ADDIS ABABA UNIVERSITY

SCHOOL OF INFORMATION SCIENCE

AND

SCHOOL OF PUBLIC HEALTH

M.Sc in Health Informatics Program

Designing a Web based TB patient Follow up Information System:

For Wolkite Health Center

By
Adem Shikur

June, 2016
Addis Ababa, Ethiopia
 ADDIS ABABA UNIVERSITY

SCHOOL OF INFORMATION SCIENCE

AND
SCHOOL OF PUBLIC HEALTH

M.Sc in HEALTH INFORMATICS PROGRAM

Designing a Web based TB patient Follow up Information System:
For Wolkite Health Center

By

Adem Shikur

A project submitted to the school of graduates studies of Addis

Ababa University in partial fulfillment of the requirement for the Degree
of Master of Science in Health Informatics

June, 2016

Addis Ababa, Ethiopia

 ADDIS ABABA UNIVERSITY
SCHOOL OF INFORMATION SCIENCE
AND
SCHOOL OF PUBLIC HEALTH

M.Sc in HEALTH INFORMATICS PROGRAM

Designing a Web based TB patient Follow up information system

For Wolkite Health Center

By

Adem Shikur

Advisors Signature Date

1 Prof. Ahmed Ali ................................ ...............................
2 Dr. Temtim Assefa ............................... .................................

Examiners Signature Date

1 Dr.Solomon Tefera ................................. .................................

2 Dr.Abera Kumie ................................... ................................

 ACKNOWLEDGEMENT

First of all I would like to thank the almighty God who gave me the ability to do this project,
Glory to Allah.

Next, I would like to express my sincere gratitude to my advisors Prof. Ahmed Ali and
Dr.Temtim Assefa for their patience, encouragement, inspiring advices and valuable support
to conduct this project. Their guidance and constructive suggestions helped me through my
entire research project work.

I am grateful to Addis Ababa University School of Information Science and School of Public
Health for their financial support for my project work.

A special thanks to Health Informatics program coordinator for facilitating the administrative
part.

My special appreciations go to the Wolkite Health Center staff specially Ato Gossaye Dawo
and Mohammed Nesru for providing me all the necessary information.

My deep appreciation and thanks are extended to my beloved family specially my mam
Ayisha Nuro who provides me special support ,and her limitless love, my brothers Ahmed
Shikur ,Hussen Shikur and Halid Shikur and my sisters for their encouragement and
financial support throughout my study.

Finally, I also wish to express my sincere gratitude to my friends Dr. Asrar Seman,
Abdulkerim Gragn, Mohammed Jemal (Mood),Siraj Sibhatu, and all other friends who have
helped me in various ways during my study.

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 TABLE OF CONTENTS

ACKNOWLEDGEMENT i
TABLE OF CONTENTS ii
LIST OF TABLES v
LIST OF FIGURES vi
LISTS OF ACRONYMS vii
ABSTRACT ix
CHAPTER ONE 1
1. INTRODUCTION 1
1.1. Background 1
1.1. Statement of the Problem 2
1.3. Objective of the Study 5
1.3.1. General Objective 5
1.3.2. Specific Objectives 5
1.4. Scope and limitation of the Study 5
1.5. Significance of Study 6
CHAPTER TWO 7
2. LITERATURES OVERVIEW 7
2.1. Web-based Health Care System 7
2.2. Health Information System in Health Center 7
2.3. Health Information Technology 9
2.4. Theoretical Concepts of Health Management Information System 10
2.5. Tuberculosis Patients Information Systems 11
2.6. Tuberculosis Care and Control System 11
2.7. Managing and Monitoring Tuberculosis Using Web-Based Tools 12
2.8. TB Laboratory Information Management Systems. 13
2.9. Directly Observed Therapy Monitoring Systems. 13
2.10. Patient Tracking Systems 14
2.11. Tuberculosis Patients Improvement System 14
2.12. Related Works on TB Care Information System 16
CHAPTER THREE 19
3. METHODOLOGY 19

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 3.1. Study Area and period 19
3.2. Study Design 19
3.3. Data Gathering Source 20
3.4. Requirements Collection Procedure 20
3.4.1. Interview 20
3.4.2. Document Analysis 20
3.5. Data Analysis Procedure 20
3.6. System Development Phases 20
3.6.1. Object-Oriented Analysis (OOA) 21
3.6.2. Object-Oriented Design (OOD) 21
3.7. Analysis and Design Technique 21
3.8. Analysis and Design Tools 22
3.9. Operational Definition 23
3.10. Ethical Consideration 23
CHAPTER FOUR 24
4. DISCUSSION OF RESULTS 24
4.1. Introduction 24
4.2. System Analysis 24
4.2.1 The Current System 24
4.2.1.1. Data and Process 24
4.2.1.2. Communication 25
4.2.1.3. People 26
4.2.1.4. Procedure 26
4.2.1.5. Software 26
4.2.1.6. Hardware 26
4.3. The Proposed System 27
4.3.1. User Requirements 27
4.3.2. Stakeholders 27
4.3.3. Software Requirements 29
4.3.4. Functional Requirements 29
4.3.5. Non-Functional Requirements 30
4.3.6. Contextual Model for New System 30
4.3.7. Use Case Modeling 31

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 4.3.7.1. Use Case Diagram 32
4.3.7.2. Use case System Analysis Models 32
4.3.7.3. Use Case Narrations 34
4.4. Design the System 43
4.4.1. Design Class Diagram 43
4.4.2. Sequence Diagram 47
4.4.3. Activity Diagram 57
4.4.4. System Architectures design 62
4.4.4.1. The Proposed Web System Architecture 62
4.4.5. User Interface Design 65
4.4.5.1. Interface-Flow Diagrams 66
4.4.5.2. The Home Page 66
4.4.5.3. User Interface 66
4.4.6. Entity Relationship Modeling 79
4.4.6.1. Entity Relationship Diagrams 79
4.5. Evaluate the effectiveness of system usability 81
CHAPTER FIVE 83
5. CONCLUSIONS AND RECOMMENDATIONS 83
5.1. Conclusions 83
5.2 .Recommendations 84
Reference 85
Annexes 90
Annex 1: interview 90
Annex 2: Evaluation effectiveness of the system 93
Annex 3:Organizational Structure 94

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 LIST OF TABLES

Table 1: Stakeholder Roles and Responsibility 28

Table 2:Functional Requirements 29
Table 3: Manage User Account Use Case 34
Table 4 :Login use case 35
Table 5:Registration use case 36
Table 6:Prescription Medicine use case 37
Table 7:Diagnosis request use case 38
Table 8:Use case for Patients treatment follow up 39
Table 9:Use case for Patients remind medication 40
Table 10:Use case for Patients remind schedule dates 41
Table 11:Use case for Patients report 42
Table 12:The concept of class diagram attribute and method 43
Table 13:Evaluation Checklist 82

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 LIST OF FIGURES
Figure 1:Contextual Modeling For New System 31
Figure 2:Use Case Diagram For TB Patient Follow Up System 33
Figure 3:Design Class Diagram 46
Figure 4:log in sequence diagram 47
Figure 5:Registration sequence diagram 48
Figure 6:Diagnosis request sequence diagram 49
Figure 7:Prescription Medicine Sequence Diagram 50
Figure 8:Follow Up Sequence Diagram 51
Figure 9:Medication Remind Sequence Diagram 52
Figure 10:Remind schedule date sequence diagram 53
Figure 11:Report Sequence Diagram 54
Figure 12:Add Account Sequence Diagram 55
Figure 13:Remove account sequence diagram 56
Figure 14:Login Activity Diagram 57
Figure 15:Registration Activity Diagram 58
Figure 16:Diagnosis Request Activity Diagram 59
Figure 17:Prescription Medicine Activity Diagram 60
Figure 18:Report Activity Diagram 61
Figure 19:Three-tier Architectural Diagram 64
Figure 20:Navigate Diagram 66
Figure 21:Login User Interface Screen 67
Figure 22:Main Menu User Interface Screen 68
Figure 23:Patient Registration User Interface Screen 69
Figure 24:Contact Person Registration User Interface Screen 70
Figure 25:Diagnosis Request User Interface Screen 71
Figure 26:Prescription Medicine User Interface Screen 72
Figure 27:Intensive Follow Up Treatment User Interface Screen 73
Figure 28:Continuous Follow Up User Interface Screen 74
Figure 29:Remind Medication User Interface Screen 75
Figure 30:Medication Remind Schedule Date User Interface Screen 76
Figure 31:Report User Interface Screen 77
Figure 32:Admin User Interface Screen 78
Figure 33:Entity Relationship Diagram 80

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 LISTS OF ACRONYMS

AIDS Acquired Immune Deficiency Syndrome

ART Anti-Retroviral Treatment

CCM Chronic Care Model

DBMS Database Management Systems

DOT Directly Observed Treatment

DOTs Directly Observed Therapy Short Course

DSM Distributed System Management

EC Eye Care

Ec Ethiopia calendar

EHRs Electronic Health Records

E-Health Electronic Health

EPI Expanded Program of Immunization

ER Entity Relationship

FMoH Federal Ministry of Health

FP Family Planning

GUI Graphical User Interface

HBC High Burden Country

HBCs High Burden Countries

HEW Health Extension Worker

HEWs Health Extension Workers

HIS Health Information System

HIT Health Information Technology

HIV Human Immune deficiency Virus

HMIS Health Management Information System

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MCH Maternal and Child Health Care

MDR Multi-Drug Resistance

MDR-TB Multi-Drug Resistance Tuberculosis

NHS National Health Service

OO Object Oriented

OOA Object Oriented Analysis

OOD Object Oriented Design

OOUI Object Oriented User Interface

OPD Out Patient Department

PCs Personal Computers

RHZE Rifampicin (R) Isoniazid (H) Pyrazinamide (Z) Ethambutol (E)

SMS Short Message Service

SNNPR South Nations Nationalities and Peoples Region

TB Tuberculosis

UML Unified Modeling Language

UE Usability Evaluation

UI User Interface

USA United State of America

VCT Voluntary Counseling and Testing

WSHIS Web Service-based Healthcare Information System

WSIHIS Web Service-based Integrated Healthcare Information System

viii
 ABSTRACT

Background: Tuberculosis commonly known as TB continues to be a major health problem

in the world, particularly in developing countries. Health information system is one of the
important tools for the health sector which involves stakeholders situated at national,
regional, district, service delivery and community levels. Web-based applications provide the
power of desktop and server applications with the flexibility and accessibility of the web.
Health-system-related obstacles to follow up treatment for tuberculosis include,
dissatisfaction with in health services, need for repeated visits, and delays in receiving the
results of sputum smears.
Objective: The objective of this project is designing a web based TB Patients follow up
information system at wolkite Health Center.
Methodology: This Project was conducted using a design science research method. This
method is used to develop innovative artifacts that solve societal problems. The investigator
used interview, observation and document analysis to elicit user requirements and evaluate
the proposed system. Analysis and design of the proposed system was performed using
unified modeling language diagrams (use case diagram, activity diagram, sequence diagram,
class diagram, and entity relationship diagram). The project was carried out after getting
permission from the ethical clearance committee of Addis Ababa University, Medical Faculty
through School of Public Health.
Discussion of Result: The investigator reviewed the current system of the health facility
problems in data process, communication, procedures, people, software and hardware. The
system was designed by identifying the entire process and system boundary proposed in the
use cases. The system design includes user interface, business logic and backend database
design. The user interface has different interfaces such as patient registration, display
diagnosis result, prescription, follow up, remind medication and report generate to facilitate
user and system interactions. The proposed system was evaluated for its effectiveness and
usability to support health service delivery.
Conclusion: the system did not show the entire product of the system, rather provides to
facilitate health care services for TB patients. It also improves patients’ data record and
report generation.
Key words: Information system, Medication and TB patient follow up

ix
 CHAPTER ONE

1. INTRODUCTION

1.1. Background
Tuberculosis, commonly known as TB, continues to be a major health problem in the world,
particularly in developing countries (1). There were almost nine million infections of TB in
2012, and more than one million people die every year from TB. Sub-Sahara African
countries take the lion's share with over 260 new cases per 100 000 population. One third of
the world‗s population is estimated to be infected with tubercle bacilli and hence at risk of
developing active disease (2). Globally, in 2005, the annual incidence of TB, expressed as the
number of new TB cases, was about 8.8 million people (7.4 million of these in Asia and sub-
Saharan Africa), and the annual number of deaths due to TB was 1.6 million, including
195,000 patients infected with HIV (3). Tuberculosis is a major contributor to the global
burden of disease and has received considerable attention in recent years, particularly in low-
and middle-income countries where it is closely associated with HIV/AIDS.

Ethiopia is one of the 22 HBCs (High Burden Countries) (4). The national population based
TB prevalence survey 2010/11 revealed that the prevalence of smear positive TB among
adults and all age group was found to be 108 and 63 per 100,000 populations, respectively.
According to Federal Ministry of Health (2011), health and health related indicators are
tuberculosis the third leading cause of death in Ethiopia (4).

The DOTs generally requires healthcare workers to remind and observe patients for taking
their daily TB medication (5). This process necessitates adequate human labour that is a
challenge in developing countries. The technology-assisted DOTs seek to reach more patients
at a lower cost through automated reminders via mobile phones. The process needs a few
human labour and cost less.

Health Information System is one of the important tools for the health sector which involves
stakeholders situated at national level, regional, district, service delivery and community
levels (6).Vertical information flow denotes transfer of information at certain intervals (daily,

1
weekly, monthly, quarterly) between levels of healthcare such as community, health facility,
district, regional and national level.

Health Information System as a mechanism with the ability to integrate data collection,
processing, reporting, and use of the information necessary to improve healthcare service
effectiveness and efficiency through better management at all levels of the healthcare system
(7). Health Information System plays an important role in ensuring that reliable and timely
health information is available for operational and strategic decision-making, thus providing
better healthcare services and enhancing public health. Despite its importance, HIS in many
developing countries is weak, fragmented, and often focused exclusively on disease-specific
program areas. Notwithstanding the potential of HISs, in practice, the collection, compilation,
analysis, and reporting of health data are riddled with major problems. Furthermore, the data
received are often not helpful for healthcare management decision-making because they are
incomplete, untimely, and unrelated to the priority tasks of healthcare professionals.

