User-Centered Design of Medical Learning Software
Jens Dørup*, Michael Schacht Hansen* & Finn Geneser
Section For Health Informatics*, and Institute of Anatomy, University of Aarhus, Denmark
Email: jd@hi.au.dk; WWW: http://www.intermed.dk/jd.htm
Summary
User-centered design (UCD) is a strategy to considered when constructing software. In UCD,
users influence software design from the first steps of development to assure that userperspectives are constantly reflected in the design process. UCD has shown to effectively
increase usability, usefulness and user satisfaction of new software.
Frequent interaction between developers and users and analyses of how users react to the
software is used to adapt the software to user needs and behavior in an iterative process.
During development of a histology learning tool: Histology Explorer, USD was implemented
though regular reviewing of preliminary versions of the program against a group of medical
students and teachers. Programming was done by a medical student with specific expertise in
the software used.
The interface that evolved was very simple and resulted in implementation of the following
general principles:

Contents organisation should be logically transparent to the user.

The user should always know how to navigate.

The amount of structural elements of the interface should be kept to a minimum relative to
the amount of contents (functional elements).
We conclude that an effective design strategy is an important factor for developers of medical
learning software and that UCD, which has proven valuable in software design in other areas
should be considered also by developers of medical learning software.
Zusammenfassung
Beim User-centered design (UCD) von Software wird diese bereits während der
Implementationsphase immer wieder dem Zielpublikum gezeigt und entsprechend den
aufkommenden Wünschen und Kommentaren angepasst. Dieses Designkonzept hat sich als
User-Centered Design of Medical Learning Software 02/12/16
Page 1
sehr wertvoll erwiesen im Hinblick auf Bedienbarkeit, Brauchbarkeit und die Zufriedenheit
der Benutzer mit neu entwickelter Software.
Häufige Interaktion zwischen Entwickler und Endnutzer erlaubt dabei eine Analyse der
Reaktionen des Zielpublikums auf das noch unfertige Produkt, welches dadurch in einem
schrittweisen Prozess zur Reife geführt werden kann.
Während der Entwicklung des Histology Explorers, eines computerunterstützen Programmes,
welches den Studierenden beim Erlernen der Histologie von Nutzen sein soll, wurde UDC
während der Entwicklung angewendet - so wurden die Vorversionen des Programmes durch
ein Konsortium von Lehrern und Studenten regelmässig begutachtet und kritisiert.
Dabei hat sich ein sehr einfaches Interface herauskristallisiert, welches folgende Punkte
beinhaltet:
-
Der Aufbau und Inhalte des Programms ist immer klar ersichtlich
-
Die Navigation ist klar und einfach
-
Die Darstellung des Inhaltes geniesst höchste Priorität - funktionelle Elemente (Buttons
etc.) wurden auf ein Minimum beschränkt.
Wir stellen fest, dass eine effektive Design-Strategie sehr wichtig ist bei der Entwicklung von
Lernsoftware. UDC hat sich dabei als wertvolles Hilfsmittel erwiesen.
Keywords: User-Centered Software Design. Computer Aided Learning. Medical Education.
Histology.
Introduction
The production of any piece of software can be considered a mirroring of functions of its
users. A program may help the user do things faster, easier, with a greater resultant quality,
but he will only find it useful if it reflects real needs rooted in his physical environment [1].
The user knows such needs better than anyone else. Thus, before programming is initiated an
analysis of the world of the user should be conducted.
Medical learning materials are often developed by contents experts. In addition to content
expertise, design of learning software requires knowledge on potentials and limitations of the
software and hardware. Integrating computers in the learning process, however, poses new
pedagogical problems: How is the computer positioned among other learning tools? How are
the right development tools selected for a given purpose? Is the necessary support available
User-Centered Design of Medical Learning Software 02/12/16
Page 2
among faculty? [2] See also: Bearman M. Technology in medical education. A hypertext guide
to developing interactive multimedia (IMM), computer assisted learning (CAL) and World
Wide Web applications with a focus on medical education
http://www.monash.edu.au/informatics/techme/index.htm.
Many existing programs suffer lack of quality on either the content side, if produced by
computer specialists with little intervention from medical professionals, or on the computer
side, if produced by medical professionals that may be amateurs with respect to computers.
User Centered Design (UCD) in the production of medical learning software may help to
circumvent this apparent dilemma.
The present paper describes briefly the basic principles of UCD and our experience with the
use of elements of UCD in the development of a learning programme (Histology Explorer)
used in the study of microscopic anatomy.
What is UCD?
In user-centered design (UCD), users influence software throughout the design process to
assure that user perspectives are constantly reflected [1;3;4]. For a list of references on UCD
see http://www.intermed.dk/ucd.
When the design process is understood as the entire time frame from idea to final product in
use (Fig. 1), UCD may be understood as User Centered Design, User Centered Development
and User Centered Deployment [3].
Frequent interaction between developers and users and analyses of how users react to the
software is used to adapt the software to user needs and behaviour.
UCD may help to assure that the program does what the user needs it to – not what
programmers may think the user needs. It is amazing how difficult it is for a system designer,
who knows all corners of his system, to unlearn this knowledge and image the perspectives of
an inexperienced user. Similarly, one can imagine unlearning to ride a bicycle – it may be
even harder than it was to learn to bike in the first place.
UCD helps developers maintain focus on the function of the final result. Since design and
development occurs in a sequence of cycles all involving the users, both users and developers
may learn important aspects of programming and usability in the process.
Requirements
A system that will allow for effective interaction requires an understanding that:
User-Centered Design of Medical Learning Software 02/12/16
Page 3

