Requirements engineering–based mixed-methods needs assessment for a telemedicine breast cancer follow-up system

Abstract

Introduction

Breast cancer is one of the leading causes of mortality among women worldwide. Telemedicine presents a promising pathway to improve cancer care delivery; however, structured approaches to systematically eliciting and integrating stakeholder requirements remain scarce. This study aimed to conduct a comprehensive needs assessment using requirements engineering principles to inform the design of a telemedicine-based follow-up system for breast cancer patients.

Methods

An exploratory sequential mixed-methods design was employed, encompassing five stages: requirements elicitation, data collection, data analysis, requirements validation, and use-case development. Data were collected from 41 stakeholders—including healthcare professionals, administrative staff, patients, and caregivers—using semi-structured interviews and focus group discussions. Quantitative data were analyzed descriptively, while qualitative data underwent thematic analysis.

Results

The analysis identified three key domains of requirements—organizational, system, and stakeholder. Organizational requirements underscored the importance of leadership support, sustainable funding, and comprehensive training. System requirements emphasized security, scalability, interoperability, and user-centered design. Stakeholder needs highlighted privacy protection, accessibility, and effective communication channels.

Conclusion

Applying a structured, stakeholder-driven requirements engineering approach enabled the identification of organizational, technical, and user needs essential for designing a telemedicine follow-up system for breast cancer. The developed framework provides a replicable model for implementing secure, scalable, and user-centered telemedicine solutions not only in oncology but also across other healthcare domains.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14078-0.

Introduction

Breast cancer remains one of the most prevalent and significant public health challenges globally, continuing to be a leading cause of mortality among women [1]. Recent global estimates indicate that breast cancer remains the most commonly diagnosed cancer among women, with 2.3 million new cases and 670,000 deaths worldwide in 2022, and incidence rates continuing to rise in many countries [2].

In Iran, according to the latest cancer registry reports, the crude incidence rate of breast cancer in 2016 was 38.93 per 100,000 population [3]. Breast cancer is a health concern in Iran, accounting for up to 25% of all cancers in women. The mean age at diagnosis is approximately 10–15 years younger than in developed countries, with over 30% of patients diagnosed under 30 years of age, and a trend toward earlier onset in recent years. Late-stage diagnosis, limited screening, and the relatively young age of onset contribute to higher morbidity and mortality, highlighting the critical need for effective follow-up strategies, such as telemedicine-based interventions, tailored to the Iranian context [4].

Studies show that many breast cancer patients in Iran currently face numerous and significant problems in accessing counseling services and following up on their treatment, such as lack of equal access to medical services and unequal geographical distribution of these services, the cost of patient travel and transfer, road and transportation problems, physical and mental problems that make it difficult to be physically present at the place of receiving services, overcrowding and crowding of medical centers providing health and medical services, and the occurrence and spread of pandemic events such as COVID-19 [5–7].

Delivering high-quality cancer care requires multidisciplinary collaboration. In this context, information and communication technologies (ICT) can play a pivotal role in supporting interprofessional care.

Telemedicine, defined as the use of electronic information and communication technologies to provide healthcare services across geographical distances, has emerged as a solution to enhance care quality, accessibility, and cost-effectiveness [8, 9]. Its application in oncology is rapidly expanding, providing secure and cost-effective communication channels between healthcare providers and patients [10]. Implementing telemedicine systems through ICT can effectively address many challenges in healthcare delivery. The usability evaluation of the hybrid teleoncology system indicated that users rated the system at a good level, and specialists found it practically useful for providing treatment plans to breast cancer patients. These system serves as practical alternative to traditional methods, facilitating treatment planning while potentially improving accessibility, efficiency, and quality of care in oncology settings [11].

Telemedicine enables patients to receive care remotely, reducing exposure risks for vulnerable individuals and enhancing access by lowering costs, transportation barriers, and travel time [12].

Although telemedicine is increasingly utilized in high-volume surgical oncology centers, its specific influence on the distance patients must travel and the waiting period for initial appointments is not yet fully established. Given that appointment availability and travel distance heavily affect treatment decisions in such settings, it is crucial to further assess how telemedicine influences access to care [13].

Despite the growing use of telemedicine in high-volume oncology centers, its precise role in reducing patients’ travel distances and shortening wait times for initial consultations remains insufficiently explored. In such centers—where factors like appointment scheduling and geographic accessibility play a crucial role in patient decision-making—it is important to thoroughly investigate how telemedicine affects care access [14].

Involving key stakeholders in planning and deployment of telemedicine systems helps minimize design-related issues. However, structured guidance for selecting, adopting, or operating these technologies is often lacking. To ensure effective implementation, healthcare institutions must prioritize the perspectives and requirements of end-users—patients and clinicians—rather than assuming that any telemedicine solution will suffice [15].

Home-based telemedicine consultations are increasingly recognized as viable alternatives to traditional face-to-face appointments. Yet, research on user experience and usability of these home-centered platforms remains limited. Evaluating current telemedicine systems from the end-user perspective is essential to ensure acceptance, usability, and practical implementation in real-world settings [16].

In Iran, previous studies have explored the needs for implementing telemedicine in breast cancer care, focusing on developing tele-oncology systems [6].

These challenges, as mentioned in previous studies from Iran [6], emphasize the necessity of using telemedicine-based follow-up models tailored to local healthcare conditions, facilities, and limitations.

This study aims to systematically identify and prioritize stakeholders’ requirements for establishing a telemedicine system for breast cancer patients at the Motamed Cancer Institute, using structured and replicable evaluation models. The stakeholders included clinicians