Are End-Users Participating in the Life Cycle of Healthcare Application

Development? An Analysis of the Opportunities and Challenges of the

Use of HCI Techniques in the Healthcare Sector

Jos

e Silva

, Andr

e Ara

ujo

, Fabio Coutinho

and Alenilton Silva

Computing Institute, Federal University of Alagoas, Av. Lourival Melo Mota, S/N - Cidade Universit

aria, Macei

o, Brazil

Keywords:

End-Users, Healthcare Application Development, HCI Techniques.

Abstract:

Health information systems (HIS) play a fundamental role in society, providing a solid technological basis for

collecting, storing, processing, and making decisions in the healthcare sector. Due to the signiﬁcant increase

in software solutions and the limitations arising from the difﬁculties associated with mastering healthcare, it

is appropriate to consider including end-users in the application development life cycle. This paper presents a

systematic review of the literature to identify the presence of the end-user throughout the software life cycle

and assess whether the techniques used in requirements elicitation and application evaluation are aligned with

usability standards or best practices. The study resulted in the analysis of twenty-seven studies, indicating that

many works do not incorporate end-users at all stages of development. Although many studies involve users in

software evaluation, the methods used need more support in usability standards or guidelines. In addition, little

evidence of the involvement of healthcare professionals in the development life cycle of healthcare applications

was identiﬁed in the studies, which indicates that the knowledge of the domain specialist needs to be taken

into account. Thus, it will be possible to investigate whether understanding the domain expert speciﬁed in

openEHR archetypes can improve the life cycle of healthcare applications.

1 INTRODUCTION

The global market for software products has grown

signiﬁcantly in recent years, with an annual growth

rate of 12.5% between 2022 and 2023 (Company,

2023). The market’s growth forecast indicates that

it will continue to grow signiﬁcantly in the coming

years, speciﬁcally between 2023 and 2030 (Reports,

2023). In addition, the global healthcare software

market is expected to grow at an annual rate of 19.8%

between 2022 and 2027 (Markets and Market, 2023),

and this growth is driven by the increasing and con-

stant adoption of electronic health record (EHR) soft-

ware, telemedicine, mHealth, and other digital tech-

nologies. Given this environment, technological ad-

vances have signiﬁcantly transformed the healthcare

software landscape, incorporating more and more in-

formation systems to optimize management, monitor-

ing, and service delivery processes (Pinochet et al.,

https://orcid.org/0009-0001-0225-2696

https://orcid.org/0000-0001-8321-2268

https://orcid.org/0000-0002-9892-023X

https://orcid.org/0009-0008-2989-3996

2014).

Health Information Systems (HIS) play a funda-

mental role in this context, providing a solid techno-

logical basis for collecting, storing, processing, and

analyzing data related to this domain (de Freitas

et al., 2021). However, many software resources used

in hospital environments, such as electronic patient

records, telemedicine systems, and health manage-

ment systems, have signiﬁcant limitations in terms

of usability, among other factors that include poten-

tial risks to software quality (de Freitas et al., 2021),

(Pitk

anen and Pitk

aranta, 2016), (Bitkina et al.,

2020), (Meehan, 2020). On the other hand, the use

of HIS is more comprehensive than data manipulation

in clinical and administrative environments. An ex-

ample is the chatbots aimed at the health area, which

have emerged in the literature due to their generative

capacity for services; however, domain experts have

pointed out deﬁciencies in the medical information

generated from the knowledge domain (Kowatsch

et al., 2017).

Due to the signiﬁcant increase in software solu-

tions and the limitations arising from the difﬁcul-

ties associated with mastering healthcare software, it

Silva, J., Araújo, A., Coutinho, F. and Silva, A.

Are End-Users Participating in the Life Cycle of Healthcare Application Development? An Analysis of the Opportunities and Challenges of the Use of HCI Techniques in the Healthcare Sector.

