Summary points
“What was already known before our study?”
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Shared homecare is an expanding field of interest.
In many western countries, homecare of elderly is shared between different healthcare provider organizations [1]. Several studies, e.g. [2], [3], [4], show that cooperation between different care providers in homecare needs to be improved. In integrated healthcare, professionals from different organizations work together in a team-oriented way to provide high quality care for a patient. This requires high quality of collaborative working relationships, clarity and commonality of objectives, frequent communication among team members, a clear understanding and respect of individual roles and skills within the team, and general flexibility of practitioners [5].
In non-integrated organizational structures and information systems healthcare professionals risk spending time searching for misplaced information instead of taking care of their patients [2]. A lack of adequate information access and communication tools hampers the healthcare professionals’ work; sharing information and coordinating work within the care providing team in particular.
In order to develop information and communication technology (ICT) that is easy to use and adapted to future work situations, it is essential for developers and healthcare professionals to share an understanding of work routines, information demands, and other central preconditions at the clinical level before ICT development is initiated [2]. In shared care there is the added complexity of working with many different care professions, or user groups, who have different, sometimes even contradicting, views on their mutual work process. It is therefore necessary to find techniques that enhance communication both between healthcare professionals and developers and between different care professions.
Compared to conventional requirements elicitation, that focuses on system functionality [6] and delivers a requirements specification as a result, socio-technical approaches stress that thorough insight into the specific work practices in which ICT applications will be used should be the starting point for design and implementation [7]. This requires that adequate resources are spent on work analysis and user needs analysis. In application development for healthcare, most approaches still focus on the individual healthcare professional, modeling his/her decision making process [7], [8], [9], [10], [11], [12], [13], [14], [15]. The socio-technical approach [8], [16] and computer supported cooperative work (CSCW) [17], [18], [19], differ from more traditional work views as they emphasize the need to address cooperative work processes rather than discrete tasks for individuals [20]. However, practical methods for gaining insight into the work practices of professionals are still often limited to interviews, sometimes extended to observations and sketching exercises which rarely give the end users opportunity to reflect on their cooperative work.
It is also crucial to translate the results of a work analysis into the actual design and development process. There is often a gap between work analysis and technical specification. This gap may be hard to bridge, sometimes resulting in loss of valuable insights reached in the analytical steps, and there is a need for procedures that bring an understanding of practice into specification design [2], [21]. The methodological review by Johnson et al. [22] advocates a variety of user-centered methods to conduct the analyses needed, with each method providing different but necessary components in order to design an initial prototype [22]. This viewpoint is encouraged by Kaplan, proposing methodological pluralism to increase understanding of many influences concerning development and deployment [9].
Scenarios can be applied in a multitude of ways, and are powerful tools to support communication between different parties in the system development process, as well as between different user groups. We therefore propose user-centered scenarios as part of a multi-disciplinary participatory design approach described in [23], as a tool to bridge the gap between work analysis and system design, to capture the cooperative aspects of shared care and to allow envisioning of future work.
In human-computer interaction (HCI) research scenarios have been suggested as a technique to use in development of ICT to understand the work practices that are to be supported. The concept of scenarios in system development is broad, and many different ways of using scenarios have been proposed.
Nardi defines a scenario as a description of a set of users, a work context, and a set of tasks that users perform or want to perform [24]. She also stresses the futuristic quality of scenarios, claiming that the “purpose of a scenario is to provide an explicit concrete vision of how some human activity could be supported by technology”[24].
Go and Carroll list typical scenario usage, i.e., within HCI for analyzing user tasks, envisioning future work, mock up and prototyping as well as evaluating the constructed system, and in requirements engineering for eliciting user requirements, deriving specifications and analyzing and describing the current system usage [25].
Benyon and Macauley describe a range of scenario usage, from ‘user stories’; i.e., real or imagined experiences of people, through abstract scenarios; generating ideas and developing an understanding of the domain, to concrete scenarios; useful for prototyping and walking through design ideas, and finally to use cases; providing formal specification required by software engineers [26].
Bødker discusses a wider role for scenarios, where they form the basis for overall design and for technical implementation, and are also applied as a means of cooperation within the design teams and across professional boundaries, e.g., between users and designers or between usability people and technical designers and implementers [27]. It is in this wider role, we see the use of scenarios in our work.
