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Bachelor Thesis Master's Programme in Computer Science, 300 Credits Bachelor Thesis Master's Programme in Computer Science, 300 credits EnterMedic, an E-health application for telemonitoring and health status feedback Development of a mobile healthcare tool and research about its usage in the field of E-health Computer Science and Engineering, 15 credits Halmstad 2020-06-07 Sebastian Larsson, Leif Sulaiman HALMSTAD UNIVERSITY Acknowledgements We want to start our thesis by thanking our supervisor Taha Khan who helped us immensely by making sure we got off on the right foot, providing us with knowledge about engineering combined with healthcare and answering any questions we had. Also, we would like to thank Cyrus Daneshmir, Roger Bergstrand and the development team of Entergate for helping us when we encountered issues, supplying us with endless amounts of coffee, for playing table tennis with us during their afternoon break and for keeping in touch with us during the rough times of the COVID19 outbreak. Regards, Sebastian Larsson & Leif Sulaiman Halmstad, Sweden 2020-05-10 i ii Abstract Digital tools are being implemented in every area of society. Digital healthcare, or E-health, is an area that is increasing in popularity with various mobile applications and online ser- vices available. Entergate, a company based in Halmstad, has developed a service called EnterMedic. It is a cloud service that collects data from patients through online question- naires. Once submitted, the service can directly forward data from these questionnaires to patient journals. EnterMedic also helps researchers with data to develop effective work methods in healthcare. The service was however limited to the web. This thesis consists of developing a mobile version of the service as it is more convenient to use compared to a web-based one and research contributing to what E-health applications can be used for. Interactivity is a desired feature for applications. EnterMedic will provide the users with feedback after questionnaire submissions, to help them track their state of health. Sammanfattning Digitala verktyg blir implementerade i alla omraden˚ av samhallet.¨ Digital halsov¨ ard,˚ eller E-halsa,¨ ar¨ ett omrade˚ som okar¨ i popularitet¨ med olika mobiltelefon applikationer och on- line tjanster¨ tillangliga.¨ Entergate, ett foretag¨ baserat i Halmstad, har utvecklat en tjanst¨ som heter EnterMedic. Det ar¨ en moln-tjanst¨ som samlar data fran˚ patienter genom online formular.¨ Nar¨ dessa skickas in kan tjansten¨ direkt vidarebefodra datan fran˚ formularen¨ till patient journaler. EnterMedic hjalper¨ aven¨ forskare med data for¨ att utveckla mer effek- tiva arbetsmetoder inom halsov¨ arden.˚ Tjansten¨ ar¨ dock begransad¨ till webben. Det har¨ examensarbetet bestar˚ av att utveckla en mobil version av tjansten¨ da˚ det ar¨ mer bekvamt¨ att anvanda¨ jamf¨ ort¨ med en webb-baserad tjanst¨ och forskning som bidrar till vad E-halsa¨ applikationer kan anvandas¨ for.¨ Interaktivitet ar¨ en onskad¨ funktion for¨ applikationer. En- terMedic kommer forse¨ anvandare¨ med aterkoppling˚ efter att ett formular¨ har skickats in, som i sin tur hjalper¨ dem folja¨ sitt halsotillst¨ and.˚ Keywords: Telemonitoring, E-health, Telehealth, Self Assessment Questionnaire, Digital Healthcare Tool, Healthcare Mobile Application, Cross-Platform iii iv Contents 1 Introduction 1 1.1 How EnterMedic works . 1 1.2 Purpose . 1 1.3 Problem specification . 2 1.4 Contributions . 3 1.5 Application specifications . 4 2 Background and theory 5 2.1 General . 5 2.2 Explanation of keywords . 5 2.2.1 Platform . 5 2.2.2 Cloud service . 6 2.2.3 Self assessment questionnaire . 6 2.2.4 Standard disease rating scales . 6 2.2.5 Telemonitoring . 6 2.2.6 HTTP and web requests . 7 2.2.7 GDPR . 7 2.3 API . 8 2.3.1 EnterMedic API . 8 3 Method 11 3.1 Hardware and Software Used . 11 3.1.1 Postman . 11 3.1.2 BankID . 11 3.1.3 Xamarin . 12 3.1.4 DB Browser for SQLite . 12 3.2 Method description . 13 3.2.1 Questionnaires . 13 3.2.2 Feedback . 13 3.2.3 Local database . 13 3.2.4 Web request and authentication . 14 3.2.5 Notifications . 15 3.2.6 User Interface . 16 3.2.7 Testing . 17 3.2.8 Expenses & resources . 17 3.3 Result analysis . 17 4 Results 19 5 Discussion 23 5.1 Ethics . 23 5.2 Issues encountered . 23 5.2.1 Hardware faults . 23 5.2.2 Development tools . 24 5.2.3 The impact of a global pandemic . 24 5.2.4 Focus group . 24 5.3 Usage . 25 v 5.4 Improvements and plausible extra-features . 26 5.4.1 External connections . 26 5.4.2 Feedback improvements . 27 5.4.3 Notification improvements . 27 5.4.4 Alternative login . 27 6 Conclusion 29 6.1 Experience . 29 6.2 Future implementations . 