Integrating the results of user research into medical device development: insights from a case study

Relevance of distinctions and parallels between the US and EU guidelines for determination of comparative effectiveness and safety of the orally inhaled drug products

Approval of drug products for market registration warrants, among other data, evidence to support their safety and effectiveness in the target populations. The extent of investigations to provide the supporting evidence varies between the new innovator products and their follow-on versions generally referred to as Generic Drugs Products in the United States and Hybrids in the Europe. The new drug applications entail large data sets encompassing both nonclinical and clinical product developments. Safety and effectiveness in man is studied in sequentially phased clinical trials, including post marketing evaluations (Where applicable). However, for the generic/hybrid products the safety and effectiveness are established through determination of bioequivalence in head-to-head comparison between the originator and the follow-ons. Methods for documentation of bioequivalence for drug products that reach target site(s) through systemic circulation are aligned worldwide. However, establishing bioequivalence of orally inhaled drug products is complex as drug delivery to the local site(s) of action is independent of the systemic circulation. Documentation of bioequivalence gets further complicated due to the Drug-Device combination nature of these products. The guidelines for establishment of BE of locally acting orally inhaled drugs products vary among certain geographies. This article examines the scientific underpinning of distinctions and similarities between the US and EU guidelines.

Usability issues in the operating room - Towards contextual design guidelines for medical device design

Most usability assessments of medical devices describe the problems of individual devices in detail, but few account for the real context of use or provide designers with actionable guidelines for improvement. To fill this gap, this paper reports the results of a case study on the usability of operating room technologies and documents the creation of contextual design guidelines for operating room device design. We spent 64 h in a gynecological operating unit conducting interviews with staff and observing device use during surgery. With qualitative analysis methods and based on existing usability principles, we created 21 design guidelines for the operating room context. The new guidelines highlight interactions between multiple devices, staff members, as well as other contextual factors. While the guidelines require further validation, they can potentially support the creation of more safe, ergonomic, and intuitive medical devices.

Design thinking as an approach for innovation in healthcare: systematic review and research avenues

Design thinking has been increasingly adopted as an approach to support innovation in healthcare. Recent publications report design thinking application to various innovation projects, across medical specialties, including paediatrics, psychiatry, radiology, gastroenterology, oncology, orthopaedics and surgery, as well as to innovation in hospital operations and healthcare management. Current literature in the area typically focuses on single case descriptions. With the recent increase in the number of cases, there is an opportunity to assess multiple cases to identify patterns and avenues for further research. This study provides a systematic review of published design thinking projects in healthcare. The aim of the study is to provide an overview of how design thinking has been applied in the healthcare sector. Data collection was based on Institute of Scientific Information (ISI) Web of Science, PubMed and Scopus databases. The systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 32 original pieces of research was selected for analysis, being classified and assessed. The paper presents current status of research and practice from various perspectives, including the design thinking progression phase—inspiration, ideation, implementation—and the prevalence of design thinking tools. Avenues for further research include the need to increase focus on the inspiration phase, the opportunity for platforms for leveraging the integration of individuals in innovation projects, and the opportunity to enhance the role of lead users in healthcare innovation.

Participatory co-design of patient-reported outcome indicators and N-of-1 evaluation of a dressing glove for Epidermolysis bullosa

OBJECTIVE

In autosomal recessive dystrophic Epidermolysis bullosa, repeat blistering results in finger webbing and severe contractures of the hands. The aim of this study was to codesign patient-reported outcome indicators for hand therapy with patients, carers and clinicians, and use these to proof-of-concept test a novel dressing glove for recessive dystrophic Epidermolysis bullosa, with cost analysis.

METHOD

Qualitative interviews and focus groups with patients and carers generated content for the indicators. Validity and reliability were established through expert review, piloting and consensus between patients, carers and clinicians. The indicators were self-reported by patients before and while wearing the dressing glove in an N-of-1 study. Time for dressing changes and use of conventional products were also self-reported.