This paper describes experiences from using scenarios in the 3 year action research project OLD@HOME [28]. The main purpose of the project was to provide a seamless and consistent information and communication flow between home healthcare and primary healthcare through establishment of a virtual health record (VHR) that allows for mobile information access and documentation.
The VHR was used by three main healthcare professional groups regularly involved in the homecare of elderly citizens: (1) general practitioners (GP), (2) district nurses (DN), both employed by the county council and (3) home help service personnel (HHS), mainly assistant nurses, employed by the local authority (municipality). The degree of ICT usage differed between the groups of healthcare personnel. At the start of the study, GP and DN documented digitally on their respective medical and nursing record systems when working at the office, or on paper. HHS used only paper-based documentation. None of the groups had adopted digital, mobile documentation facilities, or had digital access to another group's documentation.
The VHR enabled each healthcare professional to access relevant patient information from an integrated platform using different mobile devices, i.e., personal digital assistants (PDAs) and tablet PCs. The integrated platform incorporated a number of underlying feeder systems such as the DN's and GP's electronic health records. Examples of the patient data provided in the VHR include a modified prescription list for the HHS; an integrated care plan for HHS and DN; daily notes; risk factors; and status updates from all feeder systems [28], [29].
The objectives of this paper are to describe how using scenarios as part of the work analysis process can be useful in a shared care context and how these work scenarios can be transformed into detailed technical descriptions, i.e., use cases, that form the basis for system development. Results from the OLD@HOME action research project [30] are provided to illustrate this process.
An extensive user needs and work analysis was performed in OLD@HOME and data was mainly collected: (1) from archives, (2) through repeated interviews with all stakeholders, (3) by participatory observation [31], such as the Master-Apprentice approach [32], and (4) by iterative seminars with interdisciplinary working groups [23].
The working groups consisted of 7 experienced health specialists from different professions, i.e., GPs (n = 2), DNs (n = 2) and HHS (n = 3), medical informaticians (MI) and
In OLD@HOME, a number of different work situations were identified for each profession involved and are presented in Table 2.
This list of work situations is on a high level, and as analysis continued, the work situations were described in more detail and, when necessary, broken down into several scenarios. The task “refer patient to other care providers” was for example found to include both arranging different transportation depending on need, and providing important information to ambulance
Scenarios have been applied in system development for many different reasons, ranging from abstract descriptions of people's experiences to formal specifications. In this paper, we described our approach to using scenarios to capture work processes in cooperative work and specifically shared homecare.
One of the major issues when developing ICT for shared care, is that there is not only a lack of understanding between clinical end users and the development team, but between different healthcare
The project “OLD@HOME - Technical support for Mobile CloseCare” is supported by VINNOVA – Swedish Agency for Innovation Systems (P23037-1 A) and Trygghetsfonden, as well as by the following clinical and industrial partners: Primary Care Hälsingland, County Council of Gävleborg, Municipality of Hudiksvall, Xlent AB, Ericsson Network Technologies AB, Bergsjö Data AB and AB Hudiksvallsbostäder. Summary points “What was already known before our study?” Shared homecare is an expanding field of interest.
The scenarios supported knowledge elicitation and exchange. This is in line with their use in both medical [48–56] and non-medical contexts [3,52,57–65]. In this context, scenarios may be: “heuristic at best”; deliberately underspecified (to promote discussion and exploration); and necessarily incomplete [10]; e.g.: “The main purpose of developing scenarios is to stimulate thinking about possible occurrences, assumptions relating these occurrences, possible opportunities and risks, and courses of action.” [66].
They point out the benefits of including elderly, but also identify challenges when, for example, an older patient has problems to participate as an equal partner in the decision process. Petrakou [30] provides an ethnographic account of the use of a paper binder for communication between family members and home care workers in relation to home care work, while Hägglund et al. [16], focus on organizing healthcare professionals (i.e. general practitioners, district nurses and home care workers) from different organizations into teams in order to provide high quality homecare – the study though does not mention the role of family members. An overview of the role that collaboration plays in healthcare settings in general and the types of technology that can support collaboration among health care workers is provided by Reddy et al. [33].