Requirements of telecare in exergaming
From the perspective of the client and the healthcare provider
Miranda Rijk
Student Number: s2041049 E-mail: m.s.rijk@student.rug.nl University of Groningen
Faculty of Economics and Business
Requirements of telecare in exergaming
From the perspective of the client and the healthcare provider
M.S. Rijk Student Number: s2041049 Loppersummergang 1 9711 ST Groningen Tel.: +31 (0)6-50845346 E-mail: m.s.rijk@student.rug.nl
Supervisor: Prof. Dr. Ir. J.C. Wortmann Faculty of Economics and Business University of Groningen
Second Assessor: Dr. H. Broekhuis Faculty of Economics and Business University of Groningen
Abstract
The purpose of this research is to investigate the functional and non-functional requirements of telecare in exergaming, according to clients and healthcare providers. Exergaming is used to describe video games that encourage physical activity (Health Benefits of Gaming, 2008). Telecare is defined as the use of ICT for support the delivery of health and social care to individuals at home (Barlow et al., 2006). The objectives behind the use of telecare are the improvement of the quality of life of patients, the quality of healthcare and the quality of service provision. Telecare can lead to a decrease in hospital care (Evers et al., 2009),
In this study, telecare in exergaming is the main subject. The research question is: “What are the
functional and non-functional requirements of telecare in exergaming, according to clients and healthcare providers?” the sub-questions investigate the types of clients and healthcare providers
and their needs, and the services and processes of telecare in exergaming. The main incentive for conducting this research is the contribution to the research of telecare in exergaming of the project SPRINT, which includes the development of a skate-game as exergame, for elderly person: 70 years or older. It is expected that balance can be trained optimally with this skate-game. The practical value is that without fulfilling the wishes and requirements of clients and healthcare providers, these stakeholders will probably not use the system and thus the system will not be a success, which in turn will not result in a decrease in hospital care. The scientific relevance is providing a solution to the lack of a framework with aspects of a telecare system (Botsis et al. 2008) and the lack of human response, user-friendliness of the existing telecare devices and the need for tailoring the training to older learners (Demiris et al., 2004).
To investigate the requirements of telecare in exergaming, a part of design science research is performed. This research includes the following steps of a design science research: Identify problem and motivate, define objectives of a solution, and design. Design science research creates new reality, rather than explaining existing reality or makes sense of it (Iivari and Venable, 2009). Results will show that the services that can be distinguished in telecare in exergaming are: Information provision, consultation, diagnosis, treatment, counseling and monitoring, alarming and the exergame. These are all non-medical services, the telecare and exergame is used because of primary prevention, this is to avoid clients of falling and becoming less healthy. The telecare in exergaming processes and how they are structured, is given in a blueprint, with an explanation of how the telecare in exergaming actually works.
The main research question is answered by showing the most important requirements according to clients and healthcare providers. The functional requirements include the subjects user convenience, information, and physical presence. A telecare system needs to meet these requirements in order to function correctly. The subjects security, and cost and time are non-functional requirements, because they are not behavioral in nature. They are constraints on the development and implementation of the system (Maciaszek, 2005).
Preface
This report is my graduation thesis that I performed for my study MSc Business Administration - Operations and Supply Chains. Over the period of 5 months I have investigated what the requirements of telecare in exergaming are, which types of clients and healthcare providers are involved in the telecare in exergaming, what services can be distinguished, what the processes are, and how these processes are structured. A workshop, interviews, and meetings provided data for this research. Since, the persons I speak during my research are not mentioned by name, in this way I want to give them special thanks for all their inputs to the research.
A special thanks goes to Prof. Dr. Ir. J.C. Wortmann and Drs. J.B. van Meurs for their guidance and support during this process. I want to thank them for their assisting and supervising role. Secondly, I would like to thank my second assessor Dr. H. Broekhuis for all the feedback.
At last, I would like to thank everybody else who was not mentioned by name but supported me during this period. I want to thank them for their advice, critical comments and support when writing my thesis.
Miranda Rijk
Index
1 Introduction ... 1
1.1 Research objective ... 1
1.2 Background project SPRINT ... 2
1.3 Problem definition ... 2
1.4 Research relevance ... 3
1.5 Research questions ... 4
1.6 Limitations and boundaries ... 4
1.7 Report structure ... 4 2 Theoretical background ... 5 2.1 E-health ... 5 2.2 Telecare ... 6 2.3 Telecare services ... 7 2.4 Exergaming ... 7
2.5 Requirements of telecare and exergaming ... 8
2.6 Contribution of the literature ... 10
3 Methods ... 11
3.1 Design science research ... 11
3.2 Research design ... 12
3.3 Selection of respondents ... 13
3.4 Data analysis ... 15
4 Results ... 18
4.1 Types of clients and healthcare providers ... 18
4.2 Services of telecare in exergaming ... 18
4.3 The process of telecare in exergaming... 21
4.4 Needs of clients and healthcare providers in the different services... 26
5 Conclusion and discussion ... 36
5.1 Conclusion ... 36
5.2 Discussion ... 38
5.3 Further research ... 40
A Summary interviewed clients and healthcare providers ... 44
B Interview questions client ... 61
C Results of the interviews with clients ... 63
D Interview questions healthcare provider ... 80
E. Interview questions general practitioner ... 82
1 Introduction
The Dutch population is ageing. In the next twenty years the amount of elderly people of 65 years and older will be doubled from 14% in 2005 to 21% in 2025. This sharp rise will be accompanied with an increase number of people with chronicle illness, more demanding patients, a shortage of medical staff and a subsequent increase of health costs (RIVM rapport, 2007), which brings new challenges for the healthcare sector. As a result, the Dutch government, health insurers, health providers and consumers explore new solutions for adequate health provision. Healthy aging, investing in healthy and active aging, is an important topic in these new solutions.