RESULTS

A total of 11 indicators were initially generated from the thematic analysis. Expert review, piloting and consensus involved six patients, five carers and eight clinicians (total n=19). Participants agreed 14 indicators, covering hand skin condition (n=4), webbing between the digits (n=4), experiences of wearing and changing dressings (n=2), hand function (n=2), wrist function (n=1) and hand pain (n=1). In Phase 3, 12 patients scored indicators before wearing the gloves and four patients completed scoring while wearing the gloves. Statistically significant improvements between pre-glove and with-glove periods were found for most participants' experience scores. Skin appearance also improved for most participants.

CONCLUSIONS

The indicators generated useful data, differentiation between scores and participants demonstrating proof-of-concept for patients with recessive dystrophic Epidermolysis bullosa who could wear the dressing gloves. The indicators are being used in routine practice, supporting clinical follow up, commercialisation and regulatory governance of the dressing glove.

Usability Assessment of an Innovative Device in Infusion Therapy: A Mix-Method Approach Study

Background: Flushing a venous access device is an important procedure to maintain their patency and prevent malfunctioning and complications. An innovative double-chamber syringe was developed, allowing for the assessment of catheter patency, drug delivery and final flush. This study aims to assess the usability of this new device, considering three development stages (concept, semi-functional prototype, functional prototype). Methods: An iterative methodology based on a mix-method design (qualitative and quantitative) enabled the assessment of the devices’ usability by their primary end-users. A usability questionnaire was developed and applied, along with focus groups and individual interviews to nurses. Results: The usability questionnaire integrated 42 items focused on four dimensions (usefulness; ease of use; ease of learning; satisfaction and intention to use). The initial psychometric findings indicate a good internal consistency and the conceptual relevance of the items. The scores seem to be sensitive to the usability evaluation of the medical devices in different stages of product development (with lower values on functional prototype evaluation), and related to nurses’ perceptions about functional and ergonomic characteristics. Conclusions: Quantitative and qualitative data provided a comprehensive overview of the double-chamber syringes’ usability from the nurses’ point of view, informing us of features that must be addressed.

Medical Device Development Process, and Associated Risks and Legislative Aspects-Systematic Review

Objective: Medical device development, from the product's conception to release to market, is very complex and relies significantly on the application of exact processes. This paper aims to provide an analysis and summary of current research in the field of medical device development methodologies, discuss its phases, and evaluate the associated legislative and risk aspects. Methods: The literature search was conducted to detect peer-reviewed studies in Scopus, Web of Science, and Science Direct, on content published between 2007 and November 2019. Based on exclusion and inclusion criteria, 13 papers were included in the first session and 11 were included in the second session. Thus, a total of 24 papers were analyzed. Most of the publications originated in the United States (7 out of 24). Results: The medical device development process comprises one to seven stages. Six studies also contain a model of the medical device development process for all stages or for just some of the stages. These studies specifically describe the concept stage during which all uncertainties, such as the clinical need definition, customer requirements/needs, finances, reimbursement strategy, team selection, and legal aspects, must be considered. Conclusion: The crucial factor in healthcare safety is the stability of factors over a long production time. Good manufacturing practices cannot be tested on individual batches of products; they must be inherently built into the manufacturing process. The key issues that must be addressed in the future are the consistency in the classification of devices throughout the EU and globally, and the transparency of approval processes.

Sousa L, Marques IA, Costa P, Cortez S, Carneiro F, Cruz A, Salgueiro-Oliveira A. Development of an innovative double-chamber syringe for intravenous therapeutics and flushing: Nurses' involvement through a human-centred approach

BACKGROUND

In nursing practice, flushing the catheters pre and post-drug administration is considered an important clinical procedure to prevent complications, and requires the use of several syringes to comply with international standards of care. We envisioned an innovative double-chamber syringe that enables the filling and administration of both solutions. Following current international recommendations, the development of new medical devices should integrate Health Technology Assessment. The Human-centred design is usually used for that assessment purposes, as a method that actively include end-users in the devices development process.

