Introduction

Dementia is a progressive neurodegenerative syndrome that affects people’s cognitive and physical abilities [1]. In advanced stages, patients with dementia (PwD) lose self-sufficiency [2]. Day centers provide PwD and their family caregivers with comprehensive care [3], offering services such as nursing, nutrition, geriatric, and physiotherapy [4]. In these areas, formal caregivers provide healthcare for patients with dementia by assisting them in their basic needs and applying cognitive and physical therapies [5].

Patients with dementia receive specific treatment in day centers depending on certain indicators [3,4,5,6]. For instance, cognitive therapies may be decided based on the stage of the disease progression. Furthermore, daily decisions about patient care are based on indicators such as patient performance on therapies. In this context, the monitoring of PwD during their stay in the day center becomes crucial to support decision making [7, 8].

The literature reports a variety of proposals to monitor PwD. Among the monitored aspects are medication adherence [9], potentially dangerous activities [10, 11], levels of physical activity [12], and cognitive task performance [13]. However, research focused on monitoring PwD who receive comprehensive care in day centers has received less attention. Among the very few research efforts are [14] that monitors patients’ movement trajectories and [15] that monitors patients’ heart and respiratory rates as well as their time out of bed in order to detect anomalies in their physical condition. Nonetheless, most proposals for patient monitoring are designed for home settings and to monitor specific aspects of patients, e.g., pain [16]. Hence, the identification and monitoring of data useful for understanding the progression of PwD and supporting decision-making in day centers to provide better care is usually disregarded.

Alzaid is a technological platform for assisting formal caregivers in monitoring PwD. Alzaid aims to support the understanding of the progression of PwD in day centers through data consolidation and visualization. In particular, Alzaid consists of a mobile health monitoring application (see [4]); a Web application for patient data management; and a data visualization tool (see [17]). Alzaid allows formal caregivers to monitor and record patients’ behavioral, clinical, and health-related data as well as patients’ performance on cognitive and physical therapies, among other aspects. Alzaid was initially designed and implemented based on the requirements elicited from day center Dorita de Ojeda, which is a member of the Mexican Federation of Alzheimer (FEDMA). The implementation of Alzaid started in 2018, and since 2019 the formal caregivers of day center Dorita de Ojeda have been using Alzaid to support patient monitoring and decision-making. Alzaid is the result of a continuous research effort to provide formal caregivers of day centers with technology-based tools to support the care of PwD, see [4] and [17].

Even though the monitoring process of day center Dorita de Ojeda involves several areas (such as nursing and physiotherapy areas) that may be required for the care of PwD, to the best of the authors’ knowledge, there are no standard guidelines for the monitoring process of PwD to which day centers could adhere. Consequently, the adoption of the original version of Alzaid by other day centers faces a series of challenges such as agreeing on data models and terminology because different day centers may have distinct needs and may even involve different processes for patient care and monitoring. Moreover, by standardizing electronic healthcare records is expected to improve the quality of healthcare (as in [18]).

This work is an effort towards a standard monitoring process of PwD in the context of four day centers of the Mexican Federation of Alzheimer. In addition to day center Dorita de Ojeda, the requirements of three other day centers (uninvolved in Alzaid’s original/initial design) were elicited and unified to laid the foundation for the redesign of Alzaid with the aim of benefiting a larger population of PwD.

Alzaid was redesigned using a participatory design methodology consisting of three phases: i) eliciting requirements from day centers; ii) unifying functional requirements; iii) constructing and evaluating a high-fidelity prototype of the redesigned version of Alzaid using the Technology Acceptance Model 3 (TAM-3) [19].

This work contributes with:

  • A first effort towards a standard monitoring process of PwD in the context of day centers of the Mexican Federation of Alzheimer, which resulted from unifying requirements for monitoring patients of four day centers.

  • The design and evaluation of a technological platform for assisting formal caregivers in monitoring PwD that considers requirements of four Mexican day centers.

Materials and methods

The methodology used consists in three phases (Fig. 1).

