the HL7 Clinical Document Architecture (CDA) and openEHR standards. The HL7. CDA is a standard for clinical documents used for the purpose of exchanging.
A User-Centered Approach for the Development of a Pervasive Mobile Tool for Health Care Álvaro Alvares de Carvalho César Sobrinho1, Leandro Dias da Silva1, and Leonardo Melo de Medeiros2,3 1
Universidade Federal de Alagoas, Instituto de Computação, Laboratório de Computação Pervasiva. Campus A.C. Simões, 57072-970, Maceió, Alagoas, Brasil 2 Instituto Federal de Alagoas. Av. das Alagoas, 57601-220, Palmeira dos Índios, Alagoas, Brasil 3 Universidade Federal de Campina Grande, Rua Aprigio Veloso, 58429-140, Campina Grande, Paraiba, Brasil {alvaro.alvares86,leandrodds,leonardomelomedeitos}@gmail.com
Abstract. The medical assistance is an area that is in constant adaptation to the technological advances in the last decades, specifically in communications and information technology. Telemedicine has been following the growth of mobile and wireless technologies promoting a broad medical care and self-care access to patients with difficulties. However, several challenges still hamper the acceptability of solutions that offer treatment aid. The adaptation of technology to the patient's everyday life in a noninvasive and secure way are some of those challenges. In order to minimize these problems, the development of a mobile tool for medical assistance based on a User-centered approach and communications standards is proposed in this paper. Keywords: Pervasive Computing, Pervasive Healthcare, User-centered design, Mobile Applications.
1 Introduction The management and monitoring of clinical information from patients through the usage of computer systems is a way to facilitate and accelerate the health care in several contexts. However, in routine consultations or treatment of critical diseases the patients usually do not manage their clinical information, or the health institution that is attended does not use technologies that can assist in the patient care and can hinder the understanding of the patient's medical diagnoses. The use of technologies that aid the medical assistance may help the patient manage his clinical obligations and to better understand his health condition. Technologies to assist the health care may be used in different ways, resulting in infrastructures with mobile devices, embedded software, and wearable computing [3]. In this paper, we prioritize the patient mobility by the development of a tool for mobile devices, instead of the monitoring a specific environment, such as technologies at home [4]. The chosen approach allows the tool manipulation by a diverse target audience anytime and anywhere, for instance young persons, elderly, people with different deficiencies and schooling [6]. M.M. Cruz-Cunha et al. (Eds.): CENTERIS 2011, Part III, CCIS 221, pp. 384–391, 2011. © Springer-Verlag Berlin Heidelberg 2011
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The proposed tool is responsible to perform critical procedures (e.g. recovery and sending clinical information in a health critical situation) to the treatment of patients with chronic diseases, thus it is necessary its validation in order to ensure the dependability of the tool. Therefore, we performed the formal modeling of some features with Coloured Petri nets (CPNs) using the CPN Tools [20]. In this paper a pervasive solution for mobile devices in order to monitor clinical information of patients is proposed. The paper is structured as follows. In the Section 2 concepts of the Pervasive Healthcare are described. Section 3 discusses concepts of the patient centered design. In the Section 4 the proposed tool and a participatory development process are presented. In the Section 5 future works are introduced. Finally, Section 6 concludes the article.
2 Pervasive Healthcare The pervasive computing paradigm each day is becoming a reality, because services may interact with devices dispersed in the environment, performing actions by contextawareness. The use of this paradigm allows a transparent interaction between human and machine [5], for instance through wireless sensors, wireless networks and Bluetooth. One of the most important sectors which the pervasive computing may be applied is the aid to health care, including support of preventive and emergency care [7]. In the context of Pervasive Healthcare applications, several kinds of infrastructure may be used, including electronic devices with embedded software and wireless sensors placed on the human body [8]. This may be implemented in specific environments such as hospitals, homes or smart devices integrated in patients’ everyday life. The main goal of the Pervasive Healthcare is to provide medical assistance anytime, anywhere and independent of the availability of health professionals [9]. These professionals need access to patient information as well as submit their own conclusions about his current health situation [10]. As an advantage of the usage this kind of system may be the patient situation visualization through several view points in the retrieval of a set of conclusions and opinions of different professionals.