DOI: 10.5220/0012572800003657

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 17th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2024) - Volume 2, pages 789-796

ISBN: 978-989-758-688-0; ISSN: 2184-4305

789

is appropriate to consider including end-users in the

application development life cycle. The inclusion

of end-users requires an approach with an emphasis

on Non-Functional Requirements (NFR), speciﬁcally

those related to the usability of systems, requiring

speciﬁc techniques and the application of a Human-

Computer Interaction (HCI) approach, an area con-

cerned with human aspects in interactive computer

systems in the development of software (Barbosa

et al., 2021), (Riasat et al., 2023), (Rosson and Car-

roll, 2009).

HCI emphasizes the active participation of the

end-user throughout their activities and decision-

making stages, presenting a more agile learning pro-

cess as a solution, which positively impacts both the

quality of the solution and the identiﬁcation and cor-

rection of possible problems (Rogers et al., 2013).

On the other hand, when considering processes that

do not adhere to HCI design approaches, the system’s

quality is compromised regarding usability when an-

alyzing the user experience during their interactions

(Couto et al., 2020).

An alternative way of approaching end-user in-

volvement in the software lifecycle is to adopt a

methodology that listens to the user’s needs, from re-

quirements elicitation to the ﬁnal phase of the appli-

cation, considering the understanding of the problem

domain, and increasing the acceptance, use, and ﬁ-

delity of the system to the natural environment of use

(Stafford et al., 2003), (Govella, 2019). Require-

ments elicitation seeks to understand end-user needs,

considering the search, discovery, acquisition, and

elaboration of requirements for computer systems, to

correctly identify the facts that make up the function-

alities so that there is correctness and completeness of

understanding of what is required (Pressman, 2011).

This article searches the literature for evidence

of end-user involvement in the development life cy-

cle of healthcare applications. Speciﬁcally, it investi-

gates whether the end user’s knowledge of the prob-

lem domain has been considered when eliciting re-

quirements and building graphical user interfaces. It

also examines which HCI techniques have been used

in the usability evaluation of healthcare applications

and which categories of end-users in the healthcare

sector are present in the studies. At the end of the

study, we aim to answer the following questions. Is

there evidence of end-user participation in the devel-

opment life cycle of healthcare applications? Are the

challenges found in the state of the art related to the

use (or not) of HCI techniques in developing health-

care applications?

The other sections of this article are organized

as follows. Section 2 presents the basic concepts

adopted to support the development of this research.

Section 3 details the state-of-the-art analysis, subse-

quently exposing the methodology used to collect the

articles covered in the study. Section 4 provides an

overview of the state-of-the-art research and discusses

the main results, leading to a more in-depth study

analysis and discussion. Finally, Section 5 describes

the ﬁnal considerations, followed by suggestions for

future research.

2 BACKGROUND

The growing insertion of software systems in health

services, from operations and processes to the new

dynamics of business models in this domain (Chan-

dran et al., 2020), has required development processes

centered on the user’s needs and perspective, inte-

grated with their context and tasks (Barbosa et al.,

2021). In this scenario, HCI provides an essential

foundation based on the interaction between differ-

ent users and the most diverse technologies in a quest

to design interactive systems that are more effective,

efﬁcient, and pleasant to use. This approach is based

on the understanding that the individual’s social con-

text inﬂuences how the user sees and behaves towards

a software system, so it is essential to consider it in

development activities (Peres and Morais, 2021).

In this context, user-centered design (UCD), as an

HCI method, considers in the development cycle the

broad participation of the end-user and other inter-

ested parties in iterative activities that believe their ex-

pectations as a knowledge base for decision-making

in a largely collaborative process (Govella, 2019).

About the health domain, this is a method that con-

siders end-users, who are mostly doctors and patients,

as key players in providing a fundamental basis for

developing software that adheres to the reality and

context of use (Ghazali et al., 2014) (Bitkina et al.,

2020). Therefore, the implementation of UCD meth-

ods for the design and development of healthcare ap-

plications will bring beneﬁts to those who use the var-

ious systems since it makes it likely to increase us-

ability and, consequently, well-being, reduce stress

levels, improve accessibility, and reduce the threat of

harm (Maramba et al., 2019).