Fig. 1
figure 1

Methodology for redesigning and evaluating Alzaid

Full size image

Phase 1. Elicitation of requirements from day centers

This phase consisted in eliciting requirements from formal caregivers and administrative staff of day centers uninvolved in the design of the original version of Alzaid.

Participants

The directors of twenty-one day centers (belonging to FEDMA) were invited by email to include their day centers as participants in the study. The eligibility criteria were as follows: i) the day center must have facilities for patient care; ii) its formal caregivers must have basic computer skills; and iii) it must be willing to participate in all the study sessions. Table 1 shows the three day centers that accepted the invitation and met the eligibility criteria.

Table 1 Participants of Phase 1: Elicitation of requirements from day centers
Full size table

Instruments

Instruments of Phase 1:

  • The original version of Alzaid that served as a starting point to generate interest in participants.

  • A questionnaire (Table 2) based on the Technology Acceptance Model 1 (TAM-1) [20] to evaluate the original version of Alzaid.

  • A semi-structured interview to investigate the processes and data requirements of the areas associated with patient care in day centers (Table 3).

Table 2 A questionnaire (based on the TAM-1) to evaluate the original version of Alzaid
Full size table
Table 3 A semi-structured interview to investigate the patient monitoring process of participant day centers
Full size table
Fig. 2
figure 2

A remote session with formal caregivers of a day center

Full size image

Procedure

  1. 1.

    Introduction and evaluation of the original version of Alzaid. Participants attended a remote training session to get familiar with the original version of Alzaid (Fig. 2) and evaluated it using the questionnaire reported in Table 2.

  2. 2.

    Requirements elicitation. Participants were interviewed (Table 3) with the aim of eliciting new requirements and/or detecting differences between their processes and the processes for monitoring PwD reflected in the original version of Alzaid. Data collected from the interviews was analyzed using the grounded theory methodology [21] to develop business process models associated with patient care and monitoring. Grounded theory was selected because it is a systematic methodology that generates a theory based on evidence [22], which has been used in software requirements engineering [23]. The resultant substantive theories and business process models of the participant day centers helped to identify new and complementary requirements as well as potentially conflicting requirements for the redesign of Alzaid.

Phase 2. Unification of requirements

This phase consisted in consolidating and unifying the requirements.

Participants

The participants were mainly directors and coordinators from the four involved day centers (Table 4). This participant type helped to reach agreements among the day centers because the participants were capable of introducing changes to their day centers’ processes.

Table 4 Participants of Phase 2: Unification of requirements
Full size table

Instruments

Instruments of Phase 2:

  • A questionnaire to guide the unification of requirements (Table 5).

  • A questionnaire to validate the requirements agreed (Table 6).

Table 5 Questionnaire to guide the unification of requirements
Full size table
Table 6 Questionnaire to validate the unified requirements
Full size table

Procedure

  1. 1.

    Consolidation of requirements. The requirements were consolidated into a list of new, complementary, and conflicting requirements.

  2. 2.

    Unification and resolution to conflicting requirements. A remote session was held with the participant day centers to resolve conflicts and unify requirements using the questionnaire reported in Table 5. Requirements were also refined and complemented.

  3. 3.

    Validation of agreed requirements. The list of unified requirements was discussed and validated by the participant day centers in a second remote session using the questionnaire reported in Table 6.

Phase 3. Construction and evaluation of the high-fidelity prototype

The objective of this phase was twofold. First, to construct a high-fidelity prototype of the redesigned version of Alzaid. Second, to evaluate the perceived usefulness, perceived ease of use, output quality, and job relevance of the high-fidelity prototype in addition to other relevant constructs.

Participants

The participants involved were directors, coordinators, and formal caregivers from the participant day centers (Table 7).

Table 7 Participants of Phase 3: Evaluation of the high-fidelity prototype of Alzaid
Full size table

Instruments

Instruments of Phase 3:

  • A video explaining how the high-fidelity prototype works (Fig. 3).

  • A questionnaire based on the TAM-3 to evaluate the high-fidelity prototype (Table 13 of Appendix B).

  • A single question to verify the compliance with the unified requirements.

Fig. 3
figure 3

Video to explain how the prototype of the redesigned version of Alzaid works

Full size image

Procedure

  1. 1.

