Mellish, Christopher Stuart

Mort, Alasdair James

Reiter, Ehud Baruch

Schneider, Anne Helen

Sharma, Nirwan

Wilson, Phil

English

This work is supported by the RCUK dot.rural Digital Economy Research Hub, University of Aberdeen (Grant reference: EP/G066051/1)Peer reviewedPreprin

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Designing a Mobile Device for Pre-hospital CareAnne SchneiderUniversity of Aberdeena.schneider@abdn.ac.ukNirwan SharmaUniversity of Aberdeenn.sharma@abdn.ac.ukAlasdair MortUniversity of Aberdeena.mort@abdn.ac.ukChris MellishUniversity of Aberdeenc.mellish@abdn.ac.ukEhud ReiterUniversity of Aberdeene.reiter@abdn.ac.ukPhil WilsonUniversity of Aberdeenp.wilson@abdn.ac.ukABSTRACTWe present the early steps in a design process within thecross-disciplinary MIME project (Managing Information inMedical Emergencies). The project aims to develop a mobilemedical monitoring system for rural pre-hospital scenariosin which the first person on-scene is typically a volunteerwith only basic first-aid training. The goal is to allow therecording of physiological data and the accurate logging ofobservations and actions by these volunteers, and to auto-mate the process of delivering a handover report to arrivingambulance teams. Pragmatic requirements were gatheredthrough surveys and focus groups with medical experts andseveral prototypes were designed and evaluated.Keywordsinterface design, pre-hospital care, user-centred design, nat-ural language generation1. INTRODUCTIONIn the case of a medical emergency in rural Scotland it cantake a considerable period of time before an ambulance ar-rives. Because the rapid availability of local family doctorscannot be guaranteed, the Scottish Ambulance Service hasdeveloped an innovative service model to care for rural pre-hospital patients whilst an ambulance is en-route. Com-munity First Responders (CFRs), volunteers with a basicmedical training and the necessary equipment to deal with arange of medical emergencies, take care of patients until pro-fessional help arrives. The cross-disciplinary MIME project(Managing Information in Medical Emergencies)1 aims atsupporting CFRs in their task by developing a mobile de-vice that is robust and connects to new lightweight medicalsensors (Figure 1). This facilitates the continuous captureof a far greater volume of physiological patient data suchas heart rate, saturation of blood with oxygen and breath-ing rate, which are currently only monitored manually and1www.dotrural.ac.uk/mimeFigure 1: First hardware prototype (Getac Z710tablet and Pulse Oximeter sensor).intermittently at best. In the long run these sensor read-ings combined with a clearly laid out interface may raisethe CFR’s awareness of a patient’s medical status so thatmore timely and appropriate care can be delivered. A moreelementary and short-term goal, however, is to produce au-tomatic handover reports that can be relayed to the respond-ing ambulance clinicians as they arrive on scene or while stillen-route. Such handover reports should also include othermore detailed information about the patient and their treat-ment (e.g. responsiveness of the patient and any drugs theyhave taken) which the CFR will need to input via the device.Designing for pre-hospital care is a complex task due to theunpredictable nature of incidents. In the case of MIME wehave had to take into account the fact that the operatorswill be volunteers with only a basic training who will onlyoccasionally encounter emergency situations.We will describe here the early steps of an iterative designprocess of the medical monitoring system for pre-hospitalcare and the special challenges it poses. After discussingthe relevant literature (Section 2) we will outline the spe-cial challenges we are faced with (Section 3) and describethe initial steps in our design process that have led to thedevelopment of a first hardware prototype (Section 4). Thepaper concludes with a discussion of the next steps in thedevelopment process and the challenges that lie ahead (Sec-tion 5).2. RELATEDWORKMedical data is often presented graphically but it has beenshown that textual summaries can lead to improved medi-cal decision processes when compared to graphical presen-tation [5]. As a consequence a plethora of applications inthe medical domain employ Natural Language Generation(NLG). The STOP project, for example, generates shorttailored smoking cessation letters for smokers based on theirresponses to questionnaires [7]. Summaries of patient’s clin-ical history are generated in the Clinical e-Science Frame-work [2], and for the Babytalk project personalised textualsummaries are compiled in the context of neonatal intensivecare [6]. NLG is also the core technology underlying theMIME project. However, Most IT projects in the medicaldomain fail for non-technical reasons and poor