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Olivia Velez - Requirements Analysis for an mHealth Application with Midwives in Ghana

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  • Design Science as a Framework for mHealthThe purpose of any design science research project is to solve problems or improve upon existing processes within a specified environment. To do this, we must understand the problems and opportunities to be addressed within the application domain 8, 9. This includes an understanding of the people involved, current technology in use and the organizational systems that will all interact with the artifact to be developed. Any health information system implementation initiates a process of organizational change through the introduction of a new tool. An approach based on design science allows for elicitation of needed changes so that appropriate tools can be structured to facilitate more efficient processes.  We used Heek’s Design-Actuality Gaps model 10 within Hevner’s overall information systems research framework to examine the current practices of midwives in rural Ghana. This information was used to identify opportunities for improvement that could be addressed using a new information-communication tool. The information systems research framework incorporates three cycles. These include the relevance cycle, the design cycle and rigor cycle. Heek’s model was used within the relevance cycle to examine the application domain or the environment within which the midwives currently practice. The model allowed for the examination of current systems including people, structures and technology and the identification of gaps between current systems and desired future systems. These data were transformed into requirements for tools that could address gaps and facilitate systems improvement. We designed an mHealth tool to address a specific gap identified through the use of the model. The tool was then tested by midwives in rural Ghana with the intention of future implementation.
  • Design Science as a Framework for mHealthThe purpose of any design science research project is to solve problems or improve upon existing processes within a specified environment. To do this, we must understand the problems and opportunities to be addressed within the application domain 8, 9. This includes an understanding of the people involved, current technology in use and the organizational systems that will all interact with the artifact to be developed. Any health information system implementation initiates a process of organizational change through the introduction of a new tool. An approach based on design science allows for elicitation of needed changes so that appropriate tools can be structured to facilitate more efficient processes.  We used Heek’s Design-Actuality Gaps model 10 within Hevner’s overall information systems research framework to examine the current practices of midwives in rural Ghana. This information was used to identify opportunities for improvement that could be addressed using a new information-communication tool. The information systems research framework incorporates three cycles. These include the relevance cycle, the design cycle and rigor cycle. Heek’s model was used within the relevance cycle to examine the application domain or the environment within which the midwives currently practice. The model allowed for the examination of current systems including people, structures and technology and the identification of gaps between current systems and desired future systems. These data were transformed into requirements for tools that could address gaps and facilitate systems improvement. We designed an mHealth tool to address a specific gap identified through the use of the model. The tool was then tested by midwives in rural Ghana with the intention of future implementation.
  • Considerations of designing for midwives/nurses
  • -Needs can often be conflicting-Hard to articulate what you need
  • Original graphic source: 777-team.org
  • Considering the extreme needs of developing countries this is even more tragic
  • Considering the extreme needs of developing countries this is even more tragic
  • Considering the extreme needs of developing countries this is even more tragic
  • Credit to Patty Brennan – Bottles have wireless capabilities to track adherence. Bottles don’t fit in medicine cabinent
  • From healthworkerscount.org – midwives at work
  • The purpose of any design science research is to solve problems or improve upon existing processes within a specified environment. To do this, we must understand the problems and opportunities to be addressed within the application domain, consisting of the people, technology, and organizational systems that will interact with the artifact to be developed. Any HIS implementation initiates a process of organizational change through the introduction of the artifact. What are the changes that need to happen?
  • Explain what the outputs are
  • Research question related to these sections (don’t read)Problems & OpportunitiesWhat is the required functionality needed for the application based on the need and constraints of the application environment?