Web-based applications provide the power of desktop and server applications with the
flexibility and accessibility of the web (8). Using web browsers, users can securely access
applications from anywhere within the reach of the organization intranet or extranet .The
special issue strives to explore the advanced web-based information systems and database
applications in healthcare area (8). A web based system to support TB patients follow up
information system in healthcare organizations are undergoing major reorganizations and
adjustments to meet the increasing demands of improved healthcare access and quality, as
well as lowered costs. The system enabled by searching and identifying patients‘ schedules
for those schedule date is approached, and generate the appropriate Short Message Text
reminder message and send to the appropriate patients and Health Extension Workers. Web-
enabled information technologies use of Information Technology (IT) to process medical data
increases, much of the critical information necessary can provide the means for greater access
and more effective integration of healthcare information system from disparate computer
applications and other information resources (8).

1.1. Statement of the Problem

Tuberculosis (TB) is a major contributor to the global burden of disease and has received
considerable attention in recent years, particularly in low and middle income countries where
TB is closely associated with HIV/AIDS (9). Encouraging patients to take their medications
2
in the hospital and admission during intensive phase help to improve treatment outcome (9).
Poor knowledge of standard TB treatment regimen by medical personnel can worsen
treatment outcome (10), while side effects of the drugs if not properly addressed can worsen
treatment outcome (11).

TB can be cured if patients strictly follow a prescribed medication procedure for a minimum
of six months. However, patients often forget to take their medicine as recommended. As a
result, the disease takes longer to be cured. It also requires more cost and medication through
treatment may no longer be successful (1, 12).

Health-system-related obstacles to follow up treatment for tuberculosis included

dissatisfaction with long waiting times in health services, the need for repeated visits, and
delays in receiving the results of sputum smears (13).

The consequences of non-adherence to treatment, include increased rates of treatment failure,

relapse, acquired drug resistance, and prolonged infectiousness of patients (14, 15).
Therefore, effective treatment of tuberculosis requires adherence to a minimum of 6 months
treatment with multiple drugs.

Defaulting from treatment remains a challenge for most tuberculosis programs. A study
conducted in Hosanna Hospital showed that 20% of patients on Treatment were defaulters
(16). On the other hand MDR-TB is a newly emerged challenge in Ethiopia. WHO estimated
that about 5000 new MDR-TB infections are documented annually (16).

Poor quality of information does not enable to see whether actions have been taken or if the
data have not been suitably entered into the information system (17). Information system
includes manual and computerized data technologies. But, the current paper-based record
systems inadequate in terms of documentation, disruption, and substantial delay in the health
services. Advanced information technologies, on the other hand, provide clinicians with real
time information access (18).

Tuberculosis patients monitoring was mainly carried out by means of ―notices‖ generated
when patients missed scheduled appointments, the issuing of pre-appointment reminders,
registration errors and identification of absentees (19).

3
Electronic systems maintain quality and accurate data, and make reporting potentially more
flexible and efficient (20). To the contrary, in paper-based systems the data is collected and
compiled manually at each site where the data is collected, a process that hinders
managers and decision makers at higher levels of the hierarchy from viewing the
disaggregated data coming from lower levels of the system (20).Besides this,
accessibility of data in the paper-based system is time consuming, potentially unreliable
and inefficient when the number of records becomes very large (21, 22).

Therefore, Ethiopia has one of the highest TB burden in the world. TB is among the leading
causes of morbidity and mortality. For this reason, the aim of this study is designing a web
based TB Patients follow up information system to enable sending reminder text messages
for medication and reminding scheduled date for patients and HEWs. The system can
improve communication and treatment success, generated quality data and aggregated report.
The system also enables to reduce waiting time and registration error, and the system
facilitates fast service in Health Center.

4
1.3. Objective of the Study

1.3.1. General Objective

The general objective of this study is to designing a web based TB patient‘s follow up
information system at Wolkite Health Center.

1.3.2. Specific Objectives

To achieve the above general objective of the study, the following specific objectives are
formulated.
 To identify system requirements and health services management information system.
 To design system model of the TB patients follow up information system.
 To evaluate the proposed system effectiveness in improving TB follow up system.

1.4. Scope and limitation of the Study

This study delimited to in geographically, conceptually and timely to tackle the research
project problem.

Geographically, this project focused on design of web based TB Patients Follow up

information system in the Gurage Zone Administration Health Department in SNNPR state,
specifically Wolkite Town Administration Health Center and in six health posts. This Health
Center serves urban and surrounding rural woreda kebeles. The system will be scaled up and
applied in other hospitals. Therefore, the project was tackling the problem by assessing the
existing situation of the health workers, patients and health facility information system and
identifies user and system requirement.

Conceptually, a web-based system is also necessary in order to improve the

accessibility of the patient information, delivery of comprehensive, reliable and timely
information needed by health professionals and patients in the health facility. After
identification of the user requirement made analyzing and design the system were done using
use case model, sequence activity, class diagram, entity relationship diagram and user
interface design.

Timely, the project was done the use of design science research method by object oriented
system analysis and design technique from January up to June, 2016 GC.

5
1.5. Significance of Study

This web based TB Patient Follow up information system would help for the TB Patients, the
Health Professional, Health Facility, Researcher and Policy Maker
For TB patients
 The system helps remind the patient to medication, treatment and follow up to the
nearest health post or health center.
 It also helps to cure the TB patient, restore quality of life and productivity, and
prevent death from active TB or its late effects.
 Patients would get guarantee access to effective personal and public health care.
For Health Professionals,
 The system makes their work easier, effective, and efficient.
 It helps them in tracing and controlling the performance of specific TB patients follow
up.
 It helps the health professionals in providing quality health care service.

For Health Facility

 It would help to improve fast communication between health center, patients and
health extension workers and would prepare organized reports.
 It helps to improve the health service, properly manage TB patients
 It provides patient information at appropriate place and time, updating patient‘s
information and generates report system.
For Researcher

 It provides complete information for TB patient follow up system study and research
purpose.
 It can be used as input other related projects.

For Policy Makers

 Policy makers was used a data generated from designed system for their decision and
to improve the effectiveness and efficiency of TB patients the health information
system in the country.

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 CHAPTER TWO

2. LITERATURES OVERVIEW
2.1. Web-based Health Care System

A web-based application is one of the technologies which is applicable in health facilities.

The Web is becoming the standard interface for accessing remote services of information
systems, hosting data centers and application service providers (23). Demands placed on Web
based services continue to grow and Web based systems are becoming more utilized than
ever.

The World Wide Web (known as ''www'' or ''web'') is growing in health facilities. It is a
source of information over internet (24). The current Web is largely based on the file system
technology, which can deal well with the resources that are primarily static .However, with
the unprecedented growth of resources; it is no longer adequate to rely on this conventional
file technology for organizing, storing, and accessing large amount of information on the
Web. Thus, many large Web sites today are turning to database technology to keep track of
the increasing amount of data (24). Database technology has played a critical role in the
information management field. Delivering information over the web is cost effective and fast,
and gives internet users easy access to databases from any location. For this reason,
technology will bring many opportunities for creating advanced information management
applications.

2.2. Health Information System in Health Center

Health information systems are frequently refer to the interaction between people, process
and technology to support operations, management in delivering essential information in
order to improve the quality of health care services (25). Similar to any other industries, the
nature of healthcare industry has changed over time from a relatively stable industry to a
dynamic one. Health information systems have evolved through several different
technologies (25).It describes systems that process data and provides information and
knowledge in health care environments as health information systems. Health Center
information systems are just instances of health information systems, in which the Health
Center is the healthcare environment as well as health care institution (26). The aim of health

7
information systems is to contribute to a high-quality, efficient patient care. Some of
terminologies related to HIS are as follows. Health Informatics is the field that concerns itself
with the cognitive, information processing, and communication tasks of medical practice,
education, and research, including the information science and technology that supports those
tasks (26). Health informatics tools, include computers as well as clinical guidelines, formal
medical terminologies, and information and communication systems. In other words, its
emphasis is on clinical and biomedical applications with added possibility of the integrating
clinical components either among themselves or to more administrative-type health
information systems.

Additionally, Health Information Technology is the application of information involving both

computer hardware and software that deals with the storage, retrieval, sharing, and use of
health care information, data, and knowledge for communication and decision is making (27).

Healthcare information systems that can record and locate important information quickly
have become a standard practice in many healthcare organizations. The milestone of
development for HIS were considered as important and summarized as follows (25).
 the shift from paper-based to computer-based processing and storage, as well as the
increase of data in health care settings;
 the shift from institution centered departmental and, later, hospital information
systems towards regional and global HIS;
 the inclusion of patients and health consumers as HIS users, besides health care
professionals and administrators;
 the use of HIS data not only for patient care and administrative purposes, but also for
health care planning as well as clinical and epidemiological research;
 the shift from focusing mainly on technical HIS problems to those of change
management as well as of strategic information management;
 the shift from mainly alphanumeric data in HIS to images and now also to data on the
molecular level;
 the steady increase of new technologies to be included, now starting to include
ubiquitous computing environments and sensor-based technologies for health
monitoring.

8
2.3. Health Information Technology

Health information technology (HIT) is ―the application of information processing

involving both computer hardware and software that deals with the storage, retrieval,
sharing, and use of health care information, data, and knowledge for communication
and decision making‖ (28). Technology is a broad concept that deals with a species'
usage and knowledge of tools and crafts, and how it affects a species' ability to control
and adapt to its environment. However, a strict definition is elusive; "technology" can
refer to material objects of use to humanity, such as machines, hardware or utensils,
but can also encompass broader themes, including systems, methods of organization,
and techniques. For HIT, technology represents computers and communications
attributes that can be networked to build systems for moving health information.
Informatics is yet another integral aspect of HIT.

Informatics refers to the science of Information, the practice of Information processing,

and the engineering of Information systems (29). Informatics underlies the academic
investigation and practitioner application of computing and communications
technology to healthcare, health education, and biomedical research. Health
informatics refers to the intersection of information science, computer science, and
health care. Health informatics describes the use and sharing of information within the
healthcare industry with contributions from computer science, mathematics, and
psychology. It deals with the resources, devices, and methods required for optimizing
the acquisition, storage, retrieval, and use of information in health and biomedicine.
Health informatics tools, include not only computers, but also clinical guidelines,
formal medical terminologies, and information and communication systems. Medical
informatics, nursing informatics, public health informatics, pharmacy informatics and
translational bioinformatics are sub disciplines that inform health informatics from
different disciplinary perspectives (29). The processes and people of concern or study
are the main variables.

Health information technology (HIT) is health information technology applied to

health and health care. It supports health information management across computerized
systems and the secure exchange of health information between consumer, providers,
payers, and quality monitors (30). Based on an often-cited 2008 report on a small

9
series of studies conducted at four sites that provide ambulatory care–three U.S.A
medical centers and one in the Netherlands the use of Electronic Health Records
(EHRs) was viewed as the most promising tool for improving the overall quality,
safety and efficiency of the health delivery system. A 2006 report by the Agency for
Healthcare Research and broad and consistent utilization of HIT will, (31) Improve
health care quality or effectiveness; Increase health care productivity or efficiency;
Prevent medical errors and increase health care accuracy and procedural correctness;
Reduce health care costs; Increase administrative efficiencies and healthcare work
processes; Decrease paperwork and unproductive or idle work time; Extend real-time
communications of health informatics among health care professionals; and Expand
access to affordable care.

2.4. Theoretical Concepts of Health Management Information System

―HMIS is an organized system of record keeping, reporting, processing, analysis, use

and feedback of information which is designed to provide different level of
beneficiaries (clients, community, service providers, managers, planners and
policymakers) with timely and relevant information necessary to formulate policy,
plan, implement, monitor, supervise and evaluate health programmers‖ (32). Effective
and efficient HMIS would provide district health manager with the information
required to make effective strategic decision that are the vehicle for district
performance and sustainability in those decentralized health systems. Planning and
system management HIS resource, include the policy, legislative, regulatory,
management and financial environment that must be in place; and the infrastructure
and resources required to ensure a fully functional health information system.

The National Health Information System of Ethiopia focuses on the promotion and
prevention of disease targeting on primary health care (PHC) services through
provision of information for planning and managing the health care system (63).
Health promotion and prevention of disease is facilitated with decentralized
administration in which Woreda have the mandate to decide on their budget. Thus
districts become the most appropriate level for top- down and bottom-up planning and
coordinating stakeholder effort through improved health information system (63).
Although reliable and timely health information is the foundation of public health
action, it is often unavailable due to under-investment in systems for data collection,

10
analysis, dissemination and use. Consequently, decision-makers cannot identify
problems and needs, track progress, evaluate the impact of interventions and make
evidence-based decisions on health policy, programme design and resource allocation.
The access and use of information by program managers and service providers help
resolve bottlenecks and improve program implementation. This eventually leads to
improvement in health service delivery and thereby improvement in the health status
of the population.

2.5. Tuberculosis Patients Information Systems

TB patients‘ information system will contribute to reduction of costs, improvement of

daily performance ability, operational efficiency, and mostly fundamental prevention
of tuberculosis (33). The proposed information-based medical information system will
also contribute to solve the problems of current information systems by enabling
integration of separated information and by allowing data exchange and sharing
through information. The proposed system with application is more efficient than web-
based medical information system. This information system itself provides more
flexibility and extensibility than previous information systems (33).

2.6. Tuberculosis Care and Control System

Recording and reporting of data is a fundamental component of care of patients with

tuberculosis (TB) and control of the disease (34). Data recording and reporting is
necessary to monitor trends in the TB epidemic at global, national and sub national
levels. To monitor progress in the treatment of individual patients and groups (cohorts)
of patients and ensure continuity of care. When patients are referred between health
care facilities; and to plan, raise funds for, implement and evaluate programmatic
efforts to control TB, including forecasting the numbers of cases and the associated
requirements for staffing, medicines and laboratory supplies; and analyzing treatment
outcomes. When high-quality data are available, successes can be documented and
corrective actions taken to address problems that are identified.

Recording and reporting data about people who have TB symptoms and those who are
diagnosed with TB is, nonetheless, a data-intensive process (34). Treatment regimens

11
span many months (or years in some cases), and patients need to take anti-TB drugs at
least a few times a week and often daily. Compliance with treatment must be recorded
regularly (daily for drug-resistant treatment and weekly for drug-sensitive treatment).
The results of laboratory tests are needed for the microbiological diagnosis of TB; to
determine the susceptibility of Mycobacterium tuberculosis isolates to anti-TB drugs;
to monitor patient response to medication; and to determine cure or failure of treatment
(34).