3 Patient Centered Design A User-centered design approach consists of the user participation in the project, from beginning to end of the product development [2]. This includes the phases of data collection, development, deployment and testing. The use of this approach is able to provide the creation of products that really supply the expectations of their end users, and may increase their trustily and security. One sector that may be enough benefited by the participatory development is the health care [11][12], in which a Patient-centered design may be performed to create Patient-centered applications [23]. Pervasive Healthcare Applications manipulate information about the health situation of patients. Consequently, the data security is a relevant factor to be addressed in their design phase [16], because it is one of the reasons that may cause a decrease in the acceptance of users to use the system. To create solutions that supply real needs of patients, to help in improving their quality of life, and also increases its possibility of acceptance, it is important to conduct a detailed analysis of the problem addressed and a well-defined project. In
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this context the realization of a Patient-centered design can be an important approach for achieving the intended objectives. This participatory approach can involve not only the users of the solution as mentioned above, but relatives, friends, or anyone other person who participates in the patient care [17], what provides a better understanding of his treatment. The development of solutions to health care based on a Patient-centered design are very researched, in which may be identified several important aspects, for instance usability, user acceptance and security [23].
4 The Developed Tool The tool proposed in this paper is a solution to health care support through mobile devices, it is developed using the Qt framework and programming language C + + [13]. The recording of information in the tool is performed by the SQLITE library that is a compact database which provides simple data persistence without the necessity of configurations [14]. In the context of management information, the tool provides the control of users, medicines with the alert of times and dates, allergies, vaccinations, physicians, health plans, health problems, clinical procedures and clinical results. The tool also offers the sharing of clinical data with physicians in a moment of a routine consultation or an emergency treatment.
Fig. 1. The user interface for vaccines record. The options for handling records are divided in tabs to improve the usability of the tool.
In order to perform this proposed of information sharing we are studying the use of the HL7 Clinical Document Architecture (CDA) and openEHR standards. The HL7 CDA is a standard for clinical documents used for the purpose of exchanging information [1] and constructed in the eXtensible Markup Language (XML) format. The openEHR is the standard of specifies mechanisms for interoperability between healthcare applications [15].
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Fig. 2. The user interface for vaccines consult. By clicking on the “Consult” tab the tool lists all vaccines registered before.
Fig. 3. The user interface of a vaccine result of the tool. The consult is performed with a simple selection of one of the vaccines listed before.
4.1 Use Scenarios The proposed tool may be used in several contexts aiding in the patients care. To illustrate some these possible scenarios that patients may benefit by using the tool are described. A first scenario that we presented is the collaboration of clinical information between patients and physicians, which in a simple consultation or an emergency service, fragments of the patients’ Electronic Health Record (EHR) are needed to provide health care and also to help avoid possible lack information in a verbal communication.
