DEVELOPMENT OF A FORMAL
FRAMEWORK FOR USABLE OPERATIONS
SUPPORT IN E-HEALTH BASED SYSTEMS
Ph.D FINAL DEFENSE
BY
IKHU-OMOREGBE NICHOLAS
(CU03GP0021)
DEPARTMENT OF COMPUTER AND INFORMATION SCIENCES,
COVENANT UNIVERSITY, OTA, AFRICA

EXAMINERS

Dr. Ayo C. K.
- Chief Examiner

Dr. Ehikioya S. A. - Supervisor

Dr. Ayo C.K.
- Co-Supervisor

Prof. Katende J. - College Examiner

Dr. Adebiyi E. F. - Departmental Examiner

Prof. Sofulowe A. B - External Examiner
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CONTENTS

INTRODUCTION

STATEMENT OF THE PROBLEM

AIM/OBJECTIVES

METHODOLOGY

RESULTS/DISCUSSIONS

SUMMARY AND CONCLUSION
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
Information and Technologies have been introduced in different dimensions of health care
(Intel 2003, infoDev & Alcatel 2005).

OSS solution for e-Health takes advantage of the state-of-arts information technology to address health care enterprise-wide needs and requirements to reduce cost, provide reliable, flexible, mobile timely and secure health care delivery to patients by care provider and centers.
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
Although the health care community is embracing mobile technology and realizing its benefits, mobile computing usage is still being faced with significant number of obstacles such as (Gregg M., 2005):
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
Ease of use (usability)

Confidentiality of mobile data and
 the management of newly mobile health care workers
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
The level of an e-Health based system’s usability does not only influence the users acceptance of the system but may also greatly influence the diagnosis and treatment processes in a health care centre.

The usability of OSS is vital since its issues in software products cannot be resolved without major changes to the software architecture [Roger P., 2005]. This thesis provides answers to usability issues in mobile devices for e-Health based systems.
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AIM/OBJECTIVES OF THE STUDY

Provide a formal framework for usable operations support for e-Health based systems . ( AIM)
1. Provide a formal framework for e-Health based systems
2.Provide a robust architecture which ensures that best clinical practices are followed in a health care centre in the administration of patient care.
3.Provide a support system that distributes patient medical information amongst medical practitioners in a healthcare environment across mobile devices.
4.Implement some of the functionalities in an e-Health system to empirically validate the usability of the operations support system in the application domain.
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
To assure the quality, acceptability, and usability of the system, we used OCL and the
Unified Modeling Language (OMG 2003,
CMU/SEI 2004) for the specification, analysis, design, and verification of the system’s functionalities.
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Introduction-Definition

The Encyclopedia of Software Engineering defines Formal methods as “ A mathematical based technique for describing system properties”
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Definition

Formal Methods "refers to mathematically rigorous techniques and tools for the specification, design and verification of software and hardware systems”. (Ricky W.
Butler, 2001, NASA)
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Importance of Formal Methods

System specification may contain contradictions, ambiguities, incomplete statements etc.

When used well, a formal method should yields specifications that have significant advantages over natural language and variety of graphical notation.
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Importance (Cont.)

A formally verified system can be used unto greater reliability.

Thus the use of formal technique helps to achieve a high degree of confidence that a system has conformed to its specifications

This is particularly significant in the health care domain

We modeled the system as follows:
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Medical Personnel
-StfId
-Name
-Address
-ClinicID
-Status
-Tel
+Add()
+Update()
+View()
1 Nurse
1 Doctor 1 Pharmacist
1
Lab Technician
1 Specialist
Surgery
Appointments
+AddAppt()
+FindAppt()
+UpdateAppt()
+ViewDgns()
Diagnosis Medications
+AddDgns()
+UpdateDgns()
+ViewDgns()
+AddMed()
+UpdateMed()
+ViewMed()
0..1
0..1
0..1
Lab Test
+AddTest()
+UpdateTest()
+ViewTest()
0..1
0..1
Hospital/Clinic
-Name : char
-Idno : int
-Address : string
+AddClinic()
+DelClinic()
+UpdateClinic()
1
1..1
Patients
-PatId
-Name
-Address1
-Age
-Status
-Tel
Rooms
-RoomID
-Charges
In-Patient
-
Out-patient
Rights
0..1
Medical Record
-PatientID
-Date
-Diagnostic Info
-Test Result
-Encounter
+viewAppt()
+ViewLab()
+ViewPatient()
+ViewMed()
+FindPatient()
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Patient
Lab Technologist
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Use Cases
Patient Treatment Use Case
Retrieve patient's info
Book appointment
Take clinical measurements
«uses»
Diagnose and treat
«extends»
«extends»
Perform lab test
«extends»
Refer case medication
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Nurse
Doctor
Specialist
Pharmacist
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CareGiver
Mobile Device
Sequence Diagram
WAP Gateway WebServer Servlet Engine Database Server
RequestInfo()
Connect through WAP
Authenticate()
DisplayInfo()
Send through channel
Response Info
Activate Servlet
ExecuteQuery()
WMLContent
RetrieveInfo()
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State Chart
Visit clinic
Appointment
Treat patient
Under treatment
Medication
Clinical measurement
(pre-treatment)
H
Continue treatment
Suspend treatment
Lab test
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Diagnosis
Pay bill
17
X