The lack of an approach that considers the end-

user when developing software applications leads to

a disconnection with user needs, high error rates, late

corrections of problems, user dissatisfaction, wasted

time and resources, and high maintenance and support

costs, among others. In healthcare, there is an even

more signiﬁcant concern, as this is a highly complex

application domain linked to human lives, and a us-

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790

ability error can directly affect the doctor’s work and

put the patient’s life at risk (Meehan, 2020).

In short, a user-centered approach advocates that

by integrating the end-user into development pro-

cesses from an HCI perspective, in contrast to tra-

ditional software engineering approaches, they are

no longer only consulted during validation. Instead,

they are considered from the initial design phases,

development, and maintenance, including activities

that promote continuous feedback identifying prob-

lems and opportunities for improvement throughout

the process. This constant feedback cycle makes it

possible to make adjustments and reﬁnements to more

effectively meet user needs, keeping the technology

up to date and in line with constantly evolving expec-

tations (Govella, 2019).

3 LITERATURE REVIEW

PROCESS

This section analyzes the end user’s participation in

the development of health applications and is orga-

nized as follows. Section 3.1 presents the research

methodology used, while Section 3.2 discusses the

systematic literature review, in which the selected

works will be presented according to the acceptance

criteria adopted.

3.1 Methodology

This study used a methodological approach based on

the structured, systematic literature review process,

which adopts methods for identifying, selecting, and

critically evaluating state-of-the-art studies. A search

strategy was deﬁned as the ﬁrst activity to achieve this

goal, where relevant terms combined with Boolean

operators were considered. Thus, the search strategy

shown in Figure 1 was formulated.

Figure 1: Search Strategy.

Following the deﬁnition of the search strategy,

the repositories were chosen, and the four primary

computing-related databases were identiﬁed as ACM

Digital Library, Springer, IEEE Xplore, and Science

Direct. Furthermore, the decision was made to incor-

porate the PUBMED database because of the bound-

ary between computing and health, leading to publi-

cation in both domains.

Three hundred-seven studies were identiﬁed af-

ter applying the search strategy to the repositories.

However, the studies underwent an inclusion analysis,

which only considered studies describing the process

of developing software in the health sector and pub-

lished between 2018 and 2023. The time interval of

the last ﬁve years was adopted due to the dynamicity

of research involving the health sector and the repre-

sentativeness of recent studies in the area investigated.

Duplicate papers and papers of another nature unre-

lated to the research were also excluded. This process

was essential for identifying studies in line with the

scope of this work.

Only thirty-eight articles were chosen to move

on to the second analysis stage, following a prelim-

inary analysis that involved reviewing the abstracts

and ﬁndings of the three-hundred-seven papers. At

this stage, each of these studies was subjected to a

full reading, resulting in the ﬁnal selection of twenty-

seven relevant studies for inclusion in the systematic

review. Figure 2 represents the outline of identify-

ing these studies, which carefully examined and de-

scribed the main contributions and the execution of

individual development in each study.

Figure 2: Research Method Used.

3.2 State of the Art Analysis

The constant creation of computer solutions with dif-

ferent purposes and scope evidences the diversity of

software applications in the healthcare sector. Our

investigation identiﬁed twenty-seven studies, which

could be categorized into four different types of soft-

ware: healthcare software, software redesign, health

information and communication, and health manage-

ment systems. This categorization was done to group

studies with similar objectives, establishing connec-

tions within each identiﬁed group. In addition, the

Are End-Users Participating in the Life Cycle of Healthcare Application Development? An Analysis of the Opportunities and Challenges of

the Use of HCI Techniques in the Healthcare Sector

791

analysis consisted of four primary phases in the soft-

ware life cycle process: requirements elicitation, pro-

totyping, application development, and evaluation.

The studies analyzed in this section were cate-

gorized to answer the research questions described

in Section 1. Thus, considering software aimed at

health care, fourteen studies were identiﬁed, where

(Giachelle et al., 2021) speciﬁes a biomedical annota-

tion tool, and (Maeda et al., 2019) develops memory

care software that uses virtual agents. The end-user

is not involved in the software development process

in either work. In addition to these, other health-

care projects involved end-user participation only in

the software evaluation phase, including (Bacungan

et al., 2021), (Islam et al., 2023), (Rezaei-Hachesu

et al., 2018), and (Marinho et al., 2019), the latter of

which developed a system to support the management

of biobanks and biorepositories.

