The Design and Evaluation of a Home Health Care System

(TeamVisit)

Wesam Shishah

, Hessah AlJowesir, Omaimah Subh and Ghaida Hassan

College of Computing and Informatics, Saudi Electronic University, Riyadh, Saudi Arabia

Keywords: Health Care System, e-Heath, User Centered Design, Usability and System Design.

Abstract: The usability of computer systems used in health care is a worldwide issue. Poor usability has been reported

as one of the most common problems in human-computer interaction, negatively affecting the workflow of

health care. Today, the demand for home health care is increasing. It must therefore be supported with a

system that is easy to learn and easy to use. The department of home health care at King Abdullah Medical

Complex in Jeddah (KAMCJ) uses a semi-manual system. This research introduced a system called

“TeamVisit,” which was designed to automate services and to enhance support for workflow management at

the KAMCJ. The User Centered Design (UCD) method was applied to design the TeamVisit system. The

system was designed in three stages: the first stage identified intended users and tasks, the second stage aimed

to confirm whether the system matched user requirements, and the final stage involved initial usability testing

of the TeamVisit system. The paper also summarizes the results of each stage. The paper concludes that users

were satisfied with the design of the TeamVisit system, finding it easy to use.

1 INTRODUCTION

Home health care comprises a wide range of health-

related services provided by health professionals at

the patient’s home or another place outside a medical

facility. Home health care is beneficial in cutting

hospitals’ operational costs, as providing medical

care at home reduces the length of a hospital stay, and

reduces the number of unnecessary hospital

admissions. Home health care also provides support

for the patient’s family and improves quality of

health.

King Abdullah Medical Complex in Jeddah

(KAMCJ) is a hospital in Saudi Arabia that applies

the Saudi Ministry of Health home care program. The

home health care team arranges appointments for

patients registered at KAMCJ and visits them

frequently in their home for regular checkups.

Currently, WhatsApp is used for appointments and

communication and paper forms are used during day

visits. Also, patients must use WhatsApp and come to

the hospital if they require refill order for

supplements or medication.

Poor communication between patients and

medical providers (doctors or nurses) could lead to

https://orcid.org/ 0000-0001-6947-9927

unnecessary excessive treatment causing unwanted

side effects (Organization, 2018). A usable computer

system enables users to pay attention to their required

task rather than to the technology itself. According to

Dray (1995), usable systems are easy to learn, easy to

remember, and easy to use. They are efficient,

minimize the chance of errors, and promote user

satisfaction.

The TeamVisit system was designed to enhance

workflow and communication at KAMCJ. This paper

describes the application of User Centered Design

(UCD) to the design stages of the TeamVisit system,

which enhanced its usability.

2 RELATED WORK

2.1 Home Health Care

Home health care began in Saudi Arabia in 1991. The

Home Health Care program (HHC) was developed by

King Faisal Specialized Hospital and Research

Center for patients with terminal cancer. Later, in

2008, the Saudi Ministry of Health established a

218

Shishah, W., AlJowesir, H., Subh, O. and Hassan, G.

The Design and Evaluation of a Home Health Care System (Teamvisit).

DOI: 10.5220/0010157502180224

In Proceedings of the 4th International Conference on Computer-Human Interaction Research and Applications (CHIRA 2020), pages 218-224

ISBN: 978-989-758-480-0

home health care program to provide health services

for all those in need, wherever they may be, to reduce

the pressure of hospital waiting times. The high

quality home health care service is provided to

international standards and according to Islamic

social values and traditions (Almoajel et al., 2016).

Different countries employ a variety of definitions

of home health care, but perhaps the most useful

definition is satisfying people’s health and medical

needs while in their home by providing appropriate

and high-quality home-based long-term or a short-

term health care (Genet et al., 2011).

Home health care grew at an annual average of

5.05% from 2007 to 2012 (Gitlin and Piersol, 2015).

As the population increased and technology evolved

there was a real need to develop new technologies in

home healthcare. In the early 1990s, telecare and

telemedicine were introduced for the first time.

Telecare is the use of technology, such as remote

monitoring, to manage risks for the elderly so they

can receive help at home and continue to live

independently. Telemedicine is the use of

telecommunications technology, either synchronous

or asynchronous, to remotely consult a doctor or

access medical advice. This service may provide

valuable help in the homecare sector (Lamine et al.,

2019; Lyons et al., 2019).

Many studies have outlined the advantages of

home health care. One study, (de Mestral et al., 2019),

looked at patients who received post-surgery home

nursing, including 23,617 patients, of whom 9,002

(38%) received home medical assistance within 30

days of discharge. Results showed that there was less

chance of an emergency department visit or hospital

readmission among patients who received home

health care services (Abyad, 2017; de Mestral et al.,

2019).

