In recent years, the advances in information and communication technology (ICT) have resulted in the development of systems and applications aimed at supporting rehabilitation therapy that contributes to enrich patients’ life quality. This work is focused on the improvement of the telemedicine systems with the purpose of customizing therapies according to the profile and disability of patients. For doing this, as salient contribution, this work proposes the adoption of user-centered design (UCD) methodology for the design and development of telemedicine systems in order to support the rehabilitation of patients with neurological disorders. Finally, some applications of the UCD methodology in the telemedicine field are presented as a proof of concept.
In recent years, the advances in information and communication technology (ICT) have enabled the development of systems and applications aimed at supporting rehabilitation therapy and, therefore, contributing to the enrichment of patients’ life quality [
According to the literature [
Besides, Bernard et al. [
Through the development of user interfaces for health-care applications, researchers have empirically evaluated the effectiveness of diverse user-centered design (UCD) approaches [
According to the literature [
According to Wallach and Scholz [
Design process of the telemedicine systems centered on the user. Adaptation of Martínez Alcalá [
As Figure
Broadly, telemedicine refers to the use of information and telecommunication technologies to distribute information and/or expertise necessary for healthcare service provision, collaboration, and/or delivery among geographically separated participants, including physicians and patients [
Telemedicine covers different forms of information: (1) transmission (voice, sound, video, still picture, and text); (2) communication technologies (standard telephone lines, coaxial cable, satellite, microwave, digital wireless, ISDN, and Internet); and (3) user interfaces (desktop computers, laptop computers, personal digital assistants, fax machines, telephones, mobile phones, videophones, various stand-alone systems, and peripheries). All of them allow to carry out a wide range of activities, such as store-and-forward applications, which involve the asynchronous transmission of medical information, patient/health provider communications, and other data, and live audiographic encounters, which combine sound with still pictures, and perhaps, most importantly, the live two-way interactive video consultation [
One of the main motivations for the application of ICT in both healthcare organizations, public and private, lies in the necessity of improving the information and providing medical care to a multitude of geographically dispersed agents. Clinical studies have shown that telemedicine is safe and cost-effective, compared with hospital treatment, especially with patients suffering from chronic diseases [
In this context, it is important to mention that despite its growth, there is a general feeling that telemedicine has a long way to go before it reaches its maximum potential [
Table
Advantages and disadvantages with respect to other systems developed.
Systems | Description of system | Advantage | Disadvantages |
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The RuralHub Telepsych system [ |
Report on a geriatric telepsychiatry consultation service provided by a tertiary-care hospital to rural nursing homes located up to a few hours’ drive away. |
(i) Patients show acceptance and adherence to a treatment regimen. |
(i) It creates “an impersonal atmosphere.” |
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Portable tele-assessment system [ |
Remote evaluation of the elbow joint with spasticity and contracture in patients with neurological disorders. Especially in patients with spasticity. | (i) Provided physical as well as audiovisual interaction between the clinician and the patient. |
(i) The spasticity test is limited, because the doctor has to perform therapy exercises, burn for teaching, and the replay to be viewed by the patient. |
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AUBADE system [ |
AUBADE is an integrated platform built for the affective assessment of individuals. The system performs the evaluation of the emotional state. | (i) It has an intelligent emotion recognition module and a facial animation module. |
(i) The system's clinical application is based on the ability of supporting clinical diagnosis related to all the pathologies taking into account if the patient's capability to feel and express emotions is limited or totally absent. |
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Telemedical Interventional Monitoring in Heart Failure (TIM-HF) [ |
Wireless Bluetooth system with a personal digital assistant (PDA) that performs automated encrypted transmission via mobile phone of electrocardiogram measurement, blood pressure measurement, and body weight. |
(i) Prevents hospitalizations by early detection of disease worsening followed by immediate intervention. |
(i) Telemedical centers must operate around the clock every day of year because it requires immediate diagnosis and prompt treatment. |
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Heart failure case disease management program [ |
Is a care process that verifies the state of a patient illness throughout sending the information concerning his or her vital signs such as weight, systolic blood pressure, heart rate, dyspnoea, asthenia, edema, therapy changes, blood urea nitrogen, creatinine, sodium, potassium, and bilirubine to medical staff in order to support decision-making to prevent haemodynamic imbalance, to reinforce educational support, to optimize therapy, and to improve quality of life and outcomes. |
(i) The program uses a toll-free number. |
Management effectiveness depends on the team management, the intensity of treatment, the parameters monitored, the standardization of managerial algorithms and the characteristics of the patients. |
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eMental System* | Supports the rehabilitation of the elderly with cognitive impairment through promoting social integration. It provides a cognitive stimulation therapy to the patients, caregivers, and specialists. | (i) It manages automatically the degree of difficulty to suit the cognitive level of each patient. |
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e-Park system* | The detection of cognitive deterioration of person with Parkinson’s disease. By applying the PD-CRS test through Internet. | (i) Standardization and optimization in the application of the PD-CRS test. |
The first version of the system is not depending on the limitations of the patients. |
The design process employed in the development of the telemedicine systems was inspired on the user-centered design (UCD) approach, a widely accepted methodology for creating usable applications or systems, which aims to truly meet the needs of users [
The main challenge of this method is the customization of activities according to the user’s needs. Besides, this approach can be achieved only when the user is actively involved during the design and evaluation of an application or system.