During the last decade, software applications and products concerning e-healthcare services have been developed, including telephone services, mobile services such as SMS, e-mail, websites and video services. Most of these applications are used for elderly care, mental care, or people with heart diseases or diabetes (Evers et al., 2009). Telecare, the main subject of this research, is the use of information and communication technology (ICT) to support the delivery of health and social care to individuals, at home (Barlow et al. 2006). Telecare has the potential to increase independence and quality of life for elderly people who prefer to live in their own homes, and at the same time producing cost savings for the healthcare system (Botsis et al., 2008). While telecare products can lead to a decrease in hospital care (Evers et al., 2009), video games that encourage physical activity results in more compliance in exercises and this also results in a decrease in hospital care (Health Benefits of Gaming, 2008). This combination of exercise and video games that encourage physical activity is called exergaming. (Health Benefits of Gaming, 2008).
This research will focus on the requirements of telecare in exergaming, from the perspective of the user of the telecare and exergaming (in this thesis referred to as client) and the person who gives feedback to the user about the game (in this thesis referred to as healthcare provider). The client in this research is the elderly person, with an age above the 70 years. Demiris et al. (2004) explored the perceptions of seniors with respect to ‘smart home’ technology installed and operated in their homes, by conducting three focus groups. An overall positive attitude towards devices and sensors was reported. However, concerns were expressed about the lack of human response, user-friendliness of the devices and the need for tailoring the training to older learners. In home telecare systems, there is a lack of: “Standards to combine incompatible information systems; a framework which considers the legal ethical, organizational, economical, clinical, usability, quality and technical aspects, guidelines for the practical implementation of potential home telecare applications, and scientific evidence to demonstrate the effectiveness of home telecare applications” (Botsis et al., 2008).
1.1 Research objective
on the fundamental design principles. More specifically, this research will focus on the requirements of the artifacts, and not on the technical matters. This research is a part of a design science research. According to Iivari and Venable (2009) design science research is a research activity that invents or builds new, innovative artifacts for achieving improvements or solving problems. Thus, creating new reality, rather than explaining existing reality or helping to make sense of it. This research includes the following steps of a design science research: problem identification, definition of objectives for the solution, and design.
1.2 Background project SPRINT
To get a proper understanding of the program SPRINT, a background is provided. The SPRINT (Smart Prevention, Rehabilitation & INtervention Technologies at home for improved mobility) center, does research to training and rehabilitation at home, to increase mobility of elderly by means of prevention. They try to develop the next generation of intelligent mobility devices for the individual patient (SPRINT plan, 2010). SPRINT combines strengths of universities, including the University Medical Center Groningen (UMCG), and University of Groningen (RUG), with a large number of companies and healthcare providers. SPRINT will develop medical devices that allow patients to stay mobile for a longer period of time or become mobile more quickly. Moreover, medical devices and programs will be developed that allow patients to follow rehabilitation programs at home.
SPRINT comprises many projects. One of the projects concerns telecare and exergaming, in which this thesis has a contribution. In the project exergaming, people above 70 years old are motivated to keep moving and to train balance as fall prevention. With the use of sensor systems, the degree of balance is measured and monitored and with telecare safety is guaranteed. In 2012 and 2013 the first researches of SPRINT should be ready, in which this research project provides a contribution.
1.3 Problem definition
How to make the telecare in exergaming a success is an essential issue of this thesis. This success depends on the fit between telecare in exergaming and the requirements and wishes of the clients and healthcare providers. Determining the requirements for telecare in exergaming is an academic challenge, because the unraveling of the different types of clients and healthcare providers involved in telecare in exergaming and different types of services, and providing the right service to the right client is what makes the research complex. The different types of clients and the healthcare providers all have different requirements of the telecare in exergaming and the clients do have different health situations and experiences as for instance knowledge of ICT. In addition, there could be different (and potentially conflicting) interests between clients and healthcare providers. However, telecare is a product that requires acceptance by all stakeholders in order for it to be successful. Consequently, it is a challenge to formulate the specifications in such a way that the system will be a success. It is a complex process to obtain a suitable set of requirements for all stakeholders, which is satisfactory for each type of client and healthcare provider. The challenge is to
let the users understand the still intangible system and to get the information as complete as possible and clearly formulated out of the clients and healthcare providers.
1.4 Research relevance
Clients and healthcare providers are the main stakeholders in this research, they possibly have to work with exergaming and the associated telecare in exergaming in future. In this research, we speak about clients and not about patients, because the people involved are not under the supervision of a medical specialist. The practical value of this research is that in order for telecare in exergaming to be a success there has to be clarity and understanding of the requirements for telecare in exergaming. Without fulfilling the wishes and requirements of clients and healthcare providers, these stakeholders will probably not use the system, which in turn will not result in a decrease in hospital care.
Another relevant reason for conducting this research is the contribution to the research of telecare in exergaming of the program SPRINT. In the SPRINT program a specific project is initiated, which includes the development of a skate-game as exergame for elderly people. Expected is that balance can be trained optimal with this skate-game. The research of this thesis has societal relevance, because in the future it can contribute to similar programs. This research will focus on the skate-game and the corresponding telecare. However, the results are generalizable for other exerskate-games than the skategame investigated in this thesis. This research is independent of the actual content of exergaming. That is, the primarily concerns are functional requirements, which describes the requirements that the product must meet. It does not prescribe the details of the content (e.g. that it should be a skating game where the user must skate in Thialf). In other words, if a slightly different form of telecare is needed or another game is desired, still the same requirements can be used. Therefore, programs where telecare in combination with exergaming are implemented can use this research to keep in mind the requirements of both the healthcare provider and the client. They can anticipate on these requirements, before they start developing or implementing a system.
1.5 Research questions
In the description of the functional and non-functional requirements of telecare in exergaming, the requirements available from existing literature are used as starting point. More detailed and specific requirements will be collected from interviews and workshops. The requirements must comply with the needs of the client and the healthcare provider, otherwise, the telecare and exergaming cannot be a success. This had led to the following research question:
In order to answer the research question the following sub-questions are formulated:
1. What types of clients and which types of healthcare providers have to be distinguished in telecare related to exergaming?
2. What services can be distinguished in telecare related to exergaming? 3. What are telecare in exergaming processes and how are they structured?
4. What are the needs of the clients and healthcare providers in the different services of telecare in exergaming?
The sub-questions are answered with qualitative research, among interviews with both clients and healthcare providers.
1.6 Limitations and boundaries
For the delimitation of the study, the following conditions are drafted:
- The final report of this research has a methodologically justified approach and meets the academic requirements set by the Faculty of Economics and Business.
