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Abstract

Background

Hypertension affects 28.5% of Indians aged 18–69. Real-time registration and follow-up of persons with hypertension are possible with point-of-care digital information systems. We intend to describe herein the experiences of discovering, developing, and deploying a point-of-care digital information system for public health facilities under the India Hypertension Control Initiative.

Methods

We have adopted an agile and user-centered approach in each phase in selected states of India since 2017. A multidisciplinary team adopted a hybrid approach with quantitative and qualitative methods, such as contextual inquiries, usability testing, and semi-structured interviews with healthcare workers, to document and monitor utility and usability.

Results

During the discovery phase, we adopted a storyboard technique to understand the requirement of a digital information system. The participatory approach in discovery phase co-designed the information system with the nurses and doctors at Punjab state of India. Simple, which is the developed information system, has a front-end Android mobile application for healthcare workers and a backend dashboard for program managers. As of October 2022, over 24,31,962 patients of hypertension and 8,99,829 diabetes were registered in the information system of 10,017 health facilities. The median duration of registering a new patient was 50 seconds, and for recording a follow-up visit was 14 seconds in the app. High satisfaction was reported in 100 app users’ quarterly interviews.

Conclusion

Simple was implemented by administering a user-centered approach and agile techniques. It demonstrated high utility and usability among users, highlighting the benefits of a user-centered approach for effective digital health solutions.

Keywords

Hypertension digital information system India Hypertension Control Initiative Simple app

Introduction

Non-communicable diseases (NCDs) contributed 1.62 billion disability-adjusted life years (DALYs) in 2019.¹ It increased from 43.2% in 1990 to 63.8% in 2019. Each year, nearly 17 million premature deaths occur due to NCDs. Most of these premature deaths occur at low- and middle-income countries.² Metabolic risk factors increase the risk of NCDs. Among the risk factors, 19% of global deaths are attributed to elevated blood pressure (i.e. hypertension). The prevalence of hypertension is higher in low-income and middle-income countries than in high-income countries.³

The prevalence of hypertension in India among the age group of 18 to 69 years is 28.5%. India has approximately 220 million people with hypertension, of which 12.6% have controlled blood pressure.⁴ A poor blood pressure control status leads to unfavorable cardiovascular mortality and morbidity, such as myocardial infarction and stroke. Therefore, the treatment of hypertension requires lifelong follow-up and monitoring for better control and prevention of unfavorable health outcomes. The World Health Organization (WHO) recommended the HEARTS package with core strategies to improve blood pressure treatment and control.⁵ One of the strategies in the HEARTS package is regular monitoring of patients on treatment for blood pressure control. The WHO pharmacological treatment guideline released in 2021⁶ recommends a monthly follow-up of patients until they achieve control.

Public sector healthcare facilities cater to many patients with hypertension due to the high burden of the disease. Since people with hypertension require lifelong treatment and follow-up, the volume of information handled is huge.⁷ Recording, analyzing, and reviewing such large data require a stable information system. Relying on a pen and paper information system to handle large data is time-consuming and requires a large number of human resources. Besides monitoring patient data monthly, generating program indicators is crucial for successful implementation and outcome of the disease control program.⁸ Sufficient evidence supports the fact that data-driven decisions in public health programs produce effective outcomes.⁹ Thus, a stable, simple, reliable, and swift digital information system is essential to monitor and manage hypertension control programs.

Understanding NCDs as a public health problem, the government of India has adopted the “25 by 25” goal, which aims to reduce premature mortality due to NCDs by 25% by 2025. One of the nine voluntary targets includes reducing the high BP by 25% by 2025. The Ministry of Health & Family Welfare, Indian Council of Medical Research, State Governments, and WHO-India jointly launched the India Hypertension Control Initiative (IHCI) in November 2017. Details about the strategies of early outcomes have also been published.¹⁰

The IHCI aims to accelerate progress toward the government of India's NCD target by supplementing and intensifying evidence-based strategies to strengthen the building blocks of hypertension management and control.

Deploying a robust information system is a key strategy of the IHCI. We designed a digital information system in the IHCI, called Simple.¹¹ Simple is a fast, free, open-source digital information system with an Android application and a secured web-based dashboard. In Simple, healthcare workers record every hypertension patient's visit, and program managers receive daily reports to monitor progress.

An information system is a day-to-day tool for a busy healthcare worker. To be useful, an information system must have utility and a high level of usability. Utility refers to the system that provides the features that the users need, while usability refers to how easy the system's features are to use in practice in a complex healthcare environment.¹² In principle, usability and utility evaluation at all stages and as a continuous exercise during information system building is recommended. Traditionally analytical models^13,14 of the evaluation of usefulness of an information system involves inputs by subject matter professionals. Involving end-users for such evaluation, called empirical models,¹³ is the user-centered approach for creating software.

