Home HemoDialysis 2.0

A mobile app prototype that enhanced the user experience of the patients dialyzing at home

Project Goal

Hemodialysis patients find it difficult to do dialysis independently at home. The ultimate aim of the Home Hemodialysis 2.0 project is to encourage the dialysis patients to choose the home dialysis option over in-clinic dialysis. The goal is only possible by improving the experience of the home dialysis patients.

The Problem

Based on the patients’ feedback and stakeholders’ interview, the foundational problem behind the patients’ difficulties is the current instructional manual which has not been updated for a long time and it is difficult for an ordinary person to understand and follow the information flow because of the medical terms. Home hemodialysis patients not only experience difficulty with the instruction manual, but also face problems like machine setup (i.e., tubing), needling and troubleshooting.

UX Methods

The design thinking methodologies and human-centered design principles are applied in addressing the design challenges. In specific, the analogies approach helped in structuring and developing the insights from the patients’ perspectives. As a result, the mobile application was designed and prototyped. That will allow the patients to learn about hemodialysis even before they start the in-clinic training.

The application contains interactive games, augmented reality (AR) technology, quizzes and videos to educate the patients about machine setup and how to perform the needling process. The mobile application will be given to the patients right after they are added to the waitlist for home dialysis in-clinic training. The waiting period will act as a pre-training or preparation phase that makes the patients get ready emotionally and mentally for the home dialysis treatment. Chronic Kidney Disease patients have less immunity, so home hemodialysis will be a better option to choose especially during situations like COVID19. The Home Hemodialysis project 2.0 explored the five stages of the dialysis process and focused on the first two stages, which were machine setup and AR needling. In the future, the prototype for the other three stages of dialysis (i.e., treatment monitoring, troubleshooting and cleaning) should be designed and developed into a fully functional mobile application with AR/VR technology.

The bubble diagram helped by focusing on the right problem. Hemodialysis is one of the types of dialysis treatment. This treatment has two options: in-clinic dialysis and home dialysis. The purpose of the project is to enhance the home hemodialysis patient experience. It can be achieved by addressing three key issues, such as improving the existing manual step, providing instant in-person help when they encounter a problem in the dialysis machine, and enhancing ways that make the patient journey enjoyable during the treatment time. To further narrow down, the manual of the home hemodialysis is taken into account and is classified into five levels namely machine setup, AR needling, treatment monitoring, troubleshooting, and cleaning. From the five levels, machine setup and AR needling were considered the major problem since they are the basic steps in doing the dialysis process. The bubble diagram was useful in exploring the breadth and depth of the project.

Stakeholder Map

Stakeholders are classified into two major categories. There are primary stakeholders who directly get the benefit out of the project and secondary stakeholders who benefit indirectly.

Primary stakeholders

Primary stakeholders of the project are nurses, technologists, patients’ family members and program coordinators.

Secondary Stakeholders

The secondary stakeholders are nephrologists, OHIP and psychiatrists.

Design Journey

The design process plays an important role in identifying and addressing user goals, deeper needs and problems. Those identifications will help design a better patient experience and provide a path to achieve user satisfaction. The Design Thinking methodologies and Human-Centered Design principles are employed in exploring the design solution. Overall, this section speaks about the step-by-step design process and methodologies in finding and solving the design challenge. The design challenges might be a user’s hidden needs, concerns and barriers in achieving the goal.

User Research

During the site visit to the hospital, the self-exploration of the dialysis units and stakeholder interview were conducted. From the self-exploration activity and stakeholders’ interview, it was discovered that tube connection in the dialysis machine was not the only problem. Few other critical problems were encountered by the patients, such as self-needling, troubleshooting, cleaning, and following the information flow on the instruction manual. Furthermore, based on the user research study, it was discovered that the machine setup is the foundational problem.