- The final product has practical relevance for the telecare in exergaming project of SPRINT.
- Although the requirements of healthcare providers are investigated, the research and final product does not include the role of the UMCG.
- The requirements of the technical part of the exergaming system as device functionality, the system software and database design, the user requirements of exergaming, and the environmental requirements are outside the scope of this research.
- The research should take place from September 2012 and should be completed in February 2013.
1.7 Report structure
The next chapter, chapter 2, includes a background with literature to get more information about the telecare and exergaming, and related subjects. The method, which includes design science research, the research design and the data collection, can be found in chapter 3. The results, were a distinction is made between the four sub-questions can be found in chapter 4. Finally, a conclusion and discussion are provided in chapter 5.
2 Theoretical background
In this theoretical background, the position of telecare in the healthcare domain is given. Because telecare is primarily used for medical devices, this literature review often refers to patients. In this study, however, we focus on people who are not under supervision of a medical specialist. Consequently, we refer to these people as clients. Furthermore, this chapter includes the theory of E-health, telecare, telecare services, exergaming, and the requirements of telecare in exergaming. Finally, the main focus of this research is given.
2.1 E-health
E-health is the use of information and communication technologies in the health sector, particularly internet technology, to support and improve health and health care (RVZ, 2002). Figure 1 provides an overview of the position of telecare in the e-health domain (derived from Cocir, 2011). In this figure the E-health domain is shown as a part of the total public health. The boundary is represented by a dotted line which intersects other sub domains in healthcare such as dietics, psychiatry and surgery. This indicates that the role of e-health in these domains is growing.
Figure 1 - The position of telecare in the healthcare domain (derived from Cocir, 2011)
Telemedicine, domotica and telemonitoring are parts of the telecare domain. The telecare domain represents the providing of healthcare at a distance. “Telemedicine is a healthcare process, or the whole of health processes, in which each of the following two characteristics apply:
- Distance is spanned by using information technology and telecommunication
- At least two actors are involved, of which minimal one actor is a recognized care provider, or operates under responsibility of a recognize care provider.” (Bonke et al., 2009)
Domotica is the integration of technology and services, for a better quality of housing and living (Stichting Smart Homes, Nationaal Kenniscentrum Domotica & Slim Wonen, 2012) Thus domotica is not only about integration of technology and service in home, but also about the services from outside the home. Telemonitoring is “the use of audio, video and other electronic information
processing technologies to monitor patient status at a distance” (Meystre, 2005). These definitions exclude informal care provided by for instance voluntary care providers. Domotica, telemonitoring and telecare are more than only health; they make life more pleasant and easier. Like domotica as temperature regulation of the house, security and control of doors and windows. That is why these parts are outside the circle of public health.
NB: This study focuses on the telecare and telemonitoring. This is written as telecare, because telemonitoring is a part of telecare and further hold on one term makes this report easier to read. Domotica and telemedicine (figure 1) are outside the scope of this research.
2.2 Telecare
Telecare is a sub domain of e-health. In this research we signify telecare as the use of information and communication technology (ICT) for support the delivery of health and social care to individuals, at home (Barlow et al., 2006). Thus, the client and the healthcare provider are in different locations. Telecare concerns telecommunication between client and healthcare provider and thus also the informal care at a distance and web services with which, for example, meals can be ordered.
Telecare services are increasingly being established as ways to speed up processes, to improve accessibility to high quality care, to reduce cost, to empower patients and to bridge the gaps between mutual providers, and between patients and providers (Boonstra et al., 2011). Researches apply telecare for eliminating the travel time between a patient and the healthcare provider to increase the labor efficiency (Evers et al., 2009). Despite these high expectations, the diffusion of telecare remains limited, mainly due to the large implications in developing and implementing such a service innovation (Boonstra et al., 2011). Besides these goals of telecare, there are a number of purposes behind the use of telecare in healthcare processes (Pols et al., 2008):
- Improvement of the quality of life of clients - Improvement of the quality of healthcare - Improvement of the quality of service provision.
Improving the quality of life of clients could be seen as the most important purpose of telecare and exergaming. The client is the consumer; the improvement of the quality of life of the client should be the main goal of all telecare processes. Quality of life improvements with the use of telecare and exergaming include for instance improvement of social participation, and an improved and increased ability of client independency, because the client can contact the healthcare provider themselves, from their own home. The second purpose is the improvement of the quality of healthcare. Examples of this are the increased productivity and efficiency, improvement of therapy compliance and accelerated interventions by means of faster communication and the spanning of distance. In addition, the quality of service provision could be improved using telecare. Examples of the improvement of the quality of service provision are: A better achievement of wishes and needs and expectations of clients, a change of the attitude of care providers which might affect future healthcare, and better information provision. These not especially on medical care focused processes could also be important at the telecare in exergaming.
2.3 Telecare services
A definition that fits in describing service in the healthcare sector is based on the definition given by Looy et al (2003: 11) as all intangible activities that imply an interaction to be realized between a service provider and consumer. This definition describes a service as a process involving the consumer and the service provider, where the consumer is the client and the service provider is the healthcare provider. The healthcare provider represents the service being delivered.
2.3.1 Characteristics of services
A service has five different characteristics (Fitzsimmons and Fitzsimmons, 2011, p.18): Customer participation in the service process, simultaneity, perishability, intangibility, and heterogeneity. However, the service of the telecare process can be created and consumed simultaneously and can used in the same time by different consumers (simultaneity). Furthermore, the telecare services can be stored, because the telecare can be used when necessary, every moment of the day (perishability). Therefore, the service process of telecare has three main characteristics: Customer participation in the service, intangibility, and heterogeneity. These factors make consumers to rely on different cues and perspectives when evaluating services, which may also influence their perception of the service quality and whether they will derive satisfaction by it and how much satisfaction they can derive from consuming it.