2.7. Managing and Monitoring Tuberculosis Using Web-Based Tools

Since the invention of the World Wide Web in the early 1990s, technologic advances
have revolutionized daily life for people throughout the globe (35). Information
communication technology is being increasingly used in health care settings, and has
the potential to contribute significantly to health care provision, both as regards cost
savings and quality of care. A WHO resolution on eHealth in 2005 encouraged
member states to collaborate and provide mutual support for its integration into health
systems to improve health care, surveillance, and education. Although there remains a
―digital divide‖ with patchy provision of information communication technology
access globally, rapid advances in mobile telephone and wireless technology, and its
increasing availability in otherwise resource-limited settings, are improving this
situation (35). Integrating control programs with web-enabled applications and
wireless communication offers the potential for significant improvements in TB
service provision, with major benefits for the global fight against TB. In this review,
the researchers describe the broad range of tools and applications available from the
Internet or which incorporate real-time electronic data transfer, aimed at improving the
management of TB. Web-based tools for TB focus on some key areas. Such as: -
diagnosis, treatment, contact tracing and epidemiology, service performance
monitoring and quality assurance and teaching and training.

Web-based technology can contribute to care of patients with TB, for example,
through use of emails to speed up communication, obtain second opinions, and provide
educational materials (35). More complex systems can be used to document and track
patients‘ progress through the treatment process, monitor adherence, detect those at
risk of failing follow-up, and improve speed of communication within and between

12
institutions. At a national level, networked electronic patient records can link into
national surveillance systems and also provide a valuable research resource.

2.8. TB Laboratory Information Management Systems.

Laboratory information management systems facilitate the recording and sharing of

information regarding samples, results, quality indicators, and instruments. They can
also be used to share regulatory and safety information as well as training materials,
and a number of open access systems are now available. The ongoing training and
maintenance costs are a challenge in resource-poor settings, but if they are linked to
improved laboratory networks and prompt timely appropriate treatment in the field,
they have the potential to save money. Much work has been done in Peru by Blaya,
Fraser, and others to improve TB laboratory services and results management systems,
with very clear benefits (36). They demonstrated 87% reduction of reporting errors in
health centers using the e-Chasqui electronic laboratory information system compared
with those using a paper-based system through reductions in missing results (36). In
addition, the use of personal digital assistants resulted in faster processing of sputum
smear and TB culture results. However, their work illustrated that the improvements
only extended as far as the geographic reach of the electronic hardware introduced, i.e.,
health centers without direct access to the information system did not benefit,
highlighting again the importance of investing in comprehensive information
technology infrastructure (37).

In the future, novel web-based technologies may allow the results of diagnostic tests
carried out in the field to be integrated rapidly with laboratory information systems.
One group described the use of mobile electronic devices both to perform serologic
testing for HIV and to upload results automatically to a database in ―the cloud‖, from
where they were synchronized with an electronic health record for patients in Rwanda
(38).

2.9. Directly Observed Therapy Monitoring Systems.

A key strategy in global TB control is the use of directly observed therapy to ensure
that patients adhere to medication and complete prescribed treatment courses. In areas

13
of high TB prevalence, however, universal directly observed therapy may be
unsustainable due to limited health care staff and infrastructure capacity. The use of
electronic medication monitors has been advocated as an adjunct to directly observed
therapy. These devices record when medication is removed from the container, thus
providing a record of adherence. The simplest devices include a built-in electronic
display, but some are able to transmit data to a central point via a telephone or wireless
connection, allowing remote monitoring (39). Their use could allow health care
workers to target directly observed therapy and treatment counseling to patients who
are failing to comply with therapy, and could therefore result in improved treatment
adherence, more efficient use of staff time, and increased program cost-effectiveness.

Another recent development includes the use of web-based technology to support

directly observed therapy through ―video-observed therapy‖ (40). This is increasingly
being used in the USA for selected patients, and has the advantages of reduced travel
costs and time for staff, easy regular visual contact, and increased privacy for patients.

2.10. Patient Tracking Systems

Electronic tracking systems to monitor effective treatment and follow-up of patients

identified with multidrug-resistant TB or HIV have been reviewed by researchers (41).
They concluded that committed community health care workers provided with
personal digital assistants or smart phones would be able to trace and treat patients
who are lost to follow-up or never initiated treatment, to ensure that treatment courses
are completed. The web-based tracking and results system in Peru, also now shared
with the Philippines and elsewhere, bring clear benefits in reducing delays and errors,
and improving service efficiency, although it is not yet clear if such systems are cost-
effective in the long term (42).

2.11. Tuberculosis Patients Improvement System

Appropriate management of TB patients requires a comprehensive approach, including

diagnostic facilities, expert healthcare staff, an uninterrupted supply of drugs, and
continuing treatment. It also requires improved adherence by TB patients to
chemotherapy through health education, community involvement in the social support
of TB patients and good case follow-up (43).

14
At present, the Chronic Care Model (CCM) is considered the standard of care for
management of chronic diseases. The model comprises of six interrelated components
that interact to promote high-quality care for patients with chronic disease (43). The six
components include: healthcare organization, self-management support, delivery-
system design, decision support, the community and an information system. The service
system at the TB Clinic was improved, in terms of accessibility, waiting time, and
provider behavior. The physicians adopted the 5A technique (assess, advise, agree,
assist, and arrange) to provide effective self-management support, which included goal-
setting, action planning, problem solving, and follow-up (43). This phase also included
counseling for TB patients. Communication between doctors and patients was also
improved via the delivery-system design. The physicians were well-trained in DOTS, to
ensure they could provide effective treatment for TB patients. This was done under the
decision-support component of CCM. Care was coordinated by sharing clinical
information with patients and providers. Patient appointments were arranged by
treatment schedule. The main changes carried out to improve the hospital service
system at the TB clinic were (43):

1) Health care organization which include ownership and support, implementation of

changes recommended for improvement, the doctors and staff of TB Clinic was not be
changed, rewards for good work by healthcare staff at the TB Clinic were given, and
adequate supplies of anti-TB drugs were assured.
2) Self-management support - health care staff worked on the concept of the central role
of the patient in the management of disease, health care staff used the ―5A‖ approach
while working with patients, health care staff provided information about TB, such as
the course of treatment, side-effects of the drugs, and preventive measures.
3) Delivery system design - staff duties were made to help them work as a single unit,
unnecessary steps for service provision were eliminated, reducing waiting times, a
separate waiting room was provided to help patient feel more secure, there was
discipline at the TB clinic where every patient waited for his turn by appointment,
reports from the laboratory were sent directly to the TB Clinic instead of being handed to
patients, which created treatment delays, and scheduled follow-ups reduced default rate.
4) Decision support- the health care staff used up to date knowledge of the TB DOTS
program for treatment, health care staff applied the concept of CCM effectively,
healthcare staff provided written instructions to patients with a clear date for the next
15
appointment, staff provided necessary education regarding health problems of the TB
patients.
5) Community-fortnightly visits were made by health care staff to selected
communities, Linkage of services with community resources were made.
6) Information system - systematic follow-up of TB patients was carried out, timely
reminders were given to patients, monthly meetings of health care staff with hospital
administration were carried out to solve problems and bring about further improvement.

2.12. Related Works on TB Care Information System

The study conducted in USA (37) showed that managing and monitoring tuberculosis
using web-based tools in combination with traditional approaches. Most tuberculosis
challenged high levels of drug resistance in many parts of the world, and availability of
accurate and rapid diagnostic tests. The increasing availability and reliability of Internet
access throughout both affluent and resource-limited countries brings new opportunities
to improve TB management and control through the integration of web-based
technologies with traditional approaches (37). In this study, they explore current and
potential future use of web-based tools in areas of TB diagnosis, treatment, epidemiology,
service monitoring, and teaching and training. The purpose of this study was to integrate
control programs with web-enabled applications and wireless communication offers the
potential for significant improvements in TB service provision (37).

The study conducted in China in 2005 launched a web-based, case-based electronic

reporting and recording system for tuberculosis (TB) information management system of
the country (34). This study delivered the system with capability of holding TB patients
detailed treatment data and treatment outcomes, including demographic information,
clinical data and drug susceptibility testing results that are stored using Oracle database.

The study conducted in South Africa on how to completeness and concordance of TB

and HIV surveillance systems for TB-HIV co-infected patients .The study focused
currently maintains separate surveillance systems for tuberculosis (TB) and human
immunodeficiency virus (HIV) in a country (44). There are future plans for integration of
these systems; however, the consistency of information across the existing systems has

16
not previously been assessed. It determined the completeness and concordance of data in
the TB and HIV surveillance systems for TB-HIV co-infected patients (44).

Computerized surveillance system of tuberculosis was how to develop to be user-friendly

and to allow the evaluation of current TB problems and control issues in Japan. This
study not only introduces the new system and its results, but also discusses the role of the
TB surveillance system for national TB control. In Japan, the reporting and recording of
TB is mandatory under the Act on Prevention of Infectious Diseases and Medical Care for
Patients Suffering from Infectious Diseases (the Infectious Diseases Control Law) (45).
The proposed system used computerized TB surveillance system. The database of TB
surveillance system terminals connected to a central computer through nationwide official
private networks (45).

A Case Study conducted on the Web-Based Information Systems Development in New

Zealand explores the current software development methodologies used by organizations
in developing WWW-based information systems (46). A case study approach is used to
investigate, in the context of the organization, how various WWW-based information
systems are developed and the reasons why particular strategies are used. The
organizations were selected on differences in type, size and information systems
developed. The cases were analyzed based on the software process model, methodology,
tools and techniques within an organizational context. The core finding of the research
was that the development of WWW-based information systems is dominated by the
challenges presented by new technology. In addition, organizations take a structured
problem solving approach rather than adopting methodologies specifically designed for
the WWW. The results of the research also indicated that deficiencies existed in the
development strategies used, principally in the area of inadequate guidelines and lack of
documentation (46).

A case study conducted on Web Service-based Healthcare Information System (WSHIS)

for Interoperability Concern in Healthcare Field in the United Kingdom was a new
distributed middleware technology (47).Web Services are applied in the proposed

17
Healthcare Information System (HIS) to address the issue of system and language
interoperability raised from existing Healthcare Information systems. With the
development of HISs, hospitals and healthcare institutes have been building various HISs
for processing massive healthcare data, such as, systems built up for hospitals under the
NHS (National Health Service) to manage patients‘ records. Nowadays many healthcare
providers are willing to integrate their systems‘ functions and data for information
sharing. This has raised concerns in data transmission, data security, and network
limitation (47). Among those issues, system and language interoperability are some of the
most obvious issues since data and application integration is not an easy task due to
differences in programming languages, system platforms, Database Management Systems
(DBMS) used within different systems (47). As a new distributed middleware technology,
Web service brings an ideal solution to the issue of system and language interoperability.
Web service has been approved to be very successful in many commercial applications
(e.g. Amazon.com, Dell computer, etc.); however it is different to healthcare information
system. As the result, Web Service-based Integrated Healthcare Information System
(WSIHIS) is proposed to address the interoperability issue of existing HISs, but also to
introduce this new technology into the healthcare environment.

Another study done in Peru A web-based laboratory information system to improve

quality of care of tuberculosis patients which occurred in resource-poor settings
experience large delays in starting appropriate treatment and may not be monitored
appropriately due to an overburdened laboratory system, delays in communication of
results, and missing or error-prone laboratory data (48). The objective of this system is to
describe an electronic laboratory information system implemented to alleviate these
problems and its expanding use by the Peruvian public sector, as well as examine the
broader issues of implementing such systems in resource-poor settings (48). The system
proposed how to support a web-based laboratory information system "e-Chasqui" has
been designed and implemented in Peru to improve the timeliness and quality of
laboratory data (48). It was deployed in the national TB laboratory, two regional
laboratories and twelve pilot health centers. This system was designed to support a
national TB laboratory network connecting all participating institutions. Using needs
assessment and workflow analysis tools, e-Chasqui was designed to provide for improved
patient care, increased quality control, and more efficient laboratory monitoring and
reporting.

18
 CHAPTER THREE

3. METHODOLOGY
3.1. Study Area and period

This project studied Wolkite Town Health office, in the administrative center of the Gurage
Zone of the South Nations, Nationalities and Peoples' Region (SNNPR).This Town is located
at latitude and longitude of 80 17'N 370 47'E/ 8.2830 N 37.7830 E , and an elevation between
1910 and 1935 meters above sea level. Based on the 2007 census conducted by the Central
Statistical Agency, Wolkite Town has a total population of 28,866 of whom 15,074 are men
and 13,792 women. Those people get a health service from the health center, which is 155
km away from Addis Ababa in southern direction. This project has been conducted from
January up to June 2016 GC.

3.2. Study Design

This Project follows the design science research method (49). This method is used to develop
innovative artifacts that solve social problems. Design science is inherently a problem solving
process. Using this method solve patient follow up system for treatment, data records and
documentation. The design science research method makes the process of developing TB
patient follow up system more flexible, easily maintainable and scalable. It also supports the
use of an iterative process model which helps to improve the system step by step in a cyclic
way until it satisfies the users. It also involves a rigorous process to design artifacts to solve
observed problems, to make research contributions, to evaluate the designs, and to
communicate the results to appropriate audiences. Such artifacts may include constructs,
models, methods, and instantiations. On the other hand, design-science research addresses
important unsolved problems in unique or innovative ways or solved problems in more
effective or efficient ways. Object oriented analysis and design methodology is used for
requirement analysis and design.

19
3.3. Data Gathering Source
All health workers who were working in the TB department for the last six months, Health
Center Manager, TB focal person, TB inpatients and HMIS focal person were all involved in
the study.

3.4. Requirements Collection Procedure

This Project identified business and system requirements. The requirement collection
procedure was included interview and document analysis at the Health Center.

3.4.1. Interview
The interview sessions were conducted in groups and individually, face-to-face interview in
working places. The responses of the respondents were recorded in audio based and taking a
short note which was important input for designing a web based TB patients follow up
information system.

3.4.2. Document Analysis

Regarding document review made from the health center assess routine data recording,
processing and reporting, compiled documents, formats ,patient registration book forms,
guidelines and other formats were taken as initial requirement for the system design.

3.5. Data Analysis Procedure

The Unified Modeling Language (UML) technique is the primary modeling language used to
analyze, specify, and design new proposed systems .The data collected through interview,
observation and document review were summarized by UML modeling at varies phases. The
aggregated data were conducted based on the Federal Ministry of Health Tuberculosis
Prevention and Control Program Manual.

3.6. System Development Phases

In this study, the Object Oriented system development is followed to develop the system,
which includes object oriented analysis and design phases.
The object-oriented methodology views a system as a bottom-up approach to systems
development (50). To start with, it describes the system through a set of interacting objects to
perform business processes. It uses a set of diagrams or models to represent various views
and functionality of a system and is commonly known as Unified Modeling Language or
UML. When these models are used along with a particular method of systems development,
the OO approach later became known as the Unified process (50).