request treatment()
Collaboration Diagram
make diagnosis()
prescribe drugs()
Patient Doctors
performs surgery refer
Specialist
request test
request test
Nurse retrieve patient records () take clinical measurements() schedule appointment()
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Pharmacist dispense drug()
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Lab Technologist performs test()
18

Deployment Diagram
MOBILE DEVICES
Doctor’s Point of Access *
-802.11b
-WIRELESS LAN
WAP, SMS
SERVER
*
*
-TCP/IP
*
APACHE WEB SERVER
E-HEALTH APP.
*
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DBSERVER
PATIENT DB
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WAP/UML Extension
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An Overview of Object Constraints Language
(OCL)

OCL was developed as a modeling language within the IBM insurance division.

OCL is a pure expression language, an OCL expression is guaranteed to be without side effects. When an OCL expression is evaluated, it simply returns a value. It cannot change anything in the model.
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An Overview of OCL (Cont.)
Fully type language
-
- Boolean, Integer, Real and String as basic types
Collection such as Sets, Sequences and Bags are included
-OCL expressions can be verified
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Where to Use OCL





To specify invariant on classes and types in the class model
To describe pre and post condition on operations and methods
To describe Guards
As a navigation language
To specify constraints on operation
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Invariant , Pre-Condition
An invariant is a property that must remain true throughout the life of a model element, such as an object
A pre-condition is property that must be true before a particular part of the system is executed.
This can be applied to operation during design and implementation and to use cases during analysis.
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Post-Condition , Constraints
A post condition is something that must be true after particular part of the system is executed, if that execution was legal
A constraint is a rule that allows you to specify some limits on a model (Warmer and Klepper,
1999) describe it as a restriction on one or more values of (part of) an object-oriented model system.
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Patient
Requirements Specification: Every patient is unique
context clinic inv:
Patient->forAll(p1,p2/p1<>p2 implies p1.pid <> p2.pid)
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Patient
Requirements Specification:
To add a new patient the patient must not exist before.
context patient::regpat(p:patient) pre: not patient->include (p) post: patient->size=(patient@pre->size ) +1 and patient->include (p)
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Doctor
Requirements Specification:
Each Staff has permissible operations to perform context medicalpersonnel inv:
Self.medicalpersonel.staffid.right->exist(p/ p.diagnose() or p.addrecords () or p.updatepatientrecord() or p.viewmedication() implies medicalpersonnel.asType(doctor))
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Pharmacist
Requirements Specification:
Each Staff has permissible operations to perform context medicalpersonnel inv: self.medicalpersonel.staffid.right->exist(p/ p.viewmedication() or p.dispense ( ) ) implies medicalpersonnel.asType(pharamacist)
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Medication-Allergic
Requirements Specification:
The systems keep track of drugs a patient is allergic to: context medication::AllergicAdd(d:drug) pre: not allergic ->include (d) post: allergic ->include (d ) and allergic ->size =(allergic@pre ) + 1
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Administrator
Requirements Specification:
Each Staff has permissible operations to perform
context medicalrecords inv: self.medicalpersonel.staffid.right->exist (p/p.create( ) or p.delete()) implies medicalpersonnel.asType(administrator)
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Appointment
Requirements Specification:
No two patients will be directed to the same doctor at the same time on the same day.
context Appointment inv: not(Self.appointment-> exist(x,y/(x.doctor=y.doctor) and
(x.time=y.time) and (x.date=y.date))
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Appointment
Requirements Specification:
A request for an appointment to see a doctor must not be for a date earlier that the date of registration of patient at the clinic .
context appointment inv:
Self.dateofrequest.after(registrationdate)
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Booking Appointment
context Appointment::addapt (patId, stafid, startTime, endTime, date) pre: startTime <endTime post: duration=endTime – startTime >0 startTime = preStart + duration prevEnd = startTime
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The User
Requirements Specification:
The password and username of every user of the system must be unique.
context registeredUsers inv : not(self.users->exists(a,b/a.username= b.username ) and (a.password =b.password))
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OCL CHECKER
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ACCOMPLISHING OBJECTIVE 2
Provide a robust architecture which ensures that best clinical practices are followed in a health care centre in the administration of patient care.
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SOFTWARE ARCHITECTURE
Smart Phone
Security and Authentication
Support Service
Documentation Support
Service
USERS INTERFACE
Cell Phone
View and Report Service
Web Server WAP Gateway SMS, MMS Server
Apache Server
Data Access and Update
Support Service
Pharmacy and Billing Support
Service
Diagnostic Support Service
CARE SUPPORT SERVICES
Laboratory Test Support Service
Patient Medical Record
Support Service
Data Layer
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Logon DB
Lab. Test DB Medication DB
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Patient DB
39

