Background and Significance
Long-term care (LTC) services face several challenges due to population aging, which
has become an ongoing trend in many developed countries. An information system (IS)
can reportedly improve the efficiency and effectiveness of service provision procedures;
therefore, developing and implementing a well-designed LTCIS may help LTC facilities
enhance their service quality and performance.
In the past, the waterfall method, a system development life-cycle method, was frequently
used in health care settings; the system development process for this model includes
identifying problems and objectives; determining information requirements; analyzing
system needs; designing the system; and developing, testing, implementing, and evaluating
the system.[1]
[2]
[3] However, a major shortcoming of such methods is the difficulties in identifying
all requirements prior to system development.[4]
Information is an essential element in IS development[5]; therefore, information flow analysis has been applied in the health care field
for identifying clinical information requirements. Patient flow analysis (PFA) is
a flow mapping technique centered on patients for identifying patient flow and improving
the care process.[6] The core of PFA is care process improvement; therefore, PFA is usually combined
with other tools, such as time and motion studies or computer simulations, for enhancing
efficiency.[7]
[8] Unertl et al[9] developed the information flow model for chronic disease care, highlighting that
the patient is the information hub. Their method allows visualization of the interaction
of information between related health care providers; however, it does not focus on
plotting the health care workflow. Another model was developed by Wei and Courtney,[5] who applied information flow to identify information management functions, information
sets, nursing processes, and care collaboration required by registered nurses (RNs)
in LTC services. Their approach clearly maps the RN workflow and the actions of the
related service providers, but it is limited in that the information requirements
are centered on RNs.
Meeting user requirements is critical for IS development.[5] Identifying the different information requirements of various care providers can
be challenging in the collaborative LTC environment. Design thinking (DT) is the application
of design approaches by multidisciplinary teams to solve an existing problem; it is
used in various fields.[10] The delivery of health care services almost always requires an interdisciplinary
team, such as a combination of nurses, nurse practitioners, resident physicians, fellows,
and attending physicians in the hospital setting.[9] DT has been applied in health care for developing innovative solutions to various
problems such as the management of chronic obstructive pulmonary disease, diabetes,
caregiver stress, and posttraumatic stress disorder as well as changes in system processes,
such as nursing handoffs and drug–drug interaction alerts.[11] Wang et al[12] applied DT to design a data quality rule in a health care facility for identifying
data errors. DT also has been integrated into IS development to better identify customer
needs, requirements, and environments and to incorporate them into system analyses.[4]
[13]
DT is usually used for creating human-centered products that prioritize the development
of empathy for users, and it involves working in collaborative multidisciplinary teams.[11]
[14] From the process perspective, the core of DT is empathy toward the end user based
on contextual observation, user stories, or scenarios[15]; from a methodological perspective, the most suitable approach in the DT field is
the service blueprint (SB) one. An SB helps visualize the service process from the
user's perspective.[16]
[17]
[18]
SBs have been used in many industries to visualize the service process and interactions
between customers and service providers.[18]
[19]
[20] Several field-specific modifications to SBs have been proposed for achieving greater
consistency across disparate service fields, such as product–service systems, product-extension
services, and online-to-offline services.[19]
[21]
[22]
[23] The existing SB approaches have weak interaction with collaborative teams. Although
O'Connor et al[24] used an SB to design mobile devices, they used an original SB and focused only on
the interaction between mobile devices and users. Holdford[25] used a pre-existing SB to clarify pharmacy service processes.
Those designing LTC systems should consider service providers' preferences.[26] LTC services are provided not only by an interdisciplinary team but also by a professional
service-driven (PSD) team; all services are provided after an assessment is made by
health care providers, such as physicians, nurses, social workers, and therapists.
The pre-existing modified SB versions do not fit the LTC setting because LTC services
are a PSD system in which all services are provided on the basis of professional assessment
of residents' health status and application of residents' comprehensive health-related
information to enhance care efficiency. In this study, we propose a PSD SB approach
that suits the collaborative multidisciplinary nature of LTC. We also demonstrated
the value of this approach through a case LTC facility by incorporating the facility's
main daily care activities into the approach.
Methods
PSD SB Approach
LTCIS can assist with the health care team's daily operations; thus, both administrators
and clinicians should actively participate in the selection process to ensure that
the system reflects the requirements of their daily operations and practices. The
system selection process should be an interdisciplinary effort that involves all relevant
stakeholders in the proposed system.[3] LTC services are delivered by multidisciplinary professionals including health care
professionals,[5]
[27] and an SB visualizes the service process and depicts the interactions among people,
processes, and related resources.[19]
[20] Therefore, an SB is suitable for collecting information requirements related to
service delivery by LTC professionals.