The following sections describe each of the method phases.
Then, this phase is focused on each user. The phase begins interviewing patients and specialists to know the information that should be reflected in the system. Then, the objectives that each activity must achieve are identified. Afterwards, the user profiles, which allow the customization of activities and therapy according to the user, are defined. Finally, the analysis and definition of the therapy model are developed.
The MAIA framework is used to support the idea of institutions as a major structure for conceptualizing social systems. The MAIA framework extends and formalizes the components of the IAD4 (an institutional framework that provides a collection of concepts present in a social system with an institutional perspective) to present a metamodel for conceptualizing social systems for agent-based simulation [
The MAIA framework has been used in this research by designers with different professional profiles in order to conceptualize the components of telemedicine systems. According to Ferruzca Navarro [
Now, a conceptual model based on the framework for the analysis of interactions between agents (MAIA) is presented [
The main objective of MAIA framework is the identification of the key players involved in a telemedicine system and their relationships.
The main components of MAIA are
Conceptual model of the telemedicine system components [
A fundamental aspect of any system is the analysis and understanding of their composition. In this regard, the components (entities) related to the structure of the telemedicine system are described based on the MAIA model. According to the author in [
Questions guide to the identification of system components [
At the Laboratory of Multimedia Applications at the Universitat Politécnica de Catalunya, telemedicine systems have been developed. The telemedicine systems aim to create multimedia tools, available through the Internet, which contribute to improve patients and families life quality. The systems are intended not only to serve in the rehabilitation of patients, but also to therapists and specialists in the process of monitoring the therapy. Next a detailed description of the telemedicine systems created based on the reference model for UCD, described in the previous section, is presented.
The main objective of the eMental system is to support the rehabilitation of the elderly with cognitive impairment and to promote their social integration. The eMental system provides a cognitive stimulation therapy to the patients, caregivers, and specialists. Its primary function is to improve the capabilities of people with any cognitive alteration, through a telemedicine system.
As a result of a first approach with a hospital in Spain, it was possible to define the participation of different actors that were involved in the rehabilitation process.
The eMental system is directed to the next users: doctors, patients, caregivers, and other specialists (see Table professional cases (doctors, therapists, and other specialists) require a telemedicine system that helps them monitor and trace patients with cognitive alterations. It also should be able to manage customized therapy sessions; patient cases require an asynchronously system that allows patients to access from any point and place without going to the hospital or rehabilitation place. It allows health-care providers to follow the patient’s evolution and medication at home and, in general, monitoring the patient from a distance; patients suffering from cognitive alterations such as brain injury, mild or moderate Alzheimer, neurodegenerative disorders, psychiatric disorder associated with cognitive impairment. This procedure includes supporting family and/or caregivers that assist in the rehabilitation of patients.
Descriptions of the user types.
User types | Function |
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Patient | (i) Requests help the caregiver. |
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Caregiver | (i) Provides patient instruction. |
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Therapist | (i) Assigns therapy activities. |
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Doctor | (i) Provides indications to the therapist. |
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Administrator | Manages system resources |
To understand the needs and limitations of each user, a direct observation on the subjects of the research (patients, caregivers, and specialists) was used focusing on their situation, environment, and activity. To do so, verbal interviews were performed to all users interested in research; this allows to collecting their opinions and experiences. Then, these comments were taken into account in the system design process.
After understanding the users’ goals and needs, the next step consisted in organizing the information according to the MAIA framework [
Representation of the therapy process for the eMental system by following MAIA methodology.
In order to characterize the contents of the system as far as possible, a conceptual design of the eMental system was schematized after conducting a literature review. This process was conducted with the support of several medical specialists and taking into account the opinions and experiences gathered in the direct observation. In the traditional therapy, the therapist performs the therapy through using pencil and paper supported with a picture book with cognitive stimulation exercises.