We adopted a user-centered design (UCD) approach with an agile development model for the discovery, development, and deployment of the Simple information system. The UCD improves the uptake and impact of a digital health intervention in a health ecosystem.^15–18 The UCD approach involves the system users during discovery and repeatedly in the development and post-deployment processes. Thus, the viewpoint of the users and their needs is adopted into the information system.

In this manuscript, we documented the development process of a digital information system for tracking hypertension and diabetes patients in the primary healthcare setting of India using a user-centered design approach with agile methodology. We aim to share our experiences of how we designed, developed, and deployed a highly usable digital information system.

Table 1.

Overview of the methods employed in the Simple app design and implementation, 2017–2022.

Phase	Qualitative	Quantitative
Discovery	Discovery interviews Storyboarding Co-creation Contextual inquiry (mixed)	Contextual inquiry (mixed)
Development	Usability test User interviews A/B testing
Deployment	User interviews Pulse check interviews (mixed)	User analytics Pulse check interviews (mixed)

Methods

We adopted various methods (Table 1) in the discovery, development, and deployment phases over the period of November 2017 to June 2022. The discovery phase consisted of understanding the healthcare workers and their work environment. In this phase, we identified the need of a digital information system for a hypertension control program. The development phase consisted of priming the design of the information system and technical development. The implementation of the developed application for real-world usage occurred in the deployment phase. The development and deployment phases are a continuous iterative process where frequent cyclical steps of development, system refining, and deployment happen throughout. Under the UCD approach, we adopted generative^19–21 and evaluative methods during the three phases. We will explain the methods adopted in each phase in detail as follows:

Discovery phase

In this phase, we focused on the need for an information system for the hypertension control program and understanding the user work environment. We started the discovery of Simple in 2017 in a one-week “Design Sprint,” a UCD method first developed at Google.²² We used a graphics editing and user interface design app to build the prototypes and designs of Simple. A team of experts comprising epidemiologists, public health professionals, designers, and developers ideated and created a prototype in 1 week. With the prototype, we implemented a set of qualitative methods with Indian healthcare workers to validate the initial ideation and learn more about the needs from the field. The “Design Sprint” provided confidence in the basic concept to move forward with the project; hence, we initiated a discovery phase.

The generative exploratory methods,^{19–21,23–25} namely, discovery interviews,^26,27 storyboarding,^28,29 co-creation³⁰ technique, and contextual inquiry^31–33 were used in the user-experience study for the Simple app.

Contextual inquiry involved observation of users in-depth while performing their regular tasks in their natural setting (i.e. a healthcare facility) to gain a strong understanding of their work practice and behavior. Contextual inquiry, a qualitative ethnographic technique, attempts to obtain and understand the product users’ context by employing investigators in the user environment through participatory observation sessions.

Discovery interviews were conducted with stakeholders, wherein the problem to be solved was understood further, and study questions were formed. These interviews were conducted in the field as well as telephonically. Based on the discovery interviews, we observed the workflows of a typical staff nurse in a public health facility. We documented the pattern of concerns if they use an Android app concurrent with their work.

Storyboarding is the technique we adopted to communicate the concerns of a healthcare worker using an app to developers, designers, and product managers. Storyboarding is a visual, data-driven technique that illustrates the key parts of the user journey, which helps us to anchor many design decisions. The technique generated a deeper understanding within the internal team to sensitize them to the real-world challenges healthcare workers face.

Co-creation is a technique where we used low-fidelity paper prototypes to design solutions along with future app users. We involved the healthcare workers to refine the prototype of Simple designed by us. Co-creation involved a design-thinking iterative process such that we can document the constraints, workflows, processes, and services delivered in the healthcare worker environment.

Development phase

At the end of the discovery phase, we understood the requirements. In the Design Sprint, the needs were refined to design the prototype. The designers and engineers jointly identified the appropriate platform and program language for the app and dashboard. The development of the application was started, and the deployment of the tested application was implemented. However, when a new feature was introduced in Simple, we re-started with the discovery and proceeded to development and deployment. Development and deployment are cyclical, iterative processes. This continuous feedback for iterative development and deployment is called the agile development method.³⁴ The agile software development method is a time-bound, iterative approach to software delivery that builds software incrementally from the start of the project instead of trying to deliver all at once.³⁵ We obtained feedback from the end users with evaluative methods that included qualitative app assessments.

