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A WEB-BASED TELEPRENATOLOGY PLATFORM FOR ANTENATAL CARE
MANAGEMENT IN REMOTE AREAS
NORAINI BINTI JALIL
A thesis submitted in fulfilment of the
requirements for the award of the degree of
Master of Engineering (Biomedical)
Faculty of Biosciences and Medical Engineering
Universiti Teknologi Malaysia
MARCH 2015
iii
To my beloved parents, brothers, sisters and friends
For their endless love, support and encouragement
Only Allah will return all your kindness.
iv
ACKNOWLEDGEMENT
First and foremost, my deepest gratitude to Allah Almighty for giving me the
opportunity to work on such a fascinating topic, His blessing surely helped me to
successfully conclude the project.
I acknowledge my sincere appreciation and gratefulness to my advisor, Prof.
Dr.–Ing Eko Supriyanto for his knowledgeable guidance, caring, patience for doing
research. He supported my research financially and taught me many things beyond
the textbooks. I am specially thankful to apl. Prof. Dr.-Ing Habil Vesselin Detschew
and Prof. Dr.-Ing. Habil Jens Haueisen for their help and support and providing me
the opportunity to study in Germany. A special token of appreciation also goes to my
co-supervisor, Dr Hau Yuan Wen for giving me encouragement and advice.
I would like to thankful to all members in Rumah Sihat Budi Kemuliaan,
Jakarta, Indonesia especially Dr Rifqi for allowing me to do pilot study regarding
antenatal care. I also express my gratitude to all members from Kampar District
Health Office especially Mrs Norhaidar Lestari for guidance, valuable advice and
allowing me to carry out my surveys at many districts clinics and some hospitals in
Kampar. My genuine gratitude also goes to my research team, Jostinah Lam, Yudha
Noor Aditya and Ulfah Anwar for sharing ideas and gave me valuable suggestions.
Also, thanks to all my friends especially Siti Norzawani Ahmmad, Norliyana Safura
Hashim, Nida Iqbal Khan, Fitra Lestari, Saifaralina Jalil and others for their kindness
and moral support during my study.
To my beloved parents and all my dearest siblings, I shall remain indebted for
their love, emotional support, patience and sacrifice throughout my life. Thanks to
everyone involved directly or indirectly with this work.
v
ABSTRACT
According to World Health Organization, approximately 289,000 women had
died due to complications of pregnancy and childbirth in 2013, largely in developing
countries. Indonesia as one of the biggest developing countries in the world; the
number of midwives is high while the number of medical specialist is low. In
addition, existing ultrasound system is not suitable for midwives to manage high risk
pregnancy during remote antenatal check up. As a result, high risk pregnancy cases
detected by midwives in rural areas can not be identified and referred to medical
specialist immediately. In this study, a new teleprenatology management platform
has been designed and implemented for rural areas. This platform enables the
communication between midwives in rural area and distant medical specialists. The
platform consists of prenatal server, prenatal data assistant and prenatal workstation
with two main functions; teleconsultation and electronic medical record. A user-
friendly web-based solution was implemented using technologies such as Python
with Django framework along with JavaScript, Ajax, Jquery and html in front-ends.
To explore and describe the perceived needs and specific requirement for this
platform, the adoption of a user-centered design (UCD) approach has been proposed.
Research study had been successfully conducted at several clinics in Kampar,
Indonesia. After the platform has been designed according to the user’s feedback on
their need and specific requirement, the user usability and user acceptance of the
proposed platform were tested. User acceptance result showed that all five
constructs mean were above 60%. Among the construct, behavioural intention to use
had the highest mean values of 90.8% (±15.6). In case of usability testing, analysis
also showed an overall mean value of over 60% and ease of navigation had the
highest mean value of 84%. Images transmitted during teleconsultation met the
standard medical quality of service (m-QoS) and were sufficient for diagnosis
purposes. In conclusion, a positive agreement was observed asserting that this low
cost teleprenatology platform is acceptable and easy to use. However, further studies
are needed to improve the real-life implementation of this platform.
