DEVELOPMENT OF A FORMAL FRAMEWORK FOR USABLE OPERATIONS SUPPORT IN E-HEALTH BASED SYSTEMS

ABSTRACT

This study uses advanced communications and computing technologies to support health care delivery and education. The automated e-Health-based system was designed to eliminate clumsy and tedious treatment procedures associated with manual treatment processes prevalent in care centres, especially in the developing countries. The operations support functionalities of the system are provided within a formal framework to eliminate system errors, improve dependability and enhance its usability. The framework presented in this thesis uses algebraic specifications in object constraint language (OCL) and Unified Modelling Language (UML) in the analysis and design of some subsystems in an e-Health based system. Wireless Markup Language (WML) and Java programming language were used to develop the operations support functionality with real-time access to medical information via hand-held devices. The application was deployed on a 3-tiered client / server architecture with hand-held devices as clients, providing mobile access to real-time information from server-based systems within a care centre. The system was evaluated empirically and analytically. The application’s usability evaluation was done using a questionnaire based on the attributes suggested by ISO, ANSI and ITU. The product was found to be usable with a mean rating above 4 on a scale of 5 for all attributes used for the measurement. The study revealed that 92% of the medical professionals who evaluated the application would like to see it deployed for use in medical centres in order to enhance health care delivery.

CHAPTER ONE

INTRODUCTION

1.1     BACKGROUND INFORMATION

Over the last decade, the need to develop and organize new ways of providing efficient health care services has resulted in a dramatic increase in the use of Information and Communications Technology (ICT) based solutions in health care delivery, generally known as e-Health. In particular, the health care industry was relatively slower than other industries in the adoption and use of information technology based solutions for its services [1, 2].  The integration and assimilation of e-Health into the everyday life of people, especially health care workers, is becoming a reality in developing as well as developed countries. While developed countries such as the US, Canada, UK, Australia, have fully embraced the use of ICT in primary health care delivery [3, 4, 5], most developing countries are yet to fully embrace the concept.  One reason for the persistence of this situation is rooted in the lack of infrastructure for ICT deployment that currently pervades the health sector [6]. In addition to this, formalized applications integrated with the network for health care delivery are generally unavailable [7,  8].

E-Health is the use of advanced communications technologies, such as the Internet, portable, wireless and other sophisticated devices to support health care delivery and education [9,  10]. E-Health entails a fundamental redesign of health care processes based on the use and integration of electronic communication at all levels.  A benefit of e-Health is that patients in one country can seek treatment and other services from other countries with their patient records accessed electronically. A patient with his medical information moving electronically via mobile technology is empowered to play active role in the decision making process during treatment since decisions are made in a shared manner.  Treatment processes in care centres are facilitated with the introduction of operations support systems (OSS).

E-Health based OSS are essentially designed to automate manual health care processes, making the operations of health care practitioners more error-free and efficient. OSS solutions for e-Health take advantage of state-of-the-art information technology to address health care enterprise-wide needs and requirements to reduce costs, provide reliable, flexible, mobile, timely, and secure health care delivery to patients by health care providers, centres or practitioners [1].

Research efforts and the use of communications technologies (fixed and mobile) to extend the reach, range and manoeuvrability of health care applications and contents are covered in [11-20]. It is not uncommon in recent times, to have a number of personalized applications for prescription, research, reference, patient education, and other applications for accessing daily schedules being bundled with hand-held devices to provide supports for physicians [21, 22,  23].  However, research on applications based on wireless LAN to improve health care services in the hospitals are becoming more popular [12, 14, 24] because of  the increased demand for real-time access to medical information by medical and support personnel, the maturation of 802.11 standards, and the proliferation of    802.11-enabled devices. 

The use of mobile technology devices such as PDAs, cell phones, laptops, etc for health care (mobile health care) [25, 26] delivery promises a revolution to benefit modern health care. With mobile technologies, providers have the ability to instantly update patients’ records to ensure that they are current. Physicians with up to date information, stand to make more accurate prescription decisions, thereby reducing harmful drug interactions. In addition to enhancing quality of patient care, e-Health technology, through the elimination of redundant paperwork, also facilitates more efficient and effective delivery of patient care.