A traditional SB presents a service system through a flowchart that centers on the
customer perspective and separates service activities into frontstage and backstage
activities.[20]
[28] Such an SB not only depicts the service delivery process from the customer's viewpoint
to present the service flow but also clarifies touchpoints and interactions across
the entire service process to enable employees to understand the association between
their tasks and other parts of the system. Thus, an SB helps service providers better
understand their jobs and responsibilities.[19]
[20]
In an SB, a two-dimensional approach is used to portray the service process, with
the horizontal axis representing the chronology of customer and service provider activities
and the vertical axis act as demarcation among three distinct areas of actions (i.e.,
frontstage, backstage, and support process) or three distinct lines, including the
(1) line of interaction, which differentiates customer actions from frontstage service
provider actions; (2) line of visibility, which differentiates visible actions performed
by frontstage employees from backstage activities; and (3) line of internal physical
interaction, which differentiates backstage activities from the internal support process/related
resources.[18]
[22]
[25]
To render the PSD SB approach more comprehensive, enterprise architecture (EA) is
referenced in this study. EA is software system architecture that provides a high-level
view for holistically managing the interaction of an enterprise with its IS.[29]
[30]
[31]
[32]
[33]
[34] It separates the essential elements of software as business process, information,
application, and technology and infrastructure.[29]
[33]
[35]
[36]
[37] It is also concerned with identifying stakeholders' requirements when the whole
architecture is being developed.[36]
[37]
[38]
[39]
[40]
The proposed PSD SB approach uses some essential EA elements to translate the three
distinct areas of action (or lines) of the SB into five layers: LTC service delivery,
service providers (actors), input information, output information, and LTCIS-related
applications. Thus, seven elements (symbols or parts of symbols in a flow diagram)
are used for visualization ([Fig. 1]): LTC activity, activity flow, service providers (actors), input information, information
flow, output information, and related data files. To emphasize the interaction of
process and information, we split our information layer into layers for input and
output information. The details of the five layers are provided as follows:
Fig. 1 Long-term care PSD SB—daily care activities. PSD, professional service-driven; SB,
service blueprint.
LTC Service Delivery Layer
This layer is similar to the business or process layer of EA; all LTC services are
visually profiled in this layer. LTCIS focuses on integrating and supporting the work
of various service providers.
The purpose of LTC services is to help individuals maintain or improve their physical
functions and life quality. These services include assistance related to the activities
of daily living (ADLs), instrumental ADL, and health maintenance tasks. RNs have identified
the LTC facility's care process, which comprises assessment, outcome identification
(decision making), planning (care plan development), implementation, and evaluation.
LTC facilities may use any of the various instruments available for assessment of
resident health status.[41] Comprehensive geriatric assessment is a validated method for assessing the health
status of frail residents of LTC facilities, documenting cognition, mood, mobility,
function, appetite, weight, bowel and bladder function, medical conditions, and medications.[42] The nursing process is an information-driven process that involves history taking
and comprehensive assessment of residents (demographic data, medical history, health
assessment, and care needs) and their nursing care plan (comprehensive assessment,
nursing goals, interventions, and evaluation).[5]
[43]
Actors Layer
Services in LTC facilities are provided by RNs, physicians, nurse attendants, social
workers, physical therapists, dieticians, and pharmacists.[27] The actions of all the essential actors (stakeholders) are considered in this layer;
however, RNs and the nursing process are the ones that are crucial to the LTC service
flow.[5]
Input Information Layer
This layer involves information retrieval and verification. Before providing LTC services,
service providers must retrieve relevant details from related applications for validation,
such as basic information of residents, their care plan, and assessment data.
Output Information Layer
This layer creates and maintains records. LTC service providers are required to create
records after history taking and assessment; this process is called “output information”
in the PSD SB approach.
LTCIS-Related Application Layers
Input information is retrieved from LTCIS-related applications upon request from LTC
service providers. The IS creates or stores output information in the related applications
after service providers have finished their activities.
Seven Elements
-
PSD activity: A rectangle represents a service provider activity. For example, LTC RNs play a key
role in tending to daily care, and social workers are responsible for leading individual
or group activities, such as structured group exercise. The rectangle expresses such
critical work activities (for symbols, please see [Fig. 1]).