vi
ABSTRAK
Menurut Pertubuhan Kesihatan Sedunia (WHO), pada tahun 2013 terdapat
sekitar 289,000 wanita meninggal dunia akibat komplikasi kehamilan dan kelahiran
dan 98 peratus kes dilaporkan berlaku di negara yang sedang membangun. Di
Indonesia, jumlah doktor pakar perbidanan dan sakit puan didapati sangat kurang
dibandingkan dengan jumlah bidan terutamanya di kawasan pedalaman. Selain itu,
sistem ultrabunyi yang sedia ada tidak sesuai untuk bidan untuk menguruskan
kehamilan berisiko tinggi semasa pemeriksaan kehamilan. Akibatnya, kes berisiko
tinggi yang dikesan oleh bidan sukar dirujuk kepada pakar dengan segera. Oleh itu,
dalam kajian ini satu platform baru bagi pengurusan telepranatal telah direkabentuk
bagi kegunaan bidan di kawasan luar bandar, yang mampu untuk menghubungkan
bidan dan doktor pakar secara jarak jauh. Platform ini terdiri daripada sistem
pelayanan pranatal, pembantu data pranatal, dan stesen kerja pranatal dengan dua
fungsi utama iaitu sebagai perekod elektronik perubatan dan telekonsultasi.
Penyelesaian berasaskan web mesra pengguna ini dilaksanakan menggunakan
kerangka kerja Django dengan bahasa pengaturcaraan Python serta JavaScript, Ajax,
Jquery dan html sebagai pemproses bahagian depan. Dalam usaha untuk
menghuraikan keperluan pengguna dan spesifikasi platform ini, penyelidikan ini
menggunakan pendekatan reka bentuk berpusatkan pengguna dan tinjauan telah
dijalankan di beberapa klinik di Kampar, Indonesia. Setelah platform direka
berdasarkan maklumat dari hasil tinjauan, peratus kebolehgunaan pengguna dan
penerimaan pengguna telah diukur ke atas platform ini. Untuk penerimaan pengguna
menunjukkan bahawa semua kadar purata peratusan bagi lima parameter adalah
melebihi 60 peratus dan purata peratusan tertinggi adalah niat berperilaku iaitu
90.8% (±15.6). Bagi ujian kebolehgunaan, purata peratusan keseluruhan juga adalah
lebih dari 60% dan diantara parameter yang diukur, kelancaran pelayaran
mempunyai purata kebolehgunaan tertinggi iaitu 84%. Selain itu, imej yang dihantar
semasa telekonsultasi didapati mematuhi piawaian kualiti servis perubatan dan
mencukupi untuk tujuan diagnosis. Secara keseluruhan keputusan positif yang telah
diperoleh menegaskan bahawa platform telepranatal kos rendah ini adalah diterima
oleh pengguna dan mudah untuk digunakan, tetapi perlu diperbaiki untuk
pelaksanaan yang sebenar.
