1. Requirements Analysis for an mHealth Application with Midwives in Ghana Olivia Vlez, RN, MS, MPH, PhD Adjunct Associate Research Scientist Department of Biomedical Informatics, Columbia UniversitySenior mHealth Advisor Maternal Child Health Integrated Program(MCHIP)ICF International

2. Centering Clinical Users in UserCentered Design (on a budget) Olivia Vlez, RN, MS, MPH, PhD Adjunct Associate Research Scientist Department of Biomedical Informatics, Columbia UniversitySenior 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 wouldnt 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. Heeks 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" menuFebruary 12, 2014Page 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 CaseConstraints: 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 standardsIs achieved by enabling Functional RequirementsSystem QualitiesDesignConstraintswith these characteristicswith these restrictionsAdapted from: http://tynerblain.com/blog/2006/01/04/foundation-series-structured-requirements/ 20. Participants Interviewed/observed 6 midwives in September 2010, 7 May 2011 MidwifeInterview 1Interview 21 2 3 4 5 6 7 8X X X X X XX X X X X X XMW 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 NameKey data elementsAddendum Antenatal/Maternity Monthly Data ReturnsANC visit information; Malaria prophylaxis; Delivery informationCommunicable disease surveillance reportMalaria cases; Pneumonia cases, Diarrhea, AIDS, STDsFacility report of HIV test kit usageHIV test kits usedFamily planning returnsContraceptives administeredImmunization and vaccine monthly returnsVaccines used and immunizations given by age and doseInstitution monthly returnsMalaria medication usedMalaria reports of outpatient casesMalaria cases (by age and pregnancy)Malaria reports ITN/SP StockMalaria medication used and stock holdingsMidwives returnANC visit information; Delivery information; Postnatal data; Abortion data; PMTCT dataMonthly data returns on ArtesunateAmodiaquineMalaria medication used; Children and pregnant women receiving treatmentMedication and testing stockMalaria medication use; RDTs usedNational AIDS/STI control programme monthly returnsHIV testing and treatment; STD testing and treatment; PMTCT dataOutpatients MorbidityCauses of morbidityPMTCT monthly returnsPMTCT dataReturns on deliveriesDelivery dataStatement of OutpatientsPatient age and insurance statusWeekly notifiable diseases reportCholera, 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 dont 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 StorageMedical RecordsPersonal Health RecordsEncounter Registers 27. Fever RegisterAction 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 CategoryAccuracy Documentation InteroperabilityDocument 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.LearnabilityDue 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 UtilizationMidwives see about 30 patients in the morning. Hardware selection should support allow for this level of use without needing rechargingSecurityThe 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 observationParticipant 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 DoneRDT 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 yesIf 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 availableData for use case development came from participant observation and contextual inquiry 34. Functional Requirements Example Name Gender DOB Age DOB Estimated NHIS # Encounter dateType Text Date Number Boolean Number DatePossible Values M/F DD/MM/YYYY Calculated from DOB Yes/No Alphanumeric 16 DD/MM/YYYYDuration of feverNumberNumber of daysRDT results Danger signs, Malaria Treatment givenBoolean BooleanYes/No Yes/NoBooleanYes/NoIf yes, which medication ReferralTextACT, SP, Quinine, otherTextHospital, none, otherData Sources Contextual Inquiry (Document analysis)Participant ObservationData Analyst interviewsComparison 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