Reverse Engineering of Content to Find Usability Problems: A Healthcare Case Study

Peer-reviewed Article

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For tools that involve the creation of an artifact or document, reverse engineering potentially provides an interesting alternative to task-based usability testing. In this case study, participants were shown an artifact and asked to recreate it using a software tool. Would the reverse engineering testing method be as successful as traditional task-based methods in uncovering usability problems? Would test participants be comfortable using the method? Participants used both reverse engineering and task-based approaches to usability testing in counterbalanced order. Using an online tool for developing asthma action plans, the reverse engineering method uncovered more usability problems than the traditional task-based usability testing method. The 12 test participants had a positive attitude towards the reverse engineering method although it took them longer to perform their tasks and they faced a greater number of issues. Both the longer task time and the greater number of problems uncovered were likely caused by the greater attention to detail that reverse engineering requires of participants. This case study demonstrates that reverse engineering may be a useful alternative to pre-defining the tasks for the participant when carrying out a usability test.

Tips for Usability Practitioners

Our bottom line message for practitioners based on our experience with the case study is that the reverse-engineering approach is useful if you want to

  • Find problems with the formatting/layout aspects of a tool.
  • Avoid bias from the language used in task scenarios, for example, if an instruction says to “create a report” and the UI has a Create menu with a Report command.
  • Encourage the participants to work more slowly and explore the tool more thoroughly at first.

On the other hand, the reverse-engineering method is not recommended if

  • You want participants to use their own data or in other circumstances where participant’s motivation (or lack thereof) can have a significant effect.
  • The goal/outcome has ambiguity; it’s not clear to people when they are done.
  • Session time must be kept short. It will take longer for participants to complete tasks with reverse engineering.


The purpose of this paper is to present a case study of the use of reverse engineering as a usability testing tool instead of the traditional task-based scenario method. We have heard anecdotally of usability specialists using reverse engineering in their practice, but there seems to be a lack of published discussions of the use of the technique. Thus, in this paper we present a case study in the use of reverse engineering for usability testing in the hope that it will promote increased use of the reverse engineering technique.

Healthcare is the area of application context for this case study, and more specifically the creation of asthma action plans. These plans are important artifacts that provide guidance on how to manage asthma as a chronic condition. We chose this context to explore the value of reverse engineering.


Many methods for general purpose usability evaluation have been described (e.g., Sharp, Rogers, & Preece, 2011), both quantitative (e.g., measuring task completion time and number of errors) and qualitative (e.g., collecting feedback on user preferences through questionnaires and focus groups; Rubin, Chisnell, & Spool, 2008). However, one method that has received little attention is the case where a software tool produces a specific artifact, and participants are asked to recreate the artifact (using the tool) through a process of reverse engineering.

The term reverse engineering as it applies to software engineering is defined by Chikofsky and Cross (1990) as the following:

The process of analyzing a subject system to (i) identify the system’s components and their interrelationships and (ii) create representations of the system in another form or at a higher level of abstraction.

From a usability testing perspective, the four phases of a typical reverse engineering process(Storey, Sim, & Wong, 2002) can be adapted as the following sequential steps:

  • Step 1–Parse: The test participant is given the final product of a system (e.g., a document or graphic) and identifies the elements comprising the product.
  • Step 2–Analyze: Participant analyzes the elements of the product in order to understand how they are related to the features of the tool.
  • Step 3–Document/Visualize: Participant looks at each element in more detail and maps them to the functionality of the tool. The participant may go back to Step 2 for further analysis of the elements.
  • Step 4–Reengineer: Participant recreates the product using the tool while the observer notes any difficulties encountered during the reengineering process due to the design flaws in the system. Once the product is reengineered, the participant may go back to Step 1 and parse the product again until satisfied with the recreated product.

In the case study reported in this paper, we compared the reverse engineering approach to usability testing with a traditional task-based scenario technique. The research involved an evaluative case study using an online tool for creating asthma action plans. The tool was developed to let three different groups of stakeholders (respirologists, patients, and asthma educators/primary care physicians) create asthma action plans collaboratively. Further information on the development of the tool was provided by Wan (2009) and by Gupta, Wan, Newton, Chignell, and Straus (2011).