Continuing the analysis of the works, in (Nim-

molrat et al., 2021), a pharmaceutical application is

presented to meet the needs of visually impaired users

in managing their medicines, and the end-user is only

involved in the requirements elicitation phase. In

other studies, the end-user only actively elicited re-

quirements and evaluated the computer solutions de-

veloped (Ladwa et al., 2018), (Quinde et al., 2019).

In other studies, the end-user was actively involved

in all stages of the software cycle, a practice ob-

served in the development of mobile applications used

by health professionals and patients (Koumpouros,

2021), (Faizzati and Ariﬁansyah, 2022), (Lehmann

et al., 2022), (Veale et al., 2019). In (Dahella et al.,

2020), the end-user only participates in a tool’s re-

quirements elicitation, prototyping, and development

phase, preventing unscheduled admissions to the in-

tensive care unit.

Only two of the twenty-seven papers investigated

were classiﬁed in the software redesign category. In

(Puspitasari et al., 2018), the end-user only partici-

pated in the evaluation phase of the computer solu-

tion. In contrast, (Martini et al., 2022) proposed the

redesign of software that focuses on improving the

medication process, and in this research, the end-user

participated in all stages of the software’s life cycle.

In addition, three papers were identiﬁed in the health

management software category, where (Ishak et al.,

2021) analyzes the feasibility of cloud technologies

in a prototype, and end-user participation is only in

evaluating the tool. On the other hand, (Rahutomo

et al., 2022) only involves the end-user in the require-

ments elicitation phase. Finally, a clinical decision

support system for treating diabetes is presented in

(Fico et al., 2019), and in this work, the end-user is

involved in all phases of the software’s life cycle.

In the health information and communication cat-

egory, (Jacobs et al., 2018) develops a software ap-

plication to provide patients with access to cancer di-

agnosis information, (Falc

ao et al., 2019) speciﬁes a

solution aimed at preventing diseases transmitted by

the Aedes aegypti mosquito, while (El Hefny et al.,

2021) and (Roque et al., 2021) design chatbot ap-

plications to inform and guide the population on the

coronavirus pandemic. As a common point between

the works mentioned, the end-user was only involved

in the evaluation phase of the computer solutions de-

veloped. A step ahead of the other works in this

category, (Alabdulhaﬁth et al., 2018) includes the

end-user in the requirements elicitation and evalua-

tion phases and (Chatterjee et al., 2022) developing

a healthy lifestyle application. In both cases, end-

users are involved in requirements elicitation, proto-

typing, and coding. Finally, (Zotov et al., 2020) and

(Francese et al., 2021) propose computational solu-

tions involving the end-user throughout the software

development life cycle.

Figure 3: End-User Participation in the Life Cycle of

Healthcare Applications.

To make it easier to understand the research car-

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792

ried out in this study, Figure 3 shows the mapping

of the works considering the authors, year of publica-

tion, and end-user involvement in the software life cy-

cle. In this context, column P1 corresponds to require-

ments elicitation; P2 is equivalent to software appli-

cation prototyping; P3 covers the coding phase; and

ﬁnally, the evaluation of the computational solution

is represented by column P4. Also, in Figure 3, the

column (TE) identiﬁes the number of types of end-

users present in the studies, while the column (PE)

shows whether all kinds of end-users participated in

the phases of the software life cycle in which their

presence was found. Next, the column (PH) consid-

ers the category of software in the health area, and the

column (PHE) checks whether the health profession-

als who took part in the studies were also considered

to be end-users of the application.

4 RESULTS AND DISCUSSION

Beginning our understanding of the investigated stud-

ies, we identiﬁed six categories of end-users: patients,

students and health professionals, health managers,

and administrators. The patient category is present

in eighteen studies, and other health professionals are

present as end-users in twelve articles.