-
Activity flow: A thick arrow represents an activity flow. A PSD system requires the cooperation
and teamwork of various service providers. The thick arrow symbolizes this interaction.
-
Actors: A circle represents a service provider. Although LTC service providers include RNs,
physicians, nurse attendants, social workers, physical therapists, dieticians, and
pharmacists, the major actors in the nursing process are RNs and nurse attendants.
-
Input information: A parallelogram represents the input reference information used by actors when performing
services, such as an RN performing a holistic assessment or checking a care plan during
daily care.
-
Information flow: A thin arrow represents an information flow. Information is generated or required
by various PSD activities and actors and includes input information, output information,
and data files.
-
Output information: The document symbol represents output information. This information is created after
an actor performs a service. In LTC settings, critical output information includes
resident records, daily care activity records, nursing records, etc.
-
Data files: The database symbol is represented in the data file within the IS. The main functions
of LTC facilities include nursing, social work, rehabilitation, nutrition, and medicine
administration. All input information can be retrieved from the data file, and all
output information is stored on the data file.
Illustrated LTC Service Activity and Demonstrated LTC Facility
LTC services include diverse health care, personal care, and supportive services that
meet the needs of older adults or adults with limited self-care ability. Commonly
provided services are social work, mental health care, therapies (physical, occupational,
and speech), nursing, pharmacy, and diet and nutrition services.[44] Those services could be delivered through different types of activities such as
assistance with ADLs (e.g., dressing, bathing, and toileting); instrumental IADLs,
(e.g., recreation/activity leading/structured group exercise); and health maintenance
tasks such as vital sign measurement, rehabilitation, diet and nutrition assistance,
and medication administration.
We selected daily LTC service activity to discuss a required activity performed by
an interdisciplinary health care team; this activity included assistance with ADLs
and IADLs.
To illustrate our PSD SB approach, we applied it at case facility: Noble Healthcare
and Rehabilitation, Taipei, Taiwan (referred to herein as N). The case demonstration
method has been used in studies on product service systems, product extension service
systems, and online–offline systems.[20]
[21]
[22]
[45] A case study is an empirical research method that chiefly involved using contextually
rich data from real-world settings to investigate a focused phenomenon.[46] Case studies investigate a particular phenomenon and generally employ multiple data
sources.[47] Data collection is a crucial step in a case study.[47] We not only reviewed the literature to obtain a complete picture of daily LTC activities
but also conducted unstructured interviews to gain a comprehensive understanding of
daily living services in an LTC facility.
Our LTC case facility: N was founded in 2003 at Taipei, Taiwan. At this LTC facility,
the care process consisted of following government requirements and passing a regular
4-year evaluation in 2017. The governing body of N is required to employ full-time
RNs and nurse attendants for LTC; in addition, N hires part-time dieticians and has
contracts with rehabilitation therapists, physicians, and pharmacists.
The daily LTC activities corresponding to key actors (health care providers) are as
follows: vital sign measurement, nurse attendant or RN; daily living assistance, nurse
attendant or RN; recreation, social worker; rehabilitation, rehabilitation therapist;
diet and nutrition, nurse attendant and dietitian; medication, RN. Regarding medication,
RNs are the key actors in administering medicine and completing medication administration
records according to a physician's medical prescriptions at an LTC; physicians (contracted)
visit residents at an LTC facility every month and update medical prescriptions; pharmacists
(contracted) review and dispense medicine according to a physician's prescriptions
every week at an LTC facility. We were unable to gain permission for interviews with
the pharmacist (contracted) and physician (contracted); an RN and senior administrative
staff members were familiar with the physician and pharmacist service flow at N, so
the senior administrative staff members were recruited as interviewees. Finally, the
interviewees were nurses, nurse attendants, social workers, dieticians, and senior
administration staff (who helped to clarify the physician and pharmacist service flow).
The interview questions are as follows: Could you share your daily LTC service protocol
at N? Which information needs to be checked prior to performing your service? Which
information do you need to record or input into the system when finishing your service?
Do you have any suggestions related to your job? Data collected from the case study
interviews were used to inform the PSD SB for LTC environments. The interviewees and
interview results are summarized in [Table 1].
