VOLUME XX, 2017 1 Developing telemedicine products using [614882]

VOLUME XX, 2017 1 Developing telemedicine products using
system engineering techniques
Ruxandra Sava -Rosianu1, Eugenia Grecu2, Alsaeyd A. M. Kher1, Erwin Floroni1, Virgil
Ciobanu1, Ramona Amina Popovici1 and Serban Negru1
1University of Medicine and Pharmacy “Victor Babes” Timisoara, Romania
2Politehnica University of Timisoara, Romania
Corresponding author: Eugeni a Grecu (e-mail: [anonimizat] ).

ABSTRACT
The aim of this study is to offer a methodological solution for the development of products and services in
concordance to the functional demands and the performance needs of the user in the field of telemedicine,
and more over to satisfy a variety of users simultaneously. By means of the multidisciplinary theory of
System Engineering (SE), used mainly in the a ero-spatial field to develop more complex projects, this study
illustrates the way functional and performance needs can be fulfilled in the medical emergency and non –
emergency field by developing a new innovative telemedicine product. This case study is b ased on to sets
of qualitative research data, the first, based on interviews aiming to validate the concept of telemedicine and
to classify potential users, and the second one based on observation in order to obtain a better understanding
of the interventi on scenarios and to elaborate demands of the telemedicine users. Both sets of information
have been supported by secondary informations obtained by data analysis. The results have been taken over
for the prototype of the product for the Romanian market wit hin a project of the European Space Agency.

INDEX TERMS final users, organization responsibility, Portable Working Station (PTW) , System
Engineering (SE), telemedicine.
I. INTRODUCTION
A central aspect of medical consults, investigations and
treatments represents receiving analysis and communication
of information between health professionals and patients.
Activities within the medical care services are more often
provided through the cooperation between several persons
and institutions. This is caused a lso by the increase of
specialization within the medical activities. This is the
reason why, in order to provide qualitative medical services
to the patients, it is necessary to synchronize diverse
medical activities within a medical facility.
The increa se of demand in the communication of medical
information between several persons and institutions
supposes a more efficient use of these informations. This
demand can be only served by a judicious use of digital
information technology [1].
One of the most prosperous and modern industries which
should get special attention from the point of view of the
organisational responsibility towards the final consumers,
isrepresented by the medical device industry and
telemedicine. Thus, the health industry based on
information and communication technology brings significant contri butions to the economy nowadays [2, 3 ].
According to Vizitiu et al., 2013, by means of advances
technologies in telecommunication, telemedicine has a
great impact on the diagnose and treatme nt by inhancing
medical capability [4], as long as medical devices and other
joint technologies don’t prejudice the patients’ safety or
medical staff or aggravate the clinical status of the patients
[5].
The WHO European Health for All Target 31 aimed at the
improvement of q uality of health care by use of appropriate
health care technology and the provision of health
information sys tems [6]. In the 1990s the WHO Regional
Office for Europe developed initiatives to encourage
MemberStates to harmonize their in formation systems .
Many east -European countries traditionally recorded the
number and type of services provided but not the outcomes,
i.e. whether interventions contributed to health or not. Some
western European countries have established outcome –
oriented information systems, but neglected the
processes.[ 7, 8].
Suitable instruments based on the information and
communication technology (ICT) halp to provide adequate,

VOLUME XX, 2020 9 safe and qualitative services to the patients. At the same
time, mecessary support is provi ded to the medical staff so
a continuity in assistance and patient safety is offered and
people have access to the wright instruments.
ICT will be utilized as a strategic instrument at all levels of
the medical care system and health resources will be us ed
more efficently.
This study offers a certain methodological solution based
on a multidisciplinary theory called System engineering
(SI), used mainly during the last decades in the aero -spatial
segment to obtain complex systems, and aims to fully
satisf y final users regarding functional expectations of the
product as well as performance skills of the final
telemedicne service. The paper offers also an important
research in the fied of telemedicine succesfully creating a
''Portable Telemedicine Workstati on'' (PTW) satisfying a
large number of medical users in Romania both from the
functional point of view as well as the performance. The
research applies the improved modified SI technology to
approach several users and creates a solution based on two
qualitative analysis, dedicated to emergency and non –
emergency medical care facilites. The whole information
processing algorithm is ilustrated as follows:
1. Identification and classification of final users.
2. Determination of the responsibilities, roles, procedures
and technological means used by the final useres
3. Designing demands of the final users and creating the
functional PTW model.
It is relevant to the originality of this research, that the
presented results have already been submitted for patenting
[9].