We adopted a hybrid mixed-method technique, called usability tests,^36–39 and qualitative methods, such as user interviews⁴⁰ and A/B testing^41–44 in the development phase.

Usability testing: In usability testing, we observed users during regular clinical care and asked participants to perform tasks (i.e. task analysis). The observed and explicit verbal feedback during the completion of tasks was documented. Usability testing helped us improve the design, address pain points, and learn more about the users’ perspectives on the app. Usability testing was done with the users to evaluate the efficacy, efficiency, and user satisfaction. Multiple new features of the app underwent usability tests with at least five participants. To identify usability issues, it is recommended to interview at least five users during the evaluation.^45–47 We conducted 30 usability tests for different features in four selected project districts in India.

User interviews: We adopted qualitative user interviews among Simple users to identify the reasons for the low uptake of any specific feature and address the user issues to improve usage. A set of questions was asked, targeting the context after establishing rapport with the participant. Each user interview lasted 20–30 min. Prior to 2020, we often conducted user interviews in-person, but due to COVID-19, we conducted remoted user interviews by telephone to healthcare workers.

Deployment phase

After deployment, we continued an iterative process to steadily improve the application's performance. We adopted qualitative methods, such as user interview⁴⁰ and diary studies,^48–50 as well as quantitative methods, such as user analytics. Pulse interviews, which are a mixed method, were adopted in the post-deployment phase.

User interviews: As explained in the development phase, we conducted user interviews with a specific study question on a specific context (e.g. usage of multiple information systems to register hypertension patients). User interviews are longer (45 minutes–1 hour) qualitative interviews conducted with Simple users post-deployment to identify how Simple affected their workflow and decision-making.

Diary studies: Diary studies require users to longitudinally self-report data of their experiences and pain points. We obtained self-reported user log data about their experiences in using the app. We told the users to answer six simple questions related to new app features that they use daily. We contacted the users every day for 1 week with the same set of six questions and recorded their responses. Thus, we observed whether or not a new feature was supportive of the users’ day-to-day work and affected the app performance.

User analytics: We used a business intelligence tool called, Mixpanel, to monitor the user analytics recorded from the Simple application. We monitored the app health and specific indicators, such as the median time taken to register newly diagnosed patients, time taken to record a follow-up visit of a previously registered patient, and monthly trend of patient registration.

Pulse check interviews: These mixed-method interviews were conducted in regular intervals of shorter duration. These qualitative interviews were conducted in loop with the user analytics (explained later). User analytics generated alerts on the low uptake of a specific feature of Simple, which was clarified in the pulse check interviews. We also utilized the opportunity to gain suggestions on the features of Simple. During the pulse check interview, we conducted user-satisfaction surveys of the overall functionality of the app among the Simple users using a Likert scale.

Human ethics consideration

We obtained approval from the Institutional Human Ethics Committee of the ICMR-National Institute of Epidemiology, India (NIE/IHEC/201709-02). We obtained a written informed consent from all the participants before initiating the interview and maintained their confidentiality.

Data analysis

A quantitative analysis was employed in the usability metrics, Likert scale surveys, and user analytics that provided measurable indicators for app performance and user satisfaction. The time taken to register newly diagnosed patients, record a follow-up visit of a previously registered patient, and monthly trend of patient registration were expressed in median and interquartile ranges. User analytics from Mixpanel underwent a time-series analysis to identify the usage trends.

Thematic analysis was applied to the qualitative data obtained from the discovery interviews, usability testing, and post-deployment user interviews, revealing recurring patterns and insights. Coding techniques were used.

Results

We hereby document our observations and findings in each phase of building the Simple information system by adopting the UCD approach.

The Simple information system (https://www.simple.org) was designed to register and perform a follow-up on people with hypertension or diabetes. It has a front-end Android application and a web-based desktop application. The Android application enables the health worker at the facility to manage the data of diagnosed hypertension and diabetes patients. The web-based application has a dashboard of the data collected through the Android application and generates various reports, including treatment outcomes.

We explain herein the findings observed in the iterative discovery, development, and deployment phases of the Simple information system.

The discovery phase included observations and interactions with health care workers to understand their workflow, tasks performed in hypertension and diabetes care, and contextual factors related to the setting.

We explain below one of the methods adopted in the discovery phase using an example of nurse workflow mapping.

Discovery phase

Applying the generative methods, we mapped the work of a staff nurse and the patient flow in a primary healthcare facility. Based on our observation, a typical staff nurse works in a day between 9 a.m. and 3 p.m. There was much dynamicity in her work pattern in terms of the blood pressure measurement in a number of patients and record in the registers. A typical NCD staff nurse workflow (Figure 1) peaks between 9 a.m. and 12 p.m. with a greater number of patients waiting. There were also fluctuations in the number of patients they counseled.

