Accepted Manuscript Title: Electronic Personal Maternity Records: Both Web and Smartphone Services Author: Chung-Wei Chang Tien-Yan Ma Mei-San Choi Yu-Yun Hsu Yi-Jing Tsai Ting-Wei Hou PII: DOI: Reference:
S0169-2607(15)00043-7 http://dx.doi.org/doi:10.1016/j.cmpb.2015.02.008 COMM 3896
To appear in:
Computer Methods and Programs in Biomedicine
Received date: Revised date: Accepted date:
5-6-2014 7-2-2015 25-2-2015
Please cite this article as: C.-W.C. ,Tien-Yan Ma, M.-S. Choi, Y.-Y. Hsu, Y.-J. Tsai, T.-W. Hou, Electronic Personal Maternity Records: Both Web and Smartphone Services, Computer Methods and Programs in Biomedicine (2015), http://dx.doi.org/10.1016/j.cmpb.2015.02.008 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Electronic Personal Maternity Records: Both Web and Smartphone Services Chung-Wei Changa,Tien-Yan Maa, Mei-San Choia, Yu-Yun Hsub, Yi-Jing Tsaib, Ting-Wei Houa, c,
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Department of Engineering Science, National Cheng Kung University, Tainan, Taiwan Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan c Department of Medical Informatics, National Cheng Kung University Hospital, College of Medicine, Tainan, Taiwan
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Abstract
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This study develops an antenatal care information system to assist women during pregnancy. We designed and implemented the system as both a web-based service and a multi-platform application for smartphones and tablets. The proposed system has three novel features: (1) Web-based Maternity Records, which contains concise explanations of various antenatal screening and diagnostic tests; (2) Self-care Journals, which allow pregnant women to keep track of their gestational weight gains, blood pressure, fetal movements, and contractions; and (3) Health Education, which automatically presents detailed information on antenatal care and other pregnancy-related knowledge according to the women’s gestational age. A survey was conducted among pregnant women to evaluate the usability and acceptance of the proposed system. In order to prove that the antenatal care was effective, clinical outcomes should be provided and the results are focused on a usability evaluation.
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1. Introduction
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Keywords: Multi-platform, Antenatal, Pregnancy, Self-care, Maternity Record
A 2012 survey carried out by AlliedHealthWorld.com found that globally there are more than 500 mobile health (mHealth) projects and over 40,000 health-related apps [1], which indicates that such apps are widely accepted by users of smartphones and other hand-held devices. According to the National Institutes of Health (NIH) Consensus Group, mHealth is defined as “the use of mobile and wireless devices to improve health outcomes, healthcare services, and health research” [2], and it can be seen as the transformation of electronic healthcare (eHealth) services to mobile ones. Paper-based maternity health records have been adopted in most obstetrics hospitals in Taiwan for more than a decade. In practice, every pregnant woman is given a paper maternity record called a Maternal Health Handbook [3]. Pregnant women bring their Maternal Health Handbook when they visit obstetricians for antenatal care. During each antenatal examination, obstetricians or nurse-midwives add information to the woman’s health records, as well as details of the antenatal care they have received, giving each woman a copy of their personal maternity records. Although paper-based records are useful, they have a number of disadvantages, including poor accessibility, poor record management, being easy *
Corresponding author. Tel.: 886+62757575 ext. 63334. Email: [email protected] Page 1 of 14
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to lose, and perhaps containing incomplete data. Electronic Maternity Records (EMRs) are a form of Electronic Health Records (EHRs) used for maternal care. Fridsma noted that appropriate use of EHRs can “deliver complete and accurate health information to patients and their providers, allowing better access to that information and, ultimately, empowering patients to take an active role in their healthcare” [4]. EMRs allow obstetricians, nurses, nurse-midwives, and other related healthcare parties to exchange pregnant women’s health data, and thus provide more coordinated care. However, EMRs are generally hospital-based, and so can only be accessed within the hospital network, and in general the contents can only be seen by physicians or other medical professionals [5]. As a result, pregnant women are not able to access their own health records whenever and wherever they want, even though providing mothers-to-be with their full maternity records would enable them to feel more comfortable and informed during their pregnancies. Although the global infant mortality rate has fallen by almost 40% from 1990 to 2011 [6], it still remains relatively high. According to a statistical report produced by the US Central Intelligence Agency (CIA) [7], in 2012 there were 39.48 infant deaths globally per 1,000 live births. Most infant deaths can be prevented through the provision of appropriate antenatal care during pregnancy. A 12-year study carried out by Miller and Tucker found that a 10% increase in the use of EHRs would save the lives of 16 infants per 100,000 live births, which implies that introducing EMRs would be an effective way to help reduce infant mortality [8]. Integrating EMRs into a smartphone app is an efficient, easy, and convenient way to provide antenatal care to pregnant women because a rapidly growing number of people carry smartphones. According to a study conducted by Ericsson ConsumerLab on consumer trends for 2013, women are continuing to drive the smartphone market, and are more active users of smartphone features than are men [9]. This suggests that the idea of integrating web-based maternity records into a smartphone app in order to provide better antenatal care services is feasible, and this is the basis of the current study. In this work, we designed and implemented a smartphone-based personal antenatal care information system, called PregfoneCare, that combines a multi-platform application with a web-based information system that contains EMRs. By using PregfoneCare, mothers-to-be can easily upload, edit, and access their own maternal records, obtain pregnancy-related information and antenatal education, and understand their babies’ development. Mother-to-be can access PregfoneCare over the internet. In addition, obstetricians and nurse-midwives are able to fill out, edit, or access the maternity records of the mother-to-be, monitor their health conditions, as well as answer the women’s questions directly through the full-featured antenatal care website of PregfoneCare.
