Mixed Methodology Design for Improving Usability of ...

Mixed Methodology Design for Improving Usability of e-Health systems Yousef-Awwad Daraghmi Victoria University of Wellington, School of Information Management PO Box 600, Wellington, New Zealand [email protected]

Rowena Cullen Victoria University of Wellington, School of Information Management PO Box 600, Wellington, New Zealand [email protected]

Tiong Goh Victoria University of Wellington, School of Information Management PO Box 600, Wellington, New Zealand [email protected]

Abstract Different software methods have been used to build e-health systems for improving healthcare quality. Although some of these methods focus on users’ perspectives, the end systems sometimes fail to achieve satisfactory usability. This paper proposes a methodology by integrating rapid development methods (RAD) with User centred Design (UCD) and Participatory Design (PD) to enhance the acceptance level. The methodology also uses usability engineering theory to evaluate each development stages. This combination of mixed methodology is rarely used in ehealth systems development. The integration of different methods would overcome the drawbacks of using development methods in isolation. Further, it would minimize the incremental risks as the system moves forward and reduce post-deployment corrective actions.

1. Introduction The number of E-health applications is rapidly increasing to offer solutions to improve health quality. For example, applications for capturing healthcare records such as Electronic health records system (EHRs), telemedicine system for emergency care, remote intensive telehealth system [1][2][3]. The flexibility of Information and Communication Technology (ICT) supports providing broad solutions in variety, size, usability and complexity. Although these systems are varied, developers must consider that healthcare is a critical system and requires specific requirements. Users of healthcare systems can be patients, physicians, nurses, or administrators; this diversity implicates different users’ needs. Any e-health systems should meet these needs in order to achieve system usability. System usability is the ability of the system to deliver efficient and effective services, and to enable end users to perform system tasks safely and get satisfactory results [4]. Recently, many methods have been used to guide the development of dependable, reliable, acceptable, secure and usable e-health systems [5]. Some of these methods involve classical software development lifecycles and take a long time to deliver new products, while other rapid methods offer quick delivery but they are not user centric. Products developed would have unsatisfactory interfaces and end users would find these systems difficult to use than the conventional methods. In other words, these methods do not effectively translate users’ needs into effective system. In particular, users of an electronic healthcare system in a clinic are likely to be physicians, nurses, accountants, managers and patients. These users have different computer skills. Their jobs require different functionalities and a different workflow [6]. In addition, they are different in the way they think and in their preferences. For example, the physician may prefer an interface style or a colour which is not suitable for other users. Language is another important issue still being addressed through standards such as SNOMED which covers the medical terminologies [7]. Further, a system is more likely to be accepted if its interface has the same language as its users. Cultural and organizational values also affect the adoption of new systems [8] [9]. Ignoring these specific needs may cause tragic results. If the physician uses the system wrongly, he/she may cause a severe risk to the patient [10]. Other users may give up using the new system and go back to the old system because they find that the new system is time consuming, and does not fit well with their tasks or align with their future needs [5]. Slow development that takes long time is boring and users lose interest participating in this development [11]. So the overall results will be negative because of the time and

efforts wasted in the development process and training process. A health organization may lose a substantial investment because of ineffective electronic health systems. Thus, to achieve a more effective healthcare system development, the following key principles should be adopted:

• • • • •

User participation for exploring the work environment, tasks, policies and workflow. User-centred to focus on users’ needs Iterative development to consider emerging requirements. Empirical measurement and evaluation to achieve usability standard.

Early deployment to save time, effort and investment. This paper proposes a design and development methodology. The methodology is based on User Centred Design (UCD) to develop a usable interface and Participatory Design (PD) to develop a reliable and acceptable system by eliciting users participation in the design phase, integrated with Rapid Application Development (RAD) for early deployment. The methodology also makes use of usability engineering approaches to evaluate the new system by validating each development stage against old and emergent requirements. The next sections provide a detailed overview about the theory of the methodology.