2.3.2 Primary telecare services
Primary telecare factors include all kinds of care services where care is delivered by healthcare providers to clients. The processes of telecare can be divided in the following kinds of processes: Information provision, consultation, diagnosis, treatment, counseling, monitoring and alarming (Nieuwenweg, 2002; Peetermans, 2004). Information provision is a kind of communication where the healthcare provider informs the client about a (medical) subject. Consultation includes advice about how to cope with a certain situation or a certain subject. This consultation could take place between client and healthcare provider, but also between two healthcare providers. Diagnosis is the identification of a medical condition or a disease by means of symptoms and signs. Tele-diagnosing examples are the transfer and analysis of medical sensor data of the exergame, and measuring heart rate and blood pressure. Treatment is the application of a remedy against a medical problem such as a medical condition or a disease; it treats a specific problem with the objective to solve the problem in a short-term. An example of tele-treatment is a videoconference call between a diabetes client and a care provider. Counseling is a form of assistance, guiding and coaching to reach the goal or handle a specific situation. Monitoring is a generic term for processes such as surveillance and observation. Alarming refers to the occurrence of a critical medical situation. In practice, the primary telecare processes are not clearly defined and are the processes used in combination with each other to provide care services.
2.4 Exergaming
tool to aid rehabilitation in clinical settings (Taylor et al., 2011). Therapist and patients may offer benefits to complement traditional therapies by the active nature of these gaming systems.
The available games on the systems are distracting and entertaining, so the patient focuses on play the game rather than his or her impairment. This in turn results in more pleasurable training (Lange et al., 2009). The systems are relatively inexpensive and can be located in de person’s home to make training more convenient. Track rehabilitation at home, with specifically designed gaming programs, by internet so that a therapist can see if the patient is performing correctly, may also be feasible (Martin-Moreno et al., 2008). This is a form of exergaming combined with telecare.
2.5 Requirements of telecare and exergaming
Requirements of telecare in exergaming can be split up into requirements of exergaming and requirements of telecare.
2.5.1 Requirements of exergaming
In this sub-section, the requirements of exergaming which have a connection with telecare are described, because these requirements are the building blocks for the requirements of telecare in exergaming
Requirements from clients
Barlow et al. (2006) discusses the barriers in the implementation of innovation in healthcare. These barriers provide the basis that is included in the drafting of the final requirements with interviews, meetings and the workshop. According to Barlow et al. (2006) two barriers in the organization can be recognized. First is adequate supervision of those who are responsible for creating a review of the client and making decisions regarding selection technology. In order for innovations to be successful, technological opportunities are required to match user needs. The second barrier is the lack of awareness and knowledge among healthcare workers. Healthcare workers, who do not know how to work with the healthcare innovations, cannot use the system as is intended. From these two requirements can emerge adequate supervision and awareness in exergaming of healthcare workers. Furthermore, the exergaming-system should have low costs (Lange et al., 2009). More information about the costs of an exergaming system can be found in the thesis ‘Assessment of the sustainability of a telemonitoring of exergaming service’ from Job Havinga.
Requirements from healthcare providers
Although Barlow et al. (2006) describes the barriers in the implementation of innovation in healthcare, these are requirements of exergaming from the perspective of the client. Still little is known about requirements of exergaming from the perspective of the care provider in academic literature. According to Lange et al. (2009) an advantage in using game based tele-rehabilitation is that the supervising therapist can very precisely manipulate and control both organization and complexity. It is important that tasks can be selected based on the client’s more specific impairments. The therapist can use Progressive Part Strategy, start training with a low complexity game if the client has difficulty with complex task, and step by step increase the complexity to ensure
success along the way. Besides, the supervising therapist should get an objective view of the daily training undertaken by the client, such as number of repetitions, amount of time spent playing the games, range of motion performed when using the game, accuracy, dynamics (Popescu et al., 2000 and Bach-y-Rita et al., 2002) mechanical energy (Huberty et al., 2008), velocity, and time to reach (Broeren et al., 2007).
2.5.2 Requirements of telecare
A telecare system, which fails to adhere to requirements, will be flawed. The fundamental requirements of a telecare system can be categorized as functional and non-functional requirements. Moreover, technical matters are important for a system’s requirements (Collinge and Liu, 2009).
Functional requirements
Functional requirements are what a telecare system needs to do in order to function correctly. According to Maciaszek (2005), functional requirements can be grouped into requirements that describe the scope of the system, the necessary business functions, and the required data structures. According to Collinge and Liu (2009) functional requirements include environmental needs, communication, and generated data. The functional requirements Collinge and Liu (2009) gives in their research are divided in before, during and after gaming.
Functional requirements before gaming:
- “Systems should be adaptable to specific environmental needs (e.g. large/small house); - The chosen environment must be monitored effectively by the devices;
- The system should be capable of generating invoices for clients who rent telecare equipment from the service operator;
- The system must have adequate back-up systems and procedures in place in case of primary system breakdown. Back-up systems procedures should be detailed in a disaster plan.”
Functional requirements during gaming:
- “The system needs an effective alerting mechanism to ensure that the resident and the support-centre are aware that a particular telecare device has been activated;
- Communications throughout the telecare system should be effective and smooth;
- The system must function around the clock (24 hours a day, 7 days a week), with the residence being under continual monitoring;
- The system should record all system activity and update resident profiles accordingly (e.g. measuring types and numbers of alerts, responses, speed of responses, resolutions to alerts); - The system should continue to operate if major power sources or telecommunications are cut
temporarily.”
Functional requirements after gaming:
- “The system should inform the resident about system functionality, usage and status;
Non-functional requirements
Non-functional requirements are not behavioral in nature. They are constraints on the development and implementation of the system (Maciaszek, 2005). Non-functional requirements consist of legal requirements, regulatory requirements and ideal system characteristics (Collinge and Liu, 2009): - “Legal requirements: Cover topics as permitting access to the property in emergency situations,
and obtaining the consent of the resident to install telecare equipment;
- Ideal system characteristics: The telecare system should be mobile enough for removal and re-use if necessary. A telecare system should also be able to implement new technologies”.
Informational requirements
Further, telecare systems use data in order to function. Important principles regarding information usage are defined by five informational requirements: information security, information speed, information accuracy, reduction of superfluous information and information value (Collinge and Liu, 2009).
