however, without a clear

definition of these concepts, software engineers often discount or ignore these important

aspects of design. Seffah and Metzger (2004) stated that user-centered design techniques

“are often decoupled from mainstream software development life cycles” and that

designers often view user-centered design methods as tools for “decorating a thin

component sitting on top of the software or the ‘real’ system” (p. 73).

Human- Computer Interaction Theory: Distributed Cognition

The field of Human-Computer Interaction is a diverse and multifaceted one with

an interesting evolution of theories. The particular theory that best fits the underlying

philosophy of this paper is that of Distributed Cognition. This approach “considers

cognitive phenomena in terms of individuals, artifacts, and internal and external

representations” (Rogers, 2012, p. 37). The theory involves detailing interactions among


people, the objects that they use, and the environment in which they are working.

People’s behavior results from these interactions and their activities are guided by the

physical, social, and cultural contexts in which they are situated (Zhang & Patel, 2006).

This theory also describes how information is propagated through a cognitive system,

which could be an individual’s use of a computational tool, a partnered decision making

episode, or a team evaluating how they work together.

Rogers (2012) noted that typically, a distributed cognition analysis involves the

examination of:

• The distributed problem- solving that takes place

• The role of verbal and non-verbal behavior

• The various coordinating mechanisms that are used

• The various ways communication takes place as the collaborative activity

progresses

• How knowledge is shared and accessed

According to Rogers (2012), “the granularity of analysis varies depending on the

activities and cognitive system being observed and the research or design questions being

asked” (p. 38). An important piece of a distributed cognition analysis is an understanding

of the work that is being studied; experts in the field recommend that those performing

the analysis immerse themselves into and learn the culture, setting, and trade under study.

This level of understanding is well met in the healthcare field by Nurse Informaticists-

experienced nurses with additional education and training in the fields of Information

Technology and Human- Computer Interaction. According to the American Nurses

Association (2008), one of the core functional areas for a Nurse Informaticist is that of


coordination during implementation of informatics solutions. The Informatics Nurse is

often a bridge between users and IT experts and may evaluate the utility of the product

from the end- user’s viewpoint. Informatics Nurses in this capacity “are also acting as

usability experts and making recommendations on ideal formats for the utilization of

technology” (2008, p. 23).

The Agile Software Development Methodology

One of the most common software development methodologies in use today is the

Agile methodology. Agile is favored by the industry for its flexibility and ability to adapt

to changing requirements. Kane (2003) noted that many organizations have reported

success with Agile techniques. According to Imreh and Raisinghani (2011), Agile

methodologies are based on the following four “core values”:

• Individuals and interactions over processes and tools

• Working software over comprehensive documentation

• Customer collaboration over contract negotiation

• Responding to change over following a plan

Agile development is an iterative process that involves rapid development and

testing of increasingly functional versions of the final product, delivered as small sets of

software features and accomplished as quickly as possible (Johnson & Henderson, 2012;

Silva da Silva, Martin, Maurer, & Silveira, 2011). Often, developers adopt the idea that

the overall design of the user interface cannot be successfully predicted, leaving “blind

spots concerning interaction design, usability, user-centered design, and how they fit into

the methods” (Johnson & Henderson, 2012, p. 78). Thus, Agile methodologies are

sometimes criticized for their lack of usability features and user- centered design.


Review of Literature

Multiple databases were searched using the strategy described in the above

section. I evaluated the results for relevance to my topic and selected a total of sixteen

articles for inclusion (see table of evidence, appendix A). To evaluate the levels of

evidence, I utilized a grading system obtained from a 2007 article in the Indian Journal of

Orthopedics, which presents a clear description of each category of evidence as well as

study quality (Petrisor & Bhandari, 2007). Included in this article is a table for grading

evidence (appendix B) based on guidelines from the GRADE working group, an

organization that has “developed a common, sensible and transparent approach to grading

quality of evidence and strength of recommendations” (Grade working group, 2013).

Of the sixteen articles included in this literature review, only three were of the

highest level of evidence, ranked “high”, and included systematic reviews of the literature

and/or meta-analyses. The majority of the evidence fell into the low (case report) or very

low (expert opinion) categories, and several were classified as non-experimental or

qualitative design. Given the nature of this topic, I feel that this is a reasonable selection

of articles. While there has been much written about usability, user-centered design, and

Agile methodologies, these concepts and techniques are not often applied in experimental

designs due to the potential difficulties in applying an experimental protocol to this type

of knowledge discovery.