The eMental system was designed in a way that the therapy can be performed by the patient in the comfort of his or her home. Each of the cognitive stimulation exercises mentioned in the picture book were adapted and customized in the system so that patients could perform their exercises in a more comfortably and easily way. Furthermore, the therapists could perform the rehabilitation therapy more quickly and with a greater control over the results. This allows to attain a reduction of costs and time for both the patient and the hospital. To achieve this, the therapist classified each of the years in a total of 6 items, while the design team digitized each of the necessary fonts (
Once the components and contents were defined, the team performed several low-fidelity prototypes (sketches) through designing quick and easy user interface. These prototypes were presented to the medical team and the development team in order to get comments and new ideas regarding the design of the system framework.
Therefore, a better designed high-fidelity prototype was obtained. Next, three important areas of the system are determined in order to understand the tasks, the therapy, and the progress. These are described as follows: the task area contains customized activities that the doctor or therapist considers relevant to the patient’s rehabilitation; the therapy area has the progress area: the results obtained during the therapy process can be displayed graphically to the users.
This eMental system consists of a series of 96 exercises such as calculation, memory, attention, orientation, language, and visuospatial exercises designed to address mental capacities like attention and concentration, executive functions (reasoning, planning), perception and knowledge, language, calculation, and special orientation. Next, some prototypes designed for representing patient tasks are shown.
The eMental system provides users a greater possibility of easily access to the technology world and, at the same time, strengthens their mental functions with exercises that are displayed in a web environment. In addition, the system has an asynchronous mode, meaning that the patient performs exercises with the assistance of a family member or caregiver, anytime, anywhere. Furthermore, the system records the patient’s activities to be evaluated by a doctor or therapist and the progress of the therapy is recorded visually.
As a result, the first design proposals obtained have an intuitive graphical interface that facilitates the interaction between the user and the system without having advanced computer skills. Moreover, each of the designed activities increases the self-esteem and reinforces the skills the patient still preserves, reducing frustration towards the therapy through encouraging messages to the successes and failures of the patient. This leads to improved results, such as increasing the attention of users and minimizing external distraction.
The multimedia engineering laboratory team was responsible for installing the technological artifacts (touchscreen, camera, and microphone) within the therapy rooms. Besides, they presented the proposal for the eMental system design by considering a detailed visualization of the tasks each patient should perform and the visualization process of the therapy each therapist should receive.
In order to evaluate the first design proposals, there were selected users who had the next features: (1) were familiar with cognitive impairment (such as doctors, therapists, patients, caregivers, and other specialists); (2) had basic computer skills, such as sending and receiving e-mail and capturing images from a camera or electronic device; (3) had knowledge of the test application, time availability, and exchange experiences on the issue; and finally (4) were interested in the rehabilitation through ICTs. The characteristics of the study group will be described in the following section.
The next step to the system is conducting tests with bigger groups, considering variables such as acceptance and usability.
To evaluate the usability of the system, first, the graphical interface and digitized exercises were presented. Later, the use and functionality of the system were explained in detail. Finally, verbal questions were performed to obtain each present person’s point of view. As a result, on the one hand, small changes in the graphical interface (color, font size) were indicated. On the other hand, difficulty levels to the exercises were added.
At present, in order to improve the opportunity areas that have been identified in the first evaluation feedback, the system is in a redesign phase.
The main objective of the e-Park system is the detection of cognitive deterioration of a person with Parkinson’s disease. This is achieved through a telemedicine system that allows evaluating patients with a disease scale of PD-CRS by using telemedicine system.
As a result of a first approach with a hospital in Spain, it was possible to define the participation of the different actors that were involved in a rehabilitation process.
The e-Park system is focused on the next users: doctors, patients, caregivers, and other specialists (as described in Section professional cases (doctors, therapists, and others specialists) require a telemedicine system that helps them monitor and trace patients with cognitive deterioration. It also should be able to manage a customized therapy sessions; patient cases require an asynchronously system that allows access to patient from any point and place without going to the hospital or rehabilitation place; its require system to allow remote patient monitoring and the evolution and implementation of medication is administered at home; the patients are those who have Parkinson’s disease. This procedure includes supporting family and/or caregivers that assist in the rehabilitation of patients.
Same as the previous case study, to understand the needs and limitations of each user, a direct observation was used to understand their situation, environment, and activity. Then, all comments were taken into account in the system design process.