METHOD

Application of the Human-Centred Design through the involvement of nurses in the initial stages of the device development in order to accomplish the initial stages of Technology Readiness Level. A multi-method approach was used, including literature/guidelines review, focus groups with end-users and expert panels.

RESULTS

The involvement of nurses enabled the definition of user requirements and contexts of use, as well as the evaluation of design solutions and prototypes in order to accomplish with usability and ergonomic features of the medical device.

CONCLUSIONS

Significant contributions were made regarding the final design solution of this innovative double-chamber syringe.

Public preferences for using quantitative faecal immunochemical test versus colonoscopy as diagnostic test for colorectal cancer: evidence from an online survey

BACKGROUND

There has been interest in using the non-invasive, home-based quantitative faecal immunochemical test (FIT) to rule out colorectal cancer (CRC) in high-risk symptomatic patients.

AIM

To elicit public preferences for FIT versus colonoscopy (CC) and its delivery in primary care.

DESIGN & SETTING

A cross-sectional online survey in England.

METHOD

A total of 1057 adults (without CRC symptoms and diagnosis) aged 40-59 years were invited from an English online survey panel. Responders were asked to imagine they had been experiencing CRC symptoms that would qualify them for a diagnostic test. Participants were presented with choices between CC and FIT in ascending order of number of CRCs missed by FIT (from 1-10%). It was measured at what number of missed CRCs responders preferred CC over FIT.

RESULTS

While 150 participants did not want either of the tests when both missed 1% CRCs, the majority (n = 741, 70.0%) preferred FIT to CC at that level of accuracy. However, this preference reduced to 427 (40.4%) when FIT missed one additional cancer. Women were more likely to tolerate missing CRC when using FIT. Having lower numeracy and perceiving a higher level of risk meant participants were less likely to tolerate a false negative test. Most of those who chose FIT preferred to return it by mail (62.2%), to be informed about normal test results by letter (42.1%), and about abnormal test results face to face (32.5%).

CONCLUSION

While the majority of participants preferred FIT over CC when both tests had the same sensitivity, tolerance for missed CRCs was low.

Development of a Clinical Interface for a Novel Newborn Resuscitation Device: Human Factors Approach to Understanding Cognitive User Requirements

BACKGROUND

A novel medical device has been developed to address an unmet need of standardizing and facilitating heart rate recording during neonatal resuscitation. In a time-critical emergency resuscitation, where failure can mean death of an infant, it is vital that clinicians are provided with information in a timely, precise, and clear manner to capacitate appropriate decision making. This new technology provides a hands-free, wireless heart rate monitoring solution that easily fits the clinical pathway and procedure for neonatal resuscitation.

OBJECTIVE

This study aimed to understand the requirements of the interface design for a new device by using a human factors approach. This approach combined a traditional user-centered design approach with an applied cognitive task analysis to understand the tasks involved, the cognitive requirements, and the potential for error during a neonatal resuscitation scenario.

METHODS

Fourteen clinical staff were involved in producing the final design requirements. Two pediatric doctors supported the development of a visual representation of the activities associated with neonatal resuscitation. This design was used to develop a scenario-based workshop. Two workshops were carried out in parallel and involved three pediatric doctors, three neonatal nurses, two advance neonatal practitioners, and four midwives. Both groups came together at the end to reflect on the findings from the separate sessions.

RESULTS

The outputs of this study have provided a comprehensive description of information requirements during neonatal resuscitation and enabled product developers to understand the preferred requirements of the user interface design for the device. The study raised three key areas for the designers to consider, which had not previously been highlighted: (1) interface layout and information priority, as heart rate should be central and occupy two-thirds of the screen; (2) size and portability, to enable positioning of the product local to the baby's head and allow visibility from all angles; and (3) auditory feedback, to support visual information on heart rate rhythm and reliability of the trace with an early alert for intervention while avoiding parental distress.