2.2 Usability of Health Care Systems

Reports of unusable systems suggest the issue of

health care system usability has become a global issue

affecting health care workflow and potentially

introducing new errors, particularly those

technologically induced (Kushniruk et al., 2013).

According to (Riskin et al., 2015; Kellermann and

Jones, 2013), a number of problems have been

reported relating to human-computer interaction,

poor usage, systems failing to meet intended users’

needs, terminologies, and workflow. Several attempts

have been made, in the past, to foster the development

of health care systems and an encouraging and

compulsory user-centered system that is more usable

does exist. Different methods have been adopted for

testing for usability and for assessing systems and

their impact on patients’ safety. However,

(Kellermann and Jones, 2013; Riskin et al., 2015)

argue that reports of poor system usability continue.

User interface design must be easy to understand

and intuitive in order to prevent usability issues,

especially when designing an interface for older

adults. A study was conducted in Taiwan by (Chen

and Liu, 2017) investigating the intuitive interaction

and affordance relationship with elderly users. It

concluded that, in terms of usability, designs with the

simplest layout are best for elderly users.

Consequently, complex and composite arrangements

and information presentations that require

imaginative association should be avoided in the user

interface (Chen and Liu, 2017).

When implementing new systems in the field of

home health care, caregivers must be trained to

understand how the new system works to support the

physical, mental, and medical needs of their patients,

and adequate training must be provided for elderly

patients for them to accept and adopt the new

technological system (Chase et al., 2009). The

appropriate awareness, full commitment, and the

correct application of user-centered processes and

tools are all necessary to ensure success in the process

of designing a usable interface (Dray, 1995).

3 METHODOLOGY

The research method adopted in this project is User

Centered Design (UCD). This method emphasizes

user involvement at each stage of the design process

and Kashfi (2010) recommends its application in

health contexts. The major focus of UCD is the end

users and the needs for which the system will be used.

The main goal of this method is to make systems

usable and to achieve user satisfaction. The key

characteristic of UCD is its iterative nature, in which

prototypes are delivered to users regularly for

evaluation and enhancement during the design and

development process.

According to McCurdie et al. (2012), the UCD

process begins with the concept generation stage, in

which, once users are identified, a comprehensive

examination of their needs is performed in order to

understand the use and purpose of the system.

Different techniques can be used in this phase such as

ethnography, focus groups, and one-on-one

interviews.

On completion of the initial investigation of user

needs, our project proceeded to the next phase, which

is to translate the identified user needs into a set of

The Design and Evaluation of a Home Health Care System (Teamvisit)

219

functional requirements by designing initial

prototypes as simple sketches and wireframes.

The prototypes are then used to collect user

comments and feedback, and to get an in depth

understanding of the main goal of the system. As our

design process continued, designs were evaluated and

reframed iteratively with users through the use of

walkthroughs and usability testing. User comments

and feedback were used to verify that the

representation of the system matched user

requirements.

During walkthroughs, a facilitator supported users

through the process of using the proposed design

(Kaye and Crowley, 2000). This helped users to think

aloud and provide feedback on the issues and

obstacles they faced with the suggested workflow.

For the usability tests, a representative user

worked independently in a controlled environment

through a set of scenarios representing typical usage

of the system, while at the same time thinking aloud,

as suggested by (Fu et al., 2002). The facilitator who

observed the study, recorded notes on the

participants’ behavior as well as their comments and

issues that arose, helping to detect any hidden

requirements and interface design errors. Section 4

will describe how the UCD will be conducted in our

work and which techniques will be used.

4 THE DESIGN AND

EVALUATION OF THE

TeamVisit SYSTEM

The TeamVisit system development team was

multidisciplinary, and included an interaction design

expert, who also served as domain expert, and three

University students with different backgrounds in

software engineering, programming, and user

interface design. However, other experts and users

were involved in different phases of the evaluation.

The design of the TeamVisit system was conducted

in three stages, as discussed below.

4.1 Stage 1: Identification of Intended

Users and Task

The development team conducted a focus group with

four users, two members of the home health care team

and two members of the hospital’s IT department.

Focus groups were selected as the most suitable

method of data collection as they allow a diversity of

views to be shared, developed, and discussed (Heary

and Hennessy, 2002). The focus group lasted for

approximately two hours. The aim of this stage was

to identify the intended users and the main tasks for

each type of user. The leader of the development

team, who had experience of developing systems and

in conducting focus groups, facilitated the group

session. The remaining research team members noted

comments and suggestions during the session. An

example of questions prepared to foster this focus

group included: explain the current satiation of work,

what are the responsibilities of each member of the

home health care team, what tools are currently used,

and are there any problems or issues?

Following the focus group, the development

team designed a low-fidelity prototype (Figure 1).