Heuristics for Evaluation of Usability

Usability is routinely identified as an important characteristic of software systems,

yet it is often elusive and difficult to define or evaluate. One of the most widely accepted

methods of usability evaluation is the use of heuristics. According to Lodhi (2010), the


use of usability heuristics enables experts to assess the software at a reduced costs and

greater benefits to the designers due to the standardization in conducting usability tests.

The use of these heuristics is simpler to apply than writing test cases, and is an “easy way

to analyze and assess the users’ feedback and Usability Tester’s assessment” (p. 259).

The author presented ten general principles for user interface design, based on Nielsen’s

ten usability heuristics:

• Visibility of system status

• Match between system and the real world

• User control and freedom

• Consistency and standards

• Error prevention

• Recognition rather than recall

• Flexibility and efficiency of use

• Aesthetic and minimalist design

• Help users recognize, diagnose, and recover from errors

• Help and documentation

Usability heuristics are successfully used to evaluate many different types of

systems, including those used in healthcare. In a study by Harrington, Porch, Acosta, and

Wilkens (2011), fourteen heuristics were used as an assessment parameter to evaluate the

usability of an electronic medical record system in a large urban hospital. These authors

found that heuristic evaluation was easy to learn and implement, and concluded that

heuristic evaluation “should be used early in the system development life cycle prior to

implementation” (p. 335). Detecting issues with heuristic evaluations early in the


development of the EMR “can help reduce development and post-implementation costs,

effort, and time” (p. 334).

The Importance and Challenges of Usability

As software systems become more mainstream and increasingly complex, there is

a growing need for usability engineering in the design of these systems. Additionally,

with increased competition amongst software developers comes an increased need for

customer satisfaction; one way to improve customer satisfaction is to focus on usability.

In a case report by Anderson, Fleek, Garrity, and Drake (2001), the authors described the

process of introduction of usability practices into their analysis and design practices. In

this organization, “the [usability] team wanted to bring usability into the earliest possible

phases where it could have the most impact by improving initial design and eliminating

rework. The team members realized they had to integrate usability testing fully into the

software development process rather than continue to support it as a complementary

process” (pp. 46–47)

Some of the challenges identified by Anderson et al. included understanding

coworkers’ processes, vocabulary, tools, and perspectives. The team also faced

organizational and cultural challenges within the company itself, which “proved to be a

challenge equal to- if not greater than- the technical ones” (p. 47). Systems analysts had

always been more system- focused than user- focused, leaving the “burden on the user to

learn a complex system rather than on the development team to produce an easy- to- use

system” (p. 47). Developers were concerned that user- centered design would complicate

and lengthen the development process rather than reduce development time by improving

design specifications.


Usability and Healthcare Systems

Usability is a particularly important concept in the design of systems used in

healthcare. According to Mchome, Sachdeva, and Bhalla (2010), Information

Technology has the power to transform healthcare, but it is lagging behind other

industries “due to a number of factors, namely standardization, high expenditure,

interoperability, utility, and usability” (p. 463). The authors further attested that

acceptance or rejection of a health information system depends on its usability, and for

health IT to fully utilize its potential, usability must be addressed. However, the

Certification Committee for Health Information Technology “specifically states in its

Certification Handbook that ‘our criteria do not assess product usability’” (Mchome et

al., 2010, p. 465). This presents a difficult situation for healthcare IT: on one hand,

usability is considered a significant barrier to acceptance, and on the other, usability is

often ignored by those developing and implementing these systems.

In an article by Harrington, Porch, Acosta, and Wilkens, these authors stated that

adoption of electronic medical records (EMRs) is not without its challenges, and that

usability is an important factor in overcoming these challenges. They further attested that

“usability forms the platform for successful adoption of an EMR beyond a documentation

system” (Harrington et al., 2011, p. 331). However, a recent report by the Agency for

Healthcare Research and Quality determined that “the usability of EHR systems, while

recognized as critical for successful adoption and meaningful use, has not historically

received the same level of attention as software features, functions, and technical

requirements” (Armijo, McDonnell, & Werner, 2009, p. 1).


Usability is a critically important factor in the design of healthcare informatics

tools “because the biomedical research community involves high- cost scientific

personnel, laboratory experimentation to generate data, and bioanalytical techniques to

analyze that data” (Javahery, Seffah, & Radhakrishnan, 2004, p. 60). These authors

suggested the use of personae to place the needs of the users at the center of the design,

and report that these personae allow the user interface designers to categorize users into

groups with consistent skills and preferences. The end result of this type of design effort

are tools that have been designed specifically for the biomedical users and are therefore

more likely to be adopted by these users (Javahery et al., 2004).