As a first step, the dialysis unit at the St. Joseph’s Healthcare Hamilton was visited to explore the home hemodialysis machine that is currently used by the dialysis patients. To know the patients’ key issues, with the help of nurse Trish’s guidance, the dialysis machine was set up by referring to the instructions manual. This was a great lesson in identifying the patients’ struggles with the manual. From this self-exploratory activity, it was discovered that patients with non-medical backgrounds will find difficulty in using the instructions manual since the instructions manual has lots of medical terms. As a next step, the user interviews were conducted with the patients, nurses and technologists throughout the design process and we noted down the insights. One of the key learnings that were discovered initially was that we thought tube connectivity was the only major challenge in the dialysis process. However, in the user research, it was discovered that a bunch of other challenges existed in the whole dialysis process such as needling, troubleshooting, and cleaning. The scope of the project crept as more user challenges were identified in the user research.

Patient’s Point of View

We conducted interviews with patients to get their feedback on the current home hemodialysis process. Some of the thoughts from patients are shared below as they quote:

“I did not find much difficulty in machine setup tube connections but as a newbie, I experienced difficulties in troubleshooting, needling, and cleaning processes. In particular, the self needling was challenging”

- John Brown, a new home hemodialysis patient, St.Joseph’s Healthcare Hamilton.

“I do the connections by reading the instructions from the manual. I find it hard to read and connect the machine simultaneously. Since the steps are not easy to remember.”

- MarieAnne, wife of patient Paul, who is in-clinic Hemodialysis training.

User Persona

Empathy Map

The user persona is created to understand the patients’ interactions with the dialysis machine to identify their hidden concerns and barriers that stop them from achieving the goal. The empathy map is developed to find out the patients’ deeper needs. From the empathy map and user persona, the two points are identified as follows:

1) Goal — The patients like to be independent

2) At some point, the patients feel uncomfortable with the home dialysis treatment

User Journey Map and Storyboards

We created the user journey map to identify the reasons behind the discomfort in the home hemodialysis process. In general, the user journey map explains the whole CKD process that patients go through from the diagnosis of kidney disease up until kidney transplant. Based on the journey map, the patients will have to do a 21 day in-clinic training before they independently start home dialysis. Using the journey map information, the current scenario storyboard is designed for patients who picked the home dialysis option. From the stakeholders’ feedback, the patients undergo a wait time before starting the actual in-clinic training. Based on the brainstorming session, it is discovered that the patients need additional attention on top of the in-clinic training. The potential future scenario storyboard is designed based on the insights gained from the user feedback.

Based on the user research, it was discovered that the patients need additional attention on top of the home hemodialysis one-on-one training. So, we decided to focus on specific problems.

Problem Statement

Home hemodialysis patients experience difficulties in machine setup, troubleshooting, and self-needling while doing the dialysis process independently at home because of the lack of a proper instructional manual. It makes them feel that the dialysis process is complicated and that makes them choose the simpler option which is to be an in-clinic patient.

How Might We Statements

We used HMW statements to explore possible ideas that can help us in solving the design challenge.

1) How might we help the dialysis patients to do hemodialysis independently at home?

2) How might we make the home hemodialysis process simple?

3) How might we convert in-clinic patients into home hemodialysis patients?

4) How might we enhance the patients’ experience and also make them feel safe?

Analogies and Ideation

The direction of the project was important in achieving user goals. The journey map, current, and future scenario storyboards gave an idea about the current patient experience, the areas that have to be improved, and an outline of the design solution. But those methodologies were not enough when it came to exploring the breadth and depth of the design challenges. To stay specific with exploring and developing the ideas, the analogies are used. The analogies helped in identifying the areas of opportunities that are involved in improving the patient experience.

We developed game levels which are digital interactive instruction manuals on how to perform the home hemodialysis. They consist of games and quizzes. The game levels are designed and developed based on the analogies. Game levels are used to educate and guide the patients in their home hemodialysis process. The ideation for the game levels came from the analogies. The implementation of design solutions should not create an extra burden for patients to learn and understand. Therefore, analogies were used to introduce the game levels which can be related to their previous experiences. Some of the analogies used here are trying a MacBook in an apple store, learning by playing, and training wheels.