Both users and developers are open to input from the other part and the expertise of both
parts must be bilaterally acknowledged

The function of the final product cannot be described in all details prior to the start of
development. Rather than attempting to be 100 % complete, initial descriptions should
focus on intention and overall function.
It is important to realise that many categories of users exist (table 1) and that testing against
one group of users (i.e. students) may not always lead to success with another group of users
(i.e. teachers). UCD testing performed effectively with different groups of users may add
important information, and advice given from one user group can often be used with other
user groups as well.
Practically, in the early phases of analysis and design, UCD can be implemented by open
discussions between developers and prospective users, correlating user-needs and technical
possibilities and implications including economical consequences. This is the time to make
personal contacts between project partners and to establish whether an understanding and
collaboration can be set-up. This is also the time to back out of unrealistic projects. Early
prototyping [4] and use of comparable software examples will significantly increase the
effectiveness of such discussions and aid in filling gaps in concepts and understanding.
During the developmental phase, interaction between users and developers should aim at
reassuring the quality of contents and the effectiveness and user-friendliness of the program
interface [5]. In early developmental stages, developers should be ready to change strategy,
including the tools and platforms used, if initial assumptions regarding program performance
turn out not to be true. Returning from development to design phase is time consuming and
expensive. However, since expenses and difficulties increase as program development
advances, crucial changes need to be adopted at an early stage. At late developmental stages,
multiple interactions between developers and users at various levels may result in a magnitude
of small, yet effective changes, that may sum up to be very important for the final result.
Deployment in the present context should be understood in a broad sense and including use of
the program by users at all levels. UCD in this phase include verbal and written evaluations of
both design and contents. An effective method is to ask inexperienced users to work with the
User-Centered Design of Medical Learning Software 02/12/16
Page 4
program while video recording user actions and behaviour. Simultaneously, users may record
immediate feedback using the audio channel. Subsequent studies of such recordings may
provide developers with important information that can be used to fine-tune the program
function to user behaviour, which will eventually ease the use of the program for new users.
UCD has been successfully implemented in the development of several software packages
(See: http://www.intermed.dk/ucd for a list of Web-based references on UCD). User centered
design has been considered and studied previously in various information systems in the
health sciences [5-7]. It has been shown to effectively increase usability, usefulness and user
satisfaction of new software and to minimise the needs for training the use of new software
[3].
User-Centered Design of Medical Learning Software 02/12/16
Page 5
UCD in the development of the Histology Explorer program
During development of a histology learning tool: Histology Explorer, UCD was implemented
through regular reviewing of all preliminary versions of the program against a group of
medical students and teachers at the Faculty of Health Sciences, University of Aarhus,
Denmark. Programming was done by a medical student with specific expertise in the software
used (Macromedia Director) and every design feature was planned and implemented in close
collaboration with teachers responsible for contents and with the group. Development of the
program lasted approximately two years. Since a software company was not involved in the
production we were able to keep expenses low. This also allowed for significant software
changes at rather late stages of development, which might otherwise have been unrealistic.
An important difficulty in the Histology Explorer was the balance between a requirement for
handling very large, full colour images and the consequent load times of the images, which
were closely related to computer hardware specifications. Much emphasis and work was
devoted to this problem in the early developmental stage.
Testing of the software was conducted in a sequence of cycles involving experienced and
inexperienced users (both teachers and students) who gave feedback on contents and design
that was subsequently implemented. This feedback from users represented numerous small
components. Three examples were:

Contents of the program were arranged in the same hierarchy, generally used when
organising anatomical structures. The same hierarchy is used in most histology textbooks.

A survey image was incorporation in the corner of the interface (Fig. 2) that would always
show the entire section and a small rectangle indicating which part of the section is shown
in the large field.