An asthma action plan consists of a set of written instructions on how to treat asthma when the condition is stable, as well as when the symptoms are active (Plottel & Feldman, 2008). Asthma action plans usually use the “zone” system, patterned after the red-yellow-green lights of a traffic signal, to describe the severity of asthma symptoms and to determine the appropriate response (Sloane, Slatt, Ebell, & Jacques, 2008). Studies have shown that the use of asthma action plans for self-management of asthma symptoms greatly improves the health of adult patients (Gibson et al., 2003), and in the case of asthmatic children, significantly reduces the number of acute care visits per child (Zemek, Bhogal, & Ducharme, 2008).

The case study reported here was part of a larger project named Wikibreathe (a.k.a. Online Collaboration Tool for Asthma Action Plan with Usability [OCTAPUS]). The primary goal was to both determine the preferences of different stakeholders for the design and content of an asthma action plan and to use an online tool to collaboratively author a consensus asthma action plan.


A set of available asthma actions plans were surveyed to create an exhaustive list of features to be included in the Wikibreathe tool. Based on those features, an initial prototype was created. Then, a series of focus groups were conducted to gather initial feedback on the design of the Wikibreathe tool prototype. Based on the feedback collected, the revised prototype was developed and then evaluated using two usability testing methods: task-based and reverse engineering testing methods.


The following sections discuss the initial requirements for gathering data and the focus group that helped develop our prototype.

Initial requirements gathering

Before starting to design the Wikibreathe tool, available asthma action plans written in English were surveyed in order to create an exhaustive list of features that could potentially be included in the tool. Sixty-nine unique asthma action plans from around the world were analyzed for both content and format differences. Based on the requirements collected as a result of this survey, expert opinion, and best evidence, it was decided that the Wikibreathe tool should be able to generate an asthma action plan with the following sections:

  • Header: This section contains the basic administrative information, such as a line to write the date and patient name, as well as other pertinent information such as the severity of a patient’s overall condition.
  • Zone Description: This section contains the description of asthma symptoms divided into different sections based on the severity of each symptom. For example, a description of “breathing” in the Green zone might be “Breathing is easy” whereas in the Red zone the description would be “Very short of breath.”
  • Zone Instruction: This section describes the actions an asthma patient should take when their symptoms match one of the zone descriptions. An example of an instruction would be “Take reliever inhaler, ____ puffs every 4 to 6 hours.”
  • .3

  • Footer: This section is at the bottom of the plan and may include a space for patient or physician signatures or important reminder statements about asthma.
Focus group

An initial prototype was developed based on the format and content features identified during the initial requirements gathering phase. The overall concept for the envisioned tool was that the user would choose from a list of options on the left side of the screen to build up the asthma action plan that would then be displayed on the right side of the screen. A series of moderated focus groups and interviews were then conducted to gather feedback on the initial design of the Wikibreathe tool. In order to clearly evaluate the preferences of the stakeholders and to avoid bias, each stakeholder group was evaluated separately.

The results of all three stakeholder groups showed that participants had a positive attitude towards the Wikibreathe tool. A major difficulty across all groups of participants was lack of proper organization in the navigation system. Based on the feedback collected during these focus groups, the initial prototype was modified, and a revised prototype was developed for testing using the two contrasting methods (i.e., the traditional task-based method and the novel reverse-engineering method). See Figure 1 for the revised prototype.

One point to keep in mind in reading the case study discussion is that while asthma action plans are used by patients, the Wikibreathe tool is designed for respirologists to make it easier for them to develop well-structured asthma action plans. Thus, the intended users of the Wikibreathe system were respirologists.

Figure 1

Figure 1. Revised prototype of the Wikibreathe tool

Usability Testing Methodology

This section discusses the process used to evaluate the revised version of the Wikibreathe tool using the two usability evaluation methods.