As medical professionals begin to embrace and discover the convenience of delivering timely information to and from the point-of-care, mobile and wireless solutions have continued to gain prominence in the health care sector. Also, while the health care community is embracing mobile technology and realizing its benefits, issues such as, usability, dependability, confidentiality of mobile data, and the management of mobile health care workers still need to be addressed in order for ICT-based health care solutions to gain wider acceptance.

E-Health programmes encompass applications that directly support prevention of illnesses and diseases, patient diagnosis, patient management and care, etc. These applications include tele-consultations, tele-referrals, forward-storage concepts (e.g., tele-radiology and tele-prescriptions), and electronic patient records.

Where new applications are introduced or made to integrate with legacy system, the behaviour of the entire systems must conform to the specified requirements of the resulting system. Formal approaches are used to verify the conformance [27] aspect of an e-Health system to ensure it has the potential to improve the efficiency of health care delivery on national and global levels.

In order to provide effective health care, the activities of teams of health care professionals have to be coordinated through well-designed processes that are centred on the needs of patients [28]. For information systems to be accepted and used in such an environment they must be error-free and standardized based on shared medical knowledge with the flexibility required for customisation to the individual patient.

An e-Health system provides [28, 29]:

• Information for health promotion and awareness, medical education, health and biomedical research, evidence-based medicine, and e-learning;
• Information for health information system (disease surveillance, health statistics, management information system, financial, logistics, monitoring and evaluation);
• Information for health care delivery: diagnostics, treatment, consultation (telemedicine applications) and electronic patient records; and
• A platform to render health related services to patient such as medical diagnosis, patient care, after care interactions, training, etc.

With such support services, electronic appointment booking, electronic care records service, and electronic transmission of prescriptions can be put in place. These could transform the way information flow around the health care, making it possible to deliver faster, safer and more convenient patient care. In addition, e-Health enables patients to easily access the information they need to look after their own health.

The rapid invasion of new IT-based systems and solutions in the health care sector has made the evaluation of these systems become increasingly important. Evaluation is required in order to ensure feedback for further improvement of these systems used in this safety critical domain.

An e-Health based system can be evaluated based on the following [28]:

• Its acceptability to and usability by patients and care providers and practitioners;
• Its impact and contribution to improved health care outcomes and enhanced quality of life;
• Its safety when used by those for whom it is intended, as well as by others;
• Its cost effectiveness and efficiency (in financial and human resources terms);
• Its contribution to addressing health inequalities and promoting universal access to health information system; and
• Its cross-sector accessibility, including independent health
  care providers, local authority departments (such as social services, education, and housing), voluntary sector agencies, the police and other stakeholders committed to health care improvement.

It can be further argued that good usability is an essential feature for a successful e-Health application.

1.2     STATEMENT OF THE PROBLEM  

Though the health care community is embracing mobile technology and realizing its benefits, mobile computing usage is still being faced with significant number of obstacles such as usability of the applications, confidentiality and privacy of patient data, dependability, interoperability, and the management of mobile health care workers amongst others [2,  7,  12,  30].

The usability of OSS in e-Health based system is vital since its issues in software products cannot be resolved without major changes to the software architecture [31].  Usability issues are encapsulated in its attributes which are learnability, efficiency, satisfaction, error frequency, and memorability. 

The level of an e-Health based system’s usability does not only influence the users’ acceptance of the system but may also greatly influence the diagnosis and treatment processes in a health care centre. 

This thesis therefore, provides answers to usability issues for OSS in e-Health based systems deployed on a mobile infrastructure.

1.3     AIM AND OBJECTIVES OF THE STUDY

Answers to usability issues in OSS are fundamental to the use of mobile devices in the health care sector. Thus, the major aim of this study is to develop a formal framework for usable operations support for e-Health based systems. To achieve this aim the following are the objectives of this thesis:

• To provide a formal framework for the design of some of the subsystems in an e-Health system;
• To provide a robust architecture which ensures that best clinical practices are followed in a health care centre in the administration of patient care;
• To provide a support system that distributes patient medical information amongst medical practitioners in a health care environment via mobile devices; and
• To implement a prototype of some of the functionality in an e-Health system in order to empirically validate the usability of the operations support system in the application domain.