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2. Related works Table 1 - Comparison of the Existing Pregnancy Care Systems The AMC
The MPACSS
System [10]
System [11]
Web Interface
Yes
No
Yes
Mobile phone or Smartphone
PDA
Mobile phone
Mobile phone
A PDA
A mobile
interface
interface
No
Yes
No
Yes
Yes
No
Not stated
Yes
Self-care function
No
No
Reminders or alerts
Yes
Yes
Smartphone
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information only No
Yes
Yes
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Expert system Maternity records Antenatal health education
(proposed) Yes
No
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Mobile app
PregfoneCare
PregProSyst [12]
Yes
Yes Yes
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Several studies have explored the use of mobile phones to provide better care for pregnant women. For example, Hoang et al. designed and implemented the assistive maternity care (AMC) system [10]. Their framework consists of a health server, which contains EMRs, personal digital assistants (PDAs), which allow pregnant women to access their information, and a web system that enables users to access the data via a personal computer. This system provides a convenient platform for pregnant women and their healthcare providers to interact with each other. In 2011, Onashoga et al. proposed the mobile-based antenatal care support system (MPACSS) [11], which is composed of the patients’ mobile phones, a remote server, an EMR system, and an expert system that contains diagnostic tools. Pregnant women can log into this system using a mobile phone, and then select any symptoms that they have from a list displayed onscreen. The system then presents a diagnosis based on this information, as well as details of related treatments. Salameh et al. developed a web-based system, called PregProSyst, for pregnant women in Malaysia [12]. This system sends information about the growth of the baby, checkup reminders, and visiting schedule reminders to the mother’s mobile phone via short message service (SMS) technology. Table 1 compares these pregnancy care systems with that proposed in this work. The existing systems use a client/server architecture. While these systems work on mobile phones or PDAs with simple user interfaces, PregfoneCare uses a multi-platform application with multiple functions. In addition, none of the existing systems contains self-care functions for pregnant women, such as a weight tracker, blood pressure tracker, fetal movement tracker, and contraction tracker, all of which are included in the proposed system. 3. System design The architecture of the proposed system is presented in Fig. 1. PregfoneCare is composed of internet-connected smartphones and computers, and a PregfoneCare server, which includes a web Page 3 of 14
application server, maternity records, and a database. A woman can start using PregfoneCare after her pregnancy has been confirmed by an obstetrician.
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3.1. Proposed system PregfoneCare includes a web-based antenatal care information system and a self-care app. A use case diagram of the system is presented in Fig. 2. Pregnant women can add, retrieve, and edit personal information, maternity records, pregnancy self-care journals, and birth records. Obstetricians and nurse-midwives are able to access all of the functions of the system, and are authorized to retrieve and manage all the information of the pregnant women under their care, such as personal information, pregnancy journals, and birth records. They can also add or edit the maternity records of their patients, as well as retrieve specific access logs so as to better understand their patients’ behaviors. DB
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Obstetrician or Nurse-midwife 1 . . . Obstetrician or Nurse-midwife N
Fig. 1 - PregfoneCare system architecture.
3.2 Web-based antenatal care information system The web-based antenatal care information system (hereafter referred to as the web-based system) acts as the core of the whole system. It provides a web interface so that pregnant women or obstetrics professionals can access the system using the web browsers on their smartphones, computers, or other hand-held devices. The pregnant women and obstetrics professionals both share the same web-based system. As mentioned previously, registration and authentication are required before using the system, with the pregnant women and obstetrics physicians or nurse-midwives having different levels of authorization. Page 4 of 14
Based on these levels, different functions, information, and screens are shown. When a pregnant woman logs in to the system, she is only permitted to access and manage her own information. An authorized physician or nurse can access and manage the information of all their patients.
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Personal Info Management
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Fig. 2 - Use case diagram of PregfoneCare. Fig. 3 presents the main functions of the web-based system, which can be classified into four main parts: (1) Web-based Maternity Records, (2) Health Education, (3) Self-care Journals, and (4) Baby Birth Records.
Web-based Maternity Records
The Web-based System
Health Education
Self-care Journals
Baby Birth Records
Fig. 3 - Main functions of web-based system. Web-based Maternity Records The web-based maternity records used in our system are based on the concept of Personal Health Records (PHRs), which allow individuals to access, manage, and share their health information in a web-based application [5]. A web-based maternity record includes pregnant women’s personal information, medical and surgical history, gynecological history, pregnancy history, the results of regular antenatal checkups Page 5 of 14
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and antenatal screening and diagnostic test records, ultrasound images, and birth records. The web-based system automatically calculates the estimated date of birth (EDB) according to the first day of the women’s last menstrual period (LMP). However, since the EDB may differ from that estimated using ultrasound, a pregnant woman can modify and save the EDB after having her first ultrasound. The system also calculates her current week of pregnancy according to her LMP. The pre-pregnancy body mass index (BMI) is calculated using the woman’s height and pre-pregnancy weight, with the recommended gestational weight gain provided based on this information. Mothers-to-be can also upload their ultrasound images to the system as a keepsake. Users can upload ultrasound images using the web interface or smartphone app. Furthermore, concise explanations of each antenatal screening and diagnostic test are provided in the web-based maternity records. In addition, a pregnant woman can keep the birth records for her baby after delivery using our system.
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Information about health topics of interest to pregnant women is recommended and shown to the women according to their gestational age. There is also a search engine that mothers-to-be can use to search for maternity-related knowledge. For example, it will appear “readme” when the users click the [?] button. If the user wants to know more information about WBC, they can click the [?] button to display the corresponding information, as shown in Fig. 4. As shown in the upper left of Fig. 5, there is a “Milestones of Fetal Development” section. It shows currently in the range of 13-16 weeks, etc. And in the lower left shows the suggested readings. In addition, in order to help physicians or other healthcare providers to understand the learning progress of each pregnant woman, the system tracks the number of times the user clicks on the links for each antenatal health education topic. This makes it possible to provide coordinated antenatal care to pregnant women.
Fig. 4 – Blood test screen of web-based system.
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Self-care Journals
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Fig. 5 - Home page of web-based system.
The system also offers an area for pregnant women to record the data from each antenatal examination with four self-care journals, namely a pregnancy weight gain journal, a blood pressure journal, a fetal movement journal, and a uterine contraction journal. The journals allow pregnant women to keep track of their physical changes during pregnancy. An ideal range of gestational weight is given in the weight gain journal. The range is calculated based on a 2009 report [14] that includes weight recommendations during pregnancy. The normal range of blood pressure during pregnancy is shown in the blood pressure journal function. Mothers-to-be can record the time and frequency of fetal movements in the fetal movement journal. Finally, the uterine contraction journal can be used to record contractions. Baby Birth Records This function allows pregnant women to record and save any information about their newborn babies. For women from a Chinese culture, such as those in Taiwan, it is very important to record the exact time of birth. The system also has an export function so that mothers can save this information in PDF format.
