l" E_? «, ý

BREAST CANCER CARE SYSTEMP. KHIDMAT MAKLUMAT AKADEMIK

UNIMAS

IlIllIllIllIllIll 11111111111 1000165872

BEATRICE CHIN

This project is submitted in partial fulfillment of the requirements for the degree of Bachelor of Computer Science with Honours

(Software Engineering)

Faculty of Computer Science and Information Technology UNIVERSITI MALAYSIA SARAWAK

2006

ACKNOWLEDGEMENTS

I would like to express my appreciation and sincere gratitude towards the people who

have spent time in assisting me to successfully complete this final year project

First of all, I would like to thank Miss Chai Soo See for being a good and dedicated

supervisor all the way through this final year project. Throughout the process of

completing this project, she had given me advices and ideas on developing Breast Cancer

Care Systm. Without her guidance, I believe I will not be able to complete this project

successfully.

I would also like to extend my gratitude to my family members and friends who have

given me all the support and encouragement throughout the development of this project.

111

Fusat K1 idmat Makiuniat Akacienus. UNIVERSITI MALAYSIA SARAWAK

04301 Kota Samarahan

TABLE OF CONTENTS

Page

DECLARATION

ACKNOWLEDGEMENTS

TABLE OF CONTENTS

LIST OF FIGURES

LIST OF TABLES

ABSTRACT

ABSTRAK

CHAPTER 1: INTRODUCTION

1.1 Problem Statement

1.2 Objectives

1.3 Methodology

1.3.1 Object-Oriented Analysis (OOA)

1.3.2 Object-Oriented Design (OOD)

1.3.3 Implementation

1.3.4 Testing

1.4 Scope

1.5 Significance of Project

1.6 Project Schedule

1.7 Outcome

1.8 Outline of Project Report

1.8.1 Chapter 1 - Introduction

11

111

iv

X

xii

xiii

X1V

I

I

2

2

3

3

4

4

5

5

7

7

7

7

iv

1.8.2 Chapter 2 - Background

1.8.3 Chapter 3 - Requirement Analysis and Design

1.8.4 Chapter 4 - Implementation and Testing

1.8.5 Chapter 5 - Conclusion

CHAPTER 2: BACKGROUND

2.1 Introduction

2.2 Review on Existing Systems

2.2.1 iHealthRecord

2.2.2 CapMed

2.2.3 GlobalMedic

2.2.4 iValley

2.2.5 Comparisons of Reviewed Systems

2.3 Review on Implementation Tools

2.3.1 Programming Tools

2.3.1.1 Hypertext Preprocessor 4.0 (PHP4)

2.3.1.2 Active Server Pages+ (ASP+)

2.3.1.3 Comparisons between Different Programming Tools

2.3.2 Databases

2.3.2.1 MySQL

2.3.2.2 Oracle8

2.3.2.3 Comparisons between Different Databases

2.3.3 Web Servers

2.3.3.1 Apache Web Server

8

8

8

9

10

10

10

11

12

13

14

16

17

17

18

19

19

20

20

21

22

22

23

V

2.3.3.2 Microsoft Internet Information Services (ITS)

2.3.3.3 Comparisons between Apache and ITS

2.4 Reviews on Methods Used for Calculating Breast Cancer Risk

2.5 Conclusion

CHAPTER 3: REQUIREMENT ANALYSIS AND DESIGN

3.1 Introduction

3.2 Object-Oriented Analysis (OOA)

3.2.1 System Requirements Specification

3.2.2 Requirement Analysis

3.2.2.1 Use Case Model

3.2.2.1.1 Manage PHR Use Case Diagram

3.2.2.1.2 Access Message Center Use Case Diagram

3.2.2.1.3 Maintain Account Information Use Case Diagram

3.2.2.1.4 Retrieve Patient's PHR

3.2.2.2 Use Case Specification: Manage PHR

3.2.2.3 Use Case Specification: Login

3.2.2.4 Use Case Specification: Retrieve Patient's PHR

3.2.2.5 Use Case Specification: Register As Member

3.3 Object-Oriented Design (OOD)

3.3.1 Designing of Classes, Relationships, Attributes and Methods

3.3.2 Activity Diagram

3.3.3 Interface Design

3.3.4 Database Design

23

24

25

29

30

30

30

31

31

32

33

34

35

35

36

37

40

42

45

45

47

50

52

V1

3.3.4.1 Business Rules and Entity Relationship Diagram