vii
TABLE OF CONTENTS
CHAPTER TITLE PAGE
DECLARATION ii
DEDICATION iii
ACKNOWLEDGEMENTS iv
ABSTRACT v
ABSTRAK vi
TABLE OF CONTENT vii
LIST OF TABLE xi
LIST OF FIGURE xiii
LIST OF ABBREVIATIONS xv
LIST OF APPENDICES
xvi
1 INTRODUCTION
1.1 Background of the study
1.2 Problem statement
1.3 Research Objectives
1.4 Significant of study
1.5 Scope of the study
1
1
4
6
6
7
2 LITERATURE REVIEW
2.1 Prenatal Care
2.1.1 High Risk Pregnancy
2.1.2 Workflow of trimester visits
2.2 Telemedicine
2.2.1 Benefits of Telemedicine
8
8
9
10
15
17
viii
2.2.2 Human Factors in Telemedicine
2.2.3 Critical success factors relating to
Telemedicine
2.2.4 Electronic Medical Record
2.2.5 Teleconference
18
20
21
26
3 METHODOLOGY
3.1 System Design Process
3.1.1 Data Collection and Analysis
3.1.2 Design Solutions
3.1.3 Implementation
3.1.4 Evaluation
3.2 Research Setting
3.2.1 The profile of Indonesia
3.2.2 Telemedicine Project in Indonesia
3.3 Research Approach
3.3.1 Concurrent Triangulation Design
3.4 Data Collection
3.4.1 Questionnaires
3.4.2 Interview
3.4.3 Observation
3.4.4 Photographs
3.4.5 Identification of Research Participant
3.4.6 Data Analysis Strategy
29
29
30
30
31
31
32
33
34
37
37
39
40
41
41
42
42
43
4 DESIGN AND IMPLEMENTATION
4.1 Proposing solutions.
4.1.1 Pilot Study
4.1.2 Requirement Analysis
4.1.3 Research Instrument Used
4.1.4 System Configuration
4.2 Uses Case Diagrams
4.2.1 Process of registration
45
45
45
49
52
53
56
57
ix
4.2.2 Process of Basic Antenatal Care
4.2.3 Teleconsultation Process
4.3 Class Diagram
4.4 Software Implementation
4.4.1 Log In Interface
4.4.2 Patient Information Interface
4.4.2.1 Visits
4.4.2.2 Basic Patient Information
4.4.2.3 Demographics
4.4.2.4 Medical History
4.4.2.5 Routine Check Up
4.4.2.6 Laboratory Testing
4.4.2.7 Ultrasound Scanning
4.4.3 Teleconsultation Interface
4.4.4 Notification Interface
4.5 Algoritm Coding
4.6 Schematic View of Teleconsultation
58
59
63
65
65
67
68
68
69
69
74
74
75
75
77
77
80
5 RESULT AND DISCUSSION
5.1 Reported daily routine activities
5.2 Quantitative Results
5.2.1 Skills of midwife
5.2.2 Midwife Knowledge
5.2.3 Midwife Experience
5.2.4 Midwife Training and Seminar
5.2.5 Correlation between midwife and specialist
5.2.6 Technology in workplace
5.2.7 Readiness to use web-based
teleprenatology platform
5.3 Reported need for teleprenatology platform and
experienced problems in the daily work
5.4 Photographs
5.5 Analysis software
81
81
84
84
88
91
92
94
97
98
99
104
106
x
5.6 Technical testing
114
6 CONCLUSION AND RECOMMENDATION
6.1 Conclusion
6.2 Recommendation
117
117
119
REFERENCES
Appendices A – D
121
129-152
xi
LIST OF TABLES
TABLE NO. TITLE
PAGE
2.1 Main guide on prenatal care procedure
11
2.2 Types of classification to describe Telemedicine
application, adapted from Tuner
16
2.3 Classification of E-Health QoS requirements. Adapted
from Demosthenes et. al
17
2.4 QoS requirements. Adapted from Gallelego
17
2.5 Technology acceptance review
19
2.6 Technical standards relating to specific aspect of EMR 21
2.7 Comparison our proposed system with some of existing
system
24
3.1 Number of respondent
43
3.2 The structure of the qualitative content analysis process
44
4.1 Obstetric and Gynaecologist Specialist Acceptance about
Telemedicine
46
4.2 Requirement Result Analysis
50
4.3 Functional and Non-functional requirement
51
4.4 Research Instrument Used
52
4.5 Functional Overview
55
5.1 Variables effect midwifery skills i) Association between
own Independently Practice Midwife and level of
midwifery skills for each characteristic ii) Association
between working period and level of midwifery skills for
xii
each characteristic
87
5.2 Assessment of Midwife Knowledge. i) Specify numbers of
correct answer midwives have answer for each level
questions categories ii) Classify group of midwife of their
knowledge based on their complete marks
89
5.3 Midwife experience while working
91
5.4 Conclusion need of teleprenatology platform
102
5.5 Conclusion barriers of implementing web-based
teleprenatology platform
103
5.6 Some of photographs taken during interview
105
5.7 Software testing: i) Construct’s Reliability ii) Descriptive
statistics of TAM questionnaires model
108
5.8 Questions applied to the study group to measure user’s
usability.