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3.3 Multi-platform application
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In addition to the web-based system, an interactive multi-platform self-help application for pregnant women was developed. Registration is needed before use. Both the web-based system and the multi-platform application access the same PregfoneCare database, and thus the information in the two subsystems is interchangeable. That is, a pregnant woman can manage her pregnancy-related data either through the web-based system or the multi-platform application. To make the application user-friendly, we designed two dashboard screens to make it easy for users to find the information they are looking for. Since users frequently need to retrieve data from or post data to the database, ease of access is a critical issue in the design of the application. Fig. 4 shows how data is retrieved from the database in PregfoneCare. A PHP class is written to get data from and store data in the database. The class encodes the retrieved data into the JSON [15] format and sends it to a device. The application then parses the JSON format data and displays it on the device.
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Fig. 6 – Data exchange between PregfoneCare server and user device.
4. Implementation
The PregfoneCare web-based antenatal care information system is written in PHP5 and JavaScript and runs on a remote server with Apache HTTP Server 2.5. Users can access the system using the web browsers on their smartphones or computers. MySQL is the database used in the system. The PregfoneCare multi-platform application is written in HTML5. JSON is used for data transfer between the smartphone and the MySQL database. Data security is very important to internet systems. HTTPS is used to establish an encrypted link between the server and the client. We use OpenSSL [16] for secure transfers. OpenSSL is an open-source implementation of the Secure Sockets Layer (SSL v2/v3) and Transport Layer Security (TLS) protocols. 4.1 Home page of web-based system The home page of the web-based system is shown in Fig. 5. This page displays appropriate topics related to antenatal health education. Since there are a large number of topics related to antenatal care, the system only presents suitable topics based on the user’s gestational age. The prenatal educational information is Page 8 of 14
shown in the lower left and right parts of the screen. The middle of the screen shows the health history of the pregnant woman and records of various health checks. The upper right of the screen shows details of the baby’s growth.
Self-care Journals
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The system includes four self-care interfaces to record important information, namely the pregnant woman’s weight (Fig. 7), blood pressure (Fig. 8), fetal movement (Fig. 9), and uterine contractions (Fig. 10).
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Fig. 7 - Weight record interface on (a) web and (b) smartphone.
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Fig. 8 - Blood pressure record interface on (a) web and (b) smartphone.
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Fig. 9 - Fetal movement record interface on (a) web and (b) smartphone.
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(b)
Fig. 10 - Uterine contraction record interface on (a) web and (b) smartphone.
5. Evaluation A usability evaluation and questionnaire survey of the system were completed by experienced software developers and the proposed users, both mothers-to-be and medical professionals. 5.1. Usability Evaluation The usability evaluation was conducted using the heuristic evaluation method [17][18], as proposed by Page 10 of 14
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Nielsen and Molich (1990), with a focus on the user interface of the proposed system. Five experienced software developers were invited to evaluate the user interface of the proposed system. First, we explained the background information and characteristics of the focal domain to the evaluators, who were then asked to work alone and examine the user interface for 30 minutes. Each evaluator was then asked to list the usability problems they observed based on Nielson’s heuristics [19], as well as to give details of the severity of and underlying reasons for these problems. Based on the results, the following issues were found: 1. The system does not respond when switching between screens. 2. The camera function is not working properly. 3. The message “Saved” is not always shown when some data is saved. 4. No messages are shown to tell users when an image has been successfully uploaded. 5. Scrollbars should be included on the weight tracker, blood pressure tracker, fetal movement counter, and contraction counter screens. 6. It is not convenient for users to input the date and time manually. 7. The locations of the various features are not always clear. 8. It is confusing to have two dashboard screens. There should also be a “Home” button on the tools screen so that users can easily return to it. 9. “Close” or “Back” buttons should be included on the description screen; otherwise, users may not know how to go back to the previous screen. 10. The maternity record function does not enable users to quickly move between screens to record different kinds of information. 11. The font size of the antenatal care information is too small. We redesigned and modified the user interface of the system based on the suggestions of the evaluators and identified issues. The modified user interface was then evaluated by the five experienced software developers. The results show that all of the usability problems had been resolved. The evaluators indicated that the system could be used to improve the antenatal care of pregnant women. 5.2. Survey
68 pregnant women (age: > 20 years; gestational age: 16-24 weeks) were recruited for our study. The women used PregfoneCare until they gave birth. A survey was conducted to assess their satisfaction with the proposed system using a 16-item questionnaire. The results are presented in Table 2. Likert scales [20] were used for this questionnaire. Each topic had five items, namely strongly dissatisfied, dissatisfied, fair, satisfied, and strongly satisfied, represented by 1 to 5, respectively. The mean score for each topic was close to 4, indicating that the respondents were satisfied. The standard deviation was about 0.6, indicating that every respondent was satisfied with PregfoneCare. The respondents stated that the pregnancy calculator, estimated date of birth calculator, and BMI calculator are very useful functions to pregnant women. Moreover, 80.9% (64.7%+16.2%) of the respondents stated that the system was useful for their pregnancy, particularly the four journals. Pregnant women usually visit obstetricians after they have a diagnosis of pregnancy in the first trimester. Normally, a pregnant woman visits her doctor more than 6 times. It is reasonable to assume that each user would log in to the proposed system to record one’s latest information. As Table 3 shows, most users logged in 6-10 times, with 52 users logging in more than 6 times. 76% of the users thus used the Page 11 of 14
system frequently. Table 2 – User satisfaction with proposed system Mean
Strongly
Dissatisfied
Fair
Satisfied
Strongly
(stand
dissatisfied
(n/proportion)
(n/proportion)
(n/proportion)
satisfied
deviation)
(n/proportion)
How do you feel about the overall system?
3.93 (.61)
0
1 (1.5%)
12 (17.6%)
46 (67.6%)
Did the system help your pregnancy?
3.94 (.69)
1 (1.5%)
0
12 (17.6%)
44 (64.7%)
How do you feel about ability to upload ultrasonic pictures of your baby?
3.68 (.66)
0
1 (1.5%)
26 (38.2%)
How do you feel about weight gain journal?
3.87 (.67)
0
1(1.5%)
17(25.0%)
How do you feel about blood pressure journal?