Figure 1.

Nurse's workflow on a typical day in a primary care government health facility in India in 2019.

In addition to the workflow of a staff nurse, we mapped the patient movement, data entry process, and description of the wait time based on the observation at the small and large facilities as per the number of patients being consulted every day (Figure. 2.)

Figure 2.

Patient flow in different primary care government health facilities in India in 2019.

Storyboarding

Based on our field visits and experiences from the simulation clinic, we adopted a visual, data-driven storyboard technique that illustrates a healthcare worker workflow in a typical public health facility. We assumed a staff nurse of a PHC as part of our storyboard technique since they represented the majority of app users. Storyboarding is a visual narrative of an end-to-end story of how a staff nurse hears about the Simple app for the first time, their thoughts on using the app in their workflow, and how they would teach a colleague to use Simple. This narrative focused on using an app and encompassed the user's workflow. We sketched the key moments of the healthcare workers where we brought in facts from the user interviews and observations. We sketched the 11 key moments that reflected the healthcare workers’ experience. In each moment, we listed a healthcare worker's concern observed in our field visits and user interviews (Figure 3). We published our storyboard on our documentation site and printed out each frame. For the developers, the storyboard really helped build empathy with healthcare workers and provided them with real context. The storyboard was a reference for the app we were building and how it would affect healthcare workers. As a tool, the storyboard fostered the participation of all stakeholders in the information system design process and helped us all to make better, user-centered decisions.

Figure 3.

Storyboard illustrating a typical day of a staff nurse in a government primary health center in India in 2019.

The following were the key reflections of the storyboarding:

The app is one of the several tools a health worker uses in a busy clinic of anxious patients.

Healthcare workers will have little attention on the app; hence, it should be easy to use with less duplication of effort.

It is challenging to navigate the patient data through the combination of prescription slips, patient ID cards, and mobile device.

Simulated clinic

Following the story boarding, we simulated a clinic and conducted roleplaying as staff nurse, doctors, and patients to understand how a digital information system could affect a busy clinic. Simulated clinics helped the implementation and tech team to understand the challenges of using them in public health facilities. The detailed plan and tasks of our simulation clinic are explained in the Supplemental material.

Co-creation

Co-creation, a participatory design technique, was centered around the voice of the healthcare worker and included them during the design process. We roughly sketched our app and chose a few designs to be taken to the field. We took prints of our designs on paper, called paper prototypes (Figure 4). We visited the health facilities and asked the staff nurses to pick which paper prototype design idea they find interesting and documented the reason. We asked each healthcare worker to pick their three favorite design ideas and explain their choices. These explanations were the key to the whole co-creation process. Some of their explanations are as follows:

“I absolutely need this (an idea), no one appreciates our hard work, this is so motivating,’’ “Oh! Stock of medicines? How will you get this?” (Staff nurse X, Health facility Y)

“Oh! Can you show me daily updates? This will be super helpful in cross-checking if everything is updated.” (Staff nurse X, Health facility Y)

Figure 4.

Process of preparing and selecting paper prototype design ideas in building the Simple information system, 2017–2022. From left: Designing the app layout by hand, making paper prototype design and selecting the prototype.

We observed some suggestions for improvement in our design ideas, few examples are as follows:

“Could we see a list of patients who missed a follow-up visit?” (Staff nurse A, Health facility B)

“Can we add a list of patients who we called but who never came for a follow-up?” (Staff nurse AY, Health facility BX)

Some of the key lessons we learnt from co-creation were.

Paper prototypes helped us focus the healthcare workers’ attention on the content, not the design.

The low-fidelity paper prototypes also set the bar low; thus, nurses felt comfortable criticizing the ideas.

Since they chose from many ideas, there was no pressure to be right or wrong. Thus, nurses and doctors felt involved in the decision-making process behind an app they use daily.

Paper prototypes effectively shifted their mindset to imagine scenarios and creatively suggested how the Simple app could improve their work life.

Development phase

Based on the discovery phase, we identified the field requirement, context of the user (healthcare workers), and role of the Simple information system over the work environment. Designers liaised with the developers to build the Simple information system.

Usability test

We conducted 31 tests to determine whether or not a newly introduced feature was understood correctly and documented any apprehension on the new feature. One of the usability tests on a feature of listing overdue patients to visit the health facility is explained in this section. The overdue tab in the Simple app lists patients who missed their visit to the health facility. We provided the option to the user to call the patient and mark the outcome of the call. Based on the outcome of the call, the patient was categorized as pending to call, agreed to visit, reminded to call later, removed from the list, and had no visit in 1 year. We introduced a search bar and sections on the abovementioned categories in the overdue tab. We spoke to five users from four districts of different states to evaluate their responses on introducing this feature. All five users were clear about the meaning of the categories and functionality of the categories.