3.3.4.2 Identify Attributes and Primary Keys

3.4 Conclusion

CHAPTER 4: IMPLEMENTATION AND TESTING

4.1 Introduction

4.2 Implementation of System Module

4.2.2 Login Module

4.2.3 Registration Module

4.2.4 Patient Module

4.2.4.1 Personal Home Page

4.2.4.2 Personal Health Record (PHR)

4.2.4.3 Account Information

4.2.4.4 View/Print PHR

4.2.4.5 Delete PHR

4.2.5 Health Professional Module

4.2.5.1 Search for Patient

4.2.6 Message Center Module

4.2.7 Contact Us/Help Desk Module

4.2.8 Breast Cancer Quiz Module

4.2.9 Breast Cancer Risk Assessment Tool Module

4.2.10 Forum Module

4.2.11 Search Function

4.2.12 Encryption Feature

53

56

56

58

58

58

58

59

61

61

62

63

64

64

65

66

67

68

69

70

72

72

77

vii

4.2.13 Interface Agent Feature

4.3 Testing

4.3.1 Functionality Test

4.3.2 Graphical User Interface (GUI) Test

4.3.3 Usability Testing

4.4 Conclusion

CHAPTER 5: CONCLUSION

5.1 Introduction

5.2 Achievements

5.3 Contributions

5.4 Limitations

5.4.1 Limited Element in Personal Health Record

5.4.2 Limited Interface Agent Abilities

5.4.3 Search Engine

5.4.4 Uses Only Single Language

5.4.5 Address Book Not Available

5.4.6 Limited Information

5.5 Future Works

5.5.1 More Elements in Personal Health Record

5.5.2 A More Interactive Microsoft Agent

5.5.3 A More Sophisticated Search Engine

5.5.4 Dual Language

5.5.5 Address Book

78

79

79

82

83

85

86

86

86

88

88

88

89

89

89

90

90

90

90

91

91

92

92

viii

5.5.6 Library of Sources

5.6 Conclusion

REFERENCES

BIBLIOGRAPHIES

APPENDIX A: USE CASE SPECIFICATIONS

APPENDIX B: ATTRIBUTES AND PRIMARY KEYS

APPENDIX C: GRAPHICAL USER INTERFACE (GUI) TEST

APPENDIX D: USABILITY EVALUATION

APPENDIX E: QUESTIONNAIRE RESULTS

92

92

94

97

98

106

113

114

116

ix

LIST OF FIGURES

Figure 2.1: Screen shots of personal health record for iHealthRecord

Figure 2.2: Screen shots of personal health record for CapMed

Figure 2.3: Screen shots of GlobalMedic features

Figure 2.4: Screen shots of Walley website

Figure 3.1: Use Case diagram for Breast Cancer Care System

Figure 3.2: Use Case diagram for Manage PHR

Figure 3.3: Use Case diagram for Access Message Center

Figure 3.4: Use Case diagram for Maintain Account Information

Figure 3.5: Use Case diagram for Retrieve Patient's PHR

Figure 3.6: Sequence diagram for Manage PHR basic flow

Figure 3.7: Sequence diagram for Manage PHR alternative flow

Figure 3.8: Sequence diagram for Login basic flow

Figure 3.9: Sequence diagram for Login alternative flow I

Figure 3.10: Sequence diagram for Retrieve Patient's PHR basic flow

Figure 3.11: Sequence diagram for Retrieve Patient's PHR alternative flow

Figure 3.12: Sequence diagram for Register an Account basic flow

Figure 3.13: Sequence diagram for Register an Account alternative flow I

Figure 3.14: Sequence diagram for Register an Account alternative flow 2

Figure 3.15: Class Diagram for Breast Cancer Care System

Figure 3.16: Activity Diagram for Breast Cancer Care System

Figure 3.17: Interface design for login page

Figure 3.18: Interface design for registration page

Page

12

13

14

15

33

34

34

35

35

36

37

39

39

41

42

43

44

45

46

49

50

51

X

Figure 3.19: Interface design for cancer record page

Figure 3.20: Interface design to display search result for patient

Figure 3.21: Interface design to display patient's PHR

Figure 3.22: Interface design for main page of BCCS

Figure 3.15: Entity Relationship Diagram for Breast Cancer Care System

Figure 4.1: Patient's login page