3.82 (.62)
0
1(1.5%)
How do you feel about fetal movement journal?
3.78 (.69)
0
How do you feel about uterine contraction journal?
3.74 (.66)
0
(n/proportion)
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9 (13.3%)
11 (16.2%)
6 (8.8%)
40(58.8%)
10(14.7%)
17(25.0%)
43(63.2%)
7(10.3%)
22(32.4%)
36 (52.9%)
9(13.2%)
26(38.2%)
34(50.0%)
8(11.8%)
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Table 3 – User log in frequency Login frequency
1-5
6-10
11-15
16-20
>21
Number of users
16
32
10
8
2
6. Conclusion and Future Work
The study proposed and implemented the PregfoneCare system, a personal antenatal care information system with web-based maternity records that can be accessed via a multi-platform application. The system framework consists of smartphones, computers, and a PregfoneCare server, which is composed of a web application server, maternity records, and a database. The proposed system includes a web-based EMR system that stores the full maternity records of the users and contains information regarding various antenatal screening and diagnostic tests that pregnant women must take. The system includes four self-care tools that enable pregnant women to keep journals on their gestational weight gains, blood pressure, fetal movements, and uterine contractions, respectively. Page 12 of 14
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Moreover, the proposed system recommends appropriate health education materials to users based on their gestational age, thus increasing the pregnant women’s knowledge of antenatal care. The proposed system empowers women to self-manage their own health and thus maintain health during their pregnancies. The users can gain important pregnancy-related knowledge and access their related health records and other information easily via their smartphones or computers. In the future, the proposed system can be integrated with existing EHR systems in hospitals so that pregnancy complications can be detected more easily. In addition, health education information regarding high-risk pregnancies can also be included in the system. Finally, the proposed system could be combined with a decision support system to help women make better choices during their pregnancies.
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Acknowledgement We would like to thank Juan-Juan Chen (RN) for discussing various issues related to this research. This research was supported in part by the National Science Council of Taiwan under grant NSC 102-2221-E-006-138.
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Conflicts of interest
The authors declare that they have no conflicts of interest in relation to this work.
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REFERENCES [1] QuinStreet Inc., Smartphone = Smart Healthcare? http://www.alliedhealthworld.com/visuals/smartphone-healthcare.html. Accessed 28 Dec. 2012. [2] NIH Consensus group, Mobile Health. http://www.hrsa.gov/healthit/mhealth.html. Accessed 28 Dec. 2012. [3] Bureau of Health Promotion of the Department of Health (2012) Maternal Health Handbook. Bureau of Health Promotion. Department of Health, Taichung City, Taiwan. [4] D. Fridsma (2012) Electronic Health Records: The HHS Perspective Computer. vol. 45, no. 11, pp. 24-26. [5] I. Carrión, J.L.F Alemán, and A. Toval (2012) Personal Health Records: New Means to Safely Handle Health Data? Computer. vol. 45, no. 11, pp. 27-33. [6] UNICEF, World Health Organization, The World Bank, and United Nations Population Division (2012) Levels and Trends in Child Mortality-Report 2012. http://www.unicef.org.uk/Documents/Publications/UNICEF_2012_IGME_child_mortality_report.pdf. Accessed on December 28, 2012. [7] Central Intelligence Agency (2012) Infant Mortality Rate. https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html. Accessed on December 28, 2012. [8] Amalia R Miller and Catherine E Tucker (2011) Can Healthcare IT Save Babies? Journal of Political Economy, vol. 119, no. 2, pp. 289-324. [9] Ericsson ConsumerLab (2013) 10 Hot Consumer Trends 2013 http://www.ericsson.com/res/docs/2012/consumerlab/10-hot-consumer-trends-2013.pdf. Accessed on January 2, 2013. Page 13 of 14
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[10] D. B. Hoang, E. Lawrence, N. F. Ahmad, V. Balasubramanian, C. Homer, M. Foureur, et al. (2008) Assistive care loop with electronic maternity records. Proceeding of the 10th International Conference on e-health Networking, Applications & Services (IEEE HealthCom 2008) , Singapore, pp. 118-123. [11] S. A. Onashoga, A. S. Sodiya, T. O. Omilani, and H. O. Ajisegiri (2011) A Mobile Phone-Based Antenatal Care Support System. Proceedings of the 21st International Conference on Systems Engineering, Las Vegas, U.S.A, pp. 410-415. [12] Anas A. Mohammad Salameh, Alaa A Alkafagi, Chulawadee Khunsri, and Adib M. Monzer Habbal (2011) Web Based Support for Pregnant Mother. Proceedings of the International Conference on Advanced Science, Engineering and Information Technology 2011, Malaysia, pp. 307-310. [13] BabyCenter Medical Advisory Board (2013) Forgetfulness during pregnancy. http://www.babycenter.com/0_forgetfulness-during-pregnancy_236.bc. Accessed on January 5,
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2013. [14] Institude of Medicine Weight Gain During Pregnancy: Reexamining the Guidelines (2009) http://www.iom.edu/~/media/Files/Report%20Files/2009/Weight-Gain-During-Pregnancy-Reexamin ing-the-Guidelines/Report%20Brief%20-%20Weight%20Gain%20During%20Pregnancy.pdf. Accessed on January 13, 2013. [15] Douglas Crockford (2013) Introducing JSON. http://www.json.org/. Accessed on January 9, 2013. [16] OpenSSL. http://www.openssl.org/ . Access on January 20, 2015. [17] Jakob Nielsen and Rolf Molich (1990) Heuristic evaluation of user interfaces. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems, Seattle, Washington, USA, pp. 249-256. [18] Jakob Nielsen (2013) How to Conduct a Heuristic Evaluation. http://www.nngroup.com/articles/how-to-conduct-a-heuristic-evaluation/. Accessed on January 11, 2013. [19] Jakob Nielsen (2013) 10 Usability Heuristics. http://www.nngroup.com/articles/ten-usability-heuristics/. Accessed on January 12, 2013. [20] Trochim, William M. The Research Methods Knowledge Base, 2nd Edition. http://www.socialresearchmethods.net/kb/scallik.php. Accessed on January 12, 2013.