“All patients should be downloaded, not just patients who are yet to be called. Because these lists are shared with ANMs etc, and they will need an extensive list”. (Staff nurse XN, Facility YM)

All five users expected all patient names to be downloaded, regardless of their category. Most users preferred the new improvement in the design with a search bar and the categories for overdue patients (Figure 5)

Figure 5.

Improvements in a feature of Simple with its rating by users.

Usability testing helped us understand and make decisions on the key features of Simple, such as QR code-based patient retrieval and inclusion of overdue list with call facility.

Like app improvement, we introduced a new navigation system in the Simple dashboard. We evaluated the new feature of the dashboard among five dashboard users who were program managers supporting the hypertension control program in their respective states. We obtained feedback on the existing dashboard design and functionality. Four out of five users could use the existing dashboard design comfortably. However, they all reported certain concerns: repetition of the content across the dashboard, difficulty navigating the reports section, and lack of training materials for dashboard users and their restrictions to visualize the data based on their roles. We found a 3.4 out of five satisfaction score of the existing dashboard (Figure 6), where the responses were recorded in a 1–5 Likert scale (1—very dissatisfied and 5—very satisfied). We improvised the concerns expressed by the users in our new design. We shared the new dashboard design prototype through a link to the five users. All five users found navigation easier in the newer dashboard design and unanimously preferred the new one over the existing one.

“I will definitely prefer this over the current dashboard. It feels easier to use - I was able to find information more quickly.” (Program manager A, District B)

Figure 6.

Tasks provided to the users in usability testing for the Simple dashboard, India Hypertension Control Initiative 2021.

All five users found downloading line lists to be a very useful feature. Identifying the facility/administrative block toggle button was not immediately apparent to three users. This limited their overall experience and did not allow them to explore the newly introduced design fully. Users opined a score of 4.3 out of five for the new design.

As part of usability testing, we provided tasks to the users on specific scenarios related to the dashboard. Users were asked a series of quick questions related to the navigation of the dashboard. Some of the questions and their responses were mentioned in Panel #4.

All five users could easily identify the facilities registering hypertension patients. Except for one, four users could complete the task within 5 seconds of finding the facility registering hypertension patients using Simple. While displaying the number of facilities using the Simple app, three out of five users opined to view the denominators of each facility type.

We also documented the suggestions related to the dashboard from the users:

“If a peripheral health centre is not implementing the program, it is relatively better than a larger health facility not implementing the program. If we are able to find out if a large facility is not implementing the program, we can draw our focus to resolving this issue.” (Program manager, District Y)

Usability testing helped us corroborate the users’ interaction with the dashboard and obtain their suggestions for improvement.

User interviews

During the development, we obtained feedback from healthcare workers on the developed features through user interviews. We conducted 11 rounds of user interviews in the development phase for various functionalities and features of the system. One of the features we introduced was the instant search of patients in the Simple app instead of typing the full name or phone number. We interviewed five users in three districts of various states to evaluate their experience with the instant search and understand its influence on the user's work speed. Four of five users shared that instant search had positively affected their work as it helped reduce the time to search for patients. None reported delay in loading results. One of the users opined:

“Earlier, we spent much time entering the patient's full name and then hitting ‘Next’ to see a patient list. Now, it automatically appears as we type out a few letters. This has made our work faster.” (Staff nurse XA, facility YB)

One user shared that if they accidentally entered after the patient's name, it affected the search results, as was also considered during instant search. Three of five users shared that the overall performance of the app had improved after the recent app updates. We received a suggestion of a keyboard up screen whenever adding details to register a patient, such that this nudge mandated the user to complete the patient details.

A/B testing

While designing the dashboard on the selection of the report output, we did A/B testing with five public health managers. We compared two report concepts and obtained their feedback on which concept was useful. We did a card-by-card analysis of the key reports to be displayed in the dashboard. Regarding the implementation status of the program, four out of five program officers reported Concept A as self-explanatory and appealing. All five program officers opined on the facility's requirement of the break-up of indicators. With respect to the registration status, Concept A was preferred by four out of five officers. One of the officers suggested that adding a comparison of the registration status among districts within a state was useful.

“We can show officials that with similar conditions, this district's coverage is at 15%. We can learn from the top district what they're doing well.” (Program officer D, District E)

Three out of five officers suggested re-ordering information on the cards into 1) estimated hypertension population, 2) total registered patients, and 3) patients under care.