II. Telemedicine and system engineering
The aim of medical care services are: a healthy community,
and equity in access to medical care. High treatment needs
represent a priority.
There are a series of criteria which have to be fulfilled in
order for medica l care services to be considered as high
standard.
Efficient health services are not just vital for the health status,
safety and wellbeing of the population but also for peoples
trust in the society’s ability to respond to their own needs.
Nowadays, com munication and information technologies are
used over the entire health system, in different ways.
Nevertheless, ICT has haven’t been used to their full
potential. Up until now, only some medical fields have been
using ICT. Reasons are easily understood: difficulties in
agreeing to certain specific demands of inter -operating for e –
health solutions, low communication needs in the past, and
high costs of IT solutions.
Many information and communication technologies are used
only for a small part of the task s they could be used for and
inter-operative tasks are very limited.
It takes sustained efforts to improve the use of ICT in health.
Better deci sion making processes are neede d to introduce or change e -health solutions. Also, the management and support
of ICT can be improved. This is the reason why a new
approach towards e -health solutions is needed, a new
strategic operational perspective.
Information and communication technologies make it
possible to organize, coordinate and disseminate medical
care, an d clinical research, art reasonable costs.
Individuals, patients play an active role in defining new ways
to offer medical care, according to the ir needs and demands
[1].
Looking at the literature, the real problem in the field of
telemedicine is using a suitable methodology to collect and
understand the demands of the users in order to transform
them into services which fulfill their expectations. One of the
main contributions of this research, is offering a
methodological solution based on SI as a comple x solution
for institutions which want to obtain an improved satisfaction
from the clients/users in the field of telemedicine. SI is
defined as an interdisciplinary holistic approach to create
successful systems, concentrating simultaneously on
understandi ng the needs of interested factors, exploring
opportunities, documenting demands, synthesis checking,
validating and gradually developing solu tions, looking at the
task as an ensemble, starting from concept until it’s
elimination [10-13]. Thus, SE is based on a series of
activities and decisions to identify technological
opportunities on the market and to transform operational
needs of the clients in specifications and configurations of
the system. In this context, a system has a broader
understanding, over lapping the concept of technological
equipment and referring to a complex compound of persons,
products, knowledge and processes to obtain a solution to the
needs specified by the clients [14-17].
The strategic, operational perspective on SE in Romania
needs therefor a close cooperation between different actors in
the medical filed. It is essential to adopt a common approach
regarding the ICT strategic problems. The action domains
aren’t supposed to interfere with the structure of the medical
care services in Romania, but help to improve their quality.
III. MATERIAL AND METHODS
This case study in the field of telemedicine illustrates a
successful method based on the practical applicability of the
SE methodology, aiming to identify and classify end users to
determine and analyze specific needs and to integrate and
validate functional and performance demands in a proper
manner , in order to obtain maximum satisfaction from the
final users on the functional and performance path. The
research offers a better und erstanding of the application of
SE methodology on the complex field of telemedicine, even
though the methodology is derived from the aero -spatial
segment.
Two sets of qualitative research tools are separately applied,
having different aims.
A. INTERVIEW S