In addition to this literature, field research is necessary as well, because the requirements given above are based on a separate telecare system, rather than a telecare system that is connected with an exergame. Furthermore, these requirements do not focus on the target of telecare in exergaming. Moreover, as could be concluded while reading the requirements, these requirements are based on large medical telecare systems. Requirements as “The system must have adequate back-up systems and procedures in place in case of primary system breakdown.” are too big to fit in the profile of the systems related to this research. Consequently, additional interviews, meetings and workshops are necessary in this research. The requirements of the article of Collinge and Liu (2009) that fits into the profile of the systems related to this study can be found in chapter 4.
2.6 Contribution of the literature
3 Methods
This chapter presents the data gathering methods used for analyzing the sub-questions and the main research question. First, the type of research of this study, design science research, is explained. After this the research design is given, which distinguishes an exploratory study and a field study. This chapter concludes with a description of the data analysis.
3.1 Design science research
This research is a part of the research Telebalance in the project SPRINT. Telebalance is a design science research, of which this research is the first part. According to Iivari and Venable (2009), design science research is a research activity that invents or builds new, innovative artifacts for achieving improvements or solving problems. Creating new reality, rather than explaining existing reality or helping to make sense of it. Thus, this study does not consist of a statistic study that describes the significance of a research, about for instance the opinions of the effectiveness of a research. The aim of this research was to describe what the telecare in exergaming requirements are. The ultimate aim is not to test whether theory, when applied to practice, is a good predictor of events. Direct application of theory is not sufficient to solve those complicated problems.” (Van den Akker, 1999. pp. 8-9).
Possible Research Entry Points Identify Problem &
Motivate Define Problem Show Importance Define Objectives of a Solution What would a better artifact accomplish? Design & Development Artifact Demonstration Find suitable context Use artifact to solve problem Evaluation Observe how effective, efficient Iterate back to design Communication Scholarly publications Professional publications In fe re n c e T h e o ry H o w t o K n o w le d g e M e tr ic s , A n a ly s is K n o w le d g e D is c ip li n a ry K n o w le d g e Process Iteration Problem-Centered Initiation Objective-Centered Initiation Design and Development Centered Initiation Client / Context Centered Initiation Nominal process sequence
Figure 2 – Design science research methodology (DSRM) Process model (Pfeffers et al., 2008)
process of figure 2, is fulfilled in communication of the requirements with this thesis. The entry-point of this research is the objective-centered initiation, because the ‘problem’ is already determined by the research Telebalance. In the next section, the design of step 2 and 3 is described.
3.2 Research design
Research to investigate the answer of the research question and the sub-questions is described and executed along the guidelines of Business research methods written by Blumberg (2008). The research included two steps, an exploratory study and a field study. The exploratory study includes a literature study, an exploratory visit and a workshop. This field study consists of interviews and meetings.
3.2.1 Exploratory study
The first step of the exploratory study was a literature study of scientific articles and documents of SPRINT. In this literature study, literature that relates to the subject of the research has been reviewed. In addition to the literature study of scientific articles and documents of SPRINT, files of documentary evidence were collected throughout the course of the project. These documents mainly revealed information of other research in telecare and other research in exergaming. After the exploratory visits to different people that are involved in the study of telecare and exergaming of SPRINT, the specific subject of this research has been determined, in accordance with the supervisor of this research and the project manager. The workshop organized by the project manager and the author of this thesis is an important part of the exploratory study. In this workshop different parties discussed the user requirements of clients. For the researcher, the main objective of this workshop was to meet more people who are involved in the research of telecare in case of exergaming, to contribute to the field study. With the workshop an exploratory framework is set: What is telecare in exergaming and who are the clients and healthcare providers? After the exploratory study, the field study has been prepared.
3.2.2 Field study
With interviews, the requirements of telecare in exergaming according to clients and healthcare providers were collected. The method of interviewing is chosen, because with interviews the interviewer gets insight into what the respondents think and consider about subjects (Hannabuss, 1996). Thus, this is a good method to learn what the clients and healthcare providers actually think about which wishes and requirements are important at the telecare in exergaming.
Interview structure
The interview questions with clients are made based on personas. Personas are descriptions of persons with personal data, living environment, health situation, care needs scenario, limitations and participation problems, daily activities and the need of care (DSD group, 2009). These personas are important, because they help empathize with people and subsequently by asking the right questions to the clients. With formulating this interview questions, the advice that Lethbridge and Laganiere (2001) give in their article is included. Questions about: Specific details, ask about the five w’s: who, what, when, where, and why, the vision for the future, alternative ideas, and a minimally acceptable solution.
Sample size
In consultation with the clinical/care scientific leader SPRINT & Prof. rehabilitation medicine and the project manager, the sample size includes: Clients (N=12), consisting of clients in normal health (N = 4), clients with chronic illness (N=4), and clients who need rehabilitation of musculoskeletal (N=4). Healthcare providers (N=8), consisting of employees in the fitness center (N=3), physiotherapists (N=3), a rehabilitation physician (N=1), and a general practitioner (N=1), as can be seen in table 1. The number of interviews is not enough for statistical relevance, but that is not the goal of this research. The wishes and requirements from clients and healthcare providers telecare in exergaming are important, not the statistical relevance.
Clients N=12 Healthcare providers N=8
Clients with chronic illness N=4 Employees in the fitness center N=3 Clients who need rehabilitation of
musculoskeletal
N=4 Physiotherapists N=3 Rehabilitation physician N=1 Clients who do not have temporary or
non-temporary balance restrictions
N=4 General practitioner N=1 Table 1 - Sample sizes of participant groups
Meetings
Another part of the field study was a meeting with other researches in the same area. Researchers of Waag Society and UMCG have a lot of research-experience. With these meetings information about how according to them the exergaming of telecare process looks like (sub-question three), what important services of telecare in exergaming are (sub-question two), which clients to interview and where to get important data is collected. These meetings were a part of the field study, because they also resulted in information usable in this research.
3.3 Selection of respondents
In the selection of interviewed persons, a distinction is made between the clinical/care scientific leader SPRINT & professor rehabilitation medicine and the project manager, the clients, and the healthcare providers.