20
3.6.1. Object-Oriented Analysis (OOA)

OOA emphasizes an investigation of the problem and requirements, rather than a solution. It
concerns with determining the system requirements and identifying classes and their
relationships that make up an application. This phase also called requirement analysis. The
classes identified in this phase represented using the contextual or class models and also their
attributes and relationship are expressed. Therefore the investigator develops the domain
model in this phase using one of UML artifacts (class diagram).

3.6.2. Object-Oriented Design (OOD)

The study used OOD to define objects and how they collaborate to fulfill the requirements
independent of implementation. During object oriented design phase of the system in this
study emphasized on designing web based system objects, classes with their attributes,
methods, and interfaces using UML artifacts class diagram. Then designing entity objects in
the system database with their attributes and association between entity objects and
designing/prototyping user interface for the system where a user in the health facility
interacts. More over the design prototype user interface were evaluated based on heuristic
evaluation method.

3.7. Analysis and Design Technique

During designing this system were used Unified Modeling Language (UML modeling)
for modeling the components of the system. Such as:-

 Contextual diagram:-It shows the entire system in context with its environment. It
shows the overall business process as just one process and also shows how a system
that is being modeled is positioned in an environment with other systems and
processes.

 Use case model: - It is the simplest and most effective technique for modeling system
requirements from a user‘s perspective.

 Design class model:-It shows attribute and methods of the each class.

21
  Sequence diagram:-It used to describe patterns of communication among set of
objects which are participated in the use case. Communication between objects is
represented by message passing between the objects.

 System Architecture: - The system uses dynamic web technology, i.e., adding and
retrieving data to and from the data store whenever requested is possible.

 ER model:-It is one of the most popularly used semantic data models. A semantic data
model refers to a data model that supports a richer set of modeling constructs for
representing the semantics of entities, their relationships, and constraints.

3.8. Analysis and Design Tools

Under this project designing a web based TB patients information system Microsoft Visio
premium2010 was used as software tool. At system development the implementation and test
phase will be use:-

Front end: HTML hyper text markup language is used to create electronic documents (called
pages) that are displayed on the World Wide Web (www). CSS (cascading style sheet) allows
specifying things. It is the part that lets control the appearance of the web page. HTML also
provide a basic structure of the page, up on which CSS are overlaid to change its appearance
one could HTML as the bones (structures) of the web page, and CSS as its skin (appearance).

Middle ware: PHP (Personal Home Page) is maintaining personal home page which is
communicate with databases. it combined with MY SQL cross -platform.

Back end: is a database language that lets you store and retrieve the data as efficiently as
possible. There are many databases that support the use of SQL to access their data.

22
3.9. Operational Definition

Diagnosis: It is systematic assessment of all the evidence derived from a carful history,
clinical examination and relevant investigation.

Evaluation Usability: is itself a process that entails depending on the method employed.

Follow Up: should be assessed two weeks after treatment initiation, at the end of the
intensive phase and every two months until treatment completion.

Health Facility: are places that provide health care. They include hospital, specialized care
center, health centers, and clinics.
Information System: a transformation of data consists of basic fact into an output that is
valuable to users.

Patient: people who get service from health facilities.

Treatment Completed: a patient who completed treatment, but who does not have a
negative sputum smear or culture result in the last month of treatment and on at least one
previous occasion.

Treatment of TB: cure the TB patient and restore quality of life and productivity, prevent
death from active TB, prevent the development and transmission of drug resistance.

3.10. Ethical Consideration

The project was carried out after getting permission from the ethical clearance committee of
Addis Ababa University, Medical Faculty through School of Public Health. Data were
collected after getting written permission from Wolkite Health Center. Information sheet and
consent forms were delivered along each interview and all interviewees/respondents had been
asked their willingness to participate in requirement gathering; and informed verbal consent
would also be obtained from all study participants and from every interviewee after the
objective of the study informed.

23
 CHAPTER FOUR

4. DISCUSSION OF RESULTS
4.1. Introduction
The information about the existing system was collected using in key informant interview
and document review. The designer is designing the system by using different techniques.
Then raw data was structured using different system modeling tools. Under this chapter the
current system, the business process, the functional and non-functional requirements, new
system design and evaluation of usability are presented.

4.2. System Analysis

4.2.1 The Current System

The result from the interview shows that the current TB patient follow up information system
was managed by manual methods. The Health center existing data flow system shows as
follow.

Wolkite Health center existing data flow system

card room OPD laboratory OPD TB room Pharmacy

Health extionsion worker

client
Follow up

TB patients

The investigator tried to review the current system of the health facility to identify gaps in the
current system. The findings showed problems in data process, reports or communication,
procedures, people, software and hardware.

4.2.1.1. Data and Process

The main services delivered by the health centers included Out Patient Department (OPD),
Maternal and Child Health Care (MCH), Family planning (FP), Expanded Program of
Immunization (EPI); Tuberculosis (TB), Eye Care (EC), Voluntary Counseling and Testing
(VCT), Anti Retroviral Treatment(ART) service. The TB Patients follow up treatment
systems has intensive and continuation phases. The intensive phase starts from day one of the
TB treatment, aimed to prevent the emergence of drug resistance and determines the ultimate

24
outcome of the regimen. This phase usually lasts two months and is followed by the
continuation phase which is important to ensure or completion treatment and necessary in
order to avoid relapse after completion of treatment.
In the health Center data and information processing of the existing system are addressed the
following points. Information processed in the current system held manual or paper-based
record system. This sub-system maintains data about individual TB patients history , clinical
data (e.g. date of TB diagnosis, TB treatment phases, HIV test result, previous treatment
history), bacteriological data (e.g. sputum smear and culture results), drug susceptibility
testing results and treatment outcomes (e.g. cured, treatment completed, died, failure,
defaulter and transferred). All other forms (clinical records such as TB treatment cards and
discharge letters, registers of contacts and TB suspects, referrals, requests for investigations,
prescriptions, drugs and laboratory supplies order forms) remain paper-based. All patient data
are recorded based on national standard TB prevention and control program manual. In the
facility individual patients file stored in TB room.
The following problems identified during patients follow up and treatment regimen (51):-
 The patients did not take medication at the right time.
 Sometimes the patients did not finish the anti TB drug which is the case to relapse,
failure or defaulter.
 Changing address (living place kebele or house).
 The patient coming from surrounding woreda kebeles faced transportation problem
 The patients assume fully cured from the disease.
 Forget to take medication.
 The patients need day to day follow-up and counseling.

4.2.1.2. Communication
Reporting is used to systematically monitor and evaluate progress of patients and treatment
outcome as well as the overall program performance. The report generated from previously
recorded TB registration book. In the health center (in facility), there is no system to support
for data analysis in the existing system. The TB focal person undertakes data analysis using
health center clinic service quarterly delivery report form. The reporting of TB and TB/HIV
collaborative activities is integrated into HMIS and all forms and registers are standardized.
He /She needs Tuberculosis case detection rate (all forms), Tuberculosis retreatment rate,
Tuberculosis treatment outcome, TB case detection through community TB care, proportion
of TB case(all forms) provided treatment observation (DOT) by community among all TB
cases ,number of MDR TB case detection and etc. Reports are prepared monthly in printed
25
format on patient information submitted to facility HMIS focal person, and quarterly
submitted to health unit and zone health department for TB coordinators. Communication is
made only using paper based recorded documents.

4.2.1.3. People

The health center TB focal person can access and modify any information system concerning
Tuberculosis patient data in existing system (51). During patient data recording, the focal
person is a responsible for any errors and missing values. The TB focal person is accountable
and responsible to make reports as acquired by stakeholder. The health center has two IT
professionals who enter the data to HMIS formats and maintain the existing system. Most of
the health professionals have no computer skill within the health center.

4.2.1.4. Procedure

TB control staff in the health center is familiar with the existing health information policies
and procedures .The existing systems contains the following procedures.

 Patient sputum smear examination request should be registered ,

 Laboratory diagnosis result should be registered,
 TB suspect patient should be registered in log book,
 The TB patient should take the medication every morning at health center ,
 TB patient treatment follow up should be monitored by Health Worker and kebele
HEWs.

4.2.1.5. Software

The health center has been planned to train their health workers about computer skill to
improve health information system and specific soft ware application. But, currently there is
no any applicable soft ware to improve TB patients follow up system and no computer
network for sharing information.

4.2.1.6. Hardware

26
The health center currently has six computers which located in facility head, ART, OPD, Eye
Care, HMIS and secretary. They use this computer for the purpose of preparing report, data
records and writing letters.

4.3. The Proposed System

The proposed new system is applicable at the health facility to TB patients follow up
information system. The Web client provides an interface that will allows the professional
users on the health care provider side to visualize, navigate, and analyze patient and text
message data (52).

This proposed system would have great importance and will be used as patient‘s data record
management system; patients follow up system and report generating system. Depending on
assessment of the current system the investigator finding new system that will enable the
patients to remind the taking medication on a recommended time, remind the appointment
schedule date and generate the reports. Additionally this system will solve the problem of
patients treatment success rate i.e. relapse failure, defaulter.

4.3.1. User Requirements

User requirements (also called Stakeholder requirements) describe the tasks the users must
able to accomplish with the product (53). It is defines abstract requirements describing the
system services which people need to use the system and to integrate it with their business
processes. User requirements are usually captured in use cases or scenario descriptions.
Apparently the user requirements represent the system‘s behavior from the user‘s point of
view.

4.3.2. Stakeholders

27
Stakeholders are individuals or organizations that could influence or be influenced directly or
indirectly by the system.
Table 1: Stakeholder Roles and Responsibility

s.n Stakeholders Role and Responsibilities

1 System  Responsible for organizational structure, creating and updating user

Administrator account, set up registration form, set up patient identification number,
set up patient treatments.
2 TB focal Person  Responsible for TB patients information registry,
 Responsible to record TB treatment on patient cards
 Responsible for reminding the patients,
 Responsible for requesting the system to generate reports
3 Health  Responsible for patients to inform about the dangers of irregular or
professionals incomplete treatments.
 Responsible for providing follow up every patient takes the
recommended drugs in the right combination, on the correct
schedule, and for the appropriate duration.
4 Patients  Responsible to provide appropriate information and address
 Responsible for coming at schedule ,
 Responsible to take a medication on recommended duration and time
 Responsible to consultation with health worker for the status of
his/her health
5 HEWs  Responsible for Screening of contacts of TB patients
 Responsible for Identify and refer TB suspects
 Continuously health education TB patients
 Support and motivate TB patents.
6 Physician  Responsible to train and support TB treatment supporters
 Provide timely feedback to health workers
 responsible for Supply anti TB drugs
 Facilitate adequate supply of recording and reporting materials
7 Laboratory  Responsible for providing patient diagnosis result
technician

28
 4.3.3. Software Requirements
Software requirements consist of all the requirements the software must demonstrate for the
system to meet the user requirements (53). They are derived from analysis of user
requirements. Software requirements include the so-called functional requirements and non-
functional requirements.

4.3.4. Functional Requirements

Functional requirements (behavior requirements) define what the system does, namely, the
functions (actions) of the system (53). They describe all the inputs and outputs to and from
the system as well as information concerning how the inputs and outputs interrelate.
Table 2: Functional Requirements

ReqID Requirement Description Use case

RQ-1 The system should identification of user and administrator UC-1
RQ-2 The system should enable legal user log in to the application UC-2
RQ-3 The system should enable the users (data clerk, TB focal person ) to register UC-3
individual patients information
RQ-4 The system should enable the health professionals to show patient information UC-6
RQ-5 The system should enable the users (TB focal person, health professional, UC-6
physician, HEWs) to track patients‘ demographic information.
RQ-6 The system should enable the TB focal person to follow up treatment UC-6
RQ-7 The system should enable the users (TB focal person, physician) to view the UC-5
health laboratory diagnosis result request.
RQ-8 The system should enable the TB focal person to show previously ordered UC-4
patients medication.
RQ-9 The system should enable the user to send schedule dates for patients check up UC-8
RQ-10 The system should send the remind medication for patients UC-7
RQ-11 The system should enable the system administrator for HEWs to remind UC-8
patients schedule dates
RQ-12 The system should generate monthly and quarterly standard reports UC-9
RQ-13 The system should enable the administrator create, delete update facility user UC-1
account
RQ-14 The system should enable the health center head manage the facility services UC-2

Remark: RQ =Requirement Id, UC=Use Case Id

29
4.3.5. Non-Functional Requirements

Non-functional requirements define the constraints of the system as it performs its functional
requirements (53). They include a description of the system‘s usability, reliability,
performance, security, maintainability, portability, implementation, interface, operations,
packaging and legal obligations.

4.3.6. Contextual Model for New System

Context-aware systems are applications that adapt to several situations involving user,
network, data, hardware and the application itself. Researchers in context-awareness have
concentrated on how to capture context data and to carry it to the application (54). Data
centered applications exchange information with users at different levels of detail, content
and presentation according to several parameters which depend on the user and the
environment.

Figure 1 present the context diagram of the proposed system, which is a top level view of the
information system that shows the system‘s boundaries and scope. It also shows how the
interfaces with the outside world.

30
 Get patient
information Data clerk

Patients
TB focal person

Register patients
records
Register patients

treatment
Follow up
medication

schedule

Records
Remind

&

Request
report
web based TB patients follow
up information system
Request
HEWs
Request treatment

treatment
records
Request
report

record

Display records
Request report

Request prescription
medicine
Request diagnosis
Health professional result Physician

Request treatment
System records
administrator

Figure 1: Contextual Model for New System

4.3.7. Use Case Modeling

Use cases are the primary drivers for all of the UML diagramming techniques (55). The use
case communicates at a high level what the system needs to do, and all of the UML
diagramming techniques build on this by presenting the use case functionality in a different
way for a different purpose. Use cases capture the typical interaction of the system with the
system‘s users (end users and other systems). These interactions represent the external, or
functional, view of the system from the perspective of the user.

31
4.3.7.1. Use Case Diagram

A use case illustrates a unit of functionality provided by the system. The main purpose of the
use-case diagram is to help development teams visualize the functions of a system, including
the relationship of "actors" (human beings who will interact with the system) to essential
processes, as well as the relationships among different use cases. Use-case diagrams
generally show groups of use cases either all use cases for the complete system, or a breakout
of a particular group of use cases with related (55). Use simple lines to depict relationships
between actors and use cases, as shown in Figure 2.

