Article from the Boston Globe’s On Call Magazine, January/February 2004

By Helen Osborne, MEd, OTR/L
President of Health Literacy Consulting

People who are inexperienced or uncomfortable with computers, have physical or cognitive disabilities, or have limited literacy and language skills can all use touchscreens. Touchscreen technology makes simultaneous use of audio, video, and interactive techniques, and because a touchscreen has no keyboard or mouse, it’s easy for most people to use. That makes it simpler for people of all ages or abilities to learn at their own pace without feeling pressured or overwhelmed by information.

Tania Phocas and Yadira Ramos at the Cambridge Health Alliance’s department of community affairs in Cambridge, Massachusetts, know a lot about touchscreen technology. They, along with clinicians and administrators, have created modules used at clinics throughout their organization. In the tuberculosis clinic, for example, new patients use [ho2] a module that explains what tuberculosis is and introduces patients to the doctors and nurses they are about to meet. Both the text and audio are available in several languages. Throughout the module, patients are asked to respond to multiple-choice questions by touching colored buttons that appear on the screen. Providers get a printout of each patient’s response to this “quiz” and use it to identify areas that need reinforcement and clarification. Certainly, this is an excellent way to begin patient teaching in person.

Phocas and Ramos are enthusiastic about touchscreen technology. In a recent interview, they discussed multiple ways that this interactive technology can be used as a valuable tool for patient teaching and offered suggestions for getting the most benefit from it.

Learning and teaching. Touchscreen modules are designed to present basic health information in an organized and comprehensive fashion. Clinicians work with the design team to make sure that the module content is consistent with the actual procedures being presented. This means using the same words, examples, and equipment in the module that would be used in the clinical setting. In addition, touchscreen technology makes it fairly simple to edit the modules when it’s necessary to update for changes in current practice or to add new language.

When designing modules, it’s important to make sure you’ve organized information from the patient’s perspective. In the TB module, for example, one of the first things that patients learn  via the touchscreen is that they probably do not have active TB disease. This concept is placed at the beginning, as this is the first question most patients ask their providers.

Assessing and documenting what patients learn. You can acquire a record of what patients have learned by asking them to respond to a series of questions on-screen. These questions can be multiple choice (with several options including “not sure”), true/false, matching, or likert scales (“choose a number from 1 to 5, with 1 being… and 5 being…”). The technology not only gives patients immediate feedback and reinforcement, but also allows providers to print out copies to discuss with patients and to put in their medical record to document learning.

Giving access to printed information. A lot of information can be given to the patient in a quick and economical way. The text of all modules should be easy-to-read and should be written at levels patients can understand. This means applying the principles of plain language, such as using common words people already know, explaining new terms they need to learn, and displaying information in ways that look inviting and appealing to read.

Using visuals. Since patients are using a computer screen, you have an opportunity to present information with graphics that are tailored specifically for the user. For instance, you might insert pictures of the actual providers patients will be meeting with. You can also include visuals that are culturally relevant. For instance, if the target population for your module on diet and nutrition is Haitian, your visuals can include foods like rice, beans, and chicken that are part of a traditional Haitian diet. Whether you use simple line drawings or photographs on your module, make sure these visuals enhance the content rather than distract the reader’s attention from it.

Making learning interactive. Touchscreens allow for ongoing assessment of patient understanding. After each topic and again at the end, you can ask several questions to reinforce the patient’s understanding. For example, after teaching about how tuberculosis is contracted, you can ask “How is tuberculosis spread?” Then offer four choices: “Touching and kissing,” “Sharing food with my family,” “Breathing the same air as someone with active tuberculosis,” and “I’m not sure how tuberculosis is spread.” The program can then tell patients whether their answers are correct and reinforce the right response.

Offering information in first languages. As long as interpreters are available to record new narration and translators are able to revise the text, modules can be translated into all the languages your patients use. You can even offer information in multiple dialects of the same language. For instance, you may offer one set of modules in Portuguese for people from Brazil and another set in Portuguese for people from Portugal, using vocabulary, pictures, and examples that are unique to each.

A Team Effort

Using touchscreen technology requires a team. At a minimum, this team should include:

• administrators and clinicians to identify needs, authorize budgets, and select the most useful and feasible placement of each module
• health educators or patient-education experts to draft and review content
• a technical developer who is proficient with technology and Macromedia Authorware® software
• end users (patients) willing to test new modules
• a coordinator to oversee all aspects of module development and evaluation
• Throughout the development process, you need to test each module with those who will be using the final product. To make sure the module accomplishes what you hope it will, ask at least  five people about:
  • Content. Do people understand the key points? Can they identify the main ideas to be learned?
  • Narration. Is the audio component too fast or too slow? Can the user understand the narrator’s accent?
  • Visuals. Do the users understand, like, and relate to the drawings or photographs? If visuals are instructional, can the user “teach back” the instructions?
  • Text. Is the module written in ways people can read and understand? Are there any terms that need to be defined?
  • Interaction. Is the module easy to use? What functions could make it more ser-friendly — such as adding a “repeat audio” button?

Patients and providers alike are enthusiastic about touchscreen technology. Patients say they feel welcomed and relaxed, and are better prepared to ask questions. As a bonus, many people are delighted with their newfound “computer” skills. Providers, too, acknowledge the benefits. They report that patients are better prepared for appointments since they already know a little about the disease and its treatment. This helps free their time to focus on patients’ more specific concerns. Phocas and Ramos both emphasize that touchscreen technology doesn’t replace clinical teaching — but it does makes it more effective and efficient!

How to Find Out More

• Tania A. Phocas, MPH, was a research and evaluation associate at Cambridge Health Alliance, Department of Community Affairs.
• Yadira Ramos is the manager of Technology Based Education at Cambridge Health Alliance, Department of Community Affairs. You can contact her by e-mail at yramos@challiance.org

Printed Sources

• Neafsey PJ, Strickler Z, Shellman J, Padula AT (2001). “Delivering health information about self-medication to older adults.” Journal of Gerontological Nursing, November: 19-27.
• Wofford JL, Currin D, Michielutte et al. (2001). “The multimedia computer for low-literacy patient education: A pilot project of cancer risk perceptions.” Medscape General Medicine 3(2).