3.3.1 Clinical/care scientific leader SPRINT & Prof. rehabilitation medicine and project manager
literature written about telecare and exergaming, is closely involved in the SPRINT research project, and has contacts with as well as clients as healthcare providers. The interview gave more precise insight into the services and processes that can distinguished in telecare in exergaming. About how the processes are structured, and what could be requirements of clients and healthcare providers, the sub-questions two, three and four. There is some information in literature available, but not based on the SPRINT project, and that is the starting point of this research. Thus to complement the information from literature, get more information besides from literature, and make this information more focused on the SPRINT project, this interview was held. The project manager was interviewed because he also has knowledge about the literature written about telecare and exergaming and has contacts with students who did research in almost similar studies.
3.3.2 Clients
After interviews with the clinical/care scientific leader SPRINT & Prof. rehabilitation medicine and the project manager, clients were interviewed. The respondents of the interviews in terms of kind of clients are drafted together with the clinical/care scientific leader SPRINT & Prof. rehabilitation medicine and consist of potential users of the exergame. These potential users are:
- Clients with chronic illness: In this study the focus is on clients with diabetes
- Clients who needed rehabilitation of musculoskeletal: in this study clients with a new hip - Clients who do not have temporary or non-temporary balance restrictions
SPRINT will focus on the prevention of elderly people, 70 years or older. The interviewed people are selected on age. One group is around 75-80 years and one group is around 55 years. This is because the first age category has a different lifestyle and knowledge of ICT than the second age category of around 55 years. Age-related changes can affect balance control (Konrad et al., 1999). Examples of this are a loss of elasticity in the tissues, decreased bone density, and a decrease in muscle mass and strength (Thompson, 2008). The decrease in muscle mass and strength also hold for people who received a new hip. Some people do restore quickly (temporary balance restrictions), for others it takes a few years or they never fully recovered. Clients with diabetes are included because diabetes affects the sensory, motor and/or cognitive functions, which leads to a decreased balance, and an increased fall risk (Konrad et al., 1999). Clients who do not have temporary or non-temporary balance restrictions are included to compare with the other types of clients. Because these three types of clients all have different health situations, which affects their balance and the movements they can make, expected is that there is a difference between the requirements of these clients.
Selection of clients
Thus, it is necessary to carry out research in the province of Groningen as well. Moreover, as the distances are much larger here (e.g. between client and physiotherapist), the benefits of exergaming and telecare weigh probably quite different. This will also have an impact on the requirements. A summary of the persons interviewed can be found in appendix A. The interview questions can be found in appendix B. The results from the interviews can be found in appendix C. These results are in Dutch, because after each interview the document summarizing the interview is sent to the interviewee, along with a request for comments, and the interviewees most of the time cannot speak English.
3.3.3 Healthcare provider-interviews
Employees of the fitness center, physiotherapists and also a rehabilitation physician and a general practitioner are interviewed about how they think about the telecare in exergaming and what they think their role in telecare in exergaming is in future. These types of healthcare providers are chosen in consultation with the project manager and the clinical/care scientific leader SPRINT & Prof. rehabilitation medicine, because these healthcare providers represent a broad range of professionals who probably in the future will work with the telecare in exergaming. The rehabilitation physician and general practitioner are interviewed, because these people are probably the people who have to convince clients to use the exergame and the telecare. The healthcare providers are from the province Groningen.
The interview questions can be found in appendix D and E. The interview questions of the general practitioner differs from the questions of other healthcare providers, because from the general practitioner we only want to know how he thinks about the exergame and what his contribution could be in the system. According to the researcher and the participants of the works, he does not have to give feedback (not possible with this kind of a job, do not have, and cannot make time for this), that is why the other questions are excluded. The results from the interviews can be found in appendix F.
3.4 Data analysis
In this section will be explained how data will be used to the answer the different research questions. Finally, an overview of the methods used will be presented.
onstage contact person actions (second line) and system actions (third line) are important. In finalizing the blueprint, it is essential to know which actions between who take place.
The interviews provided the data needed to answer the last sub-question ‘What are the needs of the clients and healthcare providers in the different services of telecare in exergaming?’ This data include the needs of clients and healthcare providers. The data are analyzed based on the example of Kvale and Brinkman (2009). Based on their suggestion, five steps for analyzing interview data with structured and open questions are used:
- Step 1: Acquire a general overview of the interview in order to obtain a preliminary sense of the context.
- Step 2: Determine the meaning of the data
- Step 3: Restate the meaning of the data as simply as possible
- Step 4: Interrogate the meaning units in terms of the specific purposes of the study. Thus, the data are restated as simple as possible, and divided into services, as written above.
- Step 5: Tied together the essential non-redundant themes of the entire interview into descriptive statements. This is done in the last section of the next chapter, which described the needs of clients and healthcare providers.
3.4.1 Validity and reliability
Approaches used to address validity and reliability in this research are member checking and an expert review. Member checking add to the validity of the interviewers’ interpretation of qualitative interviews (Simon, 2011). Member checking allows the interviewees the chance to correct errors of fact or errors of interpretation. In this research, to find out correct understandings, the interviewer should seek confirmation by summarizing the interviewee’s statements back to him. Furthermore, to obtain additional feedback and to maintain good interpersonal rapport, a document summarizing the interview is brought or sent to the interviewee within a day or two after the interview, along with a request for comments. The expert review has take place with a concept developer of Waag Society, who has conducted many interviews with clients in the past. Together with the researcher, she ensures that all of the important aspects of the study are reviewed in the interview.
During the interviews, it is clearly indicated what the situation is where the exergame takes place. In interviews with the clients is named explicitly what telecare and exergaming are and that they are performed in a home environment. This information is made clearer with a film that shows how someone is gaming with the Kinect (SPRINT intends to use a Kinect to play the exergame). Further it is important to let the client think about their needs of care on distance, and if so what is according to them needed for care on distance. Technical terms used are clearly explained.
3.4.2 Overview Research design
An overview of the methods is shown in table 2. As can be seen, an answer on the first research question is included in this table, the types of clients and healthcare providers are appointed in the table, at sub-question 4.