product de-sign has been identified to be one of the main causes [8].Human Factors and HCI research offers potential benefitsfor the field of medical informatics by assisting in designingusable systems. One popular methodology for the design ofsoftware systems is user-centred design (UCD). It is widelybeing adopted in multidisciplinary work and medical infor-matics has also been influenced by the benefits it has tooffer [9, 4]. UCD advocates an iterative design cycle, whichtakes into consideration the users of the system, their tasksand context of use. This can lead to identification of usabil-ity problems throughout the design process rather than ina final evaluation of the system. In the development of themedical monitoring device for the MIME project we followa user-centred design process, and the early steps will bedescribed in this paper.3. THECHALLENGESOFPRE-HOSPITALCAREPre-hospital care refers to the care delivered to a patientbefore they arrive at a hospital. This type of care is usu-ally associated with ambulances and paramedics. However,the term also covers a wide range of voluntary and profes-sional care groups. There are a multitude of challenges todelivering pre-hospital care. The pre-hospital environmentis inherently unpredictable and the actual clinical conditionof a patient may be quite different (better or worse) to thatconveyed in the original call for help. It may be difficult toaccess and assess the patient in order to ascertain the fullextent of their injuries or medical requirements. Further-more, the development of a device for pre-hospital care hasto take into consideration usage in poor lighting, confinedspaces, adverse weather conditions and potential contamina-tion with body fluids. Not only is the unpredictable natureof pre-hospital incidents a design challenge but in additionthe fact that in our scenario the end-users are volunteerswith only basic medical training. Community First Respon-der schemes recruit volunteers from local communities andgive them the necessary training and equipment to deal witha limited range of medical emergencies, including some life-threatening situations such as cardiac arrest. The premiseis that even those with basic first-aid skills can save lives.CFRs often have to deal with situations for which they havelittle training. It is also very likely that they will be un-der time pressure. Therefore, the user interface we developneeds to be simple and intuitive in use, avoiding what hasbeen termed ‘creeping featurism’ [3], whereby option satu-ration hinders task performance. It is also vital that the for-mat must enhance the readability. Furthermore, the designhas to take into account the possibility that CFRs will behighly stressed with shaky hands and it is therefore essentialto make input elements in the interface big and adequatelyspaced.4. THE MIME DESIGN PROCESSA first prototype was developed for desktop PCs, with astrong focus on the implementation of the Natural LanguageGeneration algorithm, which produces handover reports onthe basis of the input of the CFR and the physiologicaldata gathered from the medical sensors. For this first proto-type an interface was designed which targeted functionalityrather than usability and will therefore not be discussed fur-ther here. This interface was driven by a process of handoverreport analyses in which the necessary input information wasdetermined. The first prototype was tested on basis of sixscenarios with simulated data for which handover reportswere generated and analysed.Next the development process of the mobile device startedwhich included the decision process for the hardware andan iterative process of interface design. Our research hasinvolved fieldwork with a wide range of pre-hospital stake-holders, including CFRs (our end-users) and highly knowl-edgeable ambulance clinicians (our domain experts). Thepurpose of our fieldwork was to discover interface and prag-matic requirements of end-users, to verify the appropriateformat for automatic handover reports and to explore thenature of physiological sensor data.4.1 The Hardware PrototypeOur first hardware prototype is a rugged tablet that connectsto lightweight medical sensors. We decided to use the GetacZ710 tablet2 for several reasons. Due to the unpredictablenature of pre-hospital care the tablet needs to be especiallyrobust. Since it will be employed outdoors it will have tosustain adverse weather conditions, such as rain or snow.Featuring Gorilla glass and a solid rubber case the manu-facturer guarantees that the tablet can be dropped from 6feet, is vibration resistant, and can sustain wind driven rain.Further, it can operate in temperatures between -20◦C to50◦C. The resistance to water is also important for hygienicreasons, since the tablet will have to be wiped with disinfec-tants after each use. Not only