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S0169-2607(15)00043-7 http://dx.doi.org/doi:10.1016/j.cmpb.2015.02.008 COMM 3896
To appear in:
Computer Methods and Programs in Biomedicine
Received date: Revised date: Accepted date:
5-6-2014 7-2-2015 25-2-2015
Please cite this article as: C.-W.C. ,Tien-Yan Ma, M.-S. Choi, Y.-Y. Hsu, Y.-J. Tsai, T.-W. Hou, Electronic Personal Maternity Records: Both Web and Smartphone Services, Computer Methods and Programs in Biomedicine (2015), http://dx.doi.org/10.1016/j.cmpb.2015.02.008 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Electronic Personal Maternity Records: Both Web and Smartphone Services Chung-Wei Changa,Tien-Yan Maa, Mei-San Choia, Yu-Yun Hsub, Yi-Jing Tsaib, Ting-Wei Houa, c,
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Department of Engineering Science, National Cheng Kung University, Tainan, Taiwan Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan c Department of Medical Informatics, National Cheng Kung University Hospital, College of Medicine, Tainan, Taiwan
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Abstract
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This study develops an antenatal care information system to assist women during pregnancy. We designed and implemented the system as both a web-based service and a multi-platform application for smartphones and tablets. The proposed system has three novel features: (1) Web-based Maternity Records, which contains concise explanations of various antenatal screening and diagnostic tests; (2) Self-care Journals, which allow pregnant women to keep track of their gestational weight gains, blood pressure, fetal movements, and contractions; and (3) Health Education, which automatically presents detailed information on antenatal care and other pregnancy-related knowledge according to the women’s gestational age. A survey was conducted among pregnant women to evaluate the usability and acceptance of the proposed system. In order to prove that the antenatal care was effective, clinical outcomes should be provided and the results are focused on a usability evaluation.
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1. Introduction
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Keywords: Multi-platform, Antenatal, Pregnancy, Self-care, Maternity Record
A 2012 survey carried out by AlliedHealthWorld.com found that globally there are more than 500 mobile health (mHealth) projects and over 40,000 health-related apps [1], which indicates that such apps are widely accepted by users of smartphones and other hand-held devices. According to the National Institutes of Health (NIH) Consensus Group, mHealth is defined as “the use of mobile and wireless devices to improve health outcomes, healthcare services, and health research” [2], and it can be seen as the transformation of electronic healthcare (eHealth) services to mobile ones. Paper-based maternity health records have been adopted in most obstetrics hospitals in Taiwan for more than a decade. In practice, every pregnant woman is given a paper maternity record called a Maternal Health Handbook [3]. Pregnant women bring their Maternal Health Handbook when they visit obstetricians for antenatal care. During each antenatal examination, obstetricians or nurse-midwives add information to the woman’s health records, as well as details of the antenatal care they have received, giving each woman a copy of their personal maternity records. Although paper-based records are useful, they have a number of disadvantages, including poor accessibility, poor record management, being easy *
Corresponding author. Tel.: 886+62757575 ext. 63334. Email: [email protected] Page 1 of 14
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to lose, and perhaps containing incomplete data. Electronic Maternity Records (EMRs) are a form of Electronic Health Records (EHRs) used for maternal care. Fridsma noted that appropriate use of EHRs can “deliver complete and accurate health information to patients and their providers, allowing better access to that information and, ultimately, empowering patients to take an active role in their healthcare” [4]. EMRs allow obstetricians, nurses, nurse-midwives, and other related healthcare parties to exchange pregnant women’s health data, and thus provide more coordinated care. However, EMRs are generally hospital-based, and so can only be accessed within the hospital network, and in general the contents can only be seen by physicians or other medical professionals [5]. As a result, pregnant women are not able to access their own health records whenever and wherever they want, even though providing mothers-to-be with their full maternity records would enable them to feel more comfortable and informed during their pregnancies. Although the global infant mortality rate has fallen by almost 40% from 1990 to 2011 [6], it still remains relatively high. According to a statistical report produced by the US Central Intelligence Agency (CIA) [7], in 2012 there were 39.48 infant deaths globally per 1,000 live births. Most infant deaths can be prevented through the provision of appropriate antenatal care during pregnancy. A 12-year study carried out by Miller and Tucker found that a 10% increase in the use of EHRs would save the lives of 16 infants per 100,000 live births, which implies that introducing EMRs would be an effective way to help reduce infant mortality [8]. Integrating EMRs into a smartphone app is an efficient, easy, and convenient way to provide antenatal care to pregnant women because a rapidly growing number of people carry smartphones. According to a study conducted by Ericsson ConsumerLab on consumer trends for 2013, women are continuing to drive the smartphone market, and are more active users of smartphone features than are men [9]. This suggests that the idea of integrating web-based maternity records into a smartphone app in order to provide better antenatal care services is feasible, and this is the basis of the current study. In this work, we designed and implemented a smartphone-based personal antenatal care information system, called PregfoneCare, that combines a multi-platform application with a web-based information system that contains EMRs. By using PregfoneCare, mothers-to-be can easily upload, edit, and access their own maternal records, obtain pregnancy-related information and antenatal education, and understand their babies’ development. Mother-to-be can access PregfoneCare over the internet. In addition, obstetricians and nurse-midwives are able to fill out, edit, or access the maternity records of the mother-to-be, monitor their health conditions, as well as answer the women’s questions directly through the full-featured antenatal care website of PregfoneCare.