Interface keys were constructed in a way that resembles that of Internet browsers and
Windows Explorer (History – Search – Forward – and Back keys). These interface
components were well known to many users and thus eased the learning of the program.
The program was published in February 1999 by Munksgaard publishers [8] in English and in
Danish and has been used by approximately 2000 medical students in their histology studies.
A Spanish version was published by Panamericana medical publishes in august 2000. In
addition the text is being translated into German. A web based translation module has been
User-Centered Design of Medical Learning Software 02/12/16
Page 6
developed for translation into other languages. This system allows a remote translator to
modify the program text in a database located on a Danish server.
User-Centered Design of Medical Learning Software 02/12/16
Page 7
Discussion
Working with a group of users in the design process and implementing UCD principles lead
us to conclude the following rules as sound general principles for interface design for learning
software:

The user interface should be simple and should try to reuse characteristics and contexts
already known to the user.

Program features should be justified by user needs – not by computer possibilities

Organisation of contents should always be logically transparent to the user.

The user should always know exactly which part of the contents he is presently studying.

It should be easy for the user to navigate: Where am I? Where have I been? And how can I
take a specific direction relevant to my learning needs.

The amount of structural elements of the interface should be kept to a minimum relative to
the amount of contents (functional elements). This implies a rather flat contents hierarchy
where each screen contains functional information.
The requirements/recommendations are largely in accordance with recommendations recently
published by a group of German researchers on the use of IT in medical education [9].
It is important to stress however, that no golden standards have been developed for UCD. It’s
a more/less rather than an either/or. Moreover UCD - as a design strategy - is not an
alternative to other developmental strategies such as i.e. object oriented analysis and design.
Rather the object-oriented approach should be seen as an effective method for developers to
structure information on user needs and behaviour in a logical way for production of effective
programs. A complete contrast to UCD would be what has been termed System Oriented
Design – where computer systems and their characteristics are considered as the foundation
upon which design should grow.
We conclude from the present work, that an effective design strategy is an important factor
for developers of medical learning software and that developers of medical learning software
should consider UCD, which has proven valuable in software design in other areas. A demo
of Histology Explorer can be downloaded from http://www.health.au.dk/microscope. An
online version running in Macromedia Shockwave can also be tested from this web site.
User-Centered Design of Medical Learning Software 02/12/16
Page 8
Reference List
1. Newman,W.M. and Lamming,M.G. (1995) Interactive System Design. Addison-Wesley
Publishers Ltd., Harlow, UK.
2. Alexander,S. and McKenzie,J. (1998) An evaluation of information technology projects
for university learning. CUTSD, Commonwealth of Australia, Canberra.
3. Landauer,T. (1995) The Trouble With Computers. MIT press.
4. Nielsen,J. (1993) Usability Engineering. Academic Press, San Diego.
5. Bearman,M., McPhee,W., and Cesnik,B. (1995) Designing interfaces for medical
information management systems. Medinfo, 8 Pt 1, 785-788.
6. Cook,R.I., Potter,S.S., Woods,D.D., and McDonald,J.S. (1991) Evaluating the human
engineering of microprocessor-controlled operating room devices. Journal of Clinical
Monitoring, 7, 217-226.
7. Safran,C. (1994) Defining clinical 'workstation'. International Journal of Biomedical
Computing, 34, 261-265.
8.Dørup, J., Schacht Hansen, M., and Geneser, F. Histology Explorer (CD). 1999.
Copenhagen, Munksgaard.
9.Schulz,S., Auhuber,T., Schrader,U., and Klar,R. (1998) Quality criteria for electronic
publications in medicine. Studies in Health Technology and Information, 51, 217-226.
User-Centered Design of Medical Learning Software 02/12/16
Page 9
Figure 1. UCD requires user-programmer collaboration
User-Centered Design of Medical Learning Software 02/12/16
Page 10
Figure 2. An interface screen from the Histology Explorer. Most of the screen is occupied by
the section under study and all screens in the program are organized this way. The scale bar
can be grabbed with the mouse and used to measure structures in the section. Arrows appear
only when the user holds the mouse over the blue words in the legend. The survey image,
showing the entire section, is shown in the lower right corner.
User-Centered Design of Medical Learning Software 02/12/16
Page 11
Users
Developers
In-experienced end-users (students)
Publishing company
Experienced end-users (students)
Director of software company
Non authoring teachers
Professional programmer
Specialists in pedagogic, design,
Amateur programmer
publishing, or CAL programs in general
The authoring teacher
Programming teacher/student
Table 1. Representatives of Users and Developers
User-Centered Design of Medical Learning Software 02/12/16
Page 12