bad weather conditions poseproblems to the use of the tablet, also bright sunshine canbe disadvantageous to the readability of screens. The GetacZ710 tablet has a high effective contrast ratio and also a wideviewing angle screen. While being robust the touch screenhas to be sensitive enough to work if the screen gets wetand in situations where the paramedics wear medical glovesfor their own protection, which is also a feature of the Getactablet. Other requirements we determined are a long lastingbattery, a small size, and little weight. With ten hours ofbattery life in operation mode, its small dimensions (8.58” x5.6” x 1.06”) and less than one kilogram in weight the Getac2http://en.getac.com/products/Z710/Z710_overview.htmlFigure 2: Wireframe prototype (the physiological data display).Figure 3: Screenshot of the tablet interface (observations display).tablet also fulfils these requirements. However, the 7” LEDdisplay also leads to challenges concerning the design of theinterface which will be discussed in the next section.4.2 Interface DesignAfter the decision on the tablet was made a first interfaceprototype was designed using an HTML wireframe (Figure2). This was based on the simple interface for the PC ver-sion. In a focus group with our medical team members (onephysician, one physiologist) a tab-based interface was es-tablished, with a part of the screen reserved to show thereal-time data from the sensors. Following general designguidelines from the Android UI design principles3 and dis-cussions with health experts we decided to use a two-panelayout. As can be seen in Figure 2, the left pane is di-vided into two parts. The top left contains a fixed display of3http://developer.android.com/guide/topics/ui/index.htmlthe real-time data coming from the sensors. Currently themedical sensors connected to the device provide heart rate,oxygen saturation and respiratory rate data. The bottom-left part is an interactive menu where the user can choosebetween four displays. Based on the menu input on the leftpane the right pane displays either the real time data streamof the medical sensors divided into the three channels or theinput screen where CFRs can enter personal data of the pa-tient such as his name, his age or his medical history. Athird option is the input display for observations made bythe CFR such as noisy breathing by the patient or actionstaken by the CFR such as clearing the airway. The fourthoption is a display that shows the generated handover re-port.Based on this wireframe is the development of the first pro-totype of the interface for the Getac tablet (Figure 3). Thewireframe was discussed with our medical team and a fullytrained paramedic. Based on this discussion several changeswere addressed in the interface for the tablet. The basicstructure of the interface with the static display of the sen-sor readings in the upper left corner, the menu pane on thelower left hand side and the main displays on the right side ofthe display was maintained but several changes were imple-mented based on feedback on the wireframe prototype frommedical experts. Instead of four display options only threeoptions are available in the tablet interface. The displayshowing the real time medical sensor readings as a graph(as shown in Figure 2) was a remnant from the PC interfaceand was deemed dispensable by our medical experts, sincethe readings are displayed constantly in the upper left-handcorner and CFRs (our end-users) are not very familiar withthis kind of graph-like presentation of physiological data.Further, we split the observation and actions display intotwo: one for observations and one for actions. This seemedto be a logical step since the combined display was clutteredwith information which made it necessary for the CFR toscroll through the display to find desired options. Further, ina survey among paramedics the key observations and actionswere identified and unnecessary options were eliminated inthe tablet interface prototype. As a result we could makethe interface elements and the space between them in eachdisplay bigger, as can be seen in Figure 3. As discussedin Section 3 this is beneficial in cases where the users arestressed and might have shaky hands. We also encounteredproblems when we tried to port our wireframe design ontothe tablet. The wireframe was based on an Android 4 systembut the tablet runs the Android operating system version2.3.5. Android 4 already offers an out-of-the-box two paneinterface design which we had to manually reimplement forthe tablet interface because the tablet is operating on anearlier version of the operating system.5. CONCLUSIONSDeveloping the medical monitoring system for the MIMEproject is a holistic process that involves a plethora of as-pects such as the design and evaluation of an NLG algorithmthat generates the desired