Table 1
Summary of the interview results
|
Key actors and interviewees
|
Activities
|
Time/frequency
|
Input information
|
Output information
|
|
Nurse attendant/registered nurse (RN)
Interviewees: nurse attendant and RN
|
Vital sign measurement (blood pressure, respiration rate, pulse rate, and body temperature)
|
1. Before 9:00 a.m. and 4:00 p.m. every day.
2. Emergency situation
|
Vital sign measurement
|
Resident care record
|
|
Nurse attendant/RN
Interviewees: nurse attendant and RN
|
Daily living assistance (e.g., tube feeding, changing posture, and condition observation)
|
Every 2 hours
|
1. Holistic assessment
2. Care plan
|
1. Nursing records
2. Daily care records
|
|
Social worker
Interviewee: social worker
|
Recreation activity leading, structured group exercise
|
Twice a week (individual activities according to the evaluations)
|
Psychosocial assessment
|
1. Mood status record
2. Recreation activity record
3. Group exercise record
4. Activity involvement record
5. Complaint management record
|
|
Rehabilitation therapist (contracted)
Interviewee: rehabilitation therapist
|
Rehabilitation
|
Twice a week (individual activities according to the evaluations)
|
1. Rehabilitation assessment
2. Physical and occupational therapy assessment
3. Rehabilitation plan
|
1. Rehabilitation activity record
2. Therapeutic activity record
|
|
Nurse attendant/nutritionist (part time)
Interviewee: nurse attendant and nutritionist
|
Diet and nutrition
|
1. Three meals and snacks per day
2. Nutrition assessment
|
1. Meal order
2. Nutrition assessment and nutrition plan
|
1. Meals record
2. Intake/output record
3. Nutrition status record
|
|
RN/pharmacist (contracted)/physician (contracted)
Interviewee: RN and senior administration staff
|
Medication administration
|
1. Check every day according to doctor's advice and medicine list
2. Contracted physician: once a month
3. Contracted pharmacist: once a week
|
Medication preparation
|
Medication administration record (MAR)
|
Note: Input and output information that are underlined are required by the Taiwanese
government.
Results
The daily care activities summarized from the LTC-related literature and interview
results are presented in [Table 1] and [Fig. 1], which are based on the PSD SB approach. The input and output information entries
that are underlined in [Table 1] are required per Taiwanese government regulations. [Fig. 1] presents the following five layers and seven elements:
LTC Service Delivery Layer
When residents wake up in the morning, LTC facility health care teams regularly perform
daily care activities, including vital sign measurement, daily living assistance or
daily care, recreation, rehabilitation, diet and nutrition assistance, and medication
assistance.
Actors Layer
The important actors in case N are RNs, nurse attendants, social workers, and rehabilitation
therapists. Regarding diet and nutrition activity, the nurse attendant plays a major
role in delivering meals according to the meal order, and dieticians (part time) play
a secondary role in providing nutrition assessment and a nutrition plan for each resident
every 3 months. Regarding medication, RNs play the major role for completing medication
administration records; physicians (contracted) visit residents only once a month,
and pharmacists (contracted) review and dispense medicine once a week.
Input Information Layer
-
Measurement of vital signs: Nurse attendants or RNs checked residents' identification
information and measured vital signs afterwards.
-
Daily care or daily care assistance: RNs or nurse attendants checked residents' holistic
assessment data and nursing care plans before providing or assisting with residents'
daily care.
-
Recreation: Social workers checked residents' psychosocial assessment records to,
for example, determine the recreation program content and design structured group
exercises.
-
Rehabilitation: These tasks involved rehabilitation therapist–led assessments, occupational
therapy assessments, and rehabilitation for determining the ideal rehabilitation approach.
-
Diet and nutrition: Nurse attendants checked the residents' meal orders for delivering
meals, and dieticians refer to residents' current status and prior nutrition assessments
and nutrition plans for setting up appropriate meal orders.
-
Medication: RNs checked medication preparations to administer medicine.
Output Information Layer
LTC service providers created and uploaded related records after performing pertinent
services:
-
Measurement of vital signs: These were updated in the residents' information file
after each measurement.
-
Daily care or daily care assistance: Nurse attendants or RNs updated the nursing records
and daily active records for each resident.
-
Recreation: Social workers updated recreation activity records, activity involvement
records, mood status records, group exercise records, and (if relevant) complaint
management records in the information file of each resident.
-
Rehabilitation: Rehabilitation therapists updated rehabilitation activity records
and therapeutic activity records.
-
Diet and nutrition: Dieticians assessed the nutritional status of residents and developed
a nutritional plan and meal order. Nurse attendants prepared meals according to the
meal order and updated the meal records and intake–output records.