CONCLUSIONS

This study demonstrates the application of human factors and the applied cognitive task analysis method, which identified previously unidentified user requirements. This methodology provides a useful approach to aid development of the clinical interface for medical devices.

[Analytical strategy for assessment of usability of medical devices from the user's perspective: a study of hemodialysis patients]

Studies have shown the importance of including the user's experience in measuring the usability of medical devices. Still, the user's assessment depends on the context of use for the treatment received. To measure the usability in such a way as to separate these effects and understand the sources affecting users' perceptions, the article proposes an analytical strategy that assesses the effect of the context of use on measuring the device's usability. Next, we create indicators that are free of these effects to understand the overall assessment of the device. Multivariate analysis of variance and exploratory factor analysis are used to achieve the objectives. The study is illustrated by means of a survey of 200 hemodialysis patients in hospitals and clinics in Porto Alegre, Rio Grande do Sul State, Brazil. The results suggest that assessment of the medical device differs (p < 0.05) according to the setting, fistula site, and patient's sex, age, and schooling. The setting influenced the most variables, including the degree of trust in the procedures. Three indicators were created: procedures, treatment setting, and device characteristics. The indicators allowed assessing which equipment brands, types of procedures, and treatment settings provide the best results. The method can be replicated in the assessment of medical devices, training health administrators, and assessing usability through summary indicators, besides identifying aspects to improve usability in medical treatment.

Robot-Assisted Fracture Surgery: Surgical Requirements and System Design

The design of medical devices is a complex and crucial process to ensure patient safety. It has been shown that improperly designed devices lead to errors and associated accidents and costs. A key element for a successful design is incorporating the views of the primary and secondary stakeholders early in the development process. They provide insights into current practice and point out specific issues with the current processes and equipment in use. This work presents how information from a user-study conducted in the early stages of the RAFS (Robot Assisted Fracture Surgery) project informed the subsequent development and testing of the system. The user needs were captured using qualitative methods and converted to operational, functional, and non-functional requirements based on the methods derived from product design and development. This work presents how the requirements inform a new workflow for intra-articular joint fracture reduction using a robotic system. It is also shown how the various elements of the system are developed to explicitly address one or more of the requirements identified, and how intermediate verification tests are conducted to ensure conformity. Finally, a validation test in the form of a cadaveric trial confirms the ability of the designed system to satisfy the aims set by the original research question and the needs of the users.

Human factors in the design of medical devices - Approaches to meeting international standards in the European Union and USA

This paper focuses on the challenges of meeting agency requirements as it pertains to the application of human factors in the medical device development (MDD) process. Individual case studies of the design and development process for 18 medical device manufacturers located in the US and EU were analyzed and compared using a multiple case study design. The results indicate that there are four main challenges in implementing international standards. These include a lack of direct access to users for the purposes of device development; a lack of understanding by users with regards to the impact of their feedback on the development process; contract formalities limiting user exchanges; and the attitude of clinical users directly impacting on the device developer's invitation to participate in the development processes. The barriers presented in this research have the potential to be resolved but only with greater commitment by both medical device users and developers.

Awareness, Interest, and Preferences of Primary Care Providers in Using Point-of-Care Cancer Screening Technology

Well-developed point-of-care (POC) cancer screening tools have the potential to provide better cancer care to patients in both developed and developing countries. However, new medical technology will not be adopted by medical providers unless it addresses a population’s existing needs and end-users’ preferences. The goals of our study were to assess primary care providers’ level of awareness, interest, and preferences in using POC cancer screening technology in their practice and to provide guidelines to biomedical engineers for future POC technology development. A total of 350 primary care providers completed a one-time self-administered online survey, which took approximately 10 minutes to complete. A $50 Amazon gift card was given as an honorarium for the first 100 respondents to encourage participation. The description of POC cancer screening technology was provided in the beginning of the survey to ensure all participants had a basic understanding of what constitutes POC technology. More than half of the participants (57%) stated that they heard of the term “POC technology” for the first time when they took the survey. However, almost all of the participants (97%) stated they were either “very interested” (68%) or “somewhat interested” (29%) in using POC cancer screening technology in their practice. Demographic characteristics such as the length of being in the practice of medicine, the percentage of patients on Medicaid, and the average number of patients per day were not shown to be associated with the level of interest in using POC. These data show that there is a great interest in POC cancer screening technology utilization among this population of primary care providers and vast room for future investigations to further understand the interest and preferences in using POC cancer technology in practice. Ensuring that the benefits of new technology outweigh the costs will maximize the likelihood it will be used by medical providers and patients.

