In recent years, Ecuador has had large investments in the health field, being the massification and referral of patients from public to private health centres one of the evidenced problems. Likewise, the lack of organization and the misuse of the available technological resources have caused a poor flow of information within the health centres causing problems of internal mobility towards the patients, which mostly lead to absenteeism and desertion to planned medical appointments. In addition to this, the significant advancement of technology in the field of health is stood out, with e-Health being one of these trends, which promotes the application and use of Information Technology in medical processes in all its levels, providing concepts and good practices that promote the implementation of new technological trends focused on this field. This project focuses on the design of a methodological proposal which allows automating processes such as the delivery of information and internal mobility of patients, key aspects of this proposal, applied to a case study at the Integral Health Centre Asistanet Matriz Norte (CISA); For this, a Progressive Web App was developed in Ionic Framework which allows to deliver all the necessary information to the patient regarding the automated processes, and at the same time the collection and validation of the results will be carried out based on the times of internal mobilization and satisfaction of the patients, these results will be analyzed and contrasted with the CISA absenteeism rates in order to reduce them. Decreasing a 3% the absenteeism index which represents approximately 473 patients who normally attended scheduled medical appointments, avoiding economic and resource loss for the state and the CISA.
Due to the massification of both patients and specialties in health centres in
Ecuador, given the lack of information in an adequate and timely manner,
whether due to insufficient physical space, untrained personnel, or deficient use of
technological resources, mobility and accessibility problems are generated for
patients within these centres, which in most cases generates absenteeism to planned
medical consultations with an average rate of 12% [
This problem lies in the lack of internal organization and use of available
resources, especially in such a technologically advanced society tends to use old
media, generating a poor flow of information within health centres in Ecuador,
that causes discontent with patients and deprives equitable access to both
infrastructure and internal information, this is something that must be taken into
account in community establishments, based on what the National Development
Plan dictates [
This proposal aims to optimize technological resources to provide improvements in patient care regarding mobility and accessibility problems that exist within health centres in Ecuador, it will be applied to a case study with the aim of validating it. For this, it is proposed to design a portable progressive web application (Progressive Web App - PWA), which uses the geolocation of mobile devices; This technology will provide access to patients and greater usability which will help to have a greater range of patients without a high level of digital literacy.
The main contributions of our paper include: (1) to determine the associated concepts in this proposal regarding e-health, absenteeism, mobility, and prototype deployment models.; (2) to determine the appropriate technological infrastructure that the health centre should have for the implementation of this methodological proposal to be developed; (3) to design and develop a progressive web application based on geolocation that allows the evaluation of this research work. 2 2.1
The Public Health System in Ecuador has improved with the construction of new public facilities and patient care areas, currently having 910 medical centres corresponding to the IESS nationwide. According to data obtained in the web portal of the Ministry of Public Health called GeoSalud (https://geosalud.msp.gob.ec/ geovisualizador), which is an application that shows the real-time information regarding geolocation of medical centres and the main information of these, as an aid for the external mobility of patients to easily locate where to go either for emergencies or planned medical appointments.
Just as improvements have been made to the public health system, there has been an increase in the so-called “health production” by the Ministry of Public (MSP) Health as can be seen in Figure 1, denoting the growing demand in medical appointments which is not fully supplied by the number of Public Health Centres in Ecuador.
Given this referral of patients through the “Red Complementaria” which has 489 private health centres according to data from the GeoSalud portal, a problem arises regarding internal mobility in these health centres since most of the patients who are redirected there do not know how to go to the different doctor’s offices due to disorganization and lack of available information and especially because of the large number of patients. 2.2
Absenteeism is a very serious problem that occurs very often in different areas,
especially in the labor aspect, in the specific case of this project the absenteeism
of patients in medical appointments will be studied. One of the reasons that
has been evidenced for this absenteeism to occur is the lack of knowledge and
lack of information that is provided to patients in regard to health centres and
mobility within them, generating delays and absences among patients to medical
appointments [
The concept of mobility can be defined as the movement or displacement of a
person through a path or route [
e-Health Through e-Health, a redefinition of the health centres of the traditional towards digital is sought, with improvements in Information Technology and the optimization of the available resources by these centres, and thus providing better solutions to the health field that benefit the entire participating community.