Sub-question Method Who involved Results
1. Types of clients and types of healthcare providers Open interviews
Clinical/care scientific leader of SPRINT and professor rehabilitation medicine
Project manager
CH 4.1
Workshop People who are involved in the research to telecare in exergaming 2. Services telecare in exergaming Literature study Web of Science CH 4.2 Open interview
Clinical/care scientific leader SPRINT & Prof. rehabilitation medicine
Workshop People who are involved in the research to telecare in exergaming
Meetings Researchers of Waag Society 3. Processes
telecare in exergaming and how they are structured
Open interview
Clinical/care scientific leader SPRINT & Prof. rehabilitation medicine
CH 4.3 Meetings Researchers of Waag Society and UMCG
4. Needs of clients and healthcare providers in different services of telecare in exergaming Literature study Web of Science CH 4.4 Structured and open interviews
Clinical/care scientific leader SPRINT & Prof.
rehabilitation medicine Clients in normal health (N = 4), clients with chronic illness (N=4), clients who need rehabilitation of musculoskeletal (N=4).
Employees in the fitness center (N=3), physiotherapists (N=3), a rehabilitation physician (N=1), and a general practitioner (N=1)
4 Results
The main research question investigated in this thesis is divided into four sub-questions. In this chapter, the results of this study are described in order to provide an answer to the four sub-questions. First, the types of clients and healthcare providers are given. Subsequently, the services of telecare in exergaming, the telecare in exergaming process, and the needs of these stakeholders are presented.
4.1 Types of clients and healthcare providers
This section will answer the sub-question ‘What types of clients and which types of healthcare providers have to be distinguished in telecare in exergaming?’ As the question says, a distinction is made between clients and healthcare providers. The clients in this research are clients with diabetes (chronic illness), clients with a new hip (rehabilitation of musculoskeletal) and clients who do not have temporary or non-temporary balance restrictions. The types of healthcare providers interviewed in this study are employees of the fitness center, physiotherapists, a rehabilitation physician, and a general practitioner. The explanation of why exactly these types of client and healthcare providers are chosen can be found in chapter 3.3. More about tasks the healthcare providers can fulfill in the processes of telecare in exergaming can be found in chapter 4.3.
4.2 Services of telecare in exergaming
In this section, the sub-question ‘What services can be distinguished in telecare in exergaming?’ will be answered, combined with a value judgment of clients and healthcare providers, based on interview results. The literature review of chapter 3 includes services of telecare in a medical environment, based on this services the services of telecare in exergaming are described. Further, the results of an open interview, meetings and the workshop (table 2) were important to describe the services of telecare in exergaming.
4.2.1 Medical, or not?
Medical or paramedical treatment includes “nursing, psychological intervention and specialist mental health habilitation, rehabilitation and care” (Mental Health Act, 2007). In this study, a medical treatment is defined as the treatment of patients by physiotherapist (paramedical) or a physician until the client is in good health again. No medical treatment means that the client gets no medical treatment in the form of using the telecare and the exergame.
However, some medical supervision can be useful. Healthcare providers can fulfill a role within the telecare in exergaming according to the clinical/care scientific leader SPRINT & Prof. rehabilitation medicine. He is interested in the revalidation of patients at home. However, there is one big problem: When care is granted according to the official guidelines, the healthcare provider is responsible for the patients not to end up in a risky situation. The results of the interviews with physiotherapists shows that they do not know who is responsible for injury in a homecare program, they do not know what is written in the official guidelines and laws about this and about who is responsible for the patient to be safe. However, they do know that when using the exergame in a medical perspective, risks to have an accident should be as low as possible.
Further, when making the telecare and exergaming a medical product, the product must meet the CE examination certificate. Besides this, making the system a medical system results in other safety requirements and other liability and responsibilities of healthcare providers. How this is defined in legislation is outside the scope of this study. Together with the participants of the workshop is concluded that telecare in case of exergaming should in the initial phase not be a medical system. However, the opportunities to make it a medical system should be available.
4.2.2 Information provision
To use the exergame, the client needs information and help with installing the game and with the first startup of the game. Not only in the form of informing, but also executive assistance. In the interviews, clients indicated that using the exergame for the first time with medical supervision, gives them a more safety feeling. Most people preferred the physiotherapist as medical supervision. Another result from the interviews with clients shows that most of the elderly people do not have much experience with ICT. Most of them do not have a computer at home and did not know about gaming as gaming with the Kinect or Wii before the researcher told them about it and showed them the instruction video.
4.2.3 Consultation
The clients trust the physiotherapist and for them it is very important to have good contacts with this healthcare provider. Which is very clear evident in the interviews is that some clients think they cannot play the game independent. They think they need a lot of feedback from the physiotherapist. They feel very insecure about using the exergame. Other clients think they can play the game without feedback of the healthcare provider.
Figure 3 – ICT experience of elderly people (Hage, 2011)
4.2.4 Diagnosis
The diagnoses can include condition, movement, posture, heart rate, and level of the game. In telecare in case of exergaming, both the healthcare provider who gives feedback to the client if necessary, and the client himself can see the results of the game.
4.2.5 Treatment
The clients use the exergame whenever they want, not to heal from a medical problem, but to keep in good health and training balance. This means that the treatment consist of prevention. More precisely, as a result of the workshop, the telecare in exergaming will focus on primary prevention. Primary prevention includes the prevention of people of falling and becoming less healthy. Secondary prevention as for instance rehabilitation of people who had an infarction is not included.
4.2.6 Counseling and Monitoring
Counseling includes giving assistance to reach the goal or handle a specific situation. In the telecare in exergaming, this counseling is given by the system. When necessary a healthcare provider can monitor the game of the client, e.g. once a month. When he sees something notable, he can give counseling. Healthcare providers and some clients indicated the preference for different options (packages) of guidance. Another healthcare provider preferred to have the following reduction of coaching: In week 0, week 1, week 3, week 6, week 12, week 26 and week 52.
4.2.7 Alarming
Alarming refers to the occurrence of a critical situation. Most of the clients indicated in their interview that if they cannot call the alarm number themselves and if nobody is at home, it would be nice that the system can establish that the user falls and do not stand up anymore. That the system can recognize this will give them a feeling of safety. More about this can be found in section 4.3.