Using the Analytic Hierarchy Process (AHP) to understand the most important factors to design and evaluate a telehealth system for Parkinson's disease

BACKGROUND

The assessment of a new health technology is a multidisciplinary and multidimensional process, which requires a complex analysis and the convergence of different stakeholders into a common decision. This task is even more delicate when the assessment is carried out in early stage of development processes, when the maturity of the technology prevents conducting a large scale trials to evaluate the cost effectiveness through classic health economics methods. This lack of information may limit the future development and deployment in the clinical practice. This work aims to 1) identify the most relevant user needs of a new medical technology for managing and monitoring Parkinson's Disease (PD) patients and to 2) use these user needs for a preliminary assessment of a specific system called PERFORM, as a case study.

METHODS

Analytic Hierarchy Process (AHP) was used to design a hierarchy of 17 needs, grouped into 5 categories. A total of 16 experts, 6 of them with a clinical background and the remaining 10 with a technical background, were asked to rank these needs and categories.

RESULTS

On/Off fluctuations detection, Increase wearability acceptance, and Increase self-management support have been identified as the most relevant user needs. No significant differences were found between the clinician and technical groups. These results have been used to evaluate the PERFORM system and to identify future areas of improvement.

CONCLUSIONS

First of all, the AHP contributed to the elaboration of a unified hierarchy, integrating the needs of a variety of stakeholders, promoting the discussion and the agreement into a common framework of evaluation. Moreover, the AHP effectively supported the user need elicitation as well as the assignment of different weights and priorities to each need and, consequently, it helped to define a framework for the assessment of telehealth systems for PD management and monitoring. This framework can be used to support the decision-making process for the adoption of new technologies in PD.

How many testers are needed to assure the usability of medical devices?

Before releasing a product, manufacturers have to follow a regulatory framework and meet standards, producing reliable evidence that the device presents low levels of risk in use. There is, though, a gap between the needs of the manufacturers to conduct usability testing while managing their costs, and the requirements of authorities for representative evaluation data. A key issue here is the number of users that should complete this evaluation to provide confidence in a product's safety. This paper reviews the US FDA's indication that a sample composed of 15 participants per major group (or a minimum of 25 users) should be enough to identify 90-97% of the usability problems and argues that a more nuanced approach to determining sample size (which would also fit well with the FDA's own concerns) would be beneficial. The paper will show that there is no a priori cohort size that can guarantee a reliable assessment, a point stressed by the FDA in the appendices to its guidance, but that manufacturers can terminate the assessment when appropriate by using a specific approach - illustrated in this paper through a case study - called the 'Grounded Procedure'.

Experiences of multidisciplinary development team members during user-centered design of telecare products and services: a qualitative study

Background

User-centered design (UCD) methodologies can help take the needs and requirements of potential end-users into account during the development of innovative telecare products and services. Understanding how members of multidisciplinary development teams experience the UCD process might help to gain insight into factors that members with different backgrounds consider critical during the development of telecare products and services.

Objective

The primary objective of this study was to explore how members of multidisciplinary development teams experienced the UCD process of telecare products and services. The secondary objective was to identify differences and similarities in the barriers and facilitators they experienced.