2. Methodology components The methodology was developed for a situation where a rapid development of new software is required due to the urgent need for new solutions for health problems. It is believed that electronic health systems can improve healthcare quality; therefore these systems should be developed quickly in order to achieve health benefits [12]. Slow development costs the health organization money and effort. The characteristics of healthcare systems require usable, efficient, reliable and resource-effective system with an interface that matches users’ competencies. The methodology also considers the diversity of the healthcare users by letting stakeholders participate in the design so that the product will meet their needs. By adopting UCD and PD theories usable user interfaces, efficient, reliable and effective health record systems are likely to achieve. The main components of the methodology are:

2.1. Rapid Application Development (RAD) New software frameworks aim to enable developers to build high quality applications rapidly in order to meet the requirements of new businesses. RAD was developed to achieve that goal. “RAD refers to a development life cycle designed to give much faster development and higher quality results than the traditional life cycle. It is designed to take maximum advantage of powerful development software that has evolved recently”. Software development in RAD may consist of three or four stages. The four-stage cycle consists of requirements planning, user design, construction, and cutover, while in the three-stage cycle, requirements planning and user design are consolidated into one iterative activity [13]. Systems in RAD are developed quickly in a series of increments. RAD accelerates the delivery of system services by delivering the highest priority functionality to the end user in each increment. This makes RAD suitable for e-health systems development because of the urgent need for new systems and the need of involving end users in the design. However, although RAD enables user involvement in the design which gives higher possibility to meet user’s requirements, it does not give the user the chance to participate and be fully engaged in the design. Other shortcomings are summarized in the inability of RAD to provide a plan to set up a team work and manage users-developers relations, insufficient work place because the design process in RAD usually takes place in a room instead of the work field, and RAD uses the technique of demonstrating prototyping rather than cooperative prototyping [14]. Further, RAD does not provide specifications documentation which makes the evaluation difficult [15].

2.2. User Centred Design (UCD) UCD is important nowadays in designing interactive systems. UCD is “a philosophy and a process. It is a philosophy that places the person (as opposed to the 'thing') at the centre; it is a process that focuses on cognitive factors (such as perception, memory, learning, problem-solving, etc.) as they come into play during peoples' interactions with things” [16]. Norman states that UCD is a design philosophy that addresses user requirements throughout the development process and helps developing interactive software systems [17]. UCD was derived from human computer interaction theory that focuses on user needs and provides flexible models to gather user requirements and produce a suitable interface. The main advantage of UCD is that it focuses on the core of the system and minimizes unnecessary functionalities. Also the iterative nature of UCD enables all development stages to be revised [11]. Increasing user satisfaction and productivity as well as developing usability and usefulness are other advantages [17]. It is shown that UCD has been used in the development of critical systems such as healthcare systems [12] [16]. It enables developers to identify healthcare user requirements and prioritize these requirements. The final system would

have a usable interface that achieves a better interaction with the system and minimize users’ mistakes. In such a case, health organizations would be less reluctant to adopt electronic systems.

2.3. Participatory Design (PD) PD is an approach that focuses on users needs and allows users to participate in the design so that they will be satisfied with the new system. Kuhn and Muller define participatory design as “a rich diversity of theories, practices, analyses, and actions, with the goal of working directly with users (and other stakeholders) in the design of social systems including computer systems that are part of human work” [18]. PD adopts UCD principles. Recently, it has been widely used in e-health systems development. Although the results of using PD in medical products design are satisfactory because systems are reliable, acceptable, functional and usable [11] [12], the development of these systems takes much time. Time consumption is a drawback of PD development. The use of technology is not clear in the design which makes users bored and unhappy because they prefer a hands-on experience [5]. Pilemalm proposes a new generation of PD to overcome these drawbacks. The new generation is the third generation (3G) and consists of three modules. The first module covers the pre-design stage when the project plan, schedules, and contacts with stakeholders are set up. The second module represents requirements analyses, design and prototyping stages. And the third module is the post-design stage including full implementation and completion of requirements’ specifications. The new generation of PD (3GPD) is resource-effective, it has the ability to be integrated with other methods such as rapid methods, and it provides full documentation [5]. In addition to PD advantages, 3GPD achieves new advantages and overcomes the drawbacks of PD. it focuses more on the characteristics of users, their work environment and work policies. This makes it suitable for healthcare systems development because users are able to cooperate with system developers and describe their needs precisely.

2.4. Evaluative usability engineering User centred approaches and human computer interaction principles demand that formative evaluation should be performed iteratively during the development process and should consider user needs to achieve better usability. Continuous evaluation of healthcare information systems during development produces efficient and usable systems [19]. System usability is the ability of the system to deliver efficient and effective services for users. At the same time, end users can perform system tasks safely and comfortably [8]. Health information systems should be assessed and evaluated against the ease of use, mastery of the system and problems faced while using the system. Kushniruk and Patel suggest that the use of a five-phase formative evaluation during system development lifecycle would increase system reliability and efficiency. The five-phase formative evaluation includes the following [20]:

• • • • •

An exploratory test is performed to test preliminary design concepts. Usability testing to gather user requirements in elicitation stage. Prototype assessment during design stage to provide feedback. A validation test to ensure that the complete system meets the requirements. A comparison test to check alternatives solutions at any stage.