Then, the leader of the development team conducted

a one-on-one interview with the leader of the home

health care team. This interview was conducted in

order to come to an agreement about the main tasks

of the system using the low-fidelity prototype and to

elicit initial feedback for the system design. The

leader of the development team took notes that were

then taken into consideration in designing the next

prototype. The development team analyzed the

collected data and categorized the evidence.

Figure 1: Low-fidelity prototype in stage 1.

4.2 Stage 2: Confirming the Functional

Requirements and Workflow of the

Functions

The development team developed a mobile prototype

for this stage, as shown in (Figure 2). The team

examined the mobile prototype with two members of

the home health care team. Each participant examined

the features by navigating the mobile prototype and

providing feedback, comments, and notes. The

development team observed each participant and took

notes. The examination of the prototype lasted for

approximately two hours, its main goal being to test

the workflow of the system’s functions.

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Figure 2: The mobile prototype in stage 2.

4.3 Stage 3: Usability Testing of the

TeamVisit System

A responsive web application was developed (Figure

3) involving two sides: the patient and the caregiver.

This was selected in response to the requirement

identified in Stage 1 that the design of the system

should be compatible with different sizes of screen. A

responsive web application fits in any screen size,

runs on any device, and works with any operating

system. The web programming languages used were

HTML, CSS, and JavaScript for client-side scripting,

and PHP and MySQL for server-side scripting.

Testing is an important phase in software

development, and, for thoroughness, unit testing,

integration testing, and usability testing were applied.

During development, unit testing was conducted on a

daily basis for each feature to ensure that each

functionality performed as expected. After

completing development, the development team

carried out integration testing in order to verify that

all functions in the system produced the expected

results. Then, usability testing was carried out with

five participants from different backgrounds. Before

the study, the development team prepared eight test

cases to be examined (Table 3). Then, the leader

commenced the process by thanking the participants

for their participation and then explained the purposes

and aims of the research study. Participants were

asked to interact with the TeamVisit system to

perform the selected test cases. During the testing, the

leader conducted a think-aloud procedure by asking

users to verbalize their thoughts whilst performing the

tasks. The development team members observed each

participant and took notes.

Figure 3: Example of responsive web application. The left

image is the TeamVisit system on a mobile screen, the

image on the right is the TeamVisit system on a desktop

screen.

5 RESULTS AND DISCUSSION

The involvement of users in the early stages of the

design process supported developers in collecting

useful data for the TeamVisit system. This supports

the results of previous studies that highlight the

important role of the user in the design process (van

de Kar and Den Hengst, 2009).

The focus group conducted in Stage 1 identified

the direct users of TeamVisit and the main tasks. The

direct users for the system include:

 Head of the home health care department at

KAMCJ, who authorizes team members to use the

system. (Moderator)

 KAMCJ home health care team members whom

the moderator grants permission to log in.

(Caregiver)

 Patients registered with the KAMCJ home health

care department and a relative who has knowledge

of the patient’s required data. (Patients)

The use case diagram shown in (Figure 4) shows

different ways in which users (patient, caregiver, and

moderator) can interact with the TeamVisit system

and what tasks they can perform.

Feedback from the interview was highlighted for

consideration in future design. For example, rather

than specifying the type of user (caregiver, patient) at

the login page, log in to the system should be by

national ID, for both the caregiver and the patient, so

the system can automatically recognize the type of

user and move on to the appropriate page. In addition,

the design of the system should be compatible with

different sizes of screen.

The Design and Evaluation of a Home Health Care System (Teamvisit)

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Figure 4: The use case diagram.

In Stage 2 of the TeamVisit design process, the

mobile prototype proved useful, as suggested in

previous studies (Kaye and Crowley, 2000), for

getting comments and feedback from users. In

general, the home health care team agreed with most

functions of the system and the functional workflow.

Further highlighted notes need to be considered in the

design. For example, in the current design (Figure 2),

appointment bookings can only be performed by the

patient. This needs to be changed so that the caregiver

can perform the task while the patient responds by

accepting or rescheduling. The reason for this is to

allow the home health care team to organize visits so

they can visit patients who live close to each other on

the same day. The main features for caregivers are

described in Table 1 and the main features for patients

are described in Table 2. Also, the priority status for

each feature was identified as (High, Medium and

low) which help the development team in the

implementation phase.

In Stage 3 of the design process, the results of the

usability testing were summarized (Table 3). Five

users participated in this study, following (Nielsen,

2000), suggestion that testing with five users results

in identifying the majority of usability problems. All

the 5 users performed both the caregiver and the

patient tasks. The expected time to complete the tasks

is 45-50 minutes and users completed the tasks in

acceptable duration time between 40 minutes to 1

hour. In general, users seemed satisfied with the

TeamVisit system and found it interesting to use.

However, there was some apprehension that needs to

be resolved in order to enhance the usability of the

system (Table 3).

Table 1: The main features for caregivers.