For the adoption of the basic characteristics of e-Health, [
This technology within e-Health is of great help as it proposes a fast and timely
deployment method [
Within e-Health, applying cloud computing there are five essential
characteristics [
In this way, immediate information can be obtained from the health centres
for decision-making [
For the design of the application, we will work with a distributed architecture [
This prototype will be a progressive web application (PWA) developed in the Ionic Framework, which works in a hybrid way running through the web consuming Google services for geolocation and map generation.
Given this characteristic of PWA, this technology has been selected as the
most suitable for the realization of the prototype because it allows greater agility
in the execution and use of it in an environment in which it is necessary to
minimize the greatest amount of time to mobilize internally to the doctor’s
offices to attend medical appointments, since according to data obtained by the
company Google, 53% of users close websites that take more than 3 seconds
to load their content [
To facilitate the use of the application to patients and improve the time of care
within the Health Center, the prototype interface was deployed on a web server
to access from any device regardless of the type of connection [
For the design of the architectural diagram (see Fig. 3), the application will
work with a distributed architecture [
The database is on a PasS server, which is implemented in the Google Cloud Platform with a free version for students, which will take over storing the CISA information used for the prototype. This information will be extracted by the backend server which will be developed with the NodeJS language implemented through PaaS on the Microsoft Azure platform, this server will expose REST Web Services so that the prototype that will be developed in Ionic Framework can access the information through the connection to the different REST services created.
The prototype developed in Ionic Framework working on Angular allows access to REST services through an HTTP request in order to display information regarding the proposed deployment model. Finally, for the execution of the maps, the prototype will be connected through the Google Maps API for Ionic to the “Maps” and “Geolocation” services contained therein, validation being necessary through a code obtained in the Google Cloud Platform website. 2.8
The development of the prototype gave as a result in autonomy in mobility and greater access to information regarding the medical services provided by the health centre significantly reducing absenteeism and delays in medical appointments.
Because there is a large number of patients with different technological
capabilities, the prototype was designed so that it is intuitive and provides clear
and concise information, thus having a linear flow (Fig. 4 a-b-c) of information
to finally show the routes generated using the API Google Maps based on Java
script.
Google Maps provides in its own application as well as in its services the
generation of routes, but this model works on a large scale in city streets, but for
small places that are only accessed by pedestrians these services do not have
an adequate functioning anymore because do not generate routes by not having
streets or passages on their maps, so that the present project focuses on
generating routes that solve this problem, making reference to a previous study of the
researchers [
This algorithm is based on the search of the uniform cost taking as a weight of each node the distance with the consecutive node in such a way that the shortest route from the beginning to the destination is found, but this algorithm presented the problem that having the dispersed nodes tended to move away from the end in certain cases, so a heuristic is applied which consists in additionally obtaining the minimum distance between each node with the final node. Therefore, the point closest to the origin has the shortest distance in a straight line to the destination, thus obtaining the most optimal route, which allows to reduce arrival times. 3
To analyze the statistical procedure, the polynomial regression method was used, which consists in adding a curvature to the model by introducing new predictors, which are obtained by elevating all or some of the original predictors to different powers. (1) (2) We start from the linear method:
yi = β0 + β1xi + i Then a polynomial model of degree d is generated from the equation: yi = β0 + β1xi + β2x2i + β3x3i + . . . + βdxdi + i This polynomial model is adjusted by linear regression by least squares, where nonlinear models are generated, the mathematical equation is still linear equation with predictors x1, x2, x3, ..., xd, for the different routes the linear and non-linear relationship between the two variables, using a polynomial model of degree 4, which allows predicting routes based on time, initially fits a linear model by least squares specifying the dependent variable (Routes) and predictors (Time) directly.
However, a general matrix of standardized residual errors will be constructed for all routes, to analyze them respectively.