Figure 4.2: Patient's registration page

Figure 4.3: Patient's personal home page

Figure 4.4: Patient's personal health record

Figure 4.5: View PHR printable page

Figure 4.6: Delete PHR confirmation page

Figure 4.7: Health Professional's personal home page

Figure 4.8: Search for patient's record page

Figure 4.9: Inbox for Message Center page

Figure 4.10: Form to be filled in to compose message

Figure 4.11: Contact Us page

Figure 4.12: Breast Cancer Quiz

Figure 4.13: Breast Cancer Risk Assessment Tool page

Figure 4.14: Graph that depicts risk calculation results

Figure 4.15: Breast Cancer Care Forum

Figure 4.16: Search function for BCCS

Figure 4.17: Summary of GUI test results

Figure 4.18: Graph that summarizes usability evaluation testing results

51

52

52

52

54

59

61

62

63

64

65

65

66

67

68

68

69

70

71

72

79

83

84

xi

LIST OF TABLES

Page

Table 1.1: Project schedule 7

Table 2.1: Comparisons between existing systems 16

Table 2.2: Comparisons between PHP4 and ASP+ 20

Table 2.3: Comparisons between MySQL and Oracle8 22

Table 2.4: Comparisons between Apache and IIS 24

Table 2.5: Comparisons between Gail and Claus model 25

Table 3.1: Tables required for User database 55

Table 3.2: Tables required for Search database 56

Table 3.3: Tables required for Forum database 56

Table 4.1: Code segment to upload mammograms 63

Table 4.2: Code segment for generating line graph 71

Table 4.3: Code segment that shows how to obtain keywords from specified URLs 73

Table 4.4: Code segment for keyword matching 76

Table 4.5: Code segment for encryption method 77

Table 4.6: Code segment to show how Interface Agent is embedded in each webpage 78

Table 4.7: Test plan for login function 80

Table 4.8: Test plan for registration function (email address validation) 80

Table 4.9: Test plan for registration function (date validation) 80

Table 4.10: Test plan for registration function (phone number and postcode validation) 81

Table 4.11: Test plan for Breast Cancer Risk Assessment Tool function 81

Table 4: 12: Test plan for logout function 82

xii

ABSTRACT

The emergence of the Internet has impacted the health information and the healthcare

industry. The information revolution has reduced the distance between the healthcare

providers and consumers. It permits easy dissemination of information and fast

accessibility of data. With the rising cases of breast cancer among women in our country,

an idea to develop a web-based system to manage breast cancer patient's health record

evolves. The development of this system is expected to not only altered the way that

medical information is stored, shared, and generated across and within healthcare

organizations but it also promises to increase the efficiency and cost-effectiveness of

healthcare, specifically in the realm of breast cancer.

X111

ABSTRAK

Perkembangan Internet telah memberi kesan kepada bidang kesihatan dan penyebaran

maklumat kesihatan. Revolusi teknologi makiumat telah mempermudahkan cara

berkomunikasi di antara pihak kesihatan dan pengguna dan juga mempercepatkan

penyebaran dan pencapaian makiumat. Dengan kes kanser payudara yang semakin

meningkat di negara kita, telah timbttl satu idea untuk membina sistem yang dapat

mengurus rekod-rekod kesihatan para pengguna yang menghidap penyakit kanser

payudara. Sistem ini bukan sahaja mengubah cara maklumat perubatan dan kesihatan

disimpan dan diurus, ia juga dapat meningkat keberkesanan dan mengurangkan kos

dalam industri kesihatan, terutamanya dalam bidang kanserpayu dara.