  • Overall approach was user centered designExplain each stepContextual inquiry – comes from centered design
  • How much time was spent interviewing/observing midwives
  • Add data to support each itemExtensive documentation requirementsQuality of documentation tools were poorLow technical self-efficacyLimited Information Sourcesm
  • Midwives had extensive reporting and documentation requirements
  • Discuss paper record storage for picture
  • Show medical record card
  • Patient lookup and registrationMaternal Health ModuleFamily planning moduleChild health moduleReferral tracking moduleRegistry module
  • International Standards Organization (ISO) software quality requirements and evaluation (SQuaRE) standardsInterop – constraint of MGV-Net
  • Specify how data should be handled and processed
  • Uses AndroidODK
  • These need to be updated to current screen shots
  • These need to be updated to current screen shots
  • These need to be updated to current screen shots
  • Transcript

    • 1. Requirements Analysis for an mHealth Application with Midwives in Ghana Olivia Vélez, RN, MS, MPH, PhD Adjunct Associate Research Scientist Department of Biomedical Informatics, Columbia University Senior mHealth Advisor Maternal Child Health Integrated Program(MCHIP)ICF International
    • 2. Centering Clinical Users in UserCentered Design (on a budget) Olivia Vélez, RN, MS, MPH, PhD Adjunct Associate Research Scientist Department of Biomedical Informatics, Columbia University Senior mHealth Advisor Maternal Child Health Integrated Program(MCHIP)ICF International
    • 3. Overview • What is requirements analysis? • Why do we do it? • Methods for requirements analysis • Case study – Turning requirements data into functional specs
    • 4. What is Requirements Analysis? • Determining stakeholder needs and translating them into software/systems requirements • What do users need • What will you do to address those needs • Not how
    • 5. Steps for conducting requirements analysis • Identify who you are building the system for (hint: might not be just the end-user) • Interview stakeholders • Write, review, and revise requirements with stakeholders • Write developer requirements and check for consistency
    • 6. Methods for collecting requirements • Focus groups • Surveys • One-on-one interviews • Observations • Contextual interviewing
    • 7. What can we learn from focus groups/surveys/ one-on-one interviews • What stakeholders think they need • Issues • Bounce ideas off of one another • Things they wouldn’t say otherwise
    • 8. Why we need to do observations
    • 9. Why we need to do contextual interviews
    • 10. Methods for writing requirements • Vignettes • Use-cases • Data flow diagrams • User interfaces
    • 11. Challenges of Health Information Systems in Low-Resource Settings • Health information system (HIS) implementations in developing countries have a failure rate of 20-25% (Heeks, 2006) • Causes of failure – Insufficient equipment/infrastructure – Poor project buy-in – Lack of resources to support intervention – Poor design and implementation planning • Disconnect between local needs and designers
    • 12. Heek’s Design-Actuality Gaps Model
    • 13. Project Context • Millennium Villages Project (MVP) • MGV-Net: Comprehensive open source e-health delivery platform enabling – Facility-based data capture – Community-based data capture of individual-level data – Data storage of patient health records – Automated mechanism for aggregating data and generating reports and feedback to healthcare providers and managers
    • 14. Footer text is edited under "view/header and footer" menu February 12, 2014 Page 15
    • 15. Bonsaaso, Ghana • • Population: 30,000 Primarily farmers and miners
    • 16. Goals & Outputs • Understand application domain to identify problems and opportunities that can be addressed using mHealth • What is the future state we want to achieve? • Outputs: – Functional Requirements – System Qualities – Use Cases
    • 17. Research questions • People – What is the current workflow of MVP midwives? – What are the roles and responsibilities of midwives at MVP facilities? – What is the current experience of the midwives with technology and their comfort level in learning new technology? – What are the information needs and information seeking behaviors of midwives working in MVP facilities in Ghana? • Organizations – What are the issues in collecting data from the health facilities? – What is the support capacity for and HIS implementation at MVP Ghana? • Technology – What is the current technology infrastructure at MVP Ghana? • Problems & Opportunities – What is the required functionality needed for the application based on the need and constraints of the application environment?