Participant selection

A convenience sample of 12 participants (4 Male, 8 Female; these participants were not the participants used in the focus group) between the ages of 20-40 were recruited from friends and family of the researchers. Their occupations ranged from a high school teacher and music therapists to a programmer and an engineer. They spent an average of 9 hours each week on the Internet at work and 10.4 hours each week on the Internet at home. All participants had a generally positive attitude towards computers. Thus, our participants tended to be well educated and computer savvy, as would be the respirologists who were the target users of the Wikibreathe system. If we were testing the effectiveness of the tool itself, a sample of respirologists would be needed. We were interested, however, in the testing method so we decided that for a case study, the sample we used would be appropriate.

User study process

Participants used the Wikibreathe tool with both a traditional task-based scenario approach and a reverse-engineering method. Participants were asked to use the tool to perform the same task of creating an asthma action plan twice (i.e., in a within-subjects design): once using the traditional task-based method and once using the reverse engineering technique.

During the user study sessions, participants were first introduced to the goal of the project and were told that the purpose of the study was to examine the usability of the Wikibreathe tool for designing asthma action plans. They were then given a brief introduction and training on the Wikibreathe tool. Each participant received the same amount and type of training. Lastly, they were shown three asthma action plan examples that we had created previously using the Wikibreathe tool.

Participants then used the Wikibreathe tool with one of the usability testing methods, then the other. The order of methods was counterbalanced such that six participants did the task-based method first and six did the reverse engineering method first. The following describes the methods used in this case study:

  • Task-based testing method (TM): This method is based on the traditional task-based usability testing approach using invented scenarios. Participants were told to imagine that they were a respirologist who was designing an asthma action plan. They were given a set of tasks to perform using the Wikibreathe tool.
  • Reverse engineering testing method (REM): In the reverse engineering method, participants were simply given a completed asthma action plan (that was previously created using the Wikibreathe tool which was already developed by our team as part of an earlier project) and asked to recreate it as closely as possible, using the tool.

The process of preparing for the reverse engineering portion of the case study consisted of creating an asthma action plan, using the Wikibreathe tool, that participants could then attempt to duplicate. Thus, once we created an asthma action plan instance to use as the target in the reverse engineering method, the only remaining step was preparing a few straightforward instructions on how to do the reverse engineering task using the Wikibreathe tool (see Appendix A). In contrast, a detailed set of instructions and a moderator script were required as preparation for the task-based test method. A more important challenge in task-based usability testing is that the test administrator not only has to select which tasks to include and in what order but also to carefully word them so that they are clear and unambiguous. Besides, with task scenarios, it is almost impossible to probe all aspects of a product. Therefore, test administrators have to choose what to probe and that may limit their ability to uncover all of the important problems. These challenges are sidestepped in the “make what you see” approach of the reverse engineering method (Appendix A).

Because participants were to use the same tool with each evaluation method, we decided to use two different asthma action plans so as to reduce the learning effect of having to create the same plan twice. We constructed the two plans in such a way that they were different overall, but had similar tasks, so that the results were comparable.

During each user study session, the task completion time and percentage of errors made during each of the testing methods were recorded. Examples of errors included deselecting an option while the option had to be selected or not recognizing the different page layouts (Table 1). Participants were encouraged to verbalize their thoughts while using each method.

After each method, a short questionnaire was administered to the participant. The questionnaire consisted of the System Usability Scale (SUS) questions and a number of open-ended questions inquiring about the participant’s attitude towards the tool (for example, if they felt confident or frustrated while using the tool). The SUS questionnaire used a 5-point Likert scale where 1 was Strongly Disagree and 5 was Strongly Agree (Brooke, 1996).

After both of the methods were completed by the participant, a semi-structured interview was conducted. The interview inquired about the issues raised during the participant’s interaction with the tool. Participants were also asked about their overall impression of the tool.


The following sections discuss the time each participant took to complete each method, the usability problems encountered with the tool, the usability questionnaire, and a summary of the results. Overall, participants found the reverse engineering approach an enjoyable testing process although they spent more time to perform the tasks and encountered more usability problems during the tasks.