After understanding the goals and needs of users, the next step consisted in organizing the information according to the MAIA framework [
Representation of the therapy process for the e-Park system by following MAIA methodology.
In order to characterize the contents of the system as far as possible, a conceptual design of the e-Park system was schematized after conducting a literature review. This process was conducted with the support of several medical specialists and taking into account the opinions and experiences gathered in the direct observation. In the traditional therapy, the therapist performs the therapy through using pencil and paper, supported with a test called
The e-Park system was designed in a way that the therapy can be performed by the patient in the comfort of his or her home. Each question on the test was adapted and customized within the system so that the therapist could easily record the results of their patients, achieving a reduction of costs and time for both the patient and the hospital. Besides, the patients could perform the exercises in a more comfortable and easily way.
The test (PD-CRS) includes nine divisions with a maximum total score of 92 as follows: subcortical functions: attention (10), short memory (10), working memory (10) and delayed memory (12), verbal fluency and alternating action, and spontaneous drawing of clock (10); cortical functions: designation (20) and a clock copy (10).
The verbal fluency and alternating do not have maximum scores. They are obtained by adding the rating for subcortical subscales, the cortical and the total PD-CRS. Better punctuation provides better cognitive level.
Once the components and contents were defined, the team performed several low-fidelity prototypes (sketches) through designing quick and easy user interface. These prototypes were presented to the medical team and the development team in order to get comments and new ideas regarding the design of the system framework.
Therefore, a better designed high-fidelity prototype was obtained. Next, two application modes of the system are determined (see Figure online assistance, which means helping the specialist perform a real-time evaluation of the patient; self-evaluation, meaning the evaluation of the patient himself or herself with this assistance of his or her family members and caregivers previously trained in this activity.
System application modes.
The e-Park system has an asynchronous mode (remote real-time communication), meaning that the patient performs the test exercises with the assistance of a family member or caregiver, anytime and anywhere. Furthermore, it allows the specialist to manage the application of the system and their patients through using a web application such as video conferencing (see Figure
Sequence of the therapy.
The patient performs the test in front of a screen by following the specialist’s instructions, and the specialist interacts with another application. This allows guiding the execution of the PD-CRS test and the record of the results of the patient.
In order to evaluate the first design proposals, there were selected users who had the next features: (1) were familiar with Parkinson’s disease (such as doctors, therapists, patients, caregivers, and other specialists); (2) had basic computer skills, such as sending and receiving email and capturing images from a camera or electronic device; (3) had knowledge of the test application, time availability, and exchange experiences of the issue; and finally (4) were interested in the rehabilitation through ICTs. The characteristics of the study group will be described in the following section.
The next step to the system is conducting tests with bigger groups, considering variables such as acceptance and usability.
Qualitative evaluation is used in the research. Therefore, the number of participants in the case study is small. Furthermore, the qualitative analysis allows the data to be manipulated in order to extract a relevant significance regarding the objective of the research.
The patients were selected for a consecutive period of 12 weeks between April 2010 and July 2010. Appropriate cases were defined to those following patients: patient 1: patient with primary Parkinson’s disease; patient 2: patient with primary Parkinson’s disease; patient 3: patient in the predementia stage of Alzheimer’s disease; patient 4: patient in the early stage of Alzheimer’s disease.
The age range for this study is 60 years old, with only one case being under the age of 50 years. The rate for men is 75% and for women 25%.
The work team showed the functional prototype of the eMental system. The doctors and therapists visualized the tool by running the system and exercises of the patients.
Moreover, the work team showed the functional prototype of the e-Park system. The patient performed the test in front of a screen by following the specialist’s instructions, and the specialist interacted through another application.
Finally, the complete evaluation of the first proposal of the two systems took place on February 24, 2011. It involved a total of 17 people, including four patients, four caregivers, two therapists, one neurologist, three doctor, two engineers, and one web designer.
In order to carry out a first evaluation of the two systems, a questionnaire based on parameters of usability and technology acceptance (the technology acceptance evaluates a series of factors that influence the decision on
The questionnaire applied to the study group in order to get information about parameters of usability and acceptance of technology is shown in Table
Questions applied to the study group. Adaptation of Martínez Alcalá, 2012 [
Parameter | Questions |
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Easiness of navigation | (i) Is my interaction with telemedicine system clear and understandable? |
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Learnability | (i) Is it easy for me to learn how to operate the telemedicine system? |
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Satisfaction | (i) Is it helpful to implement a telemedicine system for rehabilitation? |
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Operability | (i) Does the telemedicine system design meet your expectations? |
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Functionality | Does the design of therapy allow its activities easier? |
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Open question | In general, do you think that undergoing a rehabilitation process through the telemedicine system increases the chances of improving your current condition? |
As shown previously, the questionnaire is composed of 15 closed questions, grouped into five parameters: easiness of navigation, learnability, satisfaction, operability, and functionality. The questionnaire also included one open question in order to obtain different comments and feedback of the system.