Figure 4: Requirements Elicitation Techniques Found in

Studies.

Looking at the requirements elicitation techniques

found, we mapped fourteen types of techniques, with

some studies using more than one for different pur-

poses. Furthermore, some methods did not involve

direct contact with the end-user. Thus, ﬁve studies

included a literature review, one study used business

intelligence indicators, two studies employed tool in-

spection, and four studies did not specify the use of

any requirements elicitation technique, as shown in

Figure 4.

Figure 5: Usability Methods and Standards to Support Soft-

ware Evaluation.

In addition to requirements elicitation techniques,

we also looked at the standards and good practices

used to evaluate the software studied. Twelve evalua-

tion methods and two standards were identiﬁed. Fig-

ure 5 shows this categorization and highlights some

data, such as the predominance of the system Usabil-

ity Scale (SUS) method in nine software evaluation

papers and the use of Nielsen’s heuristics in four pa-

pers. In addition, eight papers do not specify usability

evaluation methods.

Another relevant piece of information is that only

ﬁve studies use one evaluation method with at least

one usability best practice standard. However, only

two studies use a software evaluation method explic-

itly developed for application in the health care soft-

ware. Based on the state-of-the-art analysis, the re-

sults present critical reﬂections on the software de-

velopment life cycle in the health sector, and some

challenges will be addressed below.

Are End-Users Participating in the Life Cycle of Healthcare Application Development? An Analysis of the Opportunities and Challenges of

the Use of HCI Techniques in the Healthcare Sector

793

An initial observation reveals the need for more

evidence of including end-users from the health sector

throughout the software life cycle, except in the eval-

uation phase. Some studies have involved healthcare

professionals in the development process, but they

have not considered them as end-users for unspeciﬁed

reasons. This gap can result in technological solutions

that do not meet the desired needs, compromising the

quality of health services.

Although most studies have included the end-user

in the evaluation phase, not all categories have been

included in some studies. This may result in inade-

quate attention to the user’s needs, given that not all

perspectives have been analyzed. In addition, there is

a gap when we note that most of these studies, despite

using methods to evaluate the tools, need to specify

whether these measurements are based on guidelines

or technical standards for good usability practices. In

this context, although there are methods and standards

focused on developing software for the health sector,

only two studies mention and use these support re-

sources.

5 CONCLUSION

This article investigated end-user participation

throughout the software development lifecycle in the

healthcare sector. In our study, we sought to identify

whether the challenges encountered in the involve-

ment of these users are linked to the use or not of

HCI techniques during the development of healthcare

applications. Based on a careful analysis that corrob-

orated the selection of twenty-seven articles aligned

with the deﬁned theme, it was possible to identify

some gaps and challenges in adopting user-centered

processes, considering the issues addressed in this

research. However, there are some differences in the

end user’s involvement in the various phases of the

software life cycle.

In the requirements elicitation phase, many pa-

pers did not directly incorporate the end-user at this

stage. There is also a need for more evidence that

the techniques used are based on good usability prac-

tice standards. In the coding stage, some studies have

used end-users to carry out incremental and validation

tests, but the evidence still needs to be found more

participation by health domain experts.

In the evaluation stage, it was also noted that al-

though many studies involve end-users, only two use

speciﬁc methods aimed at good usability practices in

the health area. The results point to the incidence of

studies that do not involve health professionals signif-

icantly in the processes, which reﬂects an even more

signiﬁcant challenge since there is no validation of the

knowledge domain applied by these professionals. In

general terms, the studies recognize the need for end-

user participation in the life cycle of health applica-

tions. Still, more should be said explicitly about the

reason for the low level of user participation in the

studies. The lack of end-user involvement can lead to

high maintenance levels, poor usability, and the de-

velopment of software applications that do not meet

the needs of the problem domain.

To indicate future work, we intend to con-

duct a study with healthcare professionals using the

openEHR Archetype standard in the requirements

elicitation phase. The study investigates whether the

domain expert knowledge speciﬁed in a healthcare

standard can improve the software development life

cycle in the healthcare sector.

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