The task-based scenario method took participants an average of 12.6 minutes when done first and 11.4 minutes when done second. In contrast, the reverse engineering task was much faster (an average of 9.9 minutes) when done second than when done first (an average of 16.8 minutes). The longer performance time in the reverse engineering method when it is used first was likely due to increased task demands for that method. In the reverse engineering method, participants had to recreate the plan to look exactly like the one given, whereas in the task-based method, participants had more freedom to make certain decisions, such as whether the plan should be in a portrait or a landscape format. The more rigid requirements of the reverse engineering method caused participants to go through the tool in more depth (using more time) and through more paths (which would tend to take longer and potentially produce more errors).

Usability Problems

The detailed results concerning usability problems are shown in Table 1. A total of 110 usability problems were encountered, representing varying repetitions of 11 unique problems. The usability problems were identified by one of the authors (Flora Wan) acting as the tester. Problems were identified based on observation notes written during the sessions, verbal feedback from participants, and problems with the asthma action plans that were produced. In protocol B (where the reverse engineering testing method was performed first) a greater number of unique usability problems (11 unique problems compared to 9 in protocol A) were found throughout the two methods. All of the 11 unique problems were discovered during the reverse engineering testing method when it was performed first (in protocol B).

Usability problems can vary greatly in severity and uncovering more severe problems is generally more beneficial than finding minor problems (e.g., Molich & Dumas, 2008). We asked one respirologist and one human factors specialist to independently rate the 11 unique problems on a severity scale (0= not a problem, 1= cosmetic, 2 = minor, 3 = major, 4 = catastrophic). The average severity rating (across the two experts) for each usability problem is shown in the second column of Table 1 (in parentheses, following the column title). The problems ranged from an average severity rating of 1, for trying to carry out a search that was not a supported feature, to a problem with a rating of 3.5 (midway between major and catastrophic on the severity rating scale) that involved pre-selection of options.

In protocol B, participants had more difficulties using the Wikibreathe tool relative to the participants in protocol A. The six participants who were tested with protocol A encountered a total of 29 (16+13) usability problems throughout both testing methods. However, the six participants who were tested based on protocol B encountered a total of 81 (79+2) usability problems throughout both testing methods, 79 of which were encountered during the first (reverse engineering) testing method.

Table 1. Usability Problems (TM=Task-based testing method, REM=Reverse engineering testing method, Total # of participants =12, Total # of participants in each protocol = 6)

Table 1
Table 1

Reverse engineering demands more attention to details

As noted above, participants who were tested with the reverse engineering method first (protocol B) found two additional problems that were not found by the group of participants who were tested with the task-based scenario method first (protocol A). The two problems that were missed in protocol A were the following:

  • Layout (Problem #5): This usability problem relates to participants not being able to distinguish the layout of the asthma action plan using the small icons on the top of the screen (Figure 2). A possible reason would be that participants never paid attention to the icons representing different layouts and just moved forward to the next steps without making any change to the default layout.
  • Font size (Problem #10): Unlike the group of participants who started with the reverse engineering method, participants who started with task-based method raised no complaints regarding the small font size. A possible reason is that the participants who started with the task-based method focused more on the paper than the computer screen when they were following the written instructions. Therefore, participants in this group spent much less time exploring the tool and thus did not get the chance to attend to all the details including the size of the fonts used in the tool.

Figure 2

Figure 2. Selecting the layout of the asthma action plan

Both of these problems had an average severity of 2.5 placing them between minor and major on the severity scale.

One possible conclusion from this is that the reverse engineering testing method (when done first) demands more attention to detail (concerning layout and fonts in this case study) from participants as they need to compare the artifacts provided to them, as a model, with the one they are trying to create.

Why were some problems not encountered during those reverse engineering tests that were conducted after the task-based method (in Protocol A)? One possible explanation would be that when moving on to the reverse engineering testing method (second method) after performing in a task-based test method, participants were influenced by their experience with the previous method. Thus, they did not pay as much attention to the details when interacting with the product for the second time as they were already accustomed to the design of the tool and had already made some assumptions about how the system worked. This behavior would not occur in a usability test in which only reverse engineering was used.