The collection of internal mobilization times was carried out anonymously through the generation of the route from the starting point to the destination point in the application, selecting the routes most visited by patients based on the highest number of occurrences, thus obtaining an average of 200 daily samples for each route. For the analysis of the data obtained, the samples of a full month of the following three routes were taken:
Residual standard error
Without application Without application Without application – With application: – With application: – With application: 0.2627>0.206 6.10% 0.235>0.2042 3.08% 0.1511>0.057 9.41%
Without ap- Residual standard Residual standard Residual standard plication error: 0.3622 on 21 error: 0.2481 on 21 error: 0.4746 on 21 degrees of freedom. degrees of freedom. degrees of freedom. Multiple R-squared: Multiple R-squared: Multiple R-squared: 0.09427. Adjusted 0.03863. Adjusted 0.07315. Adjusted R-squared: -0.07825. R-squared: -0.1445. R-squared: -0.1034. F-statistic: 0.5464 F-statistic: 0.211 F-statistic: 0.4144 on 4 and 21 DF. on 4 and 21 DF. on 4 and 21 DF. p-value: 0.7036 p-value: 0.9294 p-value: 0.7963 With appli- Residual standard Residual standard Residual standard cation error: 0.2585 on 21 error: 0.172 on 21 error: 0.421 on 21 degrees of freedom. degrees of freedom. degrees of freedom. Multiple R-squared: Multiple R-squared: Multiple R-squared: 0.06193. Adjusted 0.0741. Adjusted 0.06538. Adjusted R-squared: -0.1168. R-squared: -0.1023. R-squared: -0.1126. F-statistic: 0.3466 F-statistic: 0.4202 F-statistic: 0.3673 on 4 and 21 DF. on 4 and 21 DF. on 4 and 21 DF. p-value: 0.8434 p-value: 0.7923 p-value: 0.8292 Residual Without application Without application Without application standard – With applica- – With application: – With application: error tion: 0.3622>0.2585 0.2481>0.172 7.61% 0.4746>0.421 5.36% 10.37%
In general, it can be stated that in all the routes generated as a function of time and that were taken from with the application, they are better than the routes that have been carried out without the application, in addition to the use of the polynomial regression model adjusted to fourth power its prediction level is better than that of the linear regression line.
The absenteeism rate during the execution month of the proposed model was 9%, while in previous months in which there was no tool to automate the processes of internal mobility and information deployment, there was an absenteeism index 12% denoting a noticeable improvement of 3% of assistance, approximately 15,000 patients per month. 4
By not adapting to the digital age, health centres do not have the necessary resources or are not properly optimized to innovate internal processes in order to improve the quality of medical services, which makes it more complicated to adopt new technological trends such as e-Health.
Thanks to the present study, it was possible to study and analyze the different factors that affect absenteeism to medical appointments, in order to provide a technological solution that helps the delivery of information to patients and the improvement of internal mobility, for that reason the concepts and characteristics of e-Health were used that allowed to have a base guide of good practices in the automation of the studied processes.
The proposed A * algorithm proved to be adequate by providing the most optimal routes in most cases, however, it presents certain problems when applied on routes with many obstacles involved generating incongruities in the final routes.
The study allowed us to validate that there is a reduction in the absenteeism rate at the “Centro de Salud Integral Asistanet”, during the time it was tested, thus demonstrating that e-Health should be progressively implemented in the health centres of the country to support the different existing processes in the health area. 5
For the deployment of the prototype, it is essential to have a means in which the patient can access the application in case of not having a mobile device or scanning the QR code, to improve the user experience and offer greater autonomy.
In places with little GPS satellite coverage, it is recommended to use devices that allow improving the accuracy in the location since the range of this tends to increase generating inaccuracy in the calculation of the routes.
For the gathering of results, it is recommended to consider a longer period of time in order to determine more accurately the absenteeism index generated in the health centre.
For future work it is recommended to complement the prototype by following the assigning and managing shifts process, allowing to obtain the data of the patient’s medical appointment, and thus directly access the route without the need for the latter to perform the search in the application. Significantly improving internal mobility times.