Never
4.2.8 The exergame
The biggest service that is delivered by the telecare in exergaming is the game. Some people are enthusiastic about the exergame, other people are very negative about it. ‘I can get my exercise without that game; I don’t need it and won’t need it’. Some people cannot walk or stand without their walker. These people do not know how they should play the game. For them is it hard to go to the toilet while the walker stands at the toilet door. They are convinced about the fact that they cannot play the skate game. In some cases, it was difficult to explain the game; especially in the cases when the people do not have a computer at home at al. The film, together with making the skate movement and an explanation were in some cases not enough to understand how the system works. This may have influenced the minds of people.
According to the healthcare providers, the exergame is a nice game, with which people can be properly monitored. However, they have worries about losing the non-verbal communication with clients. Results of the game do not show the attitudes of the clients. Healthcare providers do think the skate movement will improve the balance, but they are wondering about when the game should have good results. Is using the game 30 minutes a week enough to improve the balance? Further, they are wondering if the elderly people can and want to use the system. Do they like the skate game? Most elderly people do not like it to play sports. Besides this, the social contacts with other people will decrease if the clients have to play the game on their own. Healthcare providers do worry a lot about this subject. Many elderly people are lonely, this should not be worse. The healthcare providers told that there is an upcoming market for E-health, but they are wondering whether this is also true for elderly people.
4.3 The process of telecare in exergaming
Blueprint User actions (Client) line of interaction Onstage contact Person Line of visibility Support Processes (Telecare of Exergaming system)
Figure 4 - Blueprint Telecare of exergame
1. Can be done by rehabilitation physician, physiotherapist, and rehabilitation physician.
2. Can be done by physiotherapist or an employee from the central point (with medical experience)
3. Emergency case can be solved by the person who is called when the client used the alarm button or an employee from the central point. Starts exergame Ends exergame Starts data collection Shows results of game and gives feedback 2. Views and evaluates game data. 2. Gives feed-back to client and motivates client Starts game with feedback improvements in mind 3. Press alarmbutton or use alarm chain/ call alarmno 1. Motivates client to start using exergame Introduction or reminder from system about last game results Knows there is an emergency case Sees results of the game Gives positive feedback to client Takes feedback in mind Plays game Rings alarm at client
2. Helps client to get introduced with game/motivate to start game again
4.3.1 Dotted activities
The dotted activities in the blueprint are activities that are optional. For instance, the contact person does not always give feedback about the data to the client. However, as there is a possibility the contact person does provide feedback, these options are included in the blueprint. As this research will not focus on the technical aspects, it is not important how these options technically work. Rather, it is only important that the possibility of these options exist.
4.3.2 Before the start of using telecare and the exergame
Before the client can start using the exergame, he should purchase the exergame. Because initially the exergame is a non-medical device, is in consultation with participants of the workshop decided that the exergame can be purchased at the electronics store. The clinical/care scientific leader SPRINT & Prof. rehabilitation medicine compared the purchase of the exergame with the purchase of a walker (in Dutch: rollator). You can buy a walker also in a store like the Praxis or Belga, so why could this not be the case with the exergame? Another result of the workshop is to convince the older people to use the exergame; a healthcare provider can play an important role in this. The client most of the time trust the healthcare provider and expected is that the healthcare provider would convince the client a lot more than a seller of the electronics store would. Further, the elderly client more often goes to the healthcare provider, than to the electronics store. That is why it is important that the healthcare provider gives the client advice to start using the exergame, like the healthcare provider gives the client the advice to start using a walker.
Another possibility is that a person comes to visit the client to install and show the exergame and give an introduction about the system. The client can try the exergame and the people who come to show the client the system, gives instructions. The client can choose to keep the system or not. This is a good solution for people who cannot go to the electronics store anymore. The person should have a medical background, because it is important that the first time a client plays the game, the posture is correct. Otherwise, subsequent times the client continues using the game with an incorrect posture. These two options are not included in the blueprint, because this takes place before using the game. Coaching is another part of the telecare in exergaming. The coaching by the healthcare provider is a part of the exergame you cannot buy in the electronic store. The health insurance company should offer this. According to the clinical/care scientific leader SPRINT & Prof. rehabilitation medicine, De Friesland Health Insurance Company is willing to offer this coaching, combined with compensation. The coaching can be offered in different packages, for instance from coaching once a month until coaching every week.
4.3.3 Start of the exergame
When the client starts the exergame, he can choose to play the game alone or to play digital against other opponents. As soon as the client starts the game, the system starts to collect data, if the client gives permission for this. Permission to show the data to the healthcare provider, and permission to use the data for anonymous research. One of the first things the client will see when starting a game, are the game results from last time, to motivate the client to perform well. The system gives also positive feedback during the game, about the performance of the client. This positive feedback could also include instructions to improve the results. Further, there is an option that a backstage contact person is included to give feedback, motivates users and answers questions. This feedback can be necessary in different degrees. Some users need a lot of coaching, others think they can play the game almost without coaching. This can be decided based on a baseline measurement. When the coaching is not enough and the physiotherapist or other healthcare provider who gives the coaching does have worries about for instance the posture of the user, he can ask the user to make an appointment for a consult. When this is the case, the coaching is changed to a medical visit. This medical visit is outside the scope of the telecare in exergaming.
4.3.4 End the exergame/emergency case
When the client ends the game, the system will also ends data collection, because the client and the healthcare provider will only see data about the period the client is gaming, not before or after the game. There is a possibility an emergency case exists. There is an option that the system can determine this, but will not do anything with it. When clients are using an alarm button for personal alarm at home, they can use this button. The alarm button for personal alarm warns a relative who lives in the neighborhood, or the neighbours of the client, that the client used the alarm button. The warned person should come as soon as possible to visit the client and can choose to call a medical institution.
Another option is that the system can see that the user lies on the ground, and warned the user that within one minute a button (on e.g. the television) must be pressed. If the client does not react on this, the telecare should be activated, so some healthcare provider can talk with the client and/or call the emergency number. The physiotherapist, employee of the sports school, and general practitioner would not fulfill this task, because they do not have the time to react on emergency cases. They think someone from a central point (with medical experience) can do this. In this option, it is very important that the system does function correctly. A situation that the client is not on the ground, but went to the door to open it, can be the case. When the client did not pressed the button of the exergame because she did not hear the warning, with the result that the person from the central point also did not get response and warned the emergency number, should not occur.