“In one picture, the district official should know what the contribution of each block towards the coverage. Coverage status is an important indicator.” (Program officer B, District C)

While we obtained views on the report card on the blood pressure control status, there were differences in how it was visualized.

“During the district progress meeting, I'll need to show the bar graphs that display month-on-month progress. However, in review meetings and field visits, the maps will be useful since it highlights the block's control rate.” (Program officer Y, District Z)

Simple was built with the Fast Healthcare Interoperability Resources (FHIR) standard. The FHIR standard is a set of guidelines for exchanging health information across health information systems.

Android application features

The Simple android application has four main features: patient tab, overdue patient list tab, progress tab, and drug stock reporting.

On the patient's tab: Users register a new patient with a QR code card linkage. At the time of registration, the user could record the age, address, phone number, diagnosis, co-morbid conditions, blood pressure reading, blood sugar values, and drugs prescribed. Patient follow-up is also done on the patient's tab by scanning the QR code or manually searching the patient by name or phone number. During the follow-up, it is enough for the user to record the blood pressure or blood sugar values and update the drugs prescribed.

Overdue patient's tab: Patients who did not visit the due date at the registered health facility are listed here with the number of days overdue.

Progress tab: The progress of registrations and follow-up daily, monthly, and yearly are summarized. Patient's treatment outcome reports about the proportion of patients under controlled, uncontrolled, and missed visits are listed here.

Drug stock reporting: In the progress tab, a featured button is placed to enter the details of drug stock at the end of every month by each facility.

Dashboard features

The Simple dashboard has five main sections: Reports, Facility comparison trends, Drug stock, Overdue patients, and Administrative tools.

Reports: The user could visualize the program indicators, such as monthly registered patients, proportion of patients under controlled, uncontrolled, and missed visits. Quarterly and monthly cohort reports on the treatment outcomes of patients under care could be visualized. Users could drilldown the reports by district, block, and facility level.

Facility trends: The user could visualize and compare the facilities on its performance based on the treatment outcomes. Users could identify the facilities requiring additional support and attention to improve the treatment outcomes of their patients.

Drug stock report: Tracking of drug stock by facility, block, and district for hypertension and diabetes is viewed by users; based on the number of registered users, the number of patient days the drug stock could be observed for better planning in drug logistics.

Overdue patients: This section captures and displays patients who are overdue by block and facility. Users could download the list of overdue patients under this section to follow-up either in field or through phone.

Administrative tools: Managing the users of the Android application and other access of dashboard users is done in this section. Apart from user approval, managing the medication list, adding facilities, and bulk import of patients could be done using the admin tools. Users can access the training resources and materials under this section.

Deployment phase

We adopted the iterative deployment and development processes to obtain feedback on the overall app performance and specific features. This enabled us to document how the application responded to field conditions when introducing a new update or feature.

Pulse check interviews

We regularly reached out to the users (healthcare workers) at regular intervals to understand their pressing issues with the app, the features they like the most, and other field needs related to the app. Due to CoViD-19, we reached out to the users via telephone. We conducted 15 pulse check interviews with the healthcare workers. Each interview lasted for an average of 15 minutes.

In a pulse interview conducted in February 2022 among five Simple users, the average user satisfaction rating was 4.2 out of 5 on the app's overall functionality (Figure 7). We adopted 3 as the lowest and 5 as the maximum score on the user satisfaction scale. After introducing an instant search feature, none reported that it slowed down the app's performance. All opined it was easy to search for the patient. The users provided recommendations on the design of the overdue list. Three out of five users were concerned on the time-consuming process of securing calls from the app.

Figure 7.

Satisfaction score by the users by time on the overall performance of the Simple app, 2017–2022.

As of October 2022, over 24,31,962 hypertension and 8,99,829 diabetes patients had already been registered in the information system of 10,017 health facilities across India. We found that the median duration of entering a new patient visit in the app was 78 seconds, and a follow-up patient visit was 14 seconds.

The usability five-point scoring on user satisfaction derived a 4.3 score for the dashboards. Four out of five random users completed the task of downloading the patient line list and cohort reports from the dashboards. When testing the user satisfaction among the app users (i.e. seven out of eight times), the average satisfaction score remained above 4 out of 5.

In October 2022, the median duration of registering a new patient into the app was 50 seconds, and recording a follow-up visit took 14 seconds. Over the last 2 years, quarterly short interviews with 100 app users indicated that seven out of eight times, the average satisfaction score remained above 4 out of 5. Usability tests of Simple dashboard designs with five dashboard users derived a 4.3 score on a five-point scale. Testing also found that four out of five test participants completed the tasks of downloading patient line lists and cohort reports satisfactorily.