The analogies used in this project to implement the design solution were:

1) Trying a MacBook in an Apple store

2) Learning By Playing

3) Training Wheels

From these analogies, we created the pre-training phase that is implemented during the wait time (i.e., Training wheels analogy), the mobile application with interactive games that educate the patients about the dialysis process right before they enter into the actual training (i.e., Learning by playing analogy). Finally, by using the application itself, they will experience the dialysis process (i.e., Trying a MacBook in an Apple store).

The reasons for using the analogy were as follows:

1) The solution should be relatable and easily understandable by the patients.

2) The implementation of the design solution should not make the patients put extra effort to learn.

3) It should be something similar to the patients’ past experiences.

4) The analogies were helpful to make us understand things from the patients’ perspectives.

Game Levels

When the analogies were completed, the next step was to find ways to implement them in the application. The ideas of the game levels were constructed by talking with the stakeholders at the hospital. They told us what were the most important things to focus on from the start until the end of the dialysis process. They told us mainly that setting up the machine properly is the most important step along with monitoring what is happening during dialysis as well as cleaning the machine after dialysis is complete to get it ready for the next time the patients need to use it. In addition, they mentioned that needling is a hard step for most of the patients because they all have fear and anxiety when it comes to inserting the needle in their arms. In addition, it takes a long time for the patients to build up the courage to insert the needle by themselves in their arms. But once they do overcome their fear, they get used to the needling process and become completely independent in this step. The last thing is troubleshooting which basically teaches the patients what to do when the alarm sounds off of the dialysis machine as there are plenty of reasons why the alarm goes off. The goal was to make all of these steps interactive and teach the patients using game levels how to deal with them because using games can make them learn faster, remember the steps easily, and could be more fun than reading about it in the manual. Once the entire application is built, the need for reading the manual will be eliminated because the app should have all the instructions that the patients require and should be extremely clear to follow and use.

Machine Setup

Since the machine setup was the most important step in the dialysis process, it was important to add as much information about it as possible to our application. The storyboards just told the patients in plain text on how to set it up. However, we learned that patients will learn much more quickly and easily if videos were included that showed them how to set up the machine. So we decided to edit the storyboards and added videos to it. When the stakeholders saw the new ones, they liked the idea of adding videos to teach them about the process. However, even though this was a great addition to the storyboards, we noticed that the game level was not interactive that much. Therefore, we thought about adding a picture of the machine with all the tools needed for the setup. Furthermore, so that the patients do not get confused when they open the game, we added instructions that will tell them exactly what to do so that they do not panic.

The goal of this game is to follow the instructions carefully and to drag around the tools to place them in their designated locations. When the instructions are completed, they will turn into the green to indicate so and will move to the next steps with the new instructions. By playing this game multiple times, the patients can memorize the correct order of how to connect the tubes because this kind of interaction will help them remember the steps easily when the time comes for the actual dialysis process. Once all the steps have completed, the patients can move on to learn about the next game level which is AR Needling.

AR Needling

Since the needling process was very scary to most patients, we needed to find ways to make it more fun to make them get used to it and overcome their fears. We decided to include videos that could show and teach the patients how the needles are inserted in the arms and at which angle as well as the removal of it when dialysis is complete. Furthermore, we thought about more ways to make the needling process extremely similar to reality and teach the patients in a more interactive way than just watching the videos. Therefore, we decided to use augmented reality to give the patients a feeling of actually injecting themselves. We first made storyboards to see how the process will go with the patients. After plenty of feedback was given to us from the stakeholders, we made some changes to the storyboards to make them very similar to the real needling step. These included the order of needling such as when to use the gauze, medical tapes, and needles as well as the places on the arm that they can insert the needle in. When we showed the stakeholders our storyboards, they were very excited about the augmented reality idea since it can teach the patients the real feel of needling and makes them get used to the process before they actually start dialyzing.