110
5.9 Comparison of platform technological attributes
113
5.10 Result Quality of Standard (QoS) for teleconsultation and
ultrasound streaming
116
xiii
LIST OF FIGURES
FIGURE NO. TITLE
PAGE
3.1 The Human Centred-Design process of the
teleprenatology platform. Adaptation of Matinez Alcala
32
3.2 Map of Indonesia
34
3.3 Process to establish need and requirement
39
3.4 Adapted framework of teleprenatology
40
4.1 How the system should be implemented
49
4.2 Overall System Configuration
53
4.3 Where the system should be implemented 54
4.4 Uses Case Diagram 56
4.5 Process of registration 58
4.6 Process of Basic Antenatal Care 61
4.7 Teleconsultation Process
62
4.8 Class Diagram of web-based teleprenatology platform 64
4.9 Log in interface 65
4.10 List of patients 66
4.11 Patient’s registration for first time user 67
4.12 Visits 68
4.13 Patient’s Demographic 70
4.14 Medical history interfaces a) Family medical history b)
xiv
menstrual history c) Obstetric History d)
Gynaecological History e) Immunization History
73
4.15 Routine Check Up 74
4.16 Laboratory Test 75
4.17 Teleconsultation interface (i) List of available specialist
ii) Specialist information iii) Ultrasound streaming and
video conferencing
76
4.18 Notification Interface 77
4.19 Process making Algorithm for web-based
teleprenatology platform using Django model
79
4.20 Schematic View of Teleconsultation 80
5.1 A traditional birth attendant show her TBA’s course
certificate and assisting delivery tools
83
5.2 Midwife Skills
86
5.3 Midwife training And Seminar: i) Midwife training, ii)
Midwife seminar, iii) Frequencies attending training
and seminar
94
5.4 Explains correlation between midwife and specialist: i)
Frequencies of Interaction ii) Communication Method
iii) Reasons of Communication
96
5.5 Availability of equipment in workplace and Skills
Level of Midwife using the equipment
97
5.6 Technology use in Workplace
98
5.7 Skills Using Computer
99
5.8 The results obtained of usability evaluation 111
5.9 A recorded ultrasound images: (i) (ii) the midwife-side
interface, (iii) (iv) the Ob-Gyn interface
116
xv
LIST OF ABBREVIATIONS
ANC - Antenatal Care
EMR - Electronic Medical Record
Ob-Gyn - Obstetric And Gynaecologists
WHO - World Health Organization
IRPM - Integrated Remote Prenatal Monitoring
QoS
TBA
TT
- Quality of Service
- Traditional Birth Attendant
- Tetanus Toxoid
xvi
LIST OF APPENDICES
APPENDIX TITLE
PAGE
A Needs and problems at work 129
B Expected Barriers to use web-based Teleprenatology
platform
134
C Expectation of the platform 137
D Sample of questionnaires 140
CHAPTER 1
INTRODUCTION
1.1 Background of the Study
Maternal and infant mortality is unacceptability high. According to WHO,
almost 800 women died from preventable causes related to childbirth, whereas
stillbirths are more than 7200 in each day. In 2013, approximately 289,000 women
died due to complications of childbirth. 28% of maternal mortality rate is due to pre-
existing medical conditions exacerbated by pregnancy such as diabetes, malaria,
HIV, obesity. Meanwhile haemorrhage (27%) has been known to be the second
important cause of maternal mortality worldwide. The other causes of maternal
mortality are induced high blood pressure (14%), infection mostly after childbirth
(11%), obstructed labour and other direct causes (9%), abortion complications (8%),
and blood clots (3%). Globally, almost 99% of maternal mortality occurs in
developing countries, meanwhile two-thirds of stillbirths happened in rural areas [1].
Particularly in Indonesia, maternal mortality ratio is 240 per 100,000 live births [2].
In third world countries, the main cause of maternal mortality is due to lack
of skilled birth attendant in particular midwives and physicians. They are not always
available for essential care during childbirth and for obstetric emergencies, including
Caesarean sections. According to United Nations Population Fund (UNPF),
2
Indonesia has a high number of midwives, 93889 to cover 64,292 women of
reproductive age between 15 until 49 [2]. Unfortunately, the job scope of a midwife
is only limited to cover normal pregnancy during antenatal care. Ob-Gyn personnel
monitor for high risk pregnancy. However, there are only 870 numbers of
obstetricians which is far from sufficient to cater to the high risk pregnancy cases in
that country [2].
Maternal mortality occurs also due to shortage of maternal healthcare, and
facilities. For example, in rural clinic, there is no ultrasound to monitor pregnancy.