Discussion

We designed, developed, and deployed a point-of-care application, called the Simple app, to improve hypertension and diabetes management in the government health facilities of India. We observed that the health workforce utilized well the Simple information system with high usability. The health workers were satisfied and completed the task while providing patient care. Simple operates with the best industrial standards, including offline-first application, free open-source software, compatibility with FHIR standards, and user-centered development standards.

Of the various non-communicable diseases, the burden of hypertension and diabetes is very high in India. We could not identify any literature documenting the experience of deploying a real-time information system at scale in a public health program in low-resource settings. Hence, we need to consider the scale and volume of patients while designing the information system. If we take the example of hypertension in India, it is the most common condition for which the adult population may seek treatment in primary care. Nearly 200 million people with hypertension live in India. As per recent estimates, only 14.5% of people with hypertension are under treatment.⁴ Therefore, there are 29 million people under treatment whose care must be monitored regularly to avoid premature deaths. Assuming 50% of these patients are under care in government health facilities, nearly 15 million people with hypertension visits must be recorded to monitor their care and outcome. This will continue to increase every year. Even if they visit at least three times per year, then every year, the data of nearly 45 million visits will be recorded by any means of information system. For every patient, if only three details (e.g. blood pressure, data of visits, and drugs prescribed) are recorded, then 135 million data points for every year are recorded for 15 million patients visiting government health facilities. This data will need to be recorded every year until their lifetime. Assuming 20 years of visit, there will be nearly 400 million data points. The abovementioned estimates are for hypertension alone. Adding data generated from diabetes patients’ visit increases the size much more. The information system is expected to convert data to useful information to track key indicators, such as proportion of registered patients under regular care and proportion of patients under care who achieved treatment goals (e.g. proportion under control at the facility, district, state, and national levels). The same has been mentioned by the WHO guidance document on monitoring the framework of NCDs.⁵¹ A robust digital information system is a necessity to generate basic information from the generated data of such size over a period of time. Health workers at the ground level enter these data during patient visits at each time. Therefore, data accuracy is largely driven by the user's acceptance.

We designed and developed Simple considering the health care providers working at government health facilities. We utilized techniques and methods to identify the user requirement, experience, and usability of our digital information system, Simple. These techniques are collectively called user-centered design or approach. They are well utilized in non-health industry products, especially digital products, to improve the user experience and utilization. Spotify is a music-streaming industry with 205 million active subscribers across the globe. It invested well in user research mixed methods and improvised their products.⁵² Airbnb is a digital platform that connects individuals requiring accommodation as a guest to hosts offering their accommodation for rent. Airbnb adopted experience designing to tell the story of a customer at each moment and the ideal outcome in a technique, called storyboarding. The project, called “Snow White,” listed the emotional moments a customer experiences in their platform.⁵³ Both examples provide insight into harnessing UCD methods to improve usability and user experience. We adopted these user experience methods and storyboarding techniques in designing and developing the information system.

User experience study

Multiple factors play a role in determining the usage of a digital health application in a real-world health setting. In delivering medical care to people with hypertension and diabetes, digital health is a tool for improving the quality of care. Implementing a digital health application is a complex intervention with multiple components and contextual factors.⁵⁴ We adopted user experience study methods to understand the contextual factors that enable or halt the usage of a digital health application.^55–57The user experience study methods were conducted in an iterative discovery, development, and deployment phase cycle. The key user considerations during these phases were captured to improve the usability of the Simple application.

Agile

Traditional project management techniques in software development, such as the waterfall model,^58,59 depend on stepwise development, completely specifying the requirements, designing, and testing the system. Anticipating requirements in advance through expert input and developing a tool that delivers for healthcare workers sounds enticing. However, it still misses the key pragmatic needs of users in the field. The uncertainty and variability nature of a dynamic healthcare environment limits the usage of the waterfall method. Therefore, we adopted the agile technique with UCD throughout the development cycles. Iterative development not only helped us come up with a user-centered application, but also provided us with the opportunity to understand the field functionality of the application. The implementation of the agile method in digital health interventions brought an effective user-centered design.^22,60

User-centered development

In developing the application, we harnessed methods, such as co-designing and user interviews, to deploy a user-centered point-of-care digital health application. The end users’ views and perspectives played a larger role in the interface and, most importantly, in the operational aspect of the end product. User-centered development is considered as one of the best software development practices. As per health design thinking, the UCD plays a significant role in the functional design of equipment, product, or service.^61–63 The user-centered design, aka human-centered design, is a process where users are involved collaboratively and inclusively.⁶⁴ The inclusiveness of users in the development brought the context of using Simple in a busy clinic.