It is possible that some of the specific deficiencies found with task-based usability testing in our case (e.g., failure to uncover the layout problem) may have resulted from the specific tasks that we chose to test. However, even if this were the case, it highlights the difficulty in choosing an appropriate set of tasks in the task-based approach when doing usability testing on a reasonably complex piece of software.

Usability Questionnaire

Immediately after each method, participants were asked to complete a questionnaire about the usability of the tool and their attitude towards the particular usability testing method that was used. The first part of the questionnaire was based on the SUS. The mean overall SUS scores shown below range from 0 to 100. The closer the score to 100, the more satisfied the participant would be with the product and probably the more usable the product is perceived.

System Usability Scale (SUS)

We found a potentially interesting relationship between number of usability problems found and overall usability scores calculated based on SUS ratings. Seventy-nine of the 81 problems that the six participants following protocol B found were encountered during the first testing method used, i.e., the reverse engineering testing method. Yet, the average SUS score in protocol B was higher than the corresponding average score for participants following protocol A, and the highest overall SUS score across all four conditions was obtained for the reverse engineering method done first. However, the differences are relatively small. Without a larger number of participants and a statistical test, we cannot be sure that these results are reliable.

Table 2. Mean Overall SUS Scores (out of 100) Across the Study Conditions (TM=Task-based testing method, REM=Reverse engineering testing method)

Table 2

Attitude toward the usability method

After completing the SUS questionnaire, participants were asked to answer a number of open-ended questions inquiring about their attitude towards the tool (for example, if they felt confident or frustrated while using the tool) and the usability evaluation method. Although our sample size was small, the tool attitudes did not appear to differ between the task-based and reverse engineering methods even though results showed that participants spent more time on the reverse engineering method and encountered more issues. Overall, participants had a positive attitude toward both methods.

During the post-experiment interview, several participants commented that it was more difficult to create the plan using the reverse engineering method, but it also encouraged them to explore the tool in more depth. Those comments suggest that participants were not less satisfied with the reverse engineering method in spite of the longer time it took to perform the tasks. By exploring the tool, these participants encountered errors that the other group did not. On the other hand, participants who followed the written instructions first commented that it helped them “learn” how to use the tool.

Summary of Results

The results of comparing the reverse engineering and task-based methods for usability testing can be summarized in the following major points.

Reverse engineering has the potential to discover more issues

The results of the case study showed that the reverse engineering testing method took longer to complete and participants encountered more issues compared to the task-based method, i.e., 79 vs. 16 issues when each method performed first and 13 vs. 2 issues when performed second. Thus, reverse engineering has the potential to uncover more usability problems than the traditional task-based testing approach. It is noteworthy that 79 of the 110 (72%) usability problems encountered were found in the situation where the reverse engineering method was being used, and it was being done first. Thus over 70% of the usability problem instances were found in just one of the four contexts (reverse engineering done first) that were examined.

Reverse engineering is an enjoyable task

Even though the reverse engineering task took longer and caused participants to commit more errors, their attitudes toward the tool and usability method were consistently positive. One participant even commented that she enjoyed the visual aspect of being able to look at something and then recreate it.

We speculate that reverse engineering activities (i.e., recreating artifacts) may take away some of the stress participants normally experience when carrying out a usability test. This may be due to a tendency for reverse engineering testing to make testing more enjoyable by making it more like a problem solving activity than a task performance. In addition, reverse engineering does not require test administrators to select and order task scenarios like task-based scenarios do.

Future case studies

While the case study that we carried out has some important implications for the use of reverse engineering in usability testing, it would be useful to extend the results with a consideration of other products and better matched participants. One of the limitations of this study was that the participants were not real asthmatics, respirologists, or asthma educators. It would be useful in a future case study to focus on a different product where the test participants are the intended users of that product. Also, in a future study, it would be interesting to compare the task-based and reverse-engineering method against a “self-directed” method where participants are asked to accomplish their own goal with a tool.


This study examined whether reverse engineering is a viable usability evaluation method in comparison to traditional task-based techniques. While the concept of reverse engineering stems from software engineering, in the context of usability testing, it can be used to identify tool design flaws that cause usability problems.