The Benefits and Challenges of User- Centered Design

There are countless attestations to the benefits of user- centered design throughout

the literature. According to Lai, Honda, and Yang, user- centered design offers benefits

not only for the end users, but for the design teams as well. By focusing on the end users

and clearly defining the team’s goals, design teams are able to perform more effectively.

The authors stated that “the process of better defining problems and requirements may

lead to more thoughtful, shared team goals. In this way, user- centered design approaches

may help teams formulate these requirements and goals, thereby helping them perform

more effectively” (2010, p. 303).

In a survey of experienced user- centered design professionals, Mao,

Vrendenburg, Smith, and Carey (2005) stated that user- centered design “is generally

considered to have improved product usefulness and usability” (p. 109). However, this

study highlighted several concerns with the evaluation of the effectiveness of user-

centered design. While the professionals in the survey believed that user- centered design


improved the end products, there were no specific measures of user- centered design’s

effectiveness. Additionally, the respondents in the survey “were somewhat ambivalent

about whether UCD had produced savings in development time and costs” (p. 109).

While there are many techniques for integrating user- centered design into

software development, these are often underused by developers and organizations. Seffah

and Metzker (2004) asserted that the reason for this underutilization is that “these

techniques have been developed independently from the software engineering (SE)

community, which has its own techniques and tools for managing the software

development life cycle including usability concerns” (p. 71). These authors identified

several obstacles to the integration of usability into software engineering. One of the most

significant challenges identified is that the structure and techniques of user- centered

design “are still relatively unknown, underused, difficult to master, and essentially

inaccessible to common developers and small and medium- sized software development

teams” (p. 72). Additional obstacles include the differing definitions of usability and the

lack of user- centered design tools available to software developers.

A significant challenge to the adoption of usability and user- centered design

techniques in software development is the culture and attitudes of the developers and

organizations themselves. According to Seffah and Metzker (2004), “user interface

design skills are often haphazard and regarded as unimportant by many software

developers and managers. This explains why UCD methods often cannot be fully used”

(p. 76). User- centered design techniques are often decoupled from the mainstream

software development life cycle; as such, the concept of usability gives the impression

that user- centered design methods are “only for decorating a thin component sitting on


top of the software or the ‘real’ system” (p. 73). This philosophical difference leads to

barriers between user interface designers and software engineers and ultimately can result

in an inferior product.

User- Centered Design and Agile Software Development

The Agile software development methodology and its techniques are some of the

most commonly applied in the design and development of information technology. In

many instances, the results of this approach have been positive. However, experts have

identified that “these techniques have not directly or explicitly incorporated the

knowledge of usability engineering, even though it is valuable for customers to have

usable software” (Kane, 2003, p. 5). Usability is not fully addressed by or enmeshed with

this popular design methodology, leaving gaps in the design of the final product.

From the viewpoint of many design professionals, the tenets and culture of the

Agile software development methodology seem to conflict with those of user- centered

design. One of the primary ideas behind Agile is ‘LDUF’ (Little Design Up Front),

whereby designers “strive to deliver small sets of features to customers as quickly as

possible in short iterations” (Silva da Silva et al., 2011, p. 77). Conversely, the research

and design efforts of user- centered design professionals may take several months and

result in very lengthy user interface specification documents.

One of the biggest problems faced by software developers is the lack of

understanding of customers’ needs. The Agile methodology utilizes multiple iterations to

specify customer requirements, “but the endless iteration can’t help developing team [sic]

to satisfy exactly what users want in a short time” (Xiong & Wang, 2010, p. 1). This

mismatch between user needs and software design can ultimately lead to the designers


losing their competitive positioning within the market and losing customers (Xiong &

Wang, 2010).

In a survey of software design professionals, Majid, Noor, Adnan, and Mansor

determined that developers have historically involved users during the phases of project

selection, planning, and requirements gathering, in order to identify the major

functionalities of the system (2010). However, user involvement is not often sought

during the development process itself, which can lead to missed requirements and poor

usability design. These authors concluded that “in order to produce a usable software

product, the software development process must [be] focused on the real user and their

needs from the very beginning until the end of the development process” (p. 243).

The Tradeoffs Between Usability and Functionality

Usability and functionality are two main components of software systems that are

important for user acceptance. Users tend to “prefer products that are ‘simple and easy to

use’ and it is adequate if they merely function, as they are expected to or slightly better”

(Bayraktaroglu, Calisir, & Gumussoy, 2009, p. 2019). Successful use of any system

depends on the users’ acceptance and ability to interact with and understand the

functionality of the system. However, Bayraktaroglu et al. (2009) asserted that “the

greater the functionality offered to the users the more skilled users must cope with the

complex and time- consuming structure of the system. Therefore, superfluous

functionality can actually bring about a decrease in the usability of the software” (p.