    Construction of the high-fidelity prototype. A high-fidelity prototype of the redesigned version of Alzaid was designed and developed based on the unified requirements.

  2. 2.

    Evaluation of the high-fidelity prototype. Personnel of the four participant day centers evaluated the high-fidelity prototype. A video explaining its functionalities was shared with the participants. After becoming familiar with the prototype, the participants were instructed to complete a 51-item questionnaire based on the TAM-3 (Table 13 of Appendix B).

The participants’ Likert responses were analyzed using Shapiro-Wilk’s tests to assess normality and one-sample Wilcoxon signed-rank tests to assess the significance of the medians.

Results

In this analysis, a p-value less than 0.05 was considered statistically significant. The results of Shapiro-Wilk’s tests revealed that, for each evaluation construct, the participants’ Likert responses are not normally distributed. Consequently, one-sample Wilcoxon signed-rank tests were used to evaluate the significance of the evaluation constructs’ medians.

Results of the elicitation of requirements

The evaluation of the original version of Alzaid and the semi-structured interviews provided a basis for eliciting new requirements. The results of one-sample Wilcoxon signed-rank tests revealed that the medians of the responses on the perceived usefulness (\(\mu _{1/2}\) = 6) and perceived ease of use (\(\mu _{1/2}\) = 6) of the original version of Alzaid (Fig. 4) are significantly greater than a specified median of 5. Then, overall, the original version of Alzaid was perceived as quite likely to be usable and quite likely to be useful regardless of the fact that the processes related to patient monitoring of participant day centers were different from the monitoring process for which the original version of Alzaid was designed. As shown in Fig. 4, responses different from the median of 6 were considered outliers according to Tukey’s rule. Fig. 5 shows a word cloud (generated using a bag-of-words model) of the comments made by the participants in relation to the original version of Alzaid. As observed, the comments of participants were mostly positive and related to usability and usefulness.

Fig. 4
figure 4

Evaluation of the original version of Alzaid using the TAM-1

Full size image
Fig. 5
figure 5

Word cloud of free-text comments made by participants regarding the original version of Alzaid

Full size image

The data from the semi-structured interviews was analyzed using the grounded theory methodology, which resulted in explanatory diagrams (Fig. 6), substantive theories (Table 8), and business process models (Figs. 10, 11, and 12 of Appendix A) for each day center. It should be noted that the business process models were validated by personnel of the participant day centers.

In particular, the qualitative analysis based on the grounded theory and the business process modeling led to the identification of new requirements for the redesign of Alzaid, which are listed in Table 9.

Fig. 6
figure 6

Explanatory diagrams of a day center Asociación Alzheimer Tampico-Madero A.C., b day center Centro Gerontológico Ryanmas A.C., c day center Alzheimer México I.A.P.

Full size image
Table 8 Substantive theories of the participant day centers
Full size table
Fig. 7
figure 7

Day centers’ level of agreement on the unification of requirements

Full size image

Results of the unification of requirements

The outcomes of the requirement unification process include i) results related to new/complementary requirements (Table 9) and conflict detection for the redesign of Alzaid; ii) results regarding a set of resolutions to the conflicts in requirements from the involved day centers (Table 10); and iii) results about the day centers’ level of agreement on the unification of requirements (Fig. 7).

Table 9 Areas according to each day center
Full size table
Table 10 Resolution to conflicting requirements
Full size table
Table 11 Resolution to conflicting requirements
Full size table

The requirements elicited were analyzed and grouped by area, which were defined by common agreement among the participant day centers (see the first column of Table 11).

As shown in Table 9, requirements were categorized according to the day center from which they were elicited and reorganized into: i) new requirement, i.e., requirements absent from the original version of Alzaid; ii) complementary requirement, i.e., requirements present in the original version of Alzaid, but that need to be adjusted; iii) requirement in conflict with the original version and/or another requirement; and iv) requirement already in the original version of Alzaid. Overall, 31 new requirements were elicited. In addition, only five original requirements required adjustments, which were mostly related to complementing information. Regarding the conflicts in requirements, these were related to metric scales and terminology.