1.4     METHODOLOGY

In achieving the set objectives for this thesis, first, we identified the main support services for the e-Health based system and used Object Constraint Language (OCL) in combination with Unified Modeling Language (UML) to specify, analyze and design some of the functionality of the system. This was to ensure the quality and enhance the usability of the final product.

Additionally, a mobile multi-tiered architecture consisting of hand-held devices (PDAs and cell phones), e-Health Application server, Database Server, Apache Server, Access Points, and other network infrastructures were provided for the deployment of the application. The robust architecture ensures that best clinical practices are followed during the treatment processes in health care centre.

The application was developed with wireless markup language (WML), Java server pages (JSP) and Java servlets. The server application provides access to Microsoft Access database. Java based technologies were used for the development of most of the subsystems in the application. Java has since emerged as an important language in the mobile device arena, and much of this is due to its platform independent nature.

The server receives a patient’s electronic records via an API that returns diagnosis, treatments or prescription information in the form of an XML document.  Any update in patient records are committed to the data base by passing the API to an XML document representing the changed data.

The e-Health Application Server exists as part of a fixed network infrastructure that is extended to the mobile client by Wi-Fi technology using an 802.11b wireless LAN. Due to the vulnerability of wireless networks additional security was provided by role-based access techniques to prevent unauthorized personnel from viewing or changing sensitive and protected patient records.

Furthermore, since PDAs have small screen and different means of navigation than traditional systems, a careful consideration was required in the design of the expected user’s interfaces. The system’s usability was measured empirically and analytically to ensure the acceptability of the application in the health care domain.

Finally, the prototype application was demonstrated on Covenant University health centre and deployed with Microsoft Windows Mobile and Server-based editions with micro browser for the client devices.

1.5    SIGNIFICANCE OF THE STUDY

The significance of this research includes among others:

• Provision of a well designed architecture that integrates the various elements of e-Health based systems from design concept to actual implementation which eliminates, some of the problems inherent in disjointed application designs.
• Provision of a robust architecture that guarantees a reliable, available, and enhanced efficiency of the application it supports. Since health care applications are safety critical systems, it is imperative that they are methodologically designed.
• The provision of a system that enhances the recording, delivery and exchange of timely information at the point-of-care. The system offers high mobility and flexibility with potential to save people’s lives.
• Provision of a system that indicates how possible it is to use mobile phones or PDA to enhance health care delivery by medical professionals.
• Designing a system to meet the objectives of the Nigerian National Policy for Information Technology on health care delivery [32], which is a model policy for other countries especially the developing nations.

1.6     MOTIVATION FOR THE STUDY

At the present stage of development, computerized patient record which is the core of e-Health support systems is being adopted by only few health care institutions even though the driving forces for its adoption are already existent and the continued use of paper-based systems are becoming more non-viable [34].

The motivations for this thesis are as follows:

• Take Advantage of Trends in Devices to Enhance Health Care Delivery: With the increasing capabilities, compactness and ubiquity of computing devices, health care providers can enhance their performance. Providers can exploit these trends in electronic devices to provide efficient services.  The use of PDA by physicians to record and transmit PMR (Patient Medical Record) to the central server during ward rounds and the use of cell phone to send SMS on an emergency need to server can help to facilitate timely and more productive treatment of patients in a health care centre. This is facilitated by the existence of push-to-talk feature on the Code Division Multiple Access (CDMA) 2000 / 1X system which permits point-to-point or point-to-multipoint messages. The success and acceptability of these devices depend on the usability.