X1V

CHAPTER 1: INTRODUCTION

Breast cancer is the most common cancer among Malaysian women from all

ethnicities and it is also the most common cause of cancer death among women in

Malaysia. In an effort to improve the quality of healthcare delivery to breast cancer

patients, Breast Cancer Care System (BCCS) is providing the online availability of

breast cancer patient's health record, where a patient not only can record and retrieve

her own personal health information but also able to upload their digital

mammograms. In addition, BCCS also provides concise information for people with

breast cancer concerns, breast cancer quiz to test user's knowledge about breast

cancer, risk assessment tool that calculates the risk of getting breast cancer based on

specified risk factors and forum that discusses any topics related to breast cancer.

1.1 Problem Statement

At present, every time a patient goes to a doctor's office, staffs have to put together a

chart, often involving phone calls to different specialties, including surgery, oncology

and radiology. "It takes an enormous amount of time to pull it all together, " said Dr.

Marisa Weiss, president and founder of nonprofit organization BreastCancer. org [15].

Besides, many of breast cancer patients, who travel or move frequently, find it a

major problem to ensure that their medical records follow them. Patients often have

numerous health appointments and every time patients have to attend an appointment,

they would have to bring their mammograms along. Unfortunately, patients are not

able to retain their mammograms. Patients would have to go and physically get the

images from the facility storing them, take them to their appointment, and later return

them to the original facility. Furthermore, women are often interested to know their

I

risk of getting breast cancer. They would have to pay for a high medical cost for a

doctor's visit just to know their risk. Also, women normally do not talk to their

families about their breast cancer problem and should they have questions regarding

breast cancer, they do not normally discuss with doctors, whereas it is important to

talk about it.

1.2 Objectives

At the core of this project is a system that puts together the important services as well

as general information for people with breast cancer or breast health concerns. The

main focus of this application is the electronic patient personal health record (PHR).

The objective of this feature is to enable breast cancer patients to store and manage

their own health records electronically and make them accessible by health providers

anywhere and at anytime in a secure way. It also allows patients and their health

providers to interact among each other to discuss further on patient's health or to

make appointments. The breast cancer quiz that is included in this application is to

enable users to test their knowledge about breast cancer. The goal of breast cancer

risk assessment, on the other hand, is to personalize management strategies for all

women, with the aim of increasing survival in high-risk women while decreasing cost

and complications in low-risk women. The application also provides forum, where

patients and caregivers can debate and exchange information regarding their personal

experiences with disease and health care.

1.3 Methodology

The methodology used in this project is based on the Object-Oriented System

Development, which consists of 4 activities: object-oriented analysis, object-oriented

2

design, implementation and testing. This methodology is chosen because it involves

incremental development, which best suits this project.

1.3.1 Object-Oriented Analysis (OOA)

This phase of software development is concerned with determining the system

requirements and identifying classes and their relationships to other classes in

the problem domain. To understand the system requirement, users or actors of

the system is identified. Use Case model, which represents users' view of the

system and users' needs are developed in this phase. Each Use Case is

described in a use case specification that contains pre- and post-conditions that

must be met and also basic and alternative flows of the use case scenario. Each

flow is followed by a sequence diagram. Chapter 3 explains in more details the

activities involved in this phase.

1.3.2 Object-Oriented Design (OOD)

In OOD, classes and relationships between classes are identified. Attributes

and methods for each class are also discovered in this phase. The classes

identified are then modeled in a UML class diagram that shows the

relationship between classes, its attributes and its operations. In addition, the

flow of the system is also designed in this phase and it is modeled in an

activity diagram shown in Figure 3.16. The interface design of the system is

also outlined in this phase. A medium-fidelity is developed for the interfaces

of the system based on the requirements obtained from OOA. Also, design of

the databases used in the development of this system is also discussed briefly

in OOD, whereby the entity, attributes and primary key are identified and

3

shown in a table. All the activities involved in this phase is further discussed

in Chapter 3.