    • 18. Design & Procedures • User centered design approach • Participant Observation • Contextual inquiry1 • Review of paper tools (document analysis) • Iterative Design through usability testing/evaluation • General interviews – Non-Governmental Organization (NGO) ICT eReadiness Self-Assessment Readiness Tool used to guide interview2 – Data quality assessment • Comparison to country and/or international standards 1. Coble, Maffitt, Orland, & Kahn, 1995 2. VanBelle, 2009
    • 19. Turning data sources into design Goal Is achieved by enabling… Use Case Constraints: restrictions on System What we aka of Functional Description to user Use cases: Requirements: how GOALS:Qualities:want Non-what functional are system interaction such as and the requirementsto be achievesystem inputs, how does can implemented availability, task the system behave, etc. complete a security, how are the inputs processed, what are the Example: Appropriate testing outputs Data sources: Participant and treatment of all patients who interviews, interviews participant observation observation, Midwife present with a fever interviews, Data sources: use cases, contextual inquiry, document interviews, document and analysis, comparison analysis, Data sources: Midwifewith staff standards international standards interviews, contextual inquiry, document analysis, comparison with international standards Is achieved by enabling… Functional Requirements System Qualities Design Constraints …with these characteristics …with these restrictions Adapted from: http://tynerblain.com/blog/2006/01/04/foundation-series-structured-requirements/
    • 20. Participants • Interviewed/observed 6 midwives in September 2010, 7 May 2011 Midwife Interview 1 Interview 2 1 2 3 4 5 6 7 8 X X X X X X X X X X X X X MW Years Exp. Nursing Exp. 20 Yes 26 Yes 3 Yes 43 Yes 4 No 42 Yes 8 Yes 2 Yes • Interviewed key staff members at MVP administrative site: IT manager, Health Manager, Data Analyst, Data Manager, Telemedicine Project Lead
    • 21. Results – People • Midwives had heavy patient loads and intense work schedules – Average 30 patients a day – Every other weekend off, 24/7 call schedule – Little administrative support • Extensive reporting and documentation requirements – High degree of duplication
    • 22. Monthly Reporting Requirements Report Name Key data elements Addendum Antenatal/Maternity Monthly Data Returns ANC visit information; Malaria prophylaxis; Delivery information Communicable disease surveillance report Malaria cases; Pneumonia cases, Diarrhea, AIDS, STDs Facility report of HIV test kit usage HIV test kits used Family planning returns Contraceptives administered Immunization and vaccine monthly returns Vaccines used and immunizations given by age and dose Institution monthly returns Malaria medication used Malaria reports of outpatient cases Malaria cases (by age and pregnancy) Malaria reports ITN/SP Stock Malaria medication used and stock holdings Midwives return ANC visit information; Delivery information; Postnatal data; Abortion data; PMTCT data Monthly data returns on ArtesunateAmodiaquine Malaria medication used; Children and pregnant women receiving treatment Medication and testing stock Malaria medication use; RDTs used National AIDS/STI control programme monthly returns HIV testing and treatment; STD testing and treatment; PMTCT data Outpatients Morbidity Causes of morbidity PMTCT monthly returns PMTCT data Returns on deliveries Delivery data Statement of Outpatients Patient age and insurance status Weekly notifiable diseases report Cholera, meningitis, measles, H1N1, Guinea worm, yellow fever, polio
    • 23. Poor Documentation Tools
    • 24. Results – People continued • Low technical self-efficacy – “They have to come and train us so we are more confident with the computer. We don’t know what we are doing with the computer. None of us.” • Limited information resources – Relied primarily on textbooks – No access to systematic reviews, journals, or other sources of up-to-date information • Perceived limited support
    • 25. Results - Organization • Data sources are not searchable/easily referenced • High potential for errors in current documentation practice • Errors may go unnoticed for a long time
    • 26. Paper Record Storage Medical Records Personal Health Records Encounter Registers
    • 27. Fever Register Action Taken 1. ACT & home 2. ACT & referred
    • 28. Results – Organization Continued • Only 2 full time technical staff members • Distance to clinic will make supporting implementation challenging • No infrastructure for remote support currently in place