• Care for Mobile Patient: Another motivation is the need to provide health care services for the increasing mobile patient population. Patients are the major players in health care and they are mobile. Developments in computer hardware and software are occurring at blazing speeds, together with widespread connectivity through local area and wide area networks. Furthermore, the Internet have brought about new tools enabling care providers to access huge, untapped information resources,  the possibility of accessing patient records from anywhere in the world and from a variety of platforms of hardware and software. Integrated view of patient data, the connectivity of open systems and interoperable network systems provide a ripe environment for conveniently managing large amounts of patient’s information.
• Create an Environment for Paperless Record / Offices: The manual or semi manual method of keeping medical information is very challenging to health care practitioners. Vital information about a patient could be lost, multilated, and may not easily be understood by a second specialist whose opinion may be sought for the treatment of a patient. Manual medical records are equally cumbersome and time consuming, to manage and access. A fundamental building block of e-Health applications is the Electronic Health Records (EHR) [20] which allows the sharing of medical records between health care centres and service providers. EHR facilitates teleconsultation between care providers on a given patient for the purposes of obtaining second medical opinions before diagnosis and treatment of a patient, as well as teleconsultation by a health practitioner linked to the patient at home.
• Real-Time Data Access: Intrinsically high levels of mobility for medical and support staff who demand access to the same information whether they are mobile or at their workstation.
• Need for Accurate Information: Strong benefits for patient care and hospital efficiency through more timely and accurate information access that drives workforce and workflow efficiency.
• Medical Research: The growing demand for patient data for health services / research which has increased focus on content and value of therapies are a source of push for the research.
• Reforms in Health Care: The global reforms in health care to make it more responsive to patient needs, as well as, the drive to provide more affordable health care services requires the automation of records management.
• Availability of Platform: Wide coverage and subscription for mobile communication services across the country. Presently, there are about 31 million subscribers of mobile phones in Nigeria [35].

1.7     CONTRIBUTIONS TO KNOWLEDGE

The research provides a case study in the learning and transferring of skills in the design of human computer interfaces and in the development of software for mobile systems in the health care domain. This is a unique innovation in the health care domain where the availability, usability, timeliness and correctness of medical information are paramount to health care practitioners and service providers in the treatment of a patient.

To the best of our knowledge, although numerous commercial and academic prototypes of e-Health based systems are available, this research work has provided a formalized framework for usable operations support for the exchange / transfer of timely information from the point-of-care via mobile devices within a health care environment.  Consequently, the framework proposed can be very useful as a requirements specification document for the realization of mobile        e-Health based systems.

1.8     LIMITATIONS OF THE SCOPE OF STUDY

The main objective of this thesis is to emphasize the usability attributes in the design of the prototype since most users in the health care domain are not computer proficient. This thesis provides a systematic approach for realizing a prototype for a usable operations support in e-Health based systems. Usability on its own can be looked at solely quantitatively; however, we adopted both quantitative and qualitative approaches. A qualitative approach is fuzzy because it requires the detailed application of fuzzy logic and would deviate from the main focus of this thesis.

Though, the patient database could provide accurate and detailed level data that can be mined for several purposes, for examples, clinical trials, research and epidemiology to track illnesses, wellbeing programmes and outcome of disease, delving into data mining issues would deviate from the main focus of this thesis.

Further, an actual implementation would have entailed solutions that integrated functionality in an enterprise e-Health system. Security and heterogeneous database issues which could have resulted from the complexities in the transaction processes amongst the subsystems were addressed but were not the major focus of discussions.

Finally, the prototype developed was deployed and demonstrated on the Covenant University health centre intranet and not within the national health care network. This is because of inadequate robust communication infrastructures, time and logistic constraints of implementing the prototype. Thus, the CU health centre served as a test bed for the research.

1.9     THESIS ORGANIZATION

The rest of this thesis is organized as follows: Chapter Two provides an overview of technical literatures in e-Health based systems, formal framework, modeling, usability evaluation and mobile computing for pursuing this research. The various requirements for the system developed in this thesis, the support services, architecture, formal modelling and design of the system are presented in Chapter Three. Chapter Four presents the implementation detail as well as evaluation of the system’s usability. Finally, we present the summary and conclusion of the thesis in Chapter Five.

Tagged with: Development, E-Health Based Systems, Formal Framework, Usable Operations Support