1.3.3 Implementation

This phase is where the activity to develop the real system is carried out. This

involves a strong programming because this is the phase where designing

program specification, detailed coding and debugging of programs are done.

Chapter 4 describes more on the activities involved in this phase. In this

chapter, how the system works will be explained in brief by segregating the

system into few modules. The user interface for each module is also presented

in this chapter. Some of the complicated source codes will be included in this

chapter for further explanation.

1.3.4 Testing

System is tested to determine whether it conforms to the specifications of

requirements. Testing is carried out on a continuous basis and this refining

cycle is continued throughout the development process until the result is

satisfied. During this iterative process, prototypes are transformed

incrementally into the actual application. The actions involved for testing of

BCCS is discussed in Chapter 4. Functionality and usability testings are

carried out in this phase by employing few users to test the system, who are

then required to answer post-questionnaires.

4

1.4 Scope

The system developed in this project is mainly for breast cancer. As mentioned,

earlier, the features of this system include electronic personal health record for

patients, risk assessment tool and forum. Breast cancer patients are able to create their

own breast cancer record via the system. Health professionals, however, can use the

system to retrieve patients' record in case of emergency or for other purpose.

Researchers can also use this application to search for patients who are eligible for a

subject of a research or even for clinical trials. However, this system only provides the

facility to create health record that is related to breast cancer. Patient's medical

records that consist of family history, immunization and so on are not covered in this

application. Breast cancer information provided in this application only explains

general information about breast cancer, which includes the overview, stages and

treatment options. The breast cancer quiz, however, only tests users on basic

knowledge about breast cancer. Nonetheless, the breast cancer risk assessment tool,

simply calculates one's risk of getting breast cancer in 5 years and to 90 years. This is

because the formula used in Gail model [13] (a model that is used to calculate breast

cancer risk) is only to calculate risk of 5 years and lifetime. Calculation of risk in 10

years, 20 years and so on needs a different formula which are not presented in the

Gail model and therefore it is outside the scope of this project.

1.5 Significance of Project

Breast Cancer Care System is important to facilitate people with breast cancer or

breast cancer concerns to get all the services they want in a single system. Personal

health record for patients offered in this application ensures appointments with

doctors can proceed as planned with necessary data about patients easily accessible

5

and enables patients and their families to be more involved in their treatment. "With a

centralized resource, you can go from doctor to doctor in a much more powerful way.

You can streamline an inherently inefficient process", said Dr. Weiss [15]. Besides,

designing a format for organized, standardized health information, which can be

shared by patient-to-physician -to-researchers will increase the quality of healthcare

delivery. Moreover, this coordination of care between physicians and patients

improves the ability to achieve a more accurate diagnosis. Besides patients, doctors

and researchers, this application also benefits the clinicians to identify patients who

are eligible for clinical trials, whereby they could greatly reduce the cost and time

needed to search through medical records if they were available in an electronic

format. The feasibility of such an approach is becoming increasingly realistic as more

and more patient-specific medical data is being stored in electronic medical records.

BCCS benefits non-patients as well, whereby they can calculate their risk by using the

risk assessment tool featured in the application. Apart from that, all system users will

get to participate in the forum, where they can discuss and suggest any topics related

to breast cancer. This is important as nowadays, people tend to keep their problems to

themselves. Besides, some are even afraid to raise questions regarding breast cancer

to anyone. Therefore, with this forum, they can express their problem or questions

freely and discuss it with others who might experience the same problem or have a

better knowledge in breast cancer.