SOFTWARE ARCHITECTURE






A 3-tiered C/S architecture consisting of client interface, middle-tier, and database repository
Components of the client =SASS, DSS, VRS
Server-side processing carter for resources constraints
Middle-tier contains most of the application logic and translate client request into database queries =DAUSS,
PMRSS, DSS, PBSS, LTSS
The data layer is responsible for the storage, retrieval, maintenance and integrity of data
Communication between the application server and database is performed by the JDBC-ODBC bridge
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HARDWARE ARCHITECTURE
SmartPhone
Terminal
AP
Firewall
Web server
E-Health Server
Firewall
E-Health Database
Server
Laptop
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PDA
A Medical Diagnostic
Device
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Database
41

HARDWARE ARCHITECTURE





Consist of complete range of robust high performance clients and servers
Clients system include, PDAs, Cell Phones, other hand-held medical devices
The servers are used to maintain connectivity to enterprise resources
Servers provide, real-time access to point of care data base
Firewalls are set to filter all network traffic moving in an out the e-Health system
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ACCOMPLISHING OBJECTIVE 3
Provide a support system that distributes patient medical information amongst medical practitioners in a healthcare environment across mobile devices.
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PATIENT’S SUPORT
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WELCOME PAGE
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ADMINISTRATOR’S SUPPORT
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PHARMACIST’S SUPPORT SERVICE
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DOCTOR’S SUPPORT SERVICE
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MS ACCESS DATABASE
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ACCOMPLISHING OBJECTIVE 4:
Implement some of the functionalities in an e-Health system to empirically validate the usability of the operations support system in the application domain.
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DISCUSSIONS/RESULTS
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USABILITY MEASUREMENT

ISO ( 9241) Definition

The “extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use”
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USABILITY MEASUREMENT

Users – Medical Practitioners
- Doctors
- Nurses
- Lab Technologist
- Pharmacist
- IT Professional
- Patient ( Students + Others )


- Goal – Improve Health Care Delivery
- Context – Clinic (Health Care Setting)
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USABILITY ATTRIBUTES

Effectiveness:
-The accuracy and completeness with which specified users can achieve specified goals in particular environment

Efficiency:
The resources expended in relation to the accuracy and completeness of goals achieved
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USABILITY ATTRIBUTES

Satisfaction:
The “freedom of discomfort, and positive attitude to the use of the product” The comfort and acceptability of the work system to its users and other people affected by its use
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Usability Framework

We used the following seven metrics to represent the usability dimensions of the application.