-
Medication: Physician (contracted) reviewed or updated residents' prescriptions when
visiting facility N every month. Pharmacists (contracted) dispensed the medicine to
facility N every week. Nurses completed a medication administration record after delivering
medications.
LTCIS-Related Application Layer
An LTCIS should incorporate residents' basic clinic demographic information and related
nursing, social services, rehabilitation, nutrition, and medication services to support
daily living services. An IS should not only provide relevant input information but
also update the records after service delivery. All applications are interconnected
within the main system at an LTC facility. Because the nursing process is the core
of LTC, the nursing applications function in the IS should include a comprehensive
geriatric assessment function, nursing plan, nursing records (output information),
and evaluation sheets.
Discussion and Future Works
SBs can be used to explore service requirements; many modified SB techniques have
been proposed for investigating product–service systems, product-extension services,[21]
[22]
[45]
[48] in-flight services, meal order services, and online-to-offline services.[19]
[20]
[23]
[49] These modified SBs permit only weak interaction among service providers and thus
do not adequately consider multidisciplinary service settings. PFA can map health
care processes by redesigning the process or incorporating related technologies to
improve care efficiency[6]
[50]; however, PFA chiefly concerns service workflow analysis and lacks service requirement
analysis. The characteristics of LTC services are different from those of other service
fields; LTC is a PSD system in which service delivery is guided by assessments with
health care providers, and such services are always interdisciplinary.[9]
[27] Thus, traditional SBs, modified SBs, and PFAs all have limitations when applied
to the IS requirements of LTC facilities. Our proposed PSD SB can not only help visualize
health care delivery processes but also identify the information requirements of interdisciplinary
service providers. These advantages of the PSD SB can be attributed to three characteristics:
(1) an SB visualizes the nature of service processes.[18]
[19]
[20] (2) It incorporates four essential elements of EA—process, information, application,
and technology.[29]
[33]
[35]
[36] (3) An “actors” layer can be added to an SB to help identify related interdisciplinary
LTC service providers. The PSD SB is easily interpretable and can be used to gather
and visualize multidisciplinary LTC service providers' IS requirements. Future studies
should verify our results in different PSD settings in the health care industry.
Medical information technology has been rapidly progressing. Electronic medical records
(EMRs) and electronic health records (EHRs) are shared with individuals in many developed
countries[51]; online data sharing is one approach for establishing a patient–health care provider
relationship.[52] The application of Internet of Things (IoT) technology has increased considerably,
especially in vital sign monitoring.[53] Raban et al[54] reported that health care facilities can use EMRs as reminders to check and remove
medication patches. Accordingly, LTS IS can be further integrated with EMRs or EHRs
and connected with a main LTC system through a data exchange interface for relevant
applications. Wearable devices can be integrated into the input information layer
through a transmission interface or an application that connects such devices to a
main LTC system to reduce staff workload.
Many wearable devices use the IoT for data communication.[55] Verdouw et al[56] proposed six viewpoints, one of which is the IoT layer viewpoint in which the layers
are specifically defined for an IoT-based system, including IoT application functions,
capability to support application functions, network connectivity data for specific
application, and device and gateway capability. Given that Unified Modeling Language
(UML) is one of the common EA mapping tools for EA practitioners and that Verdouw
et al[56] clearly defined the IoT layer, we will work to combine our PSD SB approach with
Kruchten's 4 + 1 views,[57] the concept proposed by Verdouw et al,[56] and UML-related diagrams. We also will demonstrate the application of this approach
to an LTC facility to visualize the information requirements for enhancing the PSD
SB's acceptance.
Conclusion
LTC services are based on assessments by health care providers, and they are performed
by an interdisciplinary health care team. When developing a robust LTCIS, developers
must consider an LTC's characteristics. The study referred to DT, SB, and EA, proposed
a PSD SB, and illustrated the LTC daily care activity, the major LTC care service,
at facility N. The proposed PSD SB comprises five layers (service delivery, actor,
input information, output information, and LTCIS-related applications) and seven elements
(LTC activity, activity flow, actors, input information, information flow, output
information, and LTCIS-related applications). The PSD SB could help visualize the
service processes of various actors, demonstrate actors' input and output information
requirements, and present suggested LTCIS-related applications. Therefore, we believe
that the PSD SB approach can not only explore the interdisciplinary service team's
IS requirements but also serve as a new mapping tool for visualizing service processes.