Conflicting requirements were discussed in a remote session by all the involved day centers, which were asked for feasible conflict resolutions with the aim of unifying requirements. The mutually agreed resolutions are reported in Table 10. There was a myriad of resolutions ranging from using standard metric scales to agreeing on terminology. However, in several cases, the involved day centers requested to add a free-text field, so they can have freedom of choice as to what and how to record certain information.

The mutually agreed resolutions were validated by participants holding management-level positions in each of the involved day centers. As shown in Fig. 7, the overall median was 6 indicating that the involved day centers agreed on the unification of requirements. The results of one-sample Wilcoxon signed-rank tests revealed that such median of 6 (agree) is significantly greater than a specified median of 5 (somewhat agree), which confirmed its significance.

Results of the construction and evaluation of the high-fidelity prototype of the redesigned version of Alzaid

Figure 8 presents screens of the high-fidelity prototype of the redesigned version of Alzaid developed from the unified requirements reported in Table 12. This prototype was evaluated by 14 participants using the TAM-3.

The results of one-sample Wilcoxon signed-rank tests indicate that the medians of the perceived usefulness construct (\(\mu _{1/2} = 6\)) and of the perceived ease of use construct (\(\mu _{1/2} = 6\)) are significantly greater than a specified median of 5. This confirms that the redesigned version of Alzaid was perceived as quite likely to be useful and as quite likely to be usable (Fig. 9).

Fig. 8
figure 8

High-fidelity prototype of the redesigned version of Alzaid

Full size image
Table 12 Summary of unified requirements validated by the participant day centers
Full size table
Fig. 9
figure 9

Evaluation of the high-fidelity prototype of the redesigned version of Alzaid using the TAM-3

Full size image

Moreover, regarding Alzaid’s relevance and the participants’ intention to use it, the results of one-sample Wilcoxon signed-rank tests revealed that the medians of the job relevance construct (\(\mu _{1/2} = 7\)) and the behavioral intention construct (\(\mu _{1/2} = 7\)) are significantly greater than a specified median of 5. These results suggest that the high-fidelity prototype was perceived as (at least) quite likely to be relevant in the job of monitoring PwD and as (at least) quite likely to be used by the participants (Fig. 9).

Furthermore, regarding the quality of Alzaid’s output, the result of an one-sample Wilcoxon signed-rank test suggests that the median of the output quality construct (\(\mu _{1/2} = 6\)) is significantly greater than a specified median of 5. This indicates that the participants perceived that it was quite likely that the quality of Alzaid’s output is high (Fig. 9).

Based on the evaluation constructs’ medians of the TAM-3, other relevant results presented in Fig. 9 indicate that the participants:

  • Perceived that it is quite likely that senior management of their corresponding day center support the use of Alzaid.

  • Could complete the job using Alzaid.

  • Would find the use of Alzaid between slightly and quite likely to be enjoyable.

  • Found that it is extremely likely that the results of using Alzaid are apparent to them.

Conclusions

The relevance of this work is that (to the best of the authors’ knowledge) it is the first effort towards a standard monitoring process of PwD in the context of day centers of the Mexican Federation of Alzheimer (FEDMA). This resulted from unifying their requirements for monitoring patients, which were implemented in the redesign of Alzaid, a technological platform for assisting formal caregivers in monitoring PwD.

Overall, the participant day centers agreed on the unification of requirements. The resultant redesign of Alzaid was perceived by personnel of four participant day centers as quite likely to be useful, quite likely to be usable, and quite likely to be relevant in the job of monitoring PwD. Furthermore, in general, the participants considered the output of the redesigned version of Alzaid to be of high quality.

It is acknowledged that some participants interacted with and evaluated both the original version of Alzaid and the redesigned version of Alzaid, which may have induced a bias in the evaluation of the redesign version of Alzaid. Another limitation of this study is that only members of FEDMA participated in the redesign of Alzaid, which is an effort towards a standard monitoring process of PwD.

The implementation of the redesigned version of Alzaid based on the unified requirements is in progress. Hence, future work involves analyzing its actual adoption by the formal caregivers of the participant day centers.