VOLUME XX, 2020 9 The first set of information s has been obtained from 21 semi –
structured interviews by face -to-face open interaction with
medical staff whose activities were supposed to be
influenced in a certain manner by telemedicine. The
qualitative method of intervie w has been used in order to
obtain as many relevant and objective informations as
possible, to validate general needs of the medical users,
regarding mobile telemedicine in deprived areas, and to gain
better understanding of on the problems and needs of th ese
users. The method was also useful to identify the type of
activity and the roles of the medical users in the interventions
they perform for further classification of these users.
Questionnaires have been analyzed and results have been
enforced by the secondary informations obtained from the
analysis of internal strategic documents of the medical users.
The fact that these medical workers were experienced team
members was important and relevant.
B. PARTICIPATIVE OBSERVATION
The second set of information s has been collected after
classifying the users based on the first investigation and has
been performed through qualitative participative observation
within the specific environment of the users over a period of
three weeks, aiming to obtain a deeper unde rstanding of the
specific scenarios. These types of intervention, called “use
cases”, have been useful to determine current technological
means of the users, and the perspectives of use. During the
observation, the procedures used by the medical workers in
certain events or situations have been filled in qualitative
observation tables and diagrams have been created. In order
to obtain correct and objective informations, the results of the
participative observation have been enforced by secondary
information s obtained through the analysis of the medical
unit’s documents regarding the users’ role and
responsibilities. New diagrams have been created re garding
the types of medical interventions. The results of the second
qualitative analysis contributed to the i dentification of the
technological limitations in their use, being extremely
important for the functional demands of the performance of a
telemedicine system.
Within both qualitative research methods, eventual
limitations could appear because of the limi ted availability of
the medical workers for the interviews as well as for wo rking
with the researchers as observers, taking into account the
complexity of the medical procedures.
Regarding the limitations of the documents analysis, the
limited access of t he researchers to the internal documents
can be mentioned.
This study shows the whole chain of informational values
based on the SE method, considering the two sets of
informations coming from qualitative research in order to
obtain satisfaction from the t elemedicine users according to
functional and performance criteria.
IV. DATA ANALYSIS
CASE STUDY – USE OF THE SYSTEM ENGINEERING
METHOD IN THE FIELD OF TELEMEDICINE The study offers a comprehensive image on designing a
modern concept of mobile telemedicine called ''Portable
Telemedicine Workstation'' (PTW) aiming to satisfy the
functional needs and the performance according to the
demands of a large variety of users the preclinical medical
field especially, for medical emergencies but also for
screening programs in Romania, both activities being
provided in deprived areas. Re levant for the validation of this
study is the fact that the results have been further used for the
development of a telemedicine service in Romania.
Triggering factors for the concept of the PTW have been the
possibility to value an advanced satellite communication
technology in the field of telemedicine, based on the premise
that Romania has many deprived areas with underdeveloped
terrestrial communication structures (e.g. 50% of the country
is not covered by 3G telecommunication network), and
medical users face the impossibility to perform telemedicine
acts.
a) Identifying and classifying users
Users from the emergency and non -emergency departments
have been identified, specialists, team members, unit
managers so the sample could reflect the dominan t point of
view for the specific groups. These end -users have been
interviewed using semi -structured interviews in direct and
open conversations, aiming to confirm the general need for
mobile telemedicine in deprived areas and also to clarify
specific role s of the medical workers in the value chain of the
medical field.
The informations provided by the interviews have been
analyzed by three procedures, reduction of data, presenting
the data and formulating and validating conclusions.
Conclusions have been verified based on the informations
obtained from different documents. They have revealed that
almost all subjects have difficulties to perform medical
interventions and especially telemedicine interventions in
deprived areas inaccessible for automobile ac cess, for the
simple reason that specific equipment are either inexistent or
not adequate for pedestrian use. Secondly, all the subjects
recognized the real benefit of telemedicine, especially for
deprived areas. Interviews have also offered primary
inform ations regarding the roles of the affiliation units and
types of performed interventions, being very useful for the
classification of the selected medical workers by an
ascendant approach, in collective users (entities which group
individuals with similar actions within their interventions),
categories of users (entities that group collective users with
similar roles) and branches, which distinguish between
categories of users of emergency and non -emergency care, as
shown in fig. 3.

Fig. 1 Classification of users based on a specific SE approach
Taking into account that interviews have offered some
resemblances between the interviewed individuals, this
classification has been initiated in order to avoid duplication
and to make the needs elaboration proce ss more efficient.