3. Integration of components The previous components have the ability to be integrated together. At least two of them have been integrated and used in software development to overcome the drawbacks of each component and achieve better results. For example, Beynon-Davis and Holmes propose an approach to integrate RAD with PD [14]. This approach is used to develop new healthcare systems rapidly and to identify the major requirements by enabling end users to participate in the design process. Another example is user centred RAD (UCRAD) which is an integration of RAD with user centred techniques. It is used to develop successful applications that have good functionality, simple features and usable interface [21]. UCRAD model consists of three iterative stages. The first stage contains user interface design combined with requirements elicitation. A prototype is established to design and evaluate user interface and to manage risks. The second stage is system architecture in which the prototype is evolved into a functioning system. The third stage is system refinement where continuous evaluation of each stage and monitoring of emerging requirements are required [20]. The new model was derived from UCRAD approach. The reason for integration of these methods is that UCRAD and 3GPD consist of three stages [5] [21]. Both methods can overlap to achieve not only user involvement but also user participation since user participation is important in the healthcare system development to produce an accepted application [11], and UCRAD involves end users only in requirements elicitation and testing process. The five-phase formative evaluation (five tests) can be injected easily in each stage according to the functionality of each test and each

stage. The Five-phase formative evaluation approach is used in each stage to validate the results against user requirements and system specifications. The integration has the following advantages:

• It produces a new system quickly and allows early deployment of the system. • It meets the requirements of critical systems by producing a reliable, dependable, usable, and system. • It minimizes the post deployment corrective events, which solves incremental problems from the development process.

• It provides full documentations which makes evaluation easier. The methodology consists of three stages. Each stage is performed iteratively. Figure 1 shows the components and the stages of the methodology.

Figure 1 – Methodology - iterative stages The methodology works as the following: Stage 1 (Pre-design and interface prototyping): The development team (stakeholders and programmers) sets up project plan and schedules. After that negotiations start about the interface. Developers build a prototype before the end of this stage. However, this prototype will be completed in module 2 of 3GPD in the second stage. The system’s developers keep on assessing users’ needs and exploring the available solutions. The result of this stage is a user interface prototype and initial requirements. Stage 2 (system architecture and coding): The team updates the requirements’ documentation. The system’s developers update the prototype according to the new requirements, and then they start coding the system considering system architecture. After that, they assess the implemented version and get users’ feedback. The team keeps on exploring alternative solutions. The result of this stage is incomplete product with basic system architecture and system specifications. Stage 3 (deployment): The team again updates requirements’ documentation and starts full implementation of the system based on the basic architecture. The new system is validated against the specifications. If the system meets all requirements the project will end, otherwise the developers will continue modifying the system using new alternatives. System developers interact with stakeholders in different ways. They may interview stakeholders or work cooperatively with end users. They may need to record development and deployment sessions so that they can use it in the evaluation process. After the deployment of this methodology in real work environment and using it to develop a new system, the limitation will be identified in each stage and solutions for these limitations will be suggested. The final evaluation of the system will use summative evaluation methods such as questionnaires or interviews to identify the overall benefits.

4. Conclusion Different software engineering methods can be used for developing e-health systems. It is confirmed in the literature of e-health that the use of one method is not sufficient to produce an application that meets healthcare requirements. So a combination of different methods is proposed to overcome the drawbacks of each method and achieve better results. In this paper, a mixed methodology from RAD, PD and UCD is used to develop a new application rapidly and focus on users’ needs. Formative evaluation from usability engineering theory is used in every stage of the development process to ensure requirements are met. These methods together enable system developers to explore user requirements and system functional and non functional requirements. The proposed methodology will be used to build a system for antenatal healthcare in Palestine. The project will involve Palestinian stakeholders. A sample of pregnant women, nurses and physicians will participate in the system development. Based upon the theory of the methodology the produced system will meet the requirements of the critical systems and be reliable, dependable, secure, acceptable and resource-effective. The limitation of this methodology will be discovered during the development process and after the deployment of the new product.

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