The results of this study suggest that the technique of reverse engineering has good potential for uncovering usability problems. Although the task using the reverse engineering method took a longer time for participants to complete, and with more problems uncovered, the participants’ attitudes toward the test process remained positive. An advantage of using the reverse engineering method was the simplicity in setting up the test—one simply needed to create a product using the tool that was to be tested and then ask a participant to recreate it using the same tool. One point to keep in mind is that reverse engineering usability methods require longer session times because it takes participants longer to perform the tasks.


First, due to technical limitations, only one version of the Wikibreathe tool was used in the experiment. Because of this, each participant performed the task twice using the same tool and therefore the learning effect could not be measured properly. The task itself was also quite simple, and the study involved only 12 participants. Those participants were not respirologists, but were asked to imagine themselves in the role of a respirologist when performing the assigned tasks. For the purposes of this case study, the sample used was likely adequate to meet our goal of demonstrating the properties of the reverse engineering method of usability testing.

Further research is needed both with more participants and with different tools being tested in order to demonstrate the scientific validity of the reverse engineering method across a broad range of content and for different artifact generation tools. We had the opportunity to work with an important but some-what atypical context (asthma action plans) and it would be good to replicate the case study with a more mainstream user interface design context such as word processing or graphic design.

One final limitation was that one of the researchers acted as usability engineer in the usability testing, and thus the reporting of problems might have been biased in some way as a result. However, given that the set of problems identified were clearly defined and easy to characterize it seems unlikely that tester bias could explain the large increase in problems found when the reverse engineering method was done first. It also seems unlikely that possible tester bias could account for the SUS score that was obtained when the reverse engineering method was done first.

Tips for Usability Practitioners

We were interested in finding out if reverse engineering could be a useful alternative to task-based usability testing in this and perhaps other contexts. For a practitioner, would usability testing with reverse engineering be as easy to set up, administer, and analyze as a traditional test, and would it uncover a representative set of usability problems? Why should practitioners use the reverse engineering method when there are a number of methods already available that have a much more extensive track record?

Based on our experience, the reverse engineering method is worth a serious look. We found that participants had a positive attitude towards the reverse engineering method. Although the participants had to figure out how to carry out the task, the definition of the task seemed more straightforward and less arbitrary because they were trying to duplicate a meaningful artifact. Thus, we believe that the value of testing software using the reverse engineering method seems more self-evident to test participants than methods where they are told to carry out a series of tasks that have been defined for them.

We found that the reverse engineering method required more attention to detail by the participants, because of the requirement to make a copy of the target artifact. In some cases, this attention to detail might be beneficial in finding more problems, but in other cases it may find problems that are too detailed to concern most participants. Thus, they might put too much time and pay too much attention to some of the details that would not necessarily be confronted when using a task-based testing method. This is where practitioners have to exercise judgment in deciding whether or not reverse engineering may work for a particular tool and associated set of users. While it is possible that instructions to focus on the right level of detail might be beneficial in this regard, it was not an issue that we examined in our case study.

Our bottom line message for practitioners based on our experience with the case study is that the reverse-engineering approach is useful if you want to

  • Find problems with the formatting/layout aspects of a tool.
  • Avoid bias from the language used in task scenarios, for example, if an instruction says to “create a report” and the UI has a Create menu with a Report command.
  • Encourage the participants to work more slowly and explore the tool more thoroughly at first.

On the other hand, the reverse-engineering method is not recommended if

  • You want participants to use their own data or in other circumstances where participant’s motivation (or lack thereof) can have a significant effect.
  • The goal/outcome has ambiguity; it’s not clear to people when they are done.
  • Session time must be kept short. It will take longer for participants to complete tasks with reverse engineering.

Note that in any given study, the preferred approach might be to use a combination of usability testing methods. Reverse engineering could be used with other methods to allow participants to more fully explore products. However, based on our experience with the case study, we suggest that when reverse engineering is used along with other methods, it should generally be carried out first.

While this case study assesses the benefits of using reverse engineering for usability testing in a specific healthcare context, we believe that the benefits of the method found in this case study may apply more broadly.


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