Ultrasound is an important tool for all trimesters of pregnancy that can check baby’s
heartbeat and monitor the development of baby inside uterus. In the first trimester,
ultrasound helps to check the exact position of the developing embryo in the uterus
since ectopic pregnancy is the leading cause of maternal mortality during early
pregnancy. The most common location for an ectopic pregnancy is the fallopian
tube. There are many occurrences where women experienced abdominal pain and
vaginal bleeding within the first trimester. Since clinical signs and symptoms may
not be reliable, ultrasound can assist in early identification of high risk complications
in pregnancies and prompt intervention can be given to those women. Ultrasound
helps in identifying the mortality risk factors and estimates gestational age in second
and third trimester of pregnancy. The developed system can be very helpful in the
diagnosis and management of preterm labor and any complication during
pregnancies. Even though, ultrasound has been known to be very useful instrument,
unfortunately the existing ultrasound machines remain highly operator dependent and
necessitate training and practice for providers to produce interpretable images [3].
Furthermore diagnosis result may vary, based on their expertise and experience while
expert distribution which is Ob-Gyn concentrated in developed countries and urban
areas.
Although there is a high number of a midwife, most midwives have limited
knowledge, lack of training and skills to handle high risk pregnancy. Help and
guidance from Ob-Gyns to midwives are essential in these cases. If any
complication occurs the woman needs to be referred to hospital immediately.
3
Moreover, there are many obstacles in sending patient to hospital from remote areas.
Distance to hospital, poor road infrastructure, and lack of ambulance with complete
equipment, cost for commuting, poverty issues, and geographical problems are seen
Indonesia being an archipelago, a country comprising thousands of islands, has a
much more challenging issue to provide access to healthcare.
Good management for antenatal care is important in order to give proper care
to the pregnant woman. Most of the clinics are still using paper based record
managements instead recording them electronically. If data is misplaced or lost, they
have no back up data to restore. Currently, paper records represent massive
fragmentation of clinical health care management which is not economical or
environmental friendly. By using EMR system as a replacement for paper records,
the health services can be improved. Some advantages of using EMR over paper
health records are increasing storage capabilities for longer periods, accessible from
remote sites to many people at the same time, retrieval information almost immediate
without moving to far distance, and providing medical alert and reminders [4].
Besides that, it is very useful during emergency case, where specialists are able to
access the information before the patient arrives to hospital.
Therefore, telesonography is one of the solutions and had been implemented
to overcome the gap and distribution of problems. It combines telecommunication
technology and medical expertise for the delivery of ultrasound images for
interpretation or consultation purposes. By telesonography, patient may ask
interpretation or second opinion of ultrasound image from afar that is distance
worldwide. Telesonography can minimize maternal death because many
complications could be cured if detected early and treated effectively. This research
was designed and implemented through telehealth platform for prenatal management.
The system was invented to reduce fetal and maternal mortality rate specifically in
rural areas. Implementation of this system will indirectly help the United Nation to
achieve their fourth and fifth Millennium Development Goal (MDG) which deal with
‘reduce the child mortality’, and ‘to improve maternal health by three quarters of the
maternal mortality ratio and achieving universal access to reproductive health’ [5].
4
1.2 Problem Statement
Telemedicine is medicine practiced across distances and involves the
electronic transfer of information [6]. Telemedicine has been advocated in situations
where the health professional on duty has little or no access to expert help. It is able
to offer remote physician access to otherwise unavailable specialist opinions,
providing reassurance to both doctors and patients. There are many branches of
telemedicine applications. The telemedicine module survey of 2009 examined the
current level of development of four fields of telemedicine: telepathology,
teleradiology (telesonography), telephsycology, and teledermatology. One of the
emerging telemedicine branches is telesonography, which is ultrasound remote
diagnosis. Some of the earliest projects using telesonography were applied to
subspecialities such as obstetric and cardiology [7, 8]. There are many existing
telesonography research options in obstetrics which can reduce medical cost and
improve patient care [3, 9-14]. In previous research, they transferred two types of
data transmission between transmitter and receiver end which are synchronous (real
time) and asynchronous (store and forward) with recurrent objective themes with
respect to quality of transmitted images, clinical applications and technical and non-
technical barriers to implementation [8]. Nowadays, in this era of globalization,
telesonography is increasingly become popular and expanding. However, it is not
widely used and not being fully adopted in healthcare centres in developing
countries. One can question why telemedicine technology is not being used there
and it will be discussed later in this section.