Methods

Twenty-five members of multidisciplinary development teams of four Research and Development (R&D) projects participated in this study. The R&D projects aimed to develop telecare products and services that can support self-management in elderly people or patients with chronic conditions. Seven participants were representatives of end-users (elderly persons or patients with chronic conditions), three were professional end-users (geriatrician and nurses), five were engineers, four were managers (of R&D companies or engineering teams), and six were researchers. All participants were interviewed by a researcher who was not part of their own development team. The following topics were discussed during the interviews: (1) aim of the project, (2) role of the participant, (3) experiences during the development process, (4) points of improvement, and (5) what the project meant to the participant.

Results

Experiences of participants related to the following themes: (1) creating a development team, (2) expectations regarding responsibilities and roles, (3) translating user requirements into technical requirements, (4) technical challenges, (5) evaluation of developed products and services, and (6) valorization. Multidisciplinary team members from different backgrounds often reported similar experienced barriers (eg, different members of the development team speak a “different language”) and facilitators (eg, team members should voice expectations at the start of the project to prevent miscommunication at a later stage). However, some experienced barriers and facilitators were reported only by certain groups of participants. For example, only managers reported the experience that having different ideas about what a good business case is within one development team was a barrier, whereas only end-users emphasized the facilitating role of project management in end-user participation and the importance of continuous feedback from researchers on input of end-users.

Conclusions

Many similarities seem to exist between the experienced barriers and facilitators of members of multidisciplinary development teams during UCD of telecare products and services. However, differences in experiences between team members from various backgrounds exist as well. Insights into these similarities and differences can improve understanding between team members from different backgrounds, which can optimize collaboration during the development of telecare products and services.

Towards a low-cost mobile subcutaneous vein detection solution using near-infrared spectroscopy

Excessive venipunctures are both time- and resource-consuming events, which cause anxiety, pain, and distress in patients, or can lead to severe harmful injuries. We propose a low-cost mobile health solution for subcutaneous vein detection using near-infrared spectroscopy, along with an assessment of the current state of the art in this field. The first objective of this study was to get a deeper overview of the research topic, through the initial team discussions and a detailed literature review (using both academic and grey literature). The second objective, that is, identifying the commercial systems employing near-infrared spectroscopy, was conducted using the PubMed database. The goal of the third objective was to identify and evaluate (using the IEEE Xplore database) the research efforts in the field of low-cost near-infrared imaging in general, as a basis for the conceptual model of the upcoming prototype. Although the reviewed commercial devices have demonstrated usefulness and value for peripheral veins visualization, other evaluated clinical outcomes are less conclusive. Previous studies regarding low-cost near-infrared systems demonstrated the general feasibility of developing cost-effective vein detection systems; however, their limitations are restricting their applicability to clinical practice. Finally, based on the current findings, we outline the future research direction.

User needs elicitation via analytic hierarchy process (AHP). A case study on a Computed Tomography (CT) scanner

Background

The rigorous elicitation of user needs is a crucial step for both medical device design and purchasing. However, user needs elicitation is often based on qualitative methods whose findings can be difficult to integrate into medical decision-making. This paper describes the application of AHP to elicit user needs for a new CT scanner for use in a public hospital.

Methods

AHP was used to design a hierarchy of 12 needs for a new CT scanner, grouped into 4 homogenous categories, and to prepare a paper questionnaire to investigate the relative priorities of these. The questionnaire was completed by 5 senior clinicians working in a variety of clinical specialisations and departments in the same Italian public hospital.

Results

Although safety and performance were considered the most important issues, user needs changed according to clinical scenario. For elective surgery, the five most important needs were: spatial resolution, processing software, radiation dose, patient monitoring, and contrast medium. For emergency, the top five most important needs were: patient monitoring, radiation dose, contrast medium control, speed run, spatial resolution.

Conclusions

AHP effectively supported user need elicitation, helping to develop an analytic and intelligible framework of decision-making. User needs varied according to working scenario (elective versus emergency medicine) more than clinical specialization. This method should be considered by practitioners involved in decisions about new medical technology, whether that be during device design or before deciding whether to allocate budgets for new medical devices according to clinical functions or according to hospital department.