    • 29. Results - Technology • Power infrastructure is limited – Clinics rely on solar power • Network infrastructure inadequate – Inadequate signal strength at some of the clinics – Network outages – Internet outages at administrative site
    • 30. From Goals: Overview of Planned Forms • Patient lookup and registration • Capture patient register data needed for reporting • Fevers (malaria) • Vaccinations • Prevention of mother-to-child transmission of HIV
    • 31. System Qualities System Quality Category Accuracy Documentation Interoperability Document analysis; contextual inquiry; Rationale from data interviews with data A primary goal of this system is to improve the accuracy of data collection from the analyst/manager facilities. Data validation should be a key component of the interface Interviews with midwives; Easy-to-use, picture based manuals should be made available at the clinic due to the Interviews with IT lack to technical support available to midwives Staff Because OpenMRS will serve as the back-end the system must be fully compatible. Additional compatibility with other MVP mHealth and eHealth initiatives, particularly the telemedicine center is highly desirable. Learnability Due to the low technical self-efficacy of the end-users and the limited availability of technical support ease of learnability should take precedence over advanced functionality. Resource Utilization Midwives see about 30 patients in the morning. Hardware selection should support allow for this level of use without needing recharging Security The system will be used to collect patient data. The phones and the software itself should be secure. Remote deleting of data should be implemented in case the phone is lost. Data should be encrypted when sent over wireless network. Participant observation Participant observation; Interviews; Literature
    • 32. Constraints • Selection of OpenDataKit (ODK) – Review of existing software available that met identified system qualities and constraints • Must work with OpenMRS • Must work on low-cost Android phones • Developed within contract requirements • Minimize text entry
    • 33. Use Case Example Use Case FR1. Enter new fever encounter Primary Actor: MW Preconditions: User was found or entered in patient registration/Look-module and added to patient list Success end condition: Patient data is entered. System: Fever Register 1. MW selects patient from list 2. MW verifies patient demographic items 3. MW completes the following items Encounter date Temperature Duration of fever Test Done RDT or Malarial Smear results Danger signs of severe malaria Anti-malarial treatment given – – If RDT or Danger signs alert if no If not RDT and Dangers alert if yes If treatment yes, which medication Referral 4. MW uploads data to OpenMRS Extensions: 2a. Data needs to be updated, changes recorded to patient registration 4a. No network connection is available Data for use case development came from participant observation and contextual inquiry
    • 34. Functional Requirements Example Name Gender DOB Age DOB Estimated NHIS # Encounter date Type Text Date Number Boolean Number Date Possible Values M/F DD/MM/YYYY Calculated from DOB Yes/No Alphanumeric 16 DD/MM/YYYY Duration of fever Number Number of days RDT results Danger signs, Malaria Treatment given Boolean Boolean Yes/No Yes/No Boolean Yes/No If yes, which medication Referral Text ACT, SP, Quinine, other Text Hospital, none, other Data Sources Contextual Inquiry (Document analysis) Participant Observation Data Analyst interviews Comparison to standards
    • 35. mClinic
    • 36. mClinic
    • 37. Current Status of mClinic • Positive feedback from usability testing • Existing deployments for capturing baseline immunization data and verbal autopsy data by CHWs • Refining software and pre-implementation planning, seeking funding opportunities
    • 38. Contact Information • Email: olivia.velez@icfi.com • Twitter: @mHealthNurse • LinkedIn: www.linkedin.com/in/oliviavelez/
    • 39. Acknowledgements • National Institute for Nursing Research (P30NR010677) • Health Services Resource Administration (1D11 HP07346) • International Development Research Centre • Rockefeller Foundation • Novartis Fund for Sustainable Development • OpenROSA Consortium • Jonas Center for Nursing Excellence • National Library Medicine Biomedical Informatics Training Grant (5 T15 LM007079-20) • PAHO Collaborating Center at Columbia University