Since the beginnings of writing, the process of reading meant parsing lines of dense text, whether on parchment scrolls, clay tablets, books or screens. These days, however, reading increasingly involves visual information: icons, images, infographics, video clips. The effect of this is a blurring of the line between “reading” and “viewing”. This is not just happening on social media, digital marketing or messaging apps; it is transforming how people interact with electronic health information too.

What does this shift from text to visuals mean for usability, cognitive load and product design, especially in highly regulated fields like clinical trials?

A Reading Revolution

In the print era, literacy was centred on extended text. Newspapers, legal contacts, novels, information about health were largely word-dense, which required sustained focus and linear reading.

The rise of digital media introduced:

·       Visual-first interfaces, such as icons over labels

·       Infographics replacing longer reports

·       Video explainers over written instructions.

This transition is aligned with how we naturally process information: around 90% of the information transmitted to the brain is visual. We process visuals up to 60 000 times faster than text!

The Visual Shift in Reading

Research from user testing, such as eye-tracking studies, have shown:

·       Readers tend to skim for visual cues, such as icons, bullet points and graphics

·       The traditional liner reading pattern is often replaced by spot scanning or clustered eye movements that focus on visual hotspots

·       Readers look for visual landmarks, such as images, charts or highlighted sections, altering the more traditional Z- or F-patterns of reading.

So, on a health app, a user’s eyes may skip large text paragraphs entirely but stop on elements such as:

·       A chart summarising data

·       A progress bar or icon-based menu

·       An embedded video

·       A call-to-action button.

Why Does This Matter?

A large amount of written health information, including eCOAs, are used by older adults who may prefer simplified layouts with visual support. In addition, global clinical studies have linguistically diverse patient cohorts where visuals can overcome language barriers.

Replacing dense text with icons, visual metaphors and step-by-step visual flows can:

·       Lower the cognitive burden

·       Improve comprehension

·       Increase data accuracy in clinical trials.

However, when visuals are used across cultures, how can we be sure it is universally interpreted as the authors intended? It is possible that cross-cultural misunderstandings could increase with visuals than with written text.

A Shift Towards Human-Centred Design

Agencies like FDA and EMA emphasise patient-friendly design in digital health solutions, including eCOAs. This often means:

·       Simplified instructions supported by visual cues, such as icons and diagrams next to text

·       Progress indicators to help patients feel confident as they navigate assessments.

An example of this could be a pain assessment tool that might combine a numeric slider with emoji-style facial expressions to help patients rate their symptoms in a way that is intuitive. This is already common practice in many paediatric assessments. Again, however, we need to be certain that the facial expressions used are universally interpreted in the same way across cultures and geographies.

A Grammar of Visuals?

We have all used, or are familiar with, apps like WhatsApp, Instagram, TikTok and Slack that use visual shorthand to reduce the need for lengthy text. Similarly, dashboards in vehicles use universal icons, such as battery and tyre pressure warnings instead of textual messages. What scope is there in patient-facing documents to replace medical jargon with visuals or iconography? How much information can be contained in a single icon? Can icons be combined to communicate complex ideas, such as ‘take three times a day before meals: 7am, 2pm, 7pm, with a glass of water’? If they can be combined in this way, would there be an emergent grammar? What would be the rules of icon order and form of this grammar? When new icons are created, just as new words are coined, how quickly are they adopted and universally understood? So many questions.

Visuals as Cognitive Offloading

Visuals reduce cognitive load. This is a fact and it is something that text cannot do, not efficiently, at least. The human visual working memory can process spatial and image-based information alongside text-based information. According to dual coding theory, combining visuals with text strengthens understanding and recall.

In eCOAs, visuals could be used in the following ways:

·       Pairing short text labels with familiar icons

·       Color-coding or progress visuals could orient patients through multi-step assessments

·       Step-by-step instructions aided by visuals

·       Visual confirmation ticks (checks) after each completed task

·       Simple icons for ‘next’, ‘back’ and ‘submit’ actions.

But… while visuals can improve usability, over-reliance on them risks ambiguity. Visuals need to be properly validated to test the patients’ visual literacy. This is especially important across age groups and cultures. This means that testing visuals need to be routinely incorporated in usability testing. Similarly, visuals need to be tested as part of cognitive debriefing and not glossed over. It is vitally important to gather as much data as possible about their interpretation across cultures. Failing to pay attention to this during the cognitive debriefing process is a lost opportunity.

Visual-First Design as the Future?

Clinical tech will move – and is moving – towards voice-activated interfaces, AI and augmented reality (AR) overlays, and adaptive interfaces that shift according to users’ behaviours. It follows, then, that eCOAs and other healthcare apps will adopt more visual-first elements, that support accessibility for diverse populations.

What We Learn

The digital shift from text to visual design reflects a trend in how people now “read” information. In clinical research, user comprehension can directly affect data quality. This means that embracing this shift is essential. Visuals are not just decoration: they are critical tools for User Experience that lower cognitive effort, improve engagement and could ensure more reliable patient-reported outcomes.

On the basis of all this, could eCOA designers start embedding visual usability into development pipelines?

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, March 2025