VOLUME XX, 2020 9 Thus, classification of the users can be illustrated as follows:
categories comprising medical dispatches (emergency
dispatches, telemedicine centers), intervention teams
(emergency services, mountain rescue units), medical
practices (h ouse doctors, disaster management units) and
medical screening units within the non -emergency branch.
b) Intervention scenarios
Based on the second data set collected through participative
observation of the users, diagrams for intervention scenarios
have been designed, according to the specific interventions as
indicated in fig. 4.

Fig. 2 Structure of the intervention scenarios
By means of the intervention scenarios, a better
understanding of the procedures and technological means in
use has been gained . Of great importance is the fact that in
this manner, developers of telemedicine products can obtain
a centered perspective on projecting the systems around their
clients, perspective that can be very useful for a prompt
achievement of the users’ satisfac tion.
Main results of the intervention scenarios corresponding to
specific scenarios represent identifying the technological
limitations of the clients during the interventions, including
their problems, but also, identifying the way that users
overcom e some obstacles and limitations during the
interventions. This way, through intervention scenarios, very
important informations are assimilated regarding problems
and needs of the clients, facilitating further development of
functional demands and perform ances.
c) Functional and performance demands of the users
Demands of users are expressed enunciations from the
developer of the product/service in a clear manner describing
the system in a way that it entirely or partially satisfies the
needs of the clie nts.
Resuming the users’ demands, elaborated in the PTW
telemedicine project, the distinction between the two aspects:
functional and performance, has to be evidenced, but also the
fact that the enunciation doesn’t show how to implement the
system but ind icates the capabilities the system should have
as well as the level of performance.
Functional demands of the telemedicine system aim
functionalities as: audio/video transmitting -reception, real
time medical data transmission between the place of
interv ention and a medical dispatch in order to facilitate
telemedicine activities, capability of the system to
communicate data even in areas without terrestrial
communication infrastructure (taking into account satellite
communication technology), systems’ cap ability to offer
navigation and localization informations as well as the
essential ability to be portable. Other functional demands
have also considered some constraints (physical limitations,
impact on the environment), aspects related to human
interfac e, compatibility of the system with the users’
infrastructure, standards regarding the medical field. The performance requests reflect specific attributes as:
weight, autonomy, capacity of the communication wave,
video quality, delay in data transmission , time needed for the
connection, protection against fluids, and mechanical impacts
from the environment. All the performance demands have
been quantitatively established either as minimal values, or
as baseline. It is important to mention that the demands ,
having a clear tracing towards the users’ needs, intervention
scenarios, and collective users have been confirmed by the
users before the developer started the technical validation.
d) Validation of demands
Once the list of demands has been created, a f unctional PTW
Model has been developed, also known as PTW ''proof -of-
concept'' , aiming to test the demands considered as vital in
the technical proofing of the specificity of the concept. This
model has been developed to technically validate and in
some cases to refine the demands of the users, followed by
the prototyping and piloting of a demonstration. Based on
the functional model, various testing campaigns within the
specific environments of the users have been done,
simulating various medical interven tions with one or more
patients/victims.
Using the black box technique, functional tests have been
focused exclusively on the results of the tests in being
identical with the expected results according to the users’
demands that are vital to the technica l feasibility. Based on
the demonstration and the acceptance of the users, the SLPT
concept has been submitted for further development.
V. CONCLUSIONS
The ''Portable Telemedicine Workstation'' case study is
based on two sets of qualitative research metho dologies and
presents the way that, based on SE coming from the aero –
spatial segment, a mobile telemedicine system can be
developed, aiming to fully satisfy final users with regards, to
the functionality and performance.
The SE approach that was used in t his case study, has been
modified, bringing specific improvements in order to develop
a telemedicine product which is capable to fulfil the needs of
a large variety of users simultaneously, and this represents a
major benefit for the telemedicine industry. The mechanism
that results from this case study is marked by different
aspects like verification, validation, re -iteration, and
traceability.
Validation of the idea is based on the first set of qualitative
data, aiming to gather informations on the rol es and
responsibilities of the users for their classification, whereas,
the intervention scenarios have been developed by the second
set of data, which was important for the understanding of the
scenarios, problems and needs of the users.
The original app roach of this study could contribute to the
improvement of current techniques used in telemedicine,
aiming to offer the possibility to satisfy the functional and
performance needs of the users.

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