Feature

Feature description and the priority of

implementation

Profile

view personal information and update contact

details and password. (H)

Add new

patient

National ID, Medical Record Number (MRN),

name, age, gender, location (H)

Adds the order of medications, diet, and medical

supplements for each home health care patient

Manage refill

request

Manages patients’ requests by viewing,

accepting, editing, or rejecting. (H)

Books

appointment

Books appointments to visit patients in their

home. (H)

Visiting

requirements

Fills out the visiting requirements for

appointments (M)

Messages

Receives text or image messages from home

health care patients. (L)

Messages

status

Applies a status to messages received from

patients: read or unread. (L)

Charts Views dashboard charts. (M)

Searches using a patient name and searches

appointments by date and status (accepted,

rejected, pending, completed). (H)

Add new

caregiver

(Moderator only) can Add/Delete caregiver

members. (H)

(H) = High priority / (M) = Medium priority / (L) = Low priority

Table 2: The main features for patients.

Feature

Feature description and the priority of

implementation

Profile

view personal information and update contact

details and password. (H)

Notifications

users can be notified of scheduled appointments

and receive a response to their refill order

requests. (M)

Refilling

requests

Requesting to refill medications, diet

supplements, or medical needs. (H)

History

view the past five refill orders or appointments.

(M)

Responds to

requests

users can respond to appointment requests for

home visits arranged by the home health care

team. (H)

location

For each appointment, users can share their

current location. (M)

Messages

Users can send text messages as feedback or

comments to caregiver and upload images to

describe their health condition. (L)

view contact details about home health care team

members. (L)

Satisfaction

rating

The patient can give a satisfaction rating for the

service provided (Excellent, Very good, Good,

Acceptable, Poor). (L)

(H) = High priority / (M) = Medium priority / (L) = Low priority

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Table 3: Summary results of the usability testing.

User

background

Task given

Time

Notes by development team members

Positive

feedback

Negative

feedback

Suggestion

Business

administrator

Test Case 1:

User login.

Test Case 2:

Adding a new

caregiver user.

Test Case 3:

Adding a new patient.

Test Case 4:

Caregiver manages

refill orders for

medication or diet

supplement.

Test Case 5:

Caregiver schedules

appointment for

patients.

Test Case 6:

Caregiver adds

appointment’s

requirement on the

visit day.

Test Case 7:

Patient orders refill.

Test Case 8:

Patient sends message.

minutes

Adding a patient

is really easy and

no difficulties

were faced.

Appointment status is

confusing.

None

2 Dentist

minutes

The interface and

main functions

are easy to use

even though there

are many

scenarios.

None

The refill

feature is

limited (e.g. no

information

about dose).

3 Nurse 1hour

Managing

appointments is

smooth using the

search by date

and status.

None

Patient history

is limited.

4 IT student

minutes

The whole

system looks

good.

Some interface icons

(such as the mail icon

in the login page) does

not give the right user

impression.

None

5 Teacher 1 hour

Requesting a

medication refill

is clear.

Sending messages

without receiving a

reply is not really

useful.

None

6 CONCLUSION AND FUTURE

WORK

This paper describes the design stages of a proposed

system for the home health care department in

KAMCJ called “TeamVisit,” which aims to provide

automated services and enhance communication

between patients and the home health care team.

Users were involved at point in the design process and

initial usability testing was conducted.

Using the UCD method, users were involved in

each stage of the design in order to get appropriate

data. In Stage 1 of the design process, a focus group

and interview were used to collect data about the

intended users and their main tasks. Next, in Stage 2

of the process, a mobile prototype was used to

confirm the requirements of the TeamVisit system.

Finally, initial usability testing was conducted, which

found that users were satisfied with the TeamVisit

system and found it interesting to use.

For further research or future work, more usability

testing should be performed using other techniques in

order to gather more useful information. Also, a field

study may be conducted to gather data in a natural

setting; this can be performed by observing users

while they interact with the TeamVisit system.

Furthermore, tests could be conducted with a larger

sample of users in order to carry out quantitative

analysis of usability problems.

Further features were recommended for

development in order to enhance the performance of

the system, some of which are highlighted below:

• patient appointment booking, to give them more

flexibility;

• live direct messages with a doctor so patients

can describe their medical condition and get

immediate medical advice; a video call feature

would further improve medical consultation;

• an upgrade of the responsive web application to

a native mobile application would provide many

advantages;

• car tracking of the team member due to visit the

patient at home;

• report generation such as number of patients

served in each location, downloaded in pdf

format.

The Design and Evaluation of a Home Health Care System (Teamvisit)

223

ACKNOWLEDGEMENTS

Many thanks to all participants of this project and

special thanks to Dr. Khalid Alabbasi at King

Abdullah Medical Complex in Jeddah (KAMCJ).

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