Treatment Monitoring

When we went to the hospital to see the dialysis process for ourselves, Trish, the charge nurse, told us that some numbers are important to monitor while dialyzing as they can inform the patients when they are done with the process and can tell them the amount of fluid cleaned. Monitoring is an important action that we wanted to add to our prototype. It includes watching videos about how to sanitize properly before touching the vascular system and check for signs of cold, redness, swelling, heat, tenderness, and drainage. The patients can learn about what they can do if they feel any of the signs below. They can click on each one to identify what might go wrong and how to fix the problem they have. That way they can feel more comfortable and independent while dialyzing.

In addition, the next part will show the patients what numbers they are supposed to focus on while dialyzing such as blood pressure, amount of fluid changed and the amount left, and blood flow.

The reason we decided to include monitoring as a game level is because it was an essential process to focus on and learn to know if something can go wrong when certain numbers on the screen change. If they have this kind of knowledge, the patients can fix the problem themselves with the solutions provided to make them feel proud that they were able to do this on their own.

Troubleshooting

This step was important because the instruction manual for the alarms was misleading at some points and did not cover all of the reasons why the alarm would sound off. We wanted to include a way for the patients to interact with the troubleshooting rather than just read it from the manual. We decided to add videos and a game that show the patients the different reasons why the alarm rings. When the alarm rings, the reasons show up in a list and the patients can click on any one of them instead of physically going through all of them in the manual to locate the actual reason. In addition, the patients will have access to the troubleshooting binder in the application and can click on it to see the causes and signs of each problem. If they find the problem that is most similar to the one they are facing they can click on it from the list and then the entire list will disappear to make sure that they are focusing on that certain problem to fix it. Once this happens, they can open the binder again and follow the steps to fix the issue.

Finally, the last interactive game we added to this game level was a quiz. When the patients become confident enough in their own skills and knowledge, they can test themselves with this quiz where they will have to order the correct steps of solving each potential problem and eliminating the choices that don’t belong (Troubleshooting 12).

As the patients keep playing this interactive game, they will become more familiar and memorize the various reasons and problems of why the alarm rings and will rely less on the binder to remember how to solve them.

Cleaning

Finally, cleaning was the last thing to focus on after completing the dialysis process. Trish told us that it is important for the patients to properly clean themselves and sanitize before and after using the machine. In addition, cleaning the machine and sanitizing it was necessary after dialyzing to make sure that it is free of any germs and is ready for the next time the patients decide to dialyze. We thought about how we can make this and we initially included videos to teach the patients how to clean to give them a visual sense of it. But we wanted to take it a step further and make it more interactive so that the patients can remember the steps faster. Therefore, we thought about adding 2 games in addition to videos that teach them what tools are required in cleaning the machine. In-game #1 the patients would need to drag around the tools closer to the dustbin. The dustbin would change color and open up if the tool was correct and wouldn’t change if the tool was wrong. Furthermore, they can drag the needle out of the figure. Game #2 will teach them how to react in certain situations to ensure their health and safety.

When we showed the final storyboards to the stakeholders, they were excited about them all because they told us that way the patients can learn plenty of steps in the dialysis process without even starting their own dialysis. In addition, if the patients are scared of certain steps, they now know what to expect and can feel more comfortable when the time comes for them to start dialyzing. Moreover, they liked how we will include all of these ideas into one application and couldn’t wait to see the initial prototype that we will make. All of these affirmations and motivational feelings made us feel that we were on the right track and we couldn’t wait to start prototyping.

Prototyping and Testing

The game levels are taken individually and explore the problems that patients face in each stage of the dialysis process (i.e., machine setup, needling, treatment monitoring, troubleshooting, and cleaning). Among the five stages, machine setup and needling are considered to be major issues based on the feedback from the user interviews. Furthermore, they are foundational problems of home dialysis since the rest of the stages are classified under minor issues. The wireframes are built using the design and prototyping tools like Sketch, Invision, Adobe XD and Photoshop. The testing was later conducted with the patients to gather their feedback. We refined the wireframes to be more tangible and interactive based on the tester’s feedback.