2019). In order to meet the needs of users, designers must consider both the user interface

and the system’s operations during its design and development and balance the system’s

functionality with its usability.


Object- oriented design techniques have become one of the most common

mechanisms of designing and coding software systems. Chidamber and Kemerer (CK)

metrics are often used to evaluate the complexity of object- oriented systems. In a review

of literature by Dubey and Rana, the authors explored the usability of several software

systems and evaluated their scoring on various CK metrics. These authors found that the

higher the values of these metrics (i.e. the more complex the system), the less usable the

systems became. Their assessment of the systems studied showed that “by keeping low

values of CK metrics, system developers can improve the usability of software

applications” (Dubey & Rana, 2011, p. 5). In other words, by keeping systems simple,

developers and designers can improve their usability.

Bridging the Gap: Agile-UCD

One potential solution to the seemingly dichotomous views of user- centered

design and the Agile methodology is presented by Lee, Ko, Kang, and Lee, and is known

as the Agile-UCD. The Agile-UCD is a process that endeavors to incorporate user

experience (UX) and application features into the rapid user- context- based software

development process of the Agile methodology (Lee, Ko, Kang, & Lee, 2010). This

particular methodology employs the facilities of an Agile-UCD specialist (AUS) who

governs and controls the activities for bridging UX designers and software developers.

However, these individuals often have difficulties in communicating common

representations of end users’ tasks and software application features. In their paper, Lee

et al. “present a usability- pattern- based requirement- analysis method to help AUSs do

their tasks of requirements specification” (p. 317). They also provide a guideline “to


transform user tasks into a set of application features on a UI page, and then to integrate

requirements analysis results with probated usability factors” (p. 317).

The requirements analysis method proposed by Lee et al. helps to bridge user

tasks and application features, improving the usability of the end software product. The

authors assert that this method enhances the Agile-UCD by improving communication

and collaboration amongst all stakeholders, and helps to control the requirements

specifications provided to detail software design. This combined method also helps to

effectively combine and balance user tasks and application features with system

functionality and tasks. The application of this method holds great promise for the future

of software design.

Summary and Recommendations

In summary, there are many identified benefits as well as challenges to designing

a system for usability as well as functionality. Designing a system for usability is critical,

especially for healthcare applications, due to the technical nature and relative importance

of the work involved. However, focusing solely on usability features may lead to

increased development time and expenses, things that most projects can ill afford to

spare. Should a design team take the opposite approach and only consider the user

interface as a “thin decoration” on top of the “real” system, they risk designing a product

that does not meet the business needs of the users and may not be accepted. Based on the

results of the literature review, several important recommendations are provided.

Involve Users Throughout Entire Process

User involvement is a key element in producing a system that both meets the

business needs of the intended users and is itself usable. Users should be involved in


every step of the design and development process, from requirements gathering to

development to implementation. Doing so may disrupt the existing political and social

culture of software development organizations, but it is a critical task in order for these

organizations to remain competitive. Involving users will not only improve the end

product, but will also increase the users’ stake in the development of that product, which

can lead to greater acceptance.

Keep The Design Simple

Users prefer products that are simple and easy to use. With increased functionality

comes increased complexity, making the system more difficult to learn and navigate.

Studies have shown that the more complex the system, the less usable it becomes.

Keeping the design simple allows for easier navigation throughout the system and

completion of necessary tasks. Simplicity is usability.

Incorporate Agile-UCD Techniques

Agile is a very popular software development methodology in use today-

understandably so, as it is able to produce highly functional software in a rapid fashion.

Incorporating an Agile-UCD specialist (AUS) into this process can help bridge the gap

between usability designers and software engineers, and incorporate the best practices of

both. The use of this method improves communication amongst team members, helps to

properly define and control requirements, and ultimately leads to the creation of a highly

usable and functional end product.

Conclusions

In conclusion, while there are many tradeoffs between user- centered design and

system functionality, there are ways to successfully combine the two concepts to create a


superior final product. Considering all aspects of the user’s experience fits well within the

theory of distributed cognition, that cognitive phenomena should be viewed as

multifaceted and inclusive. This is an important concept for all involved in systems

design to consider, and doing so will lead to the creation of superior products.

Future directions of study in this area should include additional studies in the

incorporation of Agile-UCD techniques into software development practices, and the

cultural and organizational impacts of doing so. Additionally, I would like to see more

evaluations of software products that have been developed with combined methods,

especially in healthcare systems, to determine the usability and user acceptance of these

products as well as their longevity.


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