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2. Related works Table 1 - Comparison of the Existing Pregnancy Care Systems The AMC
The MPACSS
System [10]
System [11]
Web Interface
Yes
No
Yes
Mobile phone or Smartphone
PDA
Mobile phone
Mobile phone
A PDA
A mobile
interface
interface
No
Yes
No
Yes
Yes
No
Not stated
Yes
Self-care function
No
No
Reminders or alerts
Yes
Yes
Smartphone
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Multi-platform Mobile app No
information only No
Yes
Yes
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Fetal development
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Expert system Maternity records Antenatal health education
(proposed) Yes
No
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Mobile app
PregfoneCare
PregProSyst [12]
Yes
Yes Yes
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Several studies have explored the use of mobile phones to provide better care for pregnant women. For example, Hoang et al. designed and implemented the assistive maternity care (AMC) system [10]. Their framework consists of a health server, which contains EMRs, personal digital assistants (PDAs), which allow pregnant women to access their information, and a web system that enables users to access the data via a personal computer. This system provides a convenient platform for pregnant women and their healthcare providers to interact with each other. In 2011, Onashoga et al. proposed the mobile-based antenatal care support system (MPACSS) [11], which is composed of the patients’ mobile phones, a remote server, an EMR system, and an expert system that contains diagnostic tools. Pregnant women can log into this system using a mobile phone, and then select any symptoms that they have from a list displayed onscreen. The system then presents a diagnosis based on this information, as well as details of related treatments. Salameh et al. developed a web-based system, called PregProSyst, for pregnant women in Malaysia [12]. This system sends information about the growth of the baby, checkup reminders, and visiting schedule reminders to the mother’s mobile phone via short message service (SMS) technology. Table 1 compares these pregnancy care systems with that proposed in this work. The existing systems use a client/server architecture. While these systems work on mobile phones or PDAs with simple user interfaces, PregfoneCare uses a multi-platform application with multiple functions. In addition, none of the existing systems contains self-care functions for pregnant women, such as a weight tracker, blood pressure tracker, fetal movement tracker, and contraction tracker, all of which are included in the proposed system. 3. System design The architecture of the proposed system is presented in Fig. 1. PregfoneCare is composed of internet-connected smartphones and computers, and a PregfoneCare server, which includes a web Page 3 of 14
application server, maternity records, and a database. A woman can start using PregfoneCare after her pregnancy has been confirmed by an obstetrician.
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3.1. Proposed system PregfoneCare includes a web-based antenatal care information system and a self-care app. A use case diagram of the system is presented in Fig. 2. Pregnant women can add, retrieve, and edit personal information, maternity records, pregnancy self-care journals, and birth records. Obstetricians and nurse-midwives are able to access all of the functions of the system, and are authorized to retrieve and manage all the information of the pregnant women under their care, such as personal information, pregnancy journals, and birth records. They can also add or edit the maternity records of their patients, as well as retrieve specific access logs so as to better understand their patients’ behaviors. DB
PregfoneCare Server
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Android app
Smartphone
Internet
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Pregnant woman 1
. . .
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Pregnant woman 2
Smartphone
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Computer
Obstetrician or Nurse-midwife 1
Computer
Obstetrician or Nurse-midwife 1 . . . Obstetrician or Nurse-midwife N
Fig. 1 - PregfoneCare system architecture.
3.2 Web-based antenatal care information system The web-based antenatal care information system (hereafter referred to as the web-based system) acts as the core of the whole system. It provides a web interface so that pregnant women or obstetrics professionals can access the system using the web browsers on their smartphones, computers, or other hand-held devices. The pregnant women and obstetrics professionals both share the same web-based system. As mentioned previously, registration and authentication are required before using the system, with the pregnant women and obstetrics physicians or nurse-midwives having different levels of authorization. Page 4 of 14
Based on these levels, different functions, information, and screens are shown. When a pregnant woman logs in to the system, she is only permitted to access and manage her own information. An authorized physician or nurse can access and manage the information of all their patients.
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Maternity Record Management
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Personal Info Management
Pregnancy self-care Journals Management
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Birth Record Management
Patient’s Access Log Inquiry
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Patient Management
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Fig. 2 - Use case diagram of PregfoneCare. Fig. 3 presents the main functions of the web-based system, which can be classified into four main parts: (1) Web-based Maternity Records, (2) Health Education, (3) Self-care Journals, and (4) Baby Birth Records.
Web-based Maternity Records
The Web-based System
Health Education
Self-care Journals
Baby Birth Records
Fig. 3 - Main functions of web-based system. Web-based Maternity Records The web-based maternity records used in our system are based on the concept of Personal Health Records (PHRs), which allow individuals to access, manage, and share their health information in a web-based application [5]. A web-based maternity record includes pregnant women’s personal information, medical and surgical history, gynecological history, pregnancy history, the results of regular antenatal checkups Page 5 of 14
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and antenatal screening and diagnostic test records, ultrasound images, and birth records. The web-based system automatically calculates the estimated date of birth (EDB) according to the first day of the women’s last menstrual period (LMP). However, since the EDB may differ from that estimated using ultrasound, a pregnant woman can modify and save the EDB after having her first ultrasound. The system also calculates her current week of pregnancy according to her LMP. The pre-pregnancy body mass index (BMI) is calculated using the woman’s height and pre-pregnancy weight, with the recommended gestational weight gain provided based on this information. Mothers-to-be can also upload their ultrasound images to the system as a keepsake. Users can upload ultrasound images using the web interface or smartphone app. Furthermore, concise explanations of each antenatal screening and diagnostic test are provided in the web-based maternity records. In addition, a pregnant woman can keep the birth records for her baby after delivery using our system.
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Health Education
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Information about health topics of interest to pregnant women is recommended and shown to the women according to their gestational age. There is also a search engine that mothers-to-be can use to search for maternity-related knowledge. For example, it will appear “readme” when the users click the [?] button. If the user wants to know more information about WBC, they can click the [?] button to display the corresponding information, as shown in Fig. 4. As shown in the upper left of Fig. 5, there is a “Milestones of Fetal Development” section. It shows currently in the range of 13-16 weeks, etc. And in the lower left shows the suggested readings. In addition, in order to help physicians or other healthcare providers to understand the learning progress of each pregnant woman, the system tracks the number of times the user clicks on the links for each antenatal health education topic. This makes it possible to provide coordinated antenatal care to pregnant women.
Fig. 4 – Blood test screen of web-based system.
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Self-care Journals
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Fig. 5 - Home page of web-based system.
The system also offers an area for pregnant women to record the data from each antenatal examination with four self-care journals, namely a pregnancy weight gain journal, a blood pressure journal, a fetal movement journal, and a uterine contraction journal. The journals allow pregnant women to keep track of their physical changes during pregnancy. An ideal range of gestational weight is given in the weight gain journal. The range is calculated based on a 2009 report [14] that includes weight recommendations during pregnancy. The normal range of blood pressure during pregnancy is shown in the blood pressure journal function. Mothers-to-be can record the time and frequency of fetal movements in the fetal movement journal. Finally, the uterine contraction journal can be used to record contractions. Baby Birth Records This function allows pregnant women to record and save any information about their newborn babies. For women from a Chinese culture, such as those in Taiwan, it is very important to record the exact time of birth. The system also has an export function so that mothers can save this information in PDF format.