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Fig. 4. A scenario of ad hoc information sharing between patient and the physicians that perform his care
In a second scenario, the tool may be used as a manager for the intake of medicines. By using the tool, patients can register their medicines in a dynamic way (e.g. we aim to achieve the communication tool with the Google Health system [19] and use its database of medicines) or it automatically register the medicine when receive a prescription in a digital form. Finally, in the moment of need for medication intake the patient may be alerted in a visual and sound manner. 4.2 The Patient-Centered Approach In the tool development a participatory approach involving patients with chronic diseases and physicians is used. This process is based in a Patient-centered design, in which is being performed a field research in a Brazilian hospital in the state of Alagoas, with the observation of the patients’ treatment, interviews and usability testing of the tool with patients and physicians that perform their care. Currently, we are performing the interview process and usability testing of a prototype tool. This has enabled the analysis of initial results and is helping to orientate the research to aid of patients with specific clinical situations. In this paper are described some of these results that we consider relevant in the context of this research and the future direction of research is presented. As initial results of this approach the need to improvements in the tool and some good points are highlighted. Suggestions for improvement such as the record remove of the health plans for security reasons and inclusion of the National Immunization Program (NIP) table of the Brazilian government. As positive points the control of medicines and vaccines were highlighted because they are important information in a time of clinical emergency. In the process of Patient-centered design that is being performed we are identifying the need to help the care of a specific set of chronic patients. By choosing this focus we consider a specific clinical treatment that is affected by diseases that have high incidence in Brazil. Thus, this work will conduct a study of how to help the treatment of renal diseases in patients who have diabetes and/or hypertension. 4.3 Medicines Control Modeling To perform the validation and generate a documentation of the tool presented in this paper, the modeling of some resources is being performed using Coloured Petri Nets
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(CPNs). CPNs is a systems modeling language that uses programming resources in Petri nets models [18]. CPNs provides a graphical representation for systems modeling (e.g. transitions and places), a simulation of the model by the CPN Tools, and also the use of the functional programming language ML [21]. CPN Tools is a set of tools that provide an environment for the use of the CPNs language enabling the creation, analysis and simulation of the models [22]. The CPN ML is based in the ML language and offers resources for the use of data types, parameters and data manipulation in CPNs models [18]. With CPNs several kinds of software system can be modeled, which may include asynchronous and concurrent features [21]. The motivation to accomplish the modeling of the tool with the CPNs language is the possibility to ensure its proper operation to perform simulations to verify its behavior and thus improve its functionality. The reason for this concern with a formal modeling of the proposed tool is because it handles critical information and procedures to patient care, where errors may result in complications for his health condition. As a motivation example we can highlight the modeling process of the data exchange between different applications, in which some procedures proposed by communication standards (as described above HL7 CDA and openEHR) could be validated. This validation may be useful in the sharing clinical information of patients in an emergency service, for instance, the data exchange about allergies from a patient that needs of a drug intervention or that requires an anesthetic procedure.
Fig. 5. Coloured Petri Nets model developed with the CPN Tools to represent the procedure of control of medicines from chronic patients
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The application process of medicines control is shown in Fig. 5. In the initial state of the model, the medicines date/time is verified, and the sound and visual alert are triggered. Thereafter, the tool solicits confirmation of the alert visualization and medicine intake. To control the remaining medications in the tool and what the patient really has at home, an amount confirmation of medicines is solicited. Finally, the amount of remaining days and the medicine usage state are shown.
5 Future Work As future work the tool proposed in this paper can be integrated with some services provided by the Google Health system [19]. Another extension is to focus its management and monitoring information to assist patients with diabetes and hypertension in the renal disease treatment as mentioned above, and to perform the communication with wireless sensors (e.g. blood pressure). Finally, the continuation of the tool modeling by usage Coloured Petri Nets is desired.
6 Conclusion The use of Pervasive Healthcare applications to monitoring and management clinical information of patients may be a way to assist to improving the long-term health. It is also the possibility of a reduction of financial costs and guarantee care to low-income users, for instance, performs remote consultation, avoiding the need to go in places of difficult access. The proposed tool in this paper has the possibility of facilitating the everyday life of its users, offering mobility and providing medical assistance anywhere, anytime, without the need to perform certain actions explicitly and also sharing their clinical information with health professionals. One of the main results with the participatory approach that is being conducted in this research is a better understanding of the real needs of patients in which as mentioned before is directing the study to assist the treatment of specific patients with renal disease who have diabetes and/or hypertension. Acknowledgments. We thank the support from CNPq and CAPES. It is also appreciated the cooperation of everyone who has participated directly or indirectly and are collaborating and sharing their personal and professional experiences with this research including physicians, patients, medical students and all the others health professionals.
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