29 vi 1 Introduction This bachelor’s thesis is done in cooperation with Entergate, a company based in Halm- stad, Sweden. Entergate has a web-based E-health application called EnterMedic. It is a cloud service that makes it possible to directly send data to patient journals and has been used daily since 2016 by Kristianstad University, Region Varmland¨ , and Region Halland. EnterMedic was co-developed with CKF (Centrum for¨ Klinisk Forskning i Vaster¨ as˚ ). CKF works a substantial amount with questionnaires within healthcare and aims to, while col- lecting information for research, help develop effective work methods in healthcare. En- terMedic encourages patient-integration and better communication between the patient and the care-taker which makes the experience better for both parties. 1.1 How EnterMedic works The service is divided into three types of authorizations: admins, units, and respondents. An admin could be a medical board of a county. A part of what they do is to create ques- tionnaires for patients to answer. The admins send it out to units which could be hospitals or health centers in the county. These are then provided to the respondents, who are patients, to fill out and submit back to their attending doctor in the unit. This makes it easier for the doctor to diagnose a patient. It is very important to note that this is not a tool that can diagnose, but instead eases the diagnostic process and pre-visit perception of the patient for the doctor. 1.2 Purpose The purpose of the project is to create an E-health application to assist the healthcare system and the doctors by acting as a tool of telemonitoring patients, with the hope that it will play a part in decreasing the queues of healthcare in the future. It is important to note that this thesis was written during the outbreak of COVID-19. As a consequence of this pandemic, telemonitoring increases in importance as it can prevent risk- groups, such as elderly or individuals with an underlying illness or compromised immune system[1], from contracting the disease by visiting hospitals and other healthcare centers. The process of E-health can be summarized: E-health applications collect data using self- assessment questionnaires submitted by the patient. Then, from the server, transmits a disease profile of the patient as a quantified form to a doctor who uses a standard clinical rating scale to make a clinical assessment[2]. The EnterMedic application is to be considered a telemonitoring application since the pa- tient’s state of health can be reviewed remotely through questionnaires. It is important that the UI (User Interface) is appealing and simple to use so that less technical people, such as elderly or disabled individuals, can understand it. 1 1.3 Problem specification As awareness for mental illness increases, more people feel confident in seeking aid. This is visible, not least among the younger population. From 2016 to 2018 there was a 24% increase in visits to BUP (Barn- och ungdomspsykiatrin), a Swedish institute helping chil- dren and teenagers with their mental issues[3]. While doctors and nurses hired were also increased during this time, it was only by 9% and 3% respectively. However, the number of psychologists decreased by nearly 9%, making the total staff decrease in size since they represent the largest portion of the staff. There is a clear pattern here, which is that an increasing number of people need help but the availability is decreasing. The thesis was written during the global pandemic of COVID-19. In Sweden, the national protocol regarding preparations for a pandemic does not directly implement a telemoni- toring system through a mobile application[4]. A study dating back to 2015 states that telemonitoring systems show great potential during pandemic outbreaks, but require more research to be applied fully in situations similar to the COVID-19 pandemic[5]. Digitization has helped many areas of society, such as shopping for food through internet services, but also healthcare. There is a rise in the use of medical applications such as Kry and Min Doktor which had an increase in digital visits of 500% in one year[6]. This points to that patients are willing to get help through an application as an alternative to physical help when possible. Figure 1 shows that a relatively high percentage of the Swedish popu- lation already use digital tools existing in the healthcare industry. A noticeable deviation is the elder population in comparison to the population as a whole. They tend to not use these tools as much as the younger population. Figure 1: Percentage of the Swedish population (16+ years) using the healthcare system’s digital tools (blue) and healthcare apps instead of a normal visit (red), the year 2019[7]. The leftmost bars display the whole population. 2 Certain cases regarding BUP and the regular healthcare system can be time-sensitive. A patient must get to see a doctor or healthcare worker on time.
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