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3.3 Multi-platform application
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In addition to the web-based system, an interactive multi-platform self-help application for pregnant women was developed. Registration is needed before use. Both the web-based system and the multi-platform application access the same PregfoneCare database, and thus the information in the two subsystems is interchangeable. That is, a pregnant woman can manage her pregnancy-related data either through the web-based system or the multi-platform application. To make the application user-friendly, we designed two dashboard screens to make it easy for users to find the information they are looking for. Since users frequently need to retrieve data from or post data to the database, ease of access is a critical issue in the design of the application. Fig. 4 shows how data is retrieved from the database in PregfoneCare. A PHP class is written to get data from and store data in the database. The class encodes the retrieved data into the JSON [15] format and sends it to a device. The application then parses the JSON format data and displays it on the device.
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Fig. 6 – Data exchange between PregfoneCare server and user device.
4. Implementation
The PregfoneCare web-based antenatal care information system is written in PHP5 and JavaScript and runs on a remote server with Apache HTTP Server 2.5. Users can access the system using the web browsers on their smartphones or computers. MySQL is the database used in the system. The PregfoneCare multi-platform application is written in HTML5. JSON is used for data transfer between the smartphone and the MySQL database. Data security is very important to internet systems. HTTPS is used to establish an encrypted link between the server and the client. We use OpenSSL [16] for secure transfers. OpenSSL is an open-source implementation of the Secure Sockets Layer (SSL v2/v3) and Transport Layer Security (TLS) protocols. 4.1 Home page of web-based system The home page of the web-based system is shown in Fig. 5. This page displays appropriate topics related to antenatal health education. Since there are a large number of topics related to antenatal care, the system only presents suitable topics based on the user’s gestational age. The prenatal educational information is Page 8 of 14
shown in the lower left and right parts of the screen. The middle of the screen shows the health history of the pregnant woman and records of various health checks. The upper right of the screen shows details of the baby’s growth.
Self-care Journals
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The system includes four self-care interfaces to record important information, namely the pregnant woman’s weight (Fig. 7), blood pressure (Fig. 8), fetal movement (Fig. 9), and uterine contractions (Fig. 10).
(b)
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Fig. 7 - Weight record interface on (a) web and (b) smartphone.
(a)
(b)
Fig. 8 - Blood pressure record interface on (a) web and (b) smartphone.
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(b)
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Fig. 9 - Fetal movement record interface on (a) web and (b) smartphone.
(a)
(b)
Fig. 10 - Uterine contraction record interface on (a) web and (b) smartphone.
5. Evaluation A usability evaluation and questionnaire survey of the system were completed by experienced software developers and the proposed users, both mothers-to-be and medical professionals. 5.1. Usability Evaluation The usability evaluation was conducted using the heuristic evaluation method [17][18], as proposed by Page 10 of 14
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Nielsen and Molich (1990), with a focus on the user interface of the proposed system. Five experienced software developers were invited to evaluate the user interface of the proposed system. First, we explained the background information and characteristics of the focal domain to the evaluators, who were then asked to work alone and examine the user interface for 30 minutes. Each evaluator was then asked to list the usability problems they observed based on Nielson’s heuristics [19], as well as to give details of the severity of and underlying reasons for these problems. Based on the results, the following issues were found: 1. The system does not respond when switching between screens. 2. The camera function is not working properly. 3. The message “Saved” is not always shown when some data is saved. 4. No messages are shown to tell users when an image has been successfully uploaded. 5. Scrollbars should be included on the weight tracker, blood pressure tracker, fetal movement counter, and contraction counter screens. 6. It is not convenient for users to input the date and time manually. 7. The locations of the various features are not always clear. 8. It is confusing to have two dashboard screens. There should also be a “Home” button on the tools screen so that users can easily return to it. 9. “Close” or “Back” buttons should be included on the description screen; otherwise, users may not know how to go back to the previous screen. 10. The maternity record function does not enable users to quickly move between screens to record different kinds of information. 11. The font size of the antenatal care information is too small. We redesigned and modified the user interface of the system based on the suggestions of the evaluators and identified issues. The modified user interface was then evaluated by the five experienced software developers. The results show that all of the usability problems had been resolved. The evaluators indicated that the system could be used to improve the antenatal care of pregnant women. 5.2. Survey
68 pregnant women (age: > 20 years; gestational age: 16-24 weeks) were recruited for our study. The women used PregfoneCare until they gave birth. A survey was conducted to assess their satisfaction with the proposed system using a 16-item questionnaire. The results are presented in Table 2. Likert scales [20] were used for this questionnaire. Each topic had five items, namely strongly dissatisfied, dissatisfied, fair, satisfied, and strongly satisfied, represented by 1 to 5, respectively. The mean score for each topic was close to 4, indicating that the respondents were satisfied. The standard deviation was about 0.6, indicating that every respondent was satisfied with PregfoneCare. The respondents stated that the pregnancy calculator, estimated date of birth calculator, and BMI calculator are very useful functions to pregnant women. Moreover, 80.9% (64.7%+16.2%) of the respondents stated that the system was useful for their pregnancy, particularly the four journals. Pregnant women usually visit obstetricians after they have a diagnosis of pregnancy in the first trimester. Normally, a pregnant woman visits her doctor more than 6 times. It is reasonable to assume that each user would log in to the proposed system to record one’s latest information. As Table 3 shows, most users logged in 6-10 times, with 52 users logging in more than 6 times. 76% of the users thus used the Page 11 of 14
system frequently. Table 2 – User satisfaction with proposed system Mean
Strongly
Dissatisfied
Fair
Satisfied
Strongly
(stand
dissatisfied
(n/proportion)
(n/proportion)
(n/proportion)
satisfied
deviation)
(n/proportion)
How do you feel about the overall system?
3.93 (.61)
0
1 (1.5%)
12 (17.6%)
46 (67.6%)
Did the system help your pregnancy?
3.94 (.69)
1 (1.5%)
0
12 (17.6%)
44 (64.7%)
How do you feel about ability to upload ultrasonic pictures of your baby?
3.68 (.66)
0
1 (1.5%)
26 (38.2%)
How do you feel about weight gain journal?