The scale of measure used in the questionnaire corresponds to a Likert scale of seven points. The options in the scale was as follows: (a) the range of values between 1 and 3 were selected for expressing disagreement; (b) the value 1 was selected for strong disagreement; (c) the value 4 was selected for a neutral opinion; and finally (d) the range of values between
Then, a total of 16 validated questionnaires were obtained. The rate of response of the questionnaires was 82.35% (referred to the total percentage of medical personnel and patients in the hospital). The summary of results obtained from the application of the questionnaire is shown below (see Figure
The results obtained of usability evaluation.
In the analysis of the first parameter,
In the second parameter,
The third analyzed parameter is
In the parameter of
Concerning the analysis of the last parameter, functionality, the users showed a positive agreement (6), affirming that the design of therapy allowed the patients to perform rehabilitation exercises in a more easy and attractive way.
Table
Comparison of systems technological attributes.
Devices | Compatibility | Complexity | Accessibility | Portability | Satisfaction and acceptance | |
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(1) The RuralHub Telepsych system | E-mail, fax, and telephone | X | X | — | — | X |
(2) Portable teleassessment system | Cameras, microphones, and PC | X | X | — | — | — |
(3) AUBADE system | Integrated platform and PC | X | — | — | X | X |
(4) Telemedical interventional monitoring in heart failure | Personal digital assistant, home devices (ECG), and Web application | — | X | — | X | X |
(5) Heart failure case disease management program | Touchpad or mobile phone | X | — | X | X | X |
(6) eMental system | Web application, cameras, microphone, and touchscreen | X | X | X | X | X |
(7) e-Park System | Web application, cameras, microphone, and touchscreen. | X | X | X | X | X |
This comparison shows that the systems described in this research are designed step by step, with the purpose of customizing therapies according to the profile and disability of patients, taking into account the needs of patients throughout the system design process.
Telemedicine is gradually, if not rapidly, becoming a technological and clinical reality. Therefore, it is essential to address the challenge that exists in the successful evaluation of a telemedicine system. By reviewing the literature related to telemedicine systems, we noticed the necessity to concentrate on the specific user requirements, particularly referring to patients, in order to develop an intuitive and effective system.
This research work proposes a framework based on the UCD methodology and MAIA framework, to design systems customized to particular users with specific characteristics and needs, increasing the acceptance and satisfaction in the users. An important feature of the proposed framework is the involvement of end users through the design processes, which allows collecting important data of user needs. Moreover, the reliability and validation of the first functional layouts are increased. Therefore, this framework becomes the source to optimizing the design of the telemedicine systems interfaces according to users’ real needs. The proposed framework is composed of four phases: analysis, design, implementation, and evaluation.
Besides, this paper shows the performance of the proposed framework through implementing it in two case studies to design two systems: eMental system and e-Park system. These telemedicine systems were developed in real hospital environments in order to focus on monitoring the rehabilitation of patients with neurological disorders. All designed telemedicine systems were customized to cognitive and physical limitations of the patients. This way, they provided visual information of patient progress to the medical staff.
As main benefits, this approach reduces significantly the time of patients in hospitals, without reducing the continuous monitoring of patients. Moreover, it facilitates the flexible interaction between patient and doctor through using web application. This shows the efficiency of using the proposed framework to design telemedicine systems.
After implementing the proposed framework to design the two systems, we can conclude that, to achieve improvements in quality health care and to reduce errors, researchers and system developers must work together to integrate the knowledge of user-centered design toward the design of new systems customized to users with specific needs. Moreover, there is a need of collaboration among medical team, the design team, and the development team to ensure a well design and perform of telemedicine systems.
This work proposes the adoption of user-centered design (UCD) methodology for designing and developing telemedicine systems in order to support the rehabilitation of patients with mental deficiencies. Then, four research lines are identified from this research: deploy the proposed framework in other telemedicine systems and include other related technology, in order to identify more findings and get more favorable results; develop tailored versions of telemedicine system for mobile devices; implement the proposed approach in the treatment and rehabilitation therapy file; incorporate intelligent agents to support the patient and medical staff in telemedicine systems.