6

1.6 Project Schedule

The project schedule for the development of BCCS is shown below:

Activities Start date Date of completion

Introduction 16/04/2005 29/04/2005

Background 02/05/2005 27/05/2005

Requirement analysis and design 27/12/2005 27/02/2006

Implementation and testing 28/02/2006 2/05/2006

Conclusion and future works 20/04/2006 26/04/2006

Table 1.1: Project schedule

1.7 Outcome

The outcome of this project is a system that integrates web-based technology with the

healthcare industry, specifically breast cancer. It provides facility to create online

personal health record particularly for breast cancer patients and also combines the

breast-cancer related features that are useful for both patients and non-patients. This

system could support the breast cancer awareness campaign held in Malaysia and also

to improve the quality of healthcare industry in the country.

1.8 Outline of Project Report

This report consists of five chapters, which are: -

1.8.1 Chapter 1 - Introduction

This chapter provides an overview of the Breast Cancer Care System, which

consists of the introduction of the project, problem statement, objectives,

7

methodology, scope, significance of the project and expected outcome of the

project.

1.8.2 Chapter 2 - Background

This chapter, presents the literature review that has been done before the

development of the project. All the information regarding this project that has

been gathered will be stated here in this chapter and this includes the review of

the existing systems, comparison between this system and the existing systems

and also the comparison between the methods and techniques used in the

existing system.

1.8.3 Chapter 3 - Requirement analysis and design

This chapter explains on the requirement analysis and the design of the

project. The requirement analysis part comprises user requirement as well as

hardware and software requirement for the project. On the other hand, the

design part includes input and output design of the project.

1.8.4 Chapter 4 - Implementation and testing

This chapter will describe the implementation and testing phase that has been

done during the development of this project. This implementation includes the

explanation on the execution of the module that has been developed in this

project. The testing part, however, involves the evaluation of the project and

also provides various topics such as system testing, system evaluation, result

analysis and system limitations.

8

1.8.5 Chapter 5 - Conclusion and future work

This chapter concludes the project that has been developed. Accomplishment,

contributions and recommendations regarding the future work of the project is

stated in this chapter.

9

CHAPTER 2: BACKGROUND

2.1 Introduction

Web-based technology has not only altered the way medical information is stored,

shared, and generated across and within healthcare organizations; it also promises to

increase the efficiency and cost-effectiveness of healthcare. There are a vast number

of websites that provides health services and information, specifically in the realm of

breast cancer. Hence, reviews have been done to obtain sufficient information

regarding the existing systems as well as to assess the viability of web-based

technology in the healthcare industry before developing a similar application

successfully. Important information which includes reviewing of existing system, in

terms of features, functionalities, user interfaces and technologies used will be

examined closely and discussed in this chapter. In-depth explanation of various

concepts and technologies that will be used in developing Breast Cancer Care System

will also be included in this chapter. The technologies that will be reviewed are the

programming tools, databases and graphic tools. This review will be the core for the

development of Breast Cancer Care System for it provides better understanding and

knowledge about the concept and tools used to develop the proposed system. Besides,

problem areas that are found in the current system can be discovered, thus solutions to

the problems can then be provided and subsequently applied to the proposed system.

2.2 Review on Existing Systems

Based on review done, there is no system that provides personal health record

especially for breast cancer patients. Therefore, this review is based on existing

personal health record systems. The systems that are going to be reviewed are

10

iHealthRecord, CapMed, GlobalMedic and Walley. The following subsections

summarize the features provided by each application and technologies used to

developed them.

2.2.1 iHealthRecord

iHealthRecord is an application that solely provides an interactive personal

health record service to users. It is developed using Java Servlets and it uses

MySQL as the database. iHealthRecord enables users to either build personal

health record for their own or for their family members. Among the

information that can be stored in user's personal health record are patient's

immunizations, clinicians, medical histories, emergency contact, surgeries and

so on. In addition, registered users are able to enroll for various types of

programs listed in this application to help users to manage their health and

medications. Also, there is a Secure Messaging feature provided in this

application, whereby users can communicate with their clinicians, who are

also registered to the application. The following figure shows the screen shots

of some of the features provided by the system.

11