3.87 (.67)
0
1(1.5%)
17(25.0%)
How do you feel about blood pressure journal?
3.82 (.62)
0
1(1.5%)
How do you feel about fetal movement journal?
3.78 (.69)
0
How do you feel about uterine contraction journal?
3.74 (.66)
0
(n/proportion)
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0
9 (13.3%)
11 (16.2%)
6 (8.8%)
40(58.8%)
10(14.7%)
17(25.0%)
43(63.2%)
7(10.3%)
22(32.4%)
36 (52.9%)
9(13.2%)
26(38.2%)
34(50.0%)
8(11.8%)
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Topic
Table 3 – User log in frequency Login frequency
1-5
6-10
11-15
16-20
>21
Number of users
16
32
10
8
2
6. Conclusion and Future Work
The study proposed and implemented the PregfoneCare system, a personal antenatal care information system with web-based maternity records that can be accessed via a multi-platform application. The system framework consists of smartphones, computers, and a PregfoneCare server, which is composed of a web application server, maternity records, and a database. The proposed system includes a web-based EMR system that stores the full maternity records of the users and contains information regarding various antenatal screening and diagnostic tests that pregnant women must take. The system includes four self-care tools that enable pregnant women to keep journals on their gestational weight gains, blood pressure, fetal movements, and uterine contractions, respectively. Page 12 of 14
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Moreover, the proposed system recommends appropriate health education materials to users based on their gestational age, thus increasing the pregnant women’s knowledge of antenatal care. The proposed system empowers women to self-manage their own health and thus maintain health during their pregnancies. The users can gain important pregnancy-related knowledge and access their related health records and other information easily via their smartphones or computers. In the future, the proposed system can be integrated with existing EHR systems in hospitals so that pregnancy complications can be detected more easily. In addition, health education information regarding high-risk pregnancies can also be included in the system. Finally, the proposed system could be combined with a decision support system to help women make better choices during their pregnancies.
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Acknowledgement We would like to thank Juan-Juan Chen (RN) for discussing various issues related to this research. This research was supported in part by the National Science Council of Taiwan under grant NSC 102-2221-E-006-138.
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Conflicts of interest
The authors declare that they have no conflicts of interest in relation to this work.
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REFERENCES [1] QuinStreet Inc., Smartphone = Smart Healthcare? http://www.alliedhealthworld.com/visuals/smartphone-healthcare.html. Accessed 28 Dec. 2012. [2] NIH Consensus group, Mobile Health. http://www.hrsa.gov/healthit/mhealth.html. Accessed 28 Dec. 2012. [3] Bureau of Health Promotion of the Department of Health (2012) Maternal Health Handbook. Bureau of Health Promotion. Department of Health, Taichung City, Taiwan. [4] D. Fridsma (2012) Electronic Health Records: The HHS Perspective Computer. vol. 45, no. 11, pp. 24-26. [5] I. Carrión, J.L.F Alemán, and A. Toval (2012) Personal Health Records: New Means to Safely Handle Health Data? Computer. vol. 45, no. 11, pp. 27-33. [6] UNICEF, World Health Organization, The World Bank, and United Nations Population Division (2012) Levels and Trends in Child Mortality-Report 2012. http://www.unicef.org.uk/Documents/Publications/UNICEF_2012_IGME_child_mortality_report.pdf. Accessed on December 28, 2012. [7] Central Intelligence Agency (2012) Infant Mortality Rate. https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html. Accessed on December 28, 2012. [8] Amalia R Miller and Catherine E Tucker (2011) Can Healthcare IT Save Babies? Journal of Political Economy, vol. 119, no. 2, pp. 289-324. [9] Ericsson ConsumerLab (2013) 10 Hot Consumer Trends 2013 http://www.ericsson.com/res/docs/2012/consumerlab/10-hot-consumer-trends-2013.pdf. Accessed on January 2, 2013. Page 13 of 14
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[10] D. B. Hoang, E. Lawrence, N. F. Ahmad, V. Balasubramanian, C. Homer, M. Foureur, et al. (2008) Assistive care loop with electronic maternity records. Proceeding of the 10th International Conference on e-health Networking, Applications & Services (IEEE HealthCom 2008) , Singapore, pp. 118-123. [11] S. A. Onashoga, A. S. Sodiya, T. O. Omilani, and H. O. Ajisegiri (2011) A Mobile Phone-Based Antenatal Care Support System. Proceedings of the 21st International Conference on Systems Engineering, Las Vegas, U.S.A, pp. 410-415. [12] Anas A. Mohammad Salameh, Alaa A Alkafagi, Chulawadee Khunsri, and Adib M. Monzer Habbal (2011) Web Based Support for Pregnant Mother. Proceedings of the International Conference on Advanced Science, Engineering and Information Technology 2011, Malaysia, pp. 307-310. [13] BabyCenter Medical Advisory Board (2013) Forgetfulness during pregnancy. http://www.babycenter.com/0_forgetfulness-during-pregnancy_236.bc. Accessed on January 5,
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2013. [14] Institude of Medicine Weight Gain During Pregnancy: Reexamining the Guidelines (2009) http://www.iom.edu/~/media/Files/Report%20Files/2009/Weight-Gain-During-Pregnancy-Reexamin ing-the-Guidelines/Report%20Brief%20-%20Weight%20Gain%20During%20Pregnancy.pdf. Accessed on January 13, 2013. [15] Douglas Crockford (2013) Introducing JSON. http://www.json.org/. Accessed on January 9, 2013. [16] OpenSSL. http://www.openssl.org/ . Access on January 20, 2015. [17] Jakob Nielsen and Rolf Molich (1990) Heuristic evaluation of user interfaces. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems, Seattle, Washington, USA, pp. 249-256. [18] Jakob Nielsen (2013) How to Conduct a Heuristic Evaluation. http://www.nngroup.com/articles/how-to-conduct-a-heuristic-evaluation/. Accessed on January 11, 2013. [19] Jakob Nielsen (2013) 10 Usability Heuristics. http://www.nngroup.com/articles/ten-usability-heuristics/. Accessed on January 12, 2013. [20] Trochim, William M. The Research Methods Knowledge Base, 2nd Edition. http://www.socialresearchmethods.net/kb/scallik.php. Accessed on January 12, 2013.
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