Completion Time

Easy to Learn

Effective Support

Error Recovery

Comfortable

Easy to Use

Satisfaction
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USABILITY EVALUATION
-
-
-

Data Collection Technique –
Questionnaires were administered to users after interacting with the system
150 Responses were received and analyzed
The response format used a five-point,
Likert-type scale
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DATA ANALYSIS

Usability studies suggest that system with
“good usability” typically have a mean rating of 4 on a 1-5 scale rating and 5.6 on a 1-7 scale (Jeff Sauro et al, 2005)

The mean rating as follows:
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Values of Usability Attributes

Completion Time = 4.52

Easy to Learn = 4.53

Effective Support = 4.31

Error Recovery 4.55

Comfortable = 4.59

Easy to Use = 4.60

Satisfaction = 4.39
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COMPARATIVE USABILITY
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Usability Test Graph
4.8
4.7
4.6
4.5
4.4
4.3
4.2
4.1
4
3.9
Completion
Time
Easy to Learn Effective
Support
Error Recovery Comfortability Easy to Use Satisfaction
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Medical Professional
IT Professsional
Patients
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SUMMARY
By this thesis we have been able to:

Practically demonstrate the feasibility of using mobile devices such as mobile phones and
PDAs in enhancing the effectiveness of health care professionals in the delivery of services to patients

Identify the various support services in an e-
Health based systems which conform to the treatment process followed by medical professionals in delivery health care delivery.
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SUMMARY

Further more, the support services were adequately depicted in a robust software and hardware architecture for easy implementation.
Used Wireless Mark-up Language, Java server pages and other tools to provide the required functionalities for the system, while ensuring that the application is usable and deployable across various platforms.
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SUMMARY


Move from informal specifications to formal specifications, thus ensuring that ambiguities and incorrectness in specification were tactically handled to guarantee a dependable system adjudge as usable by the end users.
Provide a framework for measuring the usability of mobile heath care application by adapting the usability attributes specified by
ITU, ISO and ANSI into a seven metrics questionnaire based measurement.
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SUMMARY

Finally though, mobile health care application are still at it very early stage of implementation and adoption in Nigeria, the work provide a good specification document that will aid software developers in realizing suitable applications in this domain.
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CONCLUSION

In this thesis, we were able to demonstrate the practicability of deploying usable operation support services for care givers and other users in health care sector for the purpose of effective and productive health care delivery in care centres.
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CONCLUSION

The support services implemented were formally analyzed and designed to eliminate ambiguities and incorrectness in the product.
The application was measured with the usability dimensions suggested by ISO /
ANSI / ITU and extended to satisfy to meet the context in a clinic setting and found to have a “good usability” by the potential users of the final product.
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CONCLUSION

Finally, the adoption of the product of this research in care centres offers a good contribution for countries to meet the millennium development goals centred on health care by providing an effective IT-based support for care givers.
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PUBLICATIONS
[1] Ikhu-Omoregbe N. A., Ehikioya S.A. and Ayo C. K., “ Modelling,
Design, and Deployment of Mobile Health Care Application”
International Journal of Computer Sciences and its Application.
(To Appear).
[2] Ikhu-Omoregbe N. A., Ehikioya S.A. and Ayo C. K., “ A Formal
Framework for Deployable Mobile HealthCare Applications” ,
MEDNET, 11th World Congress on Internet in Medicine, Canada,
October, 2006. Available at: { www.mednetcongresss.com
}
[3] N.A Ikhu-Omoregbe, C. K. Ayo, S.A. Ehikioya, “A Deployable
Framework for Mobile Telemedicine Applications”, Medical and Care
Compunetics 3, L. Bos et al (Eds.) , IOS Press, The Netherlands, 2006, pp. 36-41. Available at: www.booksonline.iospress.nl/Contents/SSSH2Book/Article.aspx
?
[4] Ikhu-Omoregbe, N.A, Atayero A.A., Ayo, C.K, Olugbara, O.O.,
“ Design and Deployment of Hybrid Telemedicine Applications” , SPIE conference proceedings, Internet Imaging VI, San Jose, U.S.A., 2005, pp
191-196. Available at
: www.imaging.org/store/physpub.cfm?seriesid=24&pubid=700
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PUBLICATION/AWARD
[5] Ikhu-Omoregbe N. A., Ehikioya S.A. and Ayo C. K., “ Implementing
Operations Support Systems in E-Health Based Systems , Proceedings of
The International Conference & Workshop on 3G GSM & Mobile
Computing: An Emerging Growth Engine for National Development,
Covenant University, Nigeria, 29-31 January, 2007, pp. 191-198

Microsoft Research Inspire Programme–PhD Proposal Award
2006 (One of six recipients in the world)
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APPRECIATION

God – Gift of Life

Supervisors

Examiners

External Examiner

University Management and All Staff
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