Usability

Ample evidence in the literature supports that poor usability of the health information system is a crucial factor linked to failure.^65–68 Our usability evaluation of the application and the specific features clarified our stand on how to keep the features minimal and maximize functionality. Usability testing is considered as the best industrial practice to improve user experience.^37,69,70 The best usable product level up from a minimally viable product to a maximum lovable product by the users. The practice of usability testing in digital health is to be considered a mandate. A well-usable digital health product improves efficiency and saves lives compared to any other IT applications.

With a high proportion of hypertension and diabetes in India, detecting, treating, and performing a follow-up of patients at primary care comprise a low-cost, rapid, and reliable intervention.⁷¹ Therefore, providing a reliable information system in primary care is crucial for two main reasons, that is, patient monitoring during follow-up and program monitoring in achieving outcomes. The provision of real-time feedback about the treatment adherence by patients and the monitoring of patient cohorts by facility or geography to achieve the program outcomes in real time are critical.⁷²

Exercising UCD methods require dedicated teams to design, program, and support end-users. We did not study the scalability of our development strategy, which is one of the major limitations of our study. Although we observed a within-group change in the usage behavior of the Simple information system, we did not compare it with another information system to determine the effectiveness in registering and perfroming a follow-up with the patients. This is another limitation of our study.

Conclusion

Our experience documented the advantages of designing, developing, and deploying a highly usable and user-friendly mobile application to achieve program outcomes. Agile methodology and user-centered design supported well the successful implementation of a digital health application in busy health facilities. We recommend that digital health practitioners utilize UCD product or service development methods. Our study also suggests that digital health researchers must explore the determinants of using an information system in the public health context. Transdisciplinary knowledge exchange activities could facilitate conversations between public health researchers and digital health, bringing better digital health applications.

Supplemental Material

sj-docx-1-dhj-10.1177_20552076241250153 - Supplemental material for Discovery, development, and deployment of a user-centered point-of-care digital information system to treat and track hypertension and diabetes patients under India Hypertension Control Initiative 2019–2022, India

Supplemental material, sj-docx-1-dhj-10.1177_20552076241250153 for Discovery, development, and deployment of a user-centered point-of-care digital information system to treat and track hypertension and diabetes patients under India Hypertension Control Initiative 2019–2022, India by Parasuraman Ganeshkumar, Aarti Bhatnagar, Daniel Burka, Kiran Durgad, Ashish Krishna, Bidisha Das, Mahima Chandak, Meenakshi Sharma, Roopa Shivasankar, Anupam Khungar Pathni, Abhishek Kunwar and Prabhdeep Kaur in DIGITAL HEALTH

Footnotes

Contributorship

GP, AB, DB, KD, AK, MC, RS, AP, AK, and PK were involved in work design. AB, AK, BD, and MC were involved in data acquisition and collection. GP, DB, MS, RS, AP, AK, and PK were involved in data analysis and interpretation. GP, AB, RS, and PK were involved in manuscript preparation. All authors were involved in manuscript review and editing.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Indian Council of Medical Research.

Ethical approval

This study was approved by the Institutional Human Ethics Committee, ICMR-NIE (NIE/IHEC/201709-02).

Guarantor

PK.

ORCID iDs

Parasuraman Ganeshkumar

Anupam Khungar Pathni

Supplemental material

The supplemental material for this article is available online.

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Supplementary Material

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Discovery,development,and deployment of a user-centered point-of-care digital information system to treat and track hypertension and diabetes patients under India Hypertension Control Initiative 2019–2022,India

Abstract

Background

Methods

Results

Conclusion

Keywords

Introduction

Methods

Discovery phase

Development phase

Deployment phase

Human ethics consideration

Data analysis

Results

Discovery phase

Storyboarding

Simulated clinic

Co-creation

Development phase

Usability test

User interviews

A/B testing

Android application features

Dashboard features

Deployment phase

Pulse check interviews

Discussion

User experience study

Agile

User-centered development

Usability

Conclusion

Supplemental Material

sj-docx-1-dhj-10.1177_20552076241250153 - Supplemental material for Discovery, development, and deployment of a user-centered point-of-care digital information system to treat and track hypertension and diabetes patients under India Hypertension Control Initiative 2019–2022, India

Footnotes

Contributorship

Declaration of conflicting interests

Funding

Ethical approval

Guarantor

ORCID iDs

Supplemental material

References

Supplementary Material