handover reports, the decisionprocesses around the employed hardware (i.e. the tabletand the medical sensors) and of course the design of the sys-tem interface. We described the three development cyclesthat our project went through, which led to a first hardwareprototype. Currently, we are involved in the evaluation ofthe generated handover reports by paramedics and hope tofurther improve the NLG algorithm. In a field study wherereal sensor data will be gathered from patients, one of ourteam members will use the tablet with the current inter-face prototype to record observations and actions. Basedon his feedback we plan to improve the interface before thewhole system will be further tested in a lab experiment. Inthis experiment the end-users will use the device and enactdifferent scenarios. In this way we hope to gather meaning-ful information on the use of the system which will allowus to make improvements to the interface. One aspect forexample is the structure and organisation of the options inthe observations and actions displays. Another interestingconsideration is the influence that two-hand, left-hand orright-hand use of the tablet may have on the interface de-sign. It is for example imaginable that it is desirable tochange the position of the menu from left to right. Further,there is a trade off between energy consumption and read-ability of the screen. At the moment our interface featuresa black background and white letters which is more energyefficient on many displays but readability may be increasedwhen black letters are on a white background [1]. Finally, infuture we would like to improve the logical function behindthe pure recording of input. If a CFR for example recordsthat the airway of a patient was cleared, then it is obvious itthey must have been obstructed before, which is an optionin the observation display. In cases where the CFR failedto record such events the device could give support by sug-gesting such an input. We hope that such changes will makethe task of CFRs easier and ultimately improve pre-hospitalcare in rural settings.6. ACKNOWLEDGMENTSThis work is supported by the RCUK dot.rural Digital Econ-omy Research Hub, University of Aberdeen (Grant refer-ence: EP/G066051/1)7. REFERENCES[1] A. Buchner and N. Baumgartner. Text–backgroundpolarity affects performance irrespective of ambientillumination and colour contrast. Ergonomics,50(7):1036–1063, 2007.[2] C. Hallett, R. Power, and D. Scott. Summarisation andvisualisation of e-Health data repositories ConferenceItem Repositories. In UK E-Science All-Hands Meeting,pages 18–21, 2006.[3] I. His and C. Potts. Studying the evolution andenhancement of software features. In Proceedings of theInternational Conference on Software Maintenance,ICSM ’00, page 143, Washington, DC, USA, 2000.IEEE Computer Society.[4] C. Johnson, T. Johnson, and J. Zhang. A user-centeredframework for redesigning health care interfaces.Journal of Biomedical Informatics, 38(1):75–87, 2005.[5] A. Law, Y. Freer, J. Hunter, R. Logie, N. McIntosh,and J. Quinn. A comparison of graphical and textualpresentations of time series data to support medicaldecision making in the neonatal intensive care unit.Journal of clinical monitoring and computing,19(3):183–94, June 2005.[6] F. Portet, E. Reiter, J. Hunter, and S. Sripada.Automatic generation of textual summaries fromneonatal intensive care data. In Proccedings of the 11thConference on Artificial Intelligence in Medicine(AIME’07). LNCS, pages 227–236, 2007.[7] E. Reiter, R. Robertson, and L. Osman. Lessons from afailure: Generating tailored smoking cessation letters.Artificial Intelligence, 144(1-2):41–58, Mar. 2003.[8] S. Teasdale. Trouble in paradise—learning from hawaii.BMJ, 331(7528):1316, 12 2005.[9] J. Zhang. Human-centered computing in healthinformation systems part 1: Analysis and design.Journal of Biomedical Informatics, 38(1):1 – 3, 2005.

A comparison of graphical and textual presentations of time series data to support medical decision making in the neonatal intensive care unit. Journal of clinical monitoring and computing, 19(3):183{94,

A user-centered framework for redesigning health care interfaces.

Automatic generation of textual summaries from neonatal intensive care data.

Human-centered computing in health information systems part 1: Analysis and design.

Lessons from a failure: Generating tailored smoking cessation letters.

Studying the evolution and enhancement of software features.

Summarisation and visualisation of e-Health data repositories Conference Item Repositories.

Text{background polarity aects performance irrespective of ambient illumination and colour contrast.

Trouble in paradise|learning from hawaii.

Designing a Mobile Device for Pre-hospital Care

Designing a Mobile Device for Pre-hospital Care

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