One of the reasons telesonography is not successfully implemented is because
some critical success factors enabling adoption in healthcare and several technical
problems exist. One of them is the mismatch between technology and perceived
usability by the users. The technology acceptance by the user depends on the need
and requirement factors. It is important to identify the compelling need before
design and implementation process is done and from high level problems or several
problems, the fact is telemedicine need and can solve the problems. In addition, user
requirements are very important and need to be given consideration because it will
5
greatly affect the implementation of telemedicine applications. Most of the existing
teleultrasound systems are found not considering the human factor and too
sophisticated especially for low healthcare providers. As mentioned by Sukdershan
Singh [15], at the national level, there is no in-depth study about physician
teleconsultation, adoption, human and environmental/technology factors haven’t yet
included in the existing teleconsultation software [9, 15-17]. There are many remote
services for ultrasound; but there is no clinical telesonography for low end user like
midwives because the need of telesonography for them is not well clear understood.
Existing ultrasound system is not suitable for midwives (low end user) to manage
high risk pregnancy during remote antenatal check up [18, 19].
Besides that, one of challenges of telesonography implementation is
communication between existing medical imaging device and communication
network. Several ultrasound devices do not have connection to existing network
infrastructure so the image data cannot be delivered to a distanct location for
analysis. Also, protocol standardization of telesonography that enables
interoperability and manufacture-independence is still a big issue that limits
teleultrasound use. IT working group of German Radiology Society has proposed
standard for basic teleultrasound in 2005. It was used daily in over 50 hospitals and
institutions [20]. One of widest protocol used in telesonography is Digital Imaging
and Communication in Medicine, published by National Manufacturing Electrical
Association (NEMA) [21]. It supports off-line media environment using industry
standard media. DICOM-based softwares for telesonography application have been
developed by researchers [20, 22, 23].
Even though telesonoghraphy has been promoted, but most of the clinics are
still using paper based record for obstetric managements instead of recording in
computer or electronic medical records (EMR). If the data get lost, they don’t even
have any data back up whereas data management especially keeping data record is
very important in order to give best care to mother. Currently the paper records
represent massive fragmentation of clinical health management, which leads greater
cost due to consequent current and future patient care [24]. By using EMR as a
6
replacement for paper records, the health services can be improved. Some of
advantages using EMR over paper health records are it increases storage capabilities
for longer periods, it is accessible from remote sites to many people at the same time.
People involve can retrieve information almost immediately without moving, and
provide medical alert, reminders and many more advantages [25].
1.3 Research Objectives
In general, the objectives of this study are to design and implement a
teleprenatology platform for antenatal care management in remote areas. This
objective can be detailed as:
1. To conduct a comprehensive survey for need and requirement analysis by
considering human and environmental/technological factors for
teleprenatology platform.
2. To develop clinical teleprenatology platform that is specific for midwives
in rural areas for antenatal care.
1.4 Significance of Study
This web-based teleprenatology platform is meant to improve the
management of high risk pregnancies and can be used by midwives in rural areas to
communicate with specialist in different places. Early detections of diseases or
complications can be found on and early treatment can be provided to women by
referring to hospital. So, this model can increase the quality of prenatal care and
indirectly can reduce maternal and infant mortality. It will also indirectly help the
7
United Nations to achieve two of their Millennium Development Goal, which are
goal number four; to reduce the child mortality, along with goal number five; to
improve maternal health by reducing to three quarters of the maternal mortality ratio
and achieving universal access to reproductive health [5].
1.5 Scope of the Study
The overall studies are focused on only antenatal visits for uncomplicated
pregnancy, in first trimester, second trimester, and third trimester until delivery. The
postnatal care is not included in the research.
The users of this platform include healthcare providers such as prenatal
physicians and midwives in developing countries. Our main focus was midwives in
rural areas of Indonesia.
The technology design focused more on flowchart in the system for front end
and back end users. The web-based platform was integrated with modified
ultrasound machine to produce offline image and streaming video, however
streaming ultrasound video, existing software will be used in this study and the
application was be embedded into the platform.
121
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