4.3.7.2. Use case System Analysis Models

A use case diagram illustrates in a very simple way the main functions of the system and the
different kinds of users that will interact with it (55). Use cases are used to describe the
functionality of the system and as a model of the dialog between the actors and the system. It
is important to remember that use cases are used for both as-is and to-be behavioral models.
As-is use cases focus on the current system, while to-be use cases focus on the desired new
system (55).A use case describes a function provided by the system that yields a visible result
to the actors. In the proposed system, the following actors and use cases are identified. Figure
2 shows use case diagram of the system. List of Identified actor and use cases.
The following actors have identified to interact with the proposed system:
Data Clerk
Administrator
TB Focal Person
Physician
Health Professional
HEWs
Additionally the designer has identified the following use cases for the new proposed system:
Login
manage user account
Registration TB patient
Request diagnosis result

32
 prescription medicine
Follow up anti TB treatment
Remind medication
Remind patients schedule dates
Generate TB patient reports

Wolkite health center TB patient follow up System

«uses»
Ceate account

«uses»
Manage user account System administrator
Update account
«uses»

Data clerk
Remove account

Login
HEWs

TB focal person Registration

Diagnosis request

prescription
medicine

Physician
Health professional

Follow up treatment

Remind medication

Patient

Schedule
medication date

Generate report

Figure 2:Use Case Diagram For TB Patient Follow Up System

33
 4.3.7.3. Use Case Narrations

The use cases narrations are used to describe each process identified in a use case diagram. It
is a significance to make the end user to understand the process of the system.
Table 3: Manage User Account Use Case

Use case ID UC-1

Use Case Title Manage user account
Use case Description This use case describes the user to administer their personal information.

Primary Actor System Administrator

Trigger The administrator login into the system
Pre-Conditions The account of user must exist and authorized
Post-Conditions The system manage the user account

Main scenario 1. The system displays main menu user interface

2. The administrator open user account option
3. The system displays user account list
4. The administrator select the list user account information
5. The system confirms the inserted /updated/removed records
6. Ends use case
Alternative courses 4a. If the user wants to create account for user records.
a. The user click on create account button.
b. The system displays a form to create the user account.
c. The user fills the required information and click on submit button.
d. The system confirms the inserted data.
e. The system saves new account.
4a.1. If the user wants to remove the user account.
a. Select and click the user account.
b. The system displays confirm account remove
c. The user clicks confirm remove button.
d. The system removes the selected user account from the database
Frequency of Use >25 /months

34
 Table 4 :Login use case

Use case ID UC-2

Use Case Title Login
Use case Description This use case describes the user enable to enter into the system
Primary Actor Users ( TB focal person, Data clerk, system administrator, health professional,
HEWs, physician )
Trigger The users of the system logs into the application with the user username and
password
Pre-Conditions The user has known user name and password which is existed within the
system.
Post-Conditions The system displays system main menu interface.

Main scenario 1. The system display main menu login window

2. The users click login button.
3. The system displays login interface
4. The users enters the username and password
5. The system verifies the username and password
6. The user logged in to the system then system will display the main
menu interface.
7. Use case ends
Alternative courses 4a. If the username or password is wrong
4a.1.The user is returned to step 3 and re-enters user name and password
Frequency of Use >20 /months
Business rule The system allows accessing the system. If the user fails to enter valid
Username or password, the system locks for 120 seconds automatically.

35
Table 5:Registration use case

Use case ID UC-3

Use Case Title Registration
Use case Description This use case describes the process of patient registration
information system.
Primary Actor Users (Data clerk , TB focal person and HEWs )
Trigger User open new patient registration form to record
Pre-Conditions The user is logged into the system.
Post-Conditions The system registered patient information in to the database
Main scenario 1. The system displays user interface or user home page
2. The user click registration link from the user main menu
3. the system displays registration form
4. The user fills patient information on the patient registration
form and save the records
5. The system verifies the information
6. Use case ends
Alternative courses 4a.If the patient is already registered on the system
4a.1. The system shows messages to enter patient Id and retrieved
previous patient records.
4b. If the patient is a new
4b.1.The user add the registration form
5a. If the user clicks on cancel button
5a.1 The system return to the main menu
Frequency of Use 9-15/months

36
Table 6:Prescription Medicine use case

Use case ID UC-4

Use Case Title Prescription medicine

Use case This use case describes the health worker/physician

Description provided/prescribed medicine to the patients.
Primary Actor Users (TB focal person ,physician )
Trigger The user receives and access detail patient history information to
prescribed medicine.
Pre-Conditions The user is logged into the system.
Post-Conditions The patient detail information is available in the database system and
retrieves prescription.
Main scenario 1. The system displays prescription medicine main menu user
interface
2. The user selects prescription medicine from the main menu
option
3. The system displays the prescription medicine form
4. The user click on Add button
5. System displays the prescription medicine detail form
6. The user fills and marks prescription medicine records and
click save button
7. The system saves or stored the prescription medicine records
on the database.
Alternative courses 4a.If8.theUse
patient
caseisends
already provided the prescription medicine records
4a.1 The user search previous prescription medicine records from the
system
6a. If the user clicks on cancel button
6a.1 The system return to the main menu
6a.2. If the user clicks on reset button
6a.2.1. The system clear the input box
Frequency of Use 9-15/months

37
 Table 7:diagnosis request use case

Use case ID UC-5

Use Case Title Diagnosis request
Use case This use case describes the processes of relevant investigation patient information
Description recording system
Primary Actor Users (Health professional, TB focal person, physician )
Trigger The system display assessed patient detail information from the database system

Pre-Conditions The user is logged into the system.

Post- The diagnosis request information is available in the database system
Conditions
Main scenario 1. The system displays users main menu or user home page
2. The user selects diagnosis from the user main menu option
3. The system displays diagnosis recording form
4. The user fills and marks in diagnosis form with complete information and click
save button.
5 The system save or stored the diagnosis information on the database
6. Use case ends
Alternative 4a. If the patient is new admitted ,
courses 4a.1 The user adds new diagnosis form.
4a.2 if the patient already exist on the database,
4a.2.1 the user enter diagnosis no
4a.2.2 The system retrieves previous patient records on the database.
5a. If the user clicks on cancel button
5a.1 The system return to the main menu
5a.2. If the user clicks on reset button
5a.2.1. The system clear the input box
Frequency of >90/months
Use

38
 Table 8:Use case for Patients treatment follow up

Use case ID UC-6

Use Case Title Treatment follow up
Use case This use case describes the processes of the assessment and management of
Description patient information system
Primary Actor Users (Health professional, TB focal person, physician )
Trigger 1. The system assess patients history registered in database system

Pre-Conditions 1. The user is logged into the system.

2. The system display treatment intervention information.
Post-Conditions The patients treatment follow up information is available in the database system
Main scenario 1. The system displays users main menu or user home page
2. The user selects treatment follow up link in the user main menu option
3. The system displays intensive and continues treatment follow up phase form
4. The user fills in treatment follow up form with complete records and click on
the save button
5. The system save or stored the treatment follow up records on the database
6. Use case ends
Alternative 4a. if the patient already exist on the database
courses 4a.1 the system retrieve records from database
4b. if the user new admitted
4b.1 the system adds and updates the existing information on the patient
Database.
5a. If the user clicks on cancel button
5a.1 The system return to the main menu
Frequency of Use >96/months
5a.2. If the user clicks on reset button
5a.2.1. The system clear the input box

39
 Table 9:Use case for Patients remind medication

Use case ID UC-7

Use Case Title Reminder medication
Use case This use case describes the process of sending reminder text message for
Description medication recording process
Primary Actor Users (TB focal person, patient)
Trigger The user logged into the system
The system assess patients completed medication time which is registered in
the database
Pre-Conditions The system should have registered medication time
Post-Conditions The system send automatically a text messages remind for medication and local
level health workers or HEWs through their mobile phone address
Main scenario 1. The system displays users main menu or user home page
2. The user selects remind medication from the main menu option
3. the system displays remind medication time form.
4. The user fill patient reminds medication time form.
5. The user clicks on the alert message wizard and write a text message.
6. The user click on send button into the system.
7. The system send automatically mobile text message to the patient or
HEWs in the day.
8. Use case ends

Alternative 7a. If the patients forget to take medication on recommended time and place
courses 7a.1 The system automatically send alert mobile text message to patients and
HEWs with their address.
7a.1.1 If user ignores the text message
7a.1.2 The system automatically send text message to contact person

Frequency of Use >96/months

40
 Table 10: Use case for Patients remind schedule dates

Use case ID UC-8

Use Case Title Send schedule dates
Use case This use case describes the process of sending reminder text message patients
Description for check up diagnosis and next medication time
Primary Actor Users (TB focal person, patients )
Trigger The user logged into the system
The system displays patient records to be remind for check up diagnosis
Pre-Conditions The system should have registered patient schedule records in data base
Post-Conditions The system send automatically a text messages to remind schedule date for
registered patients and local level health workers or HEWs through their mobile
address
Main scenario 1. The system displays users main menu or user home page
2. The user selects schedule date from the main menu option
3. The system displays date schedule date form.
4. The users fill patient id and date.
5. The user click on the alert message wizard and write a text message.
6. The user click on send button into the system.
7. The system automatically send mobile text message.
8. ends use case

Alternative courses 4a. If the patients miss the schedule date

4a.1 The system automatically send alert mobile text message to patients and
HEWs with their address.
4a.1.1 If the user ignores the schedule date
4a.1.2 The system automatically send schedule date to contact person

Frequency of Use 96/months

41
 Table 11: Use case for Patients report

Use case ID UC-9

Use Case Title Generate Standard report
Use case This use case describes the process of producing an electronic standard report
Description
Primary Actor Users ( TB focal person, health professional)
Trigger The user logged into the system
The user able to generate report by selecting the report option
Pre-Conditions 1. The user is logged in to the system.
2. All data registered in data base system to generate report
Post-Conditions The system generate standard reports

Main scenario
1. The system displays main menu user interface
2. The users selects the report from menu option
3. The system displays all data records
4. The users selects and marks the data records to be generated and click on
generate button
5. The system generates the report from the database system and displays
documented report.
6. The user click save button.
7. The system saved the data on data base
8. End use case
Alternative courses 7a. If the user clicks on export button
7a .1.The system export the report
7b.If the user clicks on print button
7b .1.The system print out the report
7c. If the user clicks on cancel button
7c .1.The system return to the main menu
Frequency of Use 4/months

42
4.4. Design the System

4.4.1. Design Class Diagram

The class diagram shows how the different entities (people, things, and data) relate to each
other; in other words, it shows the static structures of the system. A class diagram can be used
to display logical classes (56). The designer develops the class diagram for design TB
patients follow up information system as follows in tables 12.
Table 12: The concept of class diagram attribute and method

Concept Attribute methods

Manage User Account User Id Login

User First Name Add User
User Last Name Remove User
Update User
User Password
User Type
Administrator User Type Login
Admin First Name Add user
Admin Last Name Remove user
User Name Update user
Password
Employee Employee Id Login
Employee First Name Update
Employee Last Name Show report
Password
Employee Type
Registration Register Patient Id Get: string ()
Register Date Set: void ()
Patient First Name
Patient Last Name
Weight
Mobile No
Patient address

43
Concept Attribute methods
Follow up Follow up No Get: string ()
Follow up Date Set: void ()
Follow up Type
Treatment Outcome Type
Remind Medication Medication No Get: string ()
Medication Date Set: void ()
Medication Type
Prescribed Medicine
Hews Mobile No
Facility Name
Patient Address
Remind Schedule Date Schedule No Get: string ()
Schedule Date Set: void ()
Schedule Type
Patient Address
Report Report No Submit()
Report Date Display ()
Report Type Get: string ()
User Type Set: void ()
Diagnosis Diagnosis No Get: string ()
Diagnosis Date Set: void ()
Diagnosis Type
Diagnosis Result
Prescription medicine Prescription No Get: string ()
Prescribed Date Set: void ()
Prescription Type
Patient First Name
Patient Last Name

44
Designing the TB patient follow up information system create the software classes. During
the analysis, after defining the use case model, the designer came up with a set of conceptual
classes and a conceptual class diagram for the entire system. As mentioned earlier, these
come from a conceptual or essential perspective. The software classes are more ‗concrete‘ in
that they correspond to the software components that make up the system. In this phase there
are two major activities.
1. Come up with a set of classes.
2. Assign responsibilities to the classes and determine the necessary data structures and
methods.

In general, it is unlikely that the designer can come up with a design simply by doing these
activities exactly once. Several iterations may be needed and classes may need to be added,
split, combined, or eliminated. In the analysis, the designer came up with a set of conceptual
classes and relationships (57). Based on the identified concept and attribute in the above
table12, the designer demonstrate the class diagram for designing TB patients follow up
information system as following in Figure 3.

45
 «interface»
«interface»
login Manage User Account add user
-User account id : int administrator
-First name : string -Admin first name : string
-Last name : string -Admin last name : string
1..* Health professional -User password : char -User password : char
-Employeeid : int -User type : string -User type : string
-First name : string +login() : void +Login () : void -1..*

manage
-Last name : string +set user id() : void +Add() : void
-User type : string +set username() : void +Update information() : void
1
+Update account() : void +set user password() : void +Remove() : void
1..* +Set report() : void
Manage

1..*
TB focal person 1..1
Follow up
-Employee id : int
request

-First name : string

-Last name : string register
-Password : string 1..* physician
1..*
order
1..* +Add patients() : void -Employee Id : int
+Update patients() : void *
1..1 -First name : string 1..*
+Remove () : void

request
-Last name : string
+Set report() : void - password : char -1..*
Patients +Update account () : void
1..1 1..* -Patient Id : int +Set report() : void
-First name : string 1..*
-Last name : string
Follow up

request

-Mobile no : int
register

-Weight : int treat

Diagnosis result
order

+Get registration no() : void

+Get registration date() : void

Follow up
+Get diagnosis date() : void
1..*
1..1 1..*

Registration Prescription Medicine

«interface»
-Registration Patient Id : int -Prescription No : int
follow up
-Registration date : int -Prescribed Date : int 1..*
-Patient first name : string -prescription Medicine Type : char Diagnosis Request
-Patient last name : string -Patient First Name : string -Diagnosis No : int
-Patient Last Name : string 1..*
-Mobile no : int -Diagnosis Date : int Follow up
-Weight : int -Diagnosis No : int -Diagnosis Result : char -Followup No : int
+Getregistrationno() : void -Emplyee No : int -Patient No : int
0..* -Followup Date : int
+Addregistor() : void +Getprescription no() : void -Patient First Name : string -Followup Type : char
0..*
+Updateinformation() : void +Getprescribeddate() : void -Patient Last Name : string -Patient Status : char 1..*
+Getpatientno() : void -Employee No : string -Patient First Name : string
+Getregistrationno() : void -Patient Last Name : string
0..*
+Getdiagnosisno() : void -Patient Mobile No : int
+Getdiagnosisdate() : void +Getfollowupdate() : void
+getdiagnosisresult() : void +Getfollowupno() : void
+Add() : void +Getpatientno() : void
+Update() : void +Add() : ushort
+Read() : void +Update() : void

+1..*
Medication reminder 1..* +1..*
Report
-Medication Remind No : int Medication Schedule Date
-Report no : int
-medication Remind Date : int
-Report date : int -Schedule Date No : int
uses

1..* -Medication Remind Type : char

-Report type : char -Schedule Date : int
-Patient Id : int
+Getreportno() : void -schedule Date Type : string
-Patient Mobile No : int
+Getreportdate() : void -Patient Mobile No : int
+Getmedicationremindno() : void -Facility Name : string
+Getreporttype() : void +1..*
+Getmedicationreminddate() : void
+Add() : void +Getscheduledateno() : void
+Getmessageno() : void
+Update() : void +Getscheduletdate() : void
+Getmessagedate() : void 1
uses

+Getmessageno() : void
+Getmobile no() : void
+Patientmobileno() : void
+Getmessagedate() : void
1..*
1..* 1 +1..*

Figure 3: Design Class Diagram

46
4.4.2. Sequence Diagram

Sequence diagrams: A sequence diagram is an interaction diagram that details exchange of

messages among classes.. Sequence diagrams are organized according to time. Time
progresses as you go down the page. Each vertical line is labeled at the top with the class
name followed by a colon followed by the instance name. The objects involved in the
operation are listed from left to right according to when they take part in the message
sequence (57).
The diagram captures the behavior of a single use case. It shows objects and the messages
that are passed between these objects in the use case.
A good design can have lots of small methods in different classes. Because of this it can be
difficult to figure out the overall sequence of behavior. This diagram is simple and visually
logical, so it is easy to see the sequence of the flow of control. The use case is runs in the
server side in the following figure 4.

User LoginInterface LoginControler UserAcount

ClickOnLoginButton()
ActivateLoginPage()

DisplayLoginPage()
EnterUser(Name,Password)
GetUser(Name,Password)
VerifyUser(Name,Password)
InvalidData()

Acknowledgement ()

Figure 4: Log in sequence diagram

47
 User Registrationinterface Registration form Registration controller Patient registration

Click ()
ActivateRegistration CreateForm

DisplayForm()
AddInfo()
Validate()

InvalidInfo()

Registor()
Acknowledgment()

Figure 5:Registration sequence diagram

48
 User DiagnosisInterface DiagnosisForm DiagnosisController Diagnosisresult

Click()
ActivateForm
CreatForm()

DisplayForm()

FillDiagnosisInfo()

Submit()
Valid()

Acknowledgment()

Figure 6:Diagnosis request sequence diagram

49
 User PrescriptionInterface PrescriptionController Prescription

Click() ActivatePrescription()

DisplayForm()

FillInfo() Validate()

Submit()
NotValidate()

Acknowledgement()

Figure 7:Prescription Medicine Sequence Diagram

50
 User Follow upInterface Follow upForm Follow upController Follow up

Click()
ActivateForm
CreateForm()

DisplayFollowupForm()

FillFollowupForm()

Save()

Validate()

InvalidateFollowup()
Execute()

Acknowledgment()

Figure 8:Follow Up Sequence Diagram

51
 User Remind medicationInterface Remind medication Form RemindmedicationController
Patient

Click() Activateremind
medication Form
CreateForm()

DisplayForm()

FillInfo()
Save()

Validate()
InvalidData()
Automatic
SendText
Message

Acknowledgment()

Figure 9: Medication Remind Sequence Diagram

52
 User Schedule dateInterface ScheduledateForm Scheduledate Controller Patient

Click() ActivateForm
CreateForm

DisplayForm()
FillInfo()
Save()

InvalidData() Validate()

Automatic
sendScheduleDate()

Acknowledgment()

Figure 10:Remind schedule date sequence diagram

53
 User ReportInterface ReportForm ReportController Report

Click() Activate() CreateForm

DisplayReportForm()

FillReport()

Submit()

Validate()
InvalidData()

DisplayReport()

Figure 11:Report Sequence Diagram

54
 Administrator SettingInterface addForm registrationController Database

Click ()
ActivateRegistration CreateForm

DisplayForm()
AddInfo()
Validate()

InvalidInfo()

Registor()
Acknowledgment()

Figure 12:Add Account Sequence Diagram

55
 Administrator SettingInterface RemoveForm RegistrationController Database

Click()
ActivateRemoveList()
SelectRemoveList

RemoveUserist()

ConfirmRemove()

InvalidUserData() Validate()

RemoveUser()

Acknowledgment()

Figure 13: Remove account sequence diagram

56
4.4.3. Activity Diagram
Activity diagram describes activities and flows of data or decisions between activities (58). It
shows the procedural flow of control between two or more different entities (people, things,
and data) while processing an activity. It provides a very broad view of business processes
and it can be used to break out the activities that occur within a use case. This diagram is
useful in showing work flow connections and describing behavior that has a lot of parallel
processing. When you use an activity diagram you can choose the order in which to do
things. It states the essential sequencing rules to follow. It is different from a flow chart in
that it shows parallel processes, not just sequential processes .The following figure show us
the proposed activity diagrams.

User clicks on “login ” button

Repeat
System display login form

User enter user name and password

Invalid
(Is verify ) System dispalys error
Valid

Accept
Cancel

Display main menu

Figure 14:Login Activity Diagram

57
 User clicks on “registration” button

Display registration form

No serach by Id
(Is new)

Yes
User get and fill registration form

Already registered
Users submits

save the information

No
Click cancel button (Is register)
Yes

Registration successful message

Figure 15:Registration Activity Diagram

58
 User clicks on “diagnosis” button

Display diagnosis form

No Enter diagnosis no
(Is new)

Yes
User Fill and mark diagnosis form

Show diagnosis
records
Users submits

save the diagnosis result

No
Click cancel button (Is register)
Yes

Register in data base

Figure 16:Diagnosis Request Activity Diagram

59
 User clicks on “prescription medicine” button

Display prescription medicine form

No Enter prescription no
(Is new)

Yes
User Fill and mark prescription form

Show prescription
medicine records
Users submits

save prescription

No
Click cancel button (Is register)
Yes

Register in data base

Figure 17:Prescription Medicine Activity Diagram

60
 User clicks on “report” button

Display report form

User Fill and select tasks to be generate

No (Is generate)
Click cancel button
Yes

Generate report

Export report

Figure 18: Report Activity Diagram

61
4.4.4. System Architectures design

A network architecture in which each computer or process on the network is either a client or
a server (59). Servers are powerful computers or processes dedicated to managing disk drives
(file servers), printers (print servers), or network traffic (network servers ). Clients are PCs or
workstations on which users run applications. Clients rely on servers for resources, such as
files, devices, and even processing power (59).

4.4.4.1. The Proposed Web System Architecture

This TB patient follow up information system is designed to have a 3-tier Client/Server

Architecture. The third tier (middle tier server) is between the user interface (client) and the
data management (server) components (59). This middle tier provides process management
where business logic and rules are executed and can accommodate hundreds of users by
providing functions such as queuing, application execution, and database staging. The three
tier architecture is used when an effective distributed client/server design is needed that
provides increased performance, flexibility, maintainability, reusability, and scalability, while
hiding the complexity of distributed processing from the user. They are also easy to manage
and deploy the network and most of the code runs on the server. The protocol of interaction
between the client and the server is as follows: The client calls for the business logic on the
server, the business logic on the behalf of the client accesses the database (59).

A three tier distributed client/server architecture includes a user system where user services
(such as session, text input, dialog, and display management) reside. The middle tier provides
process management services (such as process development, process enactment, process
monitoring, and process resourcing) that are shared by multiple applications. The third tier
provides database management functionality and is dedicated to data and file services that
can be optimized without using any proprietary database management system languages. The
client/server model accommodates all types of users, it is simple and it works well with
today‘s technologies. Let us now see which are the 3 building blocks of the client/server
system, which meet a wide spectrum of client/server needs from the tiny to the intergalactic
(59). The 3 building blocks are
1. Client

62
2. Server
3. Middleware

Let us now view each of the building blocks in detail.

1. The client building block
o Runs the client side of the application
o It runs on the Operating System that provides a Graphical User Interface
(GUI) or an Object Oriented User Interface (OOUI).This blocks the operating
system, passes the buck to the middleware and lets it handle the non-local
services.
o The client also runs a component of the Distributed System Management
element (DSM). Where the DSM could be a simple agent on a PC or a front-
end of the DSM application on a managing station.
2. The server building block
o Runs the server part of the application.
o The server is operating system dependent to interface with the middleware.
o The server also runs a DSM component, which is once again a simple agent on
a managed PC to the entire back-end of the DSM application.
3. The middleware building block
o It runs on both the client and the server sides of an application and An
integrating resource between the clients and servers. It performs the following
main activities:
 translation between the different protocols
 optimization of the load-balancing
 security control
 management of the connections
o This also has a DSM software component.
o Where middleware forms the nervous system of the client/server
infrastructure.

63
 Users
«uses»

Login interface

Account interface
Registration interface
Diagnosis interface
TB patient follow up system
User Interface Follow up interface
Prescription interface
remind interface
Schedule date interface
Generate report interface
Response

Request

Presentation Layer

Inserting process

Retrieving process

Sending process
TB patient follow up Business
Reminding process
Logic
Sending process
Scheduling process
Generating process
Data
Data

Application Layer

Registering DBMS

Managing account
«uses»

TB patient follow up database

Figure 19: Three-tier Architectural Diagram

64
4.4.5. User Interface Design

Prototyping is an iterative analysis technique in which users are actively involved in the
mocking-up of screens and reports (60). The purpose of a prototype is to show people the
possible solution.

A user interface is that portion of an interactive computer system that communicates with the
user. Design of the user interface includes any aspect of the system that is visible to the user.
Today a wide range of non specialists‘ use computers, and keyboards, mice and graphical
displays are the most common interface. The user interface is becoming a larger and larger
portion of the software system in a computer system and a more important portion, as broader
groups of people use computers. As computers become more powerful, the critical bottleneck
in applying computer based systems to solve problems is now more often in the user
interface, rather than the computer hardware or software. Because the design of the user
interface includes anything that is visible to the user, interface design extends deep into the
design of the interactive system as a whole. A good user interface cannot be applied to a
system after it is built but must be part of the design process from the beginning. Proper
design of a user interface can make a substantial difference in training time, performance
speed, error rates, user satisfaction, and the user‘s retention of knowledge of operations over
time (60). Prototyping benefits are

 services may be identified

 A working system is available early in the process
 The prototype may serve as a basis for deriving a system specification
 The system can support user training and system testing
 Improved system usability
 Closer match to the system needed
 Improved design quality
 Improved maintainability

65
4.4.5.1. Interface-Flow Diagrams

Interface-flow diagrams show the relationships between the user interface components,
screens and reports that make up the investigator application. Interface-flow diagrams enable
the investigator to validate the design of TB patients follow up information system user
interface (60).

4.4.5.2. The Home Page

After you complete the login page, the system will welcome and redirect you to the home
page. On the home page, you‘ll find the system‘s main menu.

4.4.5.3. User Interface

As you browse the system, you‘ll notice that the pages follow a standard layout. For example,
at the top of each page you find links to the main modules of the system under the following
user interface.

HOME

LOGIN

MAIN MENU

TB PATIENT FOLLOW UP USER

INFORMATION SYSTEM

Registration Add user

Diagnosis
Add patient Edit user
Prescription medicine
Edit patient
Treatment follow up Update user
Update patient
Remind medication
Show patient Remove user
Schedule date

Report

Figure 20: Navigate Diagram

66
The login page is used to authenticate the user in the system. To enter into the system, the
User will enter a user login and password. If you don‘t have one, you can receive a new one
by clicking on the link. The system will check for the User Account and Password. If you
have not entered a valid login or password, an error message will be displayed .In this case,
repeat the operation.

Login Page

WOLKITE HEALTH CENTER TB PATIENTS FOLLOW UP INFORMATION SYSTEM

LOGIN

Dialog Title
Dialog Title

USER NAME Enter user name

PASS WORD Enter pass word

Enter Cancel

Figure 21: Login User Interface Screen

67
 MAIN MENU HOME PAGE

WOLKITE HEALTH CENTER TB PATIENTS FOLLOW UP INFORMATION SYSTEM

Manage user Logout

Registration Diagnosis Prescription Follow up Medication reminder Schedule date Report
account

Create account Register patient

Intensive phase
Remove account
contact person
Continuous phase
Update account

Figure 22:Main Menu User Interface Screen

68
Go to registration window, user in the main menu page click registration button (Figure 22) ,
the system will display sub menu patient registration and contact person menu . The user
click the sub menu form .To add new patient or contact person information in the registration
sub menu form, click on add or search the existing information by patient id. Complete
information and click Save to confirm or Cancel to undo.

Registration patient

WOLKITE HEALTH CENTER TB PATIENTS FOLLOW UP INFORMATION

SYSTEM

PATIENT INFORMATION Logout

Existed patient Search If patient new Add

Patient Id Enter patient Id

patient First name Enter patient First name

patient Last name Enter patient lastr name

Sex Enter sex

Age Enter age

Country Enter country

State Enter state

Zone Enter zone

City Enter city

Woreda/Town Enter woreda/town

Enter kebele
Kebele
Enter house no
House no

Patient mob no Enter mobile no

Reset Print Cancel

Save

Figure 23:Patient Registration User Interface Screen

69
 Registration contact person

WOLKITE HEALTH CENTER TB PATIENTS FOLLOW UP INFORMATION SYSTEM

CONTACT PERSON INFORMATION Logout

Existed contact If new contact Add

Search
person person

Contact person first name Enter contact person Fname

Contact person last name Enter contact person L name

Relationship with patient Enter relationship

Occupation Enter occupation

Woreda Enter woreda

Enter kebele
kebele

House no Enter house no

Enter mobile no
Mobile no

Save Reset Print Cancel

Figure 24:Contact Person Registration User Interface Screen

70
Go to Diagnosis window, user in the main menu page click Diagnosis button (Figure 22), the
system will display Diagnosis form .To add new patient Diagnosis in the Diagnosis form,
click on add or show the existing information by patient id. Fill and Mark in all fields
displayed and click Save or Cancel to undo.

Diagnosis page

WOLKITE HEALTH CENTER TB PATIENT FOLLOW UP INFORMATION SYSTEM

Logout
Diagnosis patient information

Show Add

Show previous patient history If patient new

Patient Id Enter Id
Diagnosis No Enter No
Time dd/mm/yy

Diagnosis date 00:00:00

Patient weight Enter Weight

Sputum smear +ve result Yes No
Sputum smear _ve result Yes No

Pulmonary TB type Yes No

Extra pulmonary TB type Yes
No

Save Reset Print Cancel

Figure 25:Diagnosis Request User Interface Screen

71
Go to Prescription Medicine window, user in the main menu page click Prescription
Medicine button (Figure 22) , the system will display Prescription Medicine form .To add
new patient prescription in the Prescription Medicine form, click on add or show the existing
information by patient id . Fill and Mark in all fields displayed and click Save or Cancel to
undo.

Prescription medicine

WOLKITE HEALTH CENTER TB PATIENTS FOLLOW UP INFORMATION SYSTEM

Fill the information Logout

Show
Add

Show previous patient history

If patient new
Medication started date dd/mm/yy
Medication finished date dd/mm/yy

Patient Id Enter Id
Patient weight Enter Weight
Prescription no Enter No
Treatment regimen phase Enter regimen
Facility name Enter Name

Prescribed Employee Id Enter employee Id

prescribed fixed dose combination drugs
RHZE 150/75/400/275 mg Yes No
RHZ 150/75/400 mg Yes No
RH 150/75 mg Yes No
EH 400/150 mg
Yes
No

Save Reset Print Cancel

Figure 26:Prescription Medicine User Interface Screen

72
Go to Follow up window, user in the main menu page click Follow up button (Figure 22) ,
the system will display sub menu Intensive follow up and continuous follow up menu .The
user click the sub menu form .To add new patient intensive follow up or continuous follow
up information form in the Follow up sub menu window, click on add or show previous
patient history by patient id . Complete information and click Save or Cancel to undo.

Follow up

WOLKITE HEALTH CENTER TB PATIENTS FOLLOW UP INFORMATION SYSTEM

Logout
Intensive follow up

Show previous patient history If patient new

Show Add

Started follow up date DD/MM/YY TO Finished date DD/MM/YY

Patient Id Enter id

Follow up date Enter date

Follow up No Enter NO

Types of anti TB drugs Enter drugs

Patient Category Enter catagory

Patient Weight Enter weight

Number of tablet
Enter tablet

Follow up month Enter month

Smear result Enter result

Monitoring chart days Enter days

Employee Id Enter Id

save Print Reset Cancel

Figure 27:Intensive Follow Up Treatment User Interface Screen

73
 Follow up

WOLKITE HEALTH CENTER TB PATIENTS FOLLOW UP INFORMATION SYSTEM

Logout
Continuous follow up

Show previous patient history If patient new

Show
Add

Started follow up
date
DD/MM/YY TO Finished date DD/MM/YY

Patient Id Enter Id

Follow up No Enter No
Follow up date Enter Date
Types of anti TB drugs Enter Drugs

Patient Weight Enter Weight

Monitoring chart days Enter days

Select the treatment out come

Cured Yes No
Treatment completed Yes No
Died Yes No
Transferred
Yes No
Failure Yes No
Defaulted
Yes No

save Print Reset Cancel

Figure 28: Continuous Follow Up User Interface Screen

74
Go to Remind Medication window, user in the main menu page click Remind Medication
button (Figure 22), the system will display the form. The user defined and authorized by the
Health Facilities fill in all fields displayed, and click on Save to confirm. The medication
reminder will automatically be sent to the patient with mobile phone address generated by the
system. A message will appear informing that the operation was successful. If this message
does not appear click cancel to undo the operation.

Remind medication

WOLKITE HEALTH CENTER TB PATIENTS FOLLOW UP INFORMATION

SYSTEM

Remind medication Logout

Medication no Enter No

Medication date Enter Date

Prescribed medicine Enter Medicine
Patient mobile no Enter Mobile No
HEWs mobile no Enter Mobile No
Medication completed date Enter Date

Text message/comments Hello! Remember to come and collect

your medications to cure TB. You or a
relative must always come within the
week. Keep on taking them every day

without stopping!

Save Send Reset Cancel

Figure 29:Remind Medication User Interface Screen

75
When the user click Schedule date button in the main menu page (Figure 22), the system will
display the screen. The user defined and authorized by the Health Facilities fill in all fields
displayed, and click on Save to confirm. The medication Schedule date will automatically be
sent to the patient with mobile phone address generated by the system. A message will appear
informing that the operation was successful. If this message does not appear click cancel to
undo the operation.

Medication schedule date

WOLKITE HEALTH CENTER TB PATIENTS FOLLOW UP INFORMATION

SYSTEM

Medication schedule date Logout

Schedule no Enter No

Schedule date Enter Date

Prescribed medicine Enter Medicine
Patient mobile no Enter Mobile No
HEWs mobile no Enter Mobile No
Contact person mobile No Enter Mobile No

Text message/comments
Hello! Your health is above everything.
Remember that you had a visit scheduled for
12/6/2016. Come to your Health Center. We are
waiting for you!

Save Send Reset Cancel

Figure 30:Medication Remind Schedule Date User Interface Screen

76
When the user click Report button in the main menu page (Figure 22), the system will display
the report screen. The user fill in all fields displayed and select one of these five options
from tasks perform activities. The user click generate button can see generated report and
click on export to send out the concerned body and click Cancel

Report

WOLKITE HEALTH CENTER TB PATIENTS INFORMATION SYSTEM

Logout
Quarterly service delivery report

Start date DD/MM/YY To Finished date DD/MM/YY

Health center name Enter Name

Woreda /Town Enter woreda
Health worker name Enter Name
Health worker mobile no Enter Mobile No
Report no Enter No
Report type Enter Type

Report contained activity

Tuberculosis case detection rate

Tuberculosis re-treatment rate

TB treatment out come

HIV screening for TB patients

MDR TB case detection

Generate

Generated Report

Save Print Export Cancel

Figure 31:Report User Interface Screen

77
When the system administrator click manage user account in main menu page (Figure
22),the system will display user account from setting options, the user will follow the
following procedures:
1. To create a new user account, click on create account and the screen will appear. Enter
information in the fields, and click on Save to confirm or cancel to undo it.
2. To update user account, click on update account and the screen will appear. Enter
information in the fields, and click on Save to confirm or cancel to undo it
3. To remove user account, click on remove account in the Action column and in the
confirmation window that appears, click on OK to confirm or cancel to undo it.

Manage User Account

WOLKITE HEALTH CENTER TB PATIENTS FOLLOW UP INFORMATION SYSTEM

Home Additional information Setting Logout

Create account

Update account

Remove account

Cancel

Figure 32:Admin User Interface Screen

78
4.4.6. Entity Relationship Modeling

An entity-relationship (E-R) data model is a high-level conceptual model that describes data
as entities, attributes, and relationships (61). The E-R model is represented by E-R diagrams
that show how data will be represented and organized in the various components of the final
database. However, the model diagrams do not specify the actual data, or even exactly how it
is stored. The users and applications will create the data content and the database
management system will create the database to store the content.
This modeling method pays particular attention to relationships the interactions among
entities. Relationships require special treatment in the development of databases, because
they are the glue that holds information together and because their realization in relational
databases is particularly important. Moreover, an E-R model is usually accompanied by a
behavioral model, which describes the way that the applications of the information system
must behave. Database designer creates new database system.
An E-R model attempts to capture those aspects of the real environment that are necessary for
the proper functioning of a business or other system. Not everything about the real
environment can be captured by the E-R model (61).

4.4.6.1. Entity Relationship Diagrams

As one important aspect of E-R modeling, database designers represent their data model by
E-R diagrams. These diagrams enable the designer and users to express their understanding
of what the planned database is intended to do and how it might work ,and to communicate
about the database through a common language. The Figures 32 shows TB follow up
information system entity relationship diagram

79
 Administer
1..1
State Patient Id FirstName
LastName FirstName LastName

UserId
woreda
UserType

1..1
Registered in 1..* Update
Patients User account
registration 1..*1..*
Database
1..* Manages
PhoneNo DiagnosisResult
1..*
Kebele Sex
Follow up DiagnosisDate FirstName

Follow FirstName
DiagnosisNo
upTYpe LastName
1..*
Follow Follow up
upNo Register in Diagnosis
request
PhoneNo
LastName

PatientStat Show
us Follow
upDate FirstName
LastName Prescription
medicine
Medication
Remind OerderDate
Medication
ScheduleNo ScheduleDate
Orderno

PhoneNo FacilityName
Schedule
Remind ScheduleType
medication

RemindType FacilityName Schedule date MobileNo 1..*

RemindNo
1..*
RemindDate

Figure 33: Entity Relationship Diagram

80
4.5. Evaluate the effectiveness of system usability

The Investigator presented the designed system functionality to respondents to evaluate the
effectiveness of the system. Usefulness design TB patients follow up information system is
the issue of whether the system can be used to achieve some desired goal. Usability is the
extent to which users can use a computer system to achieve specified goals effectively and
efficiently while promoting feelings of satisfaction in a given context of use. Usability
evaluation (UE) consists of methodologies for measuring the usability aspects of a system's
user interface (UI) and identifying specific problems. Usability evaluation is an important
part of the overall user interface design process, which ideally consists of iterative cycles of
designing, prototyping, and evaluating. Usability evaluation is itself a process that entails
many activities depending on the method employed (62).
A questionnaire is a measurement tool designed to assess a user's subjective satisfaction with
a design TB patient follow up information system. It is a list of questions that are distributed
to users for responses based on system attributes. The goal is to evaluate the effectiveness of
the process and the result .The goal is to improve the interface design process and results.
Responses on a questionnaire are usually quantitative and the evaluation of the result
demonstrated in table 13.

81
 Questionnaire ratings of the design system on 5-point semantic differential scale (e.g. strong
agree=5, agree=4, not decided=3, disagree=2 and strongly disagree=1)

Table 1: Evaluation Checklist

s.n System effectiveness evaluation criteria Strongly Disagree Not Agree Strongly
disagree decided agree
1 The design system could increases the - - - 40% 60%
performance of the users
2 The design system made the user to save - - - 20% 80%
time and cost
3 The system could be automating TB - - - 100%
patient data record system.
4 The design system could be helpful to - - - 40% 60%
follow up patient in the health facility.
5 The system could be minimizing the TB - - - 20% 80%
patient defaulter, relapse and failure.
6 The system could increase TB patient cured - - - 20% 80%
success rate
7 The system could be able to improve - - - 40% 60%
medication error
8 Implementation of system could provide - - - 20% 80%
standard health service to the client.
9 The system could be helpful to remind - - - 20% 80%
medication
10 The design system could friendly use to - - - 100%
improve patient data quality
Total evaluation 22% 78%

According to the above table 13, the respondents to evaluate the proposed system
effectiveness and functionality of the system were 22 % agree and 78 % strongly agree .

82
 CHAPTER FIVE

5. CONCLUSIONS AND RECOMMENDATIONS

5.1. Conclusions

This project was conducted with a design of TB patients follow up information system which
is significant to improve TB patient treatment in Wolkite Health Center.

The current system is performing paper based system. In the Health Center the system
uses manual method which causes many problems such as duplicated data storage and
difficult retrieval, patients did not take medication at the right time, poor patient
follow up, patient data lost, wastage of time in maintaining paper work and more.
Based on the finding of this research project, the designed TB patient follow up
information system is contribute a better understanding to solve the problem being
performed by the current manual approach keeping patient data record and follow up.

The study identified critical requirements from the health facility which the
information includes, diagnosis, prescription, follow up and remind medication
associated with electronically record. The system supports to remind patient
medication and schedule date, provide fast services and enhance health worker
performance and speedy retrieve records. Additionally, in this study the national TB
prevention and control guideline were used as an input in order to determine the
requirements for the new system. Designing TB patient follow up information system
met specific objective of the project. This project conducted using design research
method. The system undertook gathering user requirement analysis and design phases.
The system is analyzed using diagrams such as business use case diagram and context
diagram. Additionally, the design phase emphasize how the system collaborate to
fulfill the requirements using UML artifacts of class diagram, sequence and activity
diagram, designing user interface prototype, and entity relationship database system
fundamental for system implementation. All section or components on the user
interfaces built to fit in to the software requirements. A design web based TB patient
follow up information system was used three-tier Client/Server Architecture model.

83
 Finally a user interface prototype shows a portion of an interactive computer system
that communicates with the user. Design of the user interface includes any aspect of
the system that is visible to the user. The investigator evaluates the effectiveness of
the system to improve the TB patient follow up system. The investigator evaluate the
effectiveness of the system includes different factors, such as performance of the
users, to improve medication error, treatment outcome, standardized health service,
perceived friendly use and timely delivered to the health workers of the study health
center.

5.2 .Recommendations

Based on the finding the following recommendations would be important to solve existing
TB patient follow up information system associated problem.

Health Facilities

The health center should install TB patients follow up information system software or
computerized system and networking for sharing the information.

The health center should communicate with stakeholders to support electronically

analysis and generate recoded patient information system.

Researchers

The investigator would like to recommend future researcher should continue the
project to complete all the remaining part of system in software development process.

Furthermore, the future studies could be implemented in TB patient follow up

information system and the system provide alert to the patient for medication and
schedule date.

84
 Reference

1. World Health Organization.Global Tuberculosis Report control: WHO Press, Genava,

Switzerland; 2012.
2. World Health Organization. Global tuberculosis surveillance: WHO Report. Geneva,
Switzerland; 2007.
3. World Health Organization. Global tuberculosis surveillance, planning and financing: WHO
Report, Geneva, Switzerland; 2005.
4. Federal Ministry of Health . Guidelines for Clinical and Programmatic Management of TB,
TB/HIV and Leprosy: Mega, 5th edition, Addis ababa, Ethiopia; 2013.
5. Gordon A.L., Nigro C.M. & Poling P.C. Technology assisted DOTs:UC Berkeley:
http://groups.school.berkeley.edu;2008.[Accessed date october 2015]
6. Bodart C., Shrestha L., Lippeveld T. & Sauerborn R. Design and Implementation of Health
Information System: Geneva ,Switzerland ;2000.
7. Dalibor S. Modeling the Health Information System: Ljublajna University, Slovenia; 2015.
8. Athina L. Web-Based Applications in Healthcare and Biomedicine: Oklahoma State
University, USA; 2010.
9. Lagrada L , Uehara N, Kawahara K. Analysis of factors of treatment completion in DOTS
health facilities: PMID ,Phillipines; 2008.
10. Busari O., Adedevo A., Olusogo B. Knowledge of TB and its management practices among
medical interns in a resource poor setting, implications for disease control. Sub Seharan
Affrica: The international journal of infectious disease; 2008.
11. Munro S., Lewin S. , Smith H. , Engel M., Frethem A., & Volmink J. Patient adherence to
tuberculosis treatment. a systemic review of qualitative research , PLoS Med; 4(7):238.
2007.[Accessed date January 2016]
12. Kaufmann S. & Britton W. Handbook of tuberculosis. Wiley- VCH,Eds;2008.
13. Peter M., Rein M., Judith R., Elizabeth L. & Katharina K. Pre-treatment loss to follow-up in
tuberculosis patients in low and lower-middle-income countries and high-burden countries.
In a systematic review and meta-analysis. London: London School of Hygiene & Tropical
Medicine; 2013.
14. Fraser H., Allen C, Bailey C. & Douglas G. Information systems for patient follow-up and
chronic management of HIV and tuberculosis. In a life-saving technology in resource-poor
areas. J Med Internet Res, e29; 2007.[Accessed date December 2015]

85
15. Weis S., Slocum P., Blais F., King B., Nunn M., Matny G., Gomez E., & Foresma B. The
effect of directly observed therapy (DOT) on the rate of drug resistance and relapse in TB. N
Engl J Med, 330: 1179-84; 1994.[Accessed date November 2015]
16. Burman W., Cohn D., Rietmeijer C., Judson F., Sbarbao J., & Reves R. Noncompliance with
directly observed therapy for tuberculosis. In epidemiology and effect on the outcome of
treatment (pp. 1168–73). Chest, 111:1168–73; 1997.
17. MOH. National Program on Tuberculosis Control. Brazilia: Health Surveillance Secretariat;
2004.
18. World Health Organization. New horizon for health through mobile technology, based of
findings of the second Global survey on ehealth. Geneva: Switzerland; 2011.
19. Elaine T.,Luiz A., Maria de Fatima. Health information technology in primary health care in
developing countries. In a literature review. Brazil: Pelotas University; 2014.
20. Braa J. Electronic Journal on information system in developing countries. Mozambique;
2001.
21. Archangel N. The critical issues affecting the introduction of health management
information system in developing countries in Africa. Master thesis . Amsterdam University
department of Informatics; 2007.
22. Faser H, Biondich P, Moodley D, Choi S, Mamlin B, Szolovits P. Implementing electronic
medical record System in developing countries. In Refereed paper (pp. 83-95). Informatics
in Primary Care; 2005.
23. World Health Organization. Toward Universal Access scaling up priority HIV/AIDS
interventions in the health sector progress report: UNAIDS, UNICEF; 2010.
24. Feng,l. ,lu, h. Integrating database and web technologies . International, journal of World
Wide Web ; (1/2). 1998; pp.73-86.
25. Haux Reinhold. Health information systems past, present, future, International Journal of
Medical Informatics. 2006; 75, 268—281.
26. Conrick, M. Health informatics: Transforming health care with technology. Thomson Social
Science Press; 2006.
27. Goldschmidt, P.G. HIT and MIS: Implications of health information technology and medical
information systems. Communications of the ACM, 2005; 48(10), 69-74.
28. Brailer D. The decade of health information technology. HHS Report; 2004.
29. When health care and computer science college. University of Illinois at Chicago; 2014.

86
30. Chaudhry B., Wang J. & Wu S. Systematic review: Impact of health information technology
on quality, efficiency, and costs of medical care, Annals of Internal Medicine; 2006;
144(10), 742–752.
31. Costs and Benefits of Health Information Technology. AHRQ, Evidence
Reports/Technology Assessments (Rockville, MD.); 2006.
32. World Health Organization. Assessment of Ethiopia National Health Information System:
Final Report; 2007.
33. Seong-Ran Lee. Effects of Information Systems Application to Improve Daily Life
Performance Ability in TB Patients: Department of Medical Information, Kongju National
University, 56 Gongjudaehak-ro, Kongju, Chungnam, South Korea, 2015; 314-701.
34. World Health Organization. Electronic recording and reporting for tuberculosis care and
control: 20 Avenue Appia, 1211 Geneva 27, WHO Press Switzerland; 2012.
35. Ann LN Chapman, Thomas C Darton, & Rachel A Foster. Managing and monitoring
tuberculosis using web-based tools in combination with traditional approaches: USA; 2013.
36. Blaya JA, Shin SS, Yale G. Electronic laboratory system reduces errors in National
Tuberculosis Program: a cluster randomized controlled trial. Int J Tuberc Lung Dis; 2010.
14:1009–1015.[Accessed date December 2015]
37. Blaya JA, Shin S, Contreras C. Full impact of laboratory information system requires direct
use by clinical staff: cluster randomized controlled trial. J Am Med Inform Assoc.; 2011;
18:11–16. [Accessed date January 2016]
38. Chin CD, Cheung YK, Laksanasopin T. Mobile device for disease diagnosis and data
tracking in resource-limited settings. Clin Chem.; 2013; 59:629–640.
39. Amet I, Walter PN, Hersberger KE. Poly medication electronic monitoring system
(POEMS) a new technology for measuring adherence. Front Pharmacol. 2013; 4:1–6.
40. Krueger K, Ruby D, Cooley P. Videophone utilization as an alternative to directly observed
therapy for tuberculosis: Int J Tuberc Lung Dis. 2010;14:779–781[Accessed date February
2016]
41. Fraser HS, Allen C, Bailey C, Douglas G, Shin S, Blaya J. Information systems for patient
follow-up and chronic management of HIV and tuberculosis: a life-saving technology in
resource-poor areas. J Med Internet Res. 2007; 9:e29.[Accessed date December 2015]
42. Fraser HS, Blaya J, Choi SS, Bonilla C, Jazayeri D. Evaluating the impact and costs of
deploying an electronic medical record system to support TB treatment in Peru. AMIA Annu
Symp Proc. 2006:264–268. [Accessed date March 2016]

87
43. Muhammad S. K., Nawarat S., Nopporn H., Oranut P. & Titipat R. Improvement Of District
Hospital Service System To Increase Treatment Adherence Among Tuberculosis Patients:
Faculty of Public Health, Mahidol University, Bangkok, Thailand; 2011.
44. S. C. Auld, L. Kim, E. K. Webb, L. J. Podewils, M. Uys . To completeness and concordance
of TB and HIV surveillance systems for TB-HIV co-infected patients. Johannesburg, South
Africa; 2012.
45. Masako OHMORI, Kazuhiro UCHIMURA, Kunihiko ITO, Masako WADA Yuko
YAMAUCHI, Hitoshi HOSHINO, et al. Computerized Surveillance System of Tuberculosis
in Japan: Its Evolution, Achievement and Challenges Research Institute Of Tuberculosis
Surveillance Center, Tokyo, Japan; 2011; 204_8533.
46. John Paynter & Michael Pearson .A Case Study Of The Web-Based Information Systems
Development: Department of Management Science and Information Systems, University of
Auckland, Private Bag 92019 Auckland, New Zealand; 1997.
47. J.K. Zhang & W. Xu . Web Service-based Healthcare Information System (WSHIS): A
Case Study for System Interoperability Concern in Healthcare Field, Centre for Biomedical
Engineering, School of Engineering, Surrey University Guildford, Surrey, U.K; 2006.
48. Joaquin A Blaya, Sonya S Shin, Martin JA Yagui, Gloria Yale, Carmen Z Suarez, Luis L
Asencios, J Peter Cegielski & Hamish SF Fraser. A web-based laboratory information
system to improve quality of care of tuberculosis patients: functional requirements,
implementation and usage statistics, Lima, Perú, 2007. /
http://www.biomedcentral.com/1472-6947/7/33.[Accessed date March 2016]
49. Hevner, A.R., March, S.T., & Park, J. Design Research in Information Systems Research:.
University of South Florida, Tampa, FL 33620, U.S.A; 2004.
50. Alan Dennis, Barbara Haley Wixom & David Tegarden. Systems Analysis and Design with
UML Version 2.0:An Object-Oriented Approach, Indiana University, University of
Virginia,Virginia Tech , John Wiley & Sons, Inc ,Second Edition; 2005.
51. Mohammed N. and Gosaye D. Interview, wolkite health center TB focal person, Ethiopia;
2016,
52. José António Nhavoto .SMSaúde: Design, Development, and Implementation of a
Remote/Mobile Patient Management System to Improve Retention in Care for HIV/AIDS
and Tuberculosis Patients, School of Business, Örebro University, Sweden; 2015.
53. Hardware & Software Minimum Requirements. MaximEyes Practice Management Software
(PMS), MaximEyes Electronic Health Records Software (EHR); 2015.

88
54. T. Chaari, F. Laforest. Design of Context-Aware Applications Based on Web Services
LIRIS, INSA Lyon, France; 2005.
55. Dolald Bell. UML basics: An introduction to the Unified Modeling Language, IBM Global
Services; 2003.
56. Roshan Chitrakar. Object Oriented Analysis and Design Conceptual Modeling; 2004.
57. Sarnath Ramnath & Brahma Dathan. Object-Oriented Analysis and Design, Department of
Computer Science, USA; 1998.
58. Massimo Felici. Activity diagram: school of informatics; 2004.
59. Channu Kambalya. Client Server 3-Tier system Architecture; 2005.
60. Scott W. Ambler. User Interface Design: Tips and Techniques, Cambridge University, 2nd
Edition; 2000.
61. Riccardi O. Data modeling with Entity-Relationship Diagrams; 2002.
62. Dix E. & Nielson J. Usability Evaluation of User Interfaces: New Jersey: Academic Press;
1998.
63. World Health Organization . Assessment of Ethiopia National Health Information System;
Final Report,2007.

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 Annexes

Annex 1: interview
ADDIS ABEBA UNIVERSITY
SCHOOL OF INFORMATION SCIENCE AND SCHOOL OF PUBLIC HEALTH
M.Sc IN HEALTH INFORMATICS PROGRAMM

Consent form

My Name is Adem Shikur .I am post graduate student of health informatics program and my
project research objective designing a Web based TB Patients follow up information system
in the case Wolkite Health Center.

To the respondents:

This interview is formulated how to analysis and design the system based on the information
acquired from the respondents. The result of this interview will be utilized for project purpose
only. It is hoped that the outcome of this study will contribute to the improvement TB
Patients follow up information system Wolkite Health Center. Therefore, you are kindly
requested to provide genuine response to the questions that follow.

"Thank you in advance for your Cooperation"

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Guide Line of Interview used for Design Web Based Tuberculosis patient follow up
information system to identifying requirement of the system and to analyze the system.

1. Data process

1. What type of information do you need for your work (clarify about patient,
policies, procedures, equipments, etc)?
2. How do you get that information?
3. What data you need to generate that information?
4. How you process the data into information?
5. How are patients data registered and stored?
6. How do you get patient history?
7. How do you retrieve patient information in the current system?
8. Is there any problem in the current information system? during patient follow up
9. What type of services or treatments the health center provides to patients?
10. How do you followed up the patients?
11. How often are you followed up the patients?
12. Did the patients check up in each treatments phase?
13. How many of the patients are registered phone address?
14. How many of the patients are read a text? Clarify
15. Did the patients complete the treatments?
16. Did the patients take medication on recommended time?
17. How do the patients come on appointment date?
18. How will data confidentiality and security be ensured?
19. How is feedback provided to system users?
20. Where the patients can get services?
2. Report/communication
21. How frequently prepare the report about patient data?
22. For whom do you submit the report?
23. How do you prepare report currently?
24. Where it is stored?
25. Is it easily accessible?

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3. People
26. Who is responsible for patient record error and how?
27. Who make the reports?
28. Did the health workers have computer skill?

4. Procedure
29. Do you have guide line to follow up patients treatments?
30. What are patient information recording procedures include?
31. Do have any system to trace the problem?
32. Do you have any integrated system? How?
5. Software
33. Is there any computer software in use for the existing system? List all
34. Is there any planned approach or computer system to improve the current system?
35. Do you have any software used to prepare reports? Which software?
6. Hardware
36. Do you have a computer? How many?
37. For what purpose do you use it?

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 Annex 2: Evaluation effectiveness of the system

Questionnaire completed at service by the respondents who are from health center. Please mark the
options which most appropriately reflect your feeling about using the design system (scales contain:
strong agree=5, agree=4, neutral=3, disagree=2 and strongly disagree=1)

1. The design system could increases the performance of the users

Strongly disagree 1 2 3 4 5 strongly agree

2. The design system made the user to save, time and cost
Strongly disagree 1 2 3 4 5 strongly agree

3. The system could be automating TB patient data record system.

Strongly disagree 1 2 3 4 5 strongly agree

4. The design system could be helpful to follow up patient in the health facility.
Strongly disagree 1 2 3 4 5 strongly agree

5. The system could be minimize the TB patient defaulter, relapse and failure
Strongly disagree 1 2 3 4 5 Strongly agree

6. The system could increase TB patient cured success rate

Strongly disagree 1 2 3 4 5 strongly agree

7. The system could be able to improve medication error

Strongly disagree 1 2 3 4 5 strongly agree

8. Implementation of system could provide standard health service to the client.

Strongly disagree 1 2 3 4 5 strongly agree

9. The system could be helpful to remind medication

Strongly disagree 1 2 3 4 5 strongly agree

10. The design system could friendly use to improve patient data quality
Strongly disagree 1 2 3 4 5 strongly agree

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 Annex 3:Organizational Structure

WOLKITE HEALTH CENTER ORGANIZATIONAL SRUCTURE

HEALTH CENTER
MANAGER
HEALTH EXTENSION
SUPPERVISOR

OPD CASE DELIVERY EMERGENCY HEALTH CARE

HRM Eye care
TEAM CASE TEAM CASE TEAM FINANCE

Guard Greener Secretary Runner Card room Cleaner HMIS

CASSHER

FP ANC DELIVERY PNC ABORTION PMTCT

Adult LABOR TB ENVIRO PHARMA ART

>5 OPD SECU EPI VCT
OPD ATORY ROOM MENTAL CY CLINIC

DISPEN ART
STORE
SERY DISPENCERY

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 Declaration

I declare that this project is my original work and has not been presented for a degree in any
other university, any that all sources of materials used for the research acknowledged.

Adem Shikur

This project has been submitted for examination with our approval as university advisors.

Prof. Ahmed Ali Dr. Temtim Assefa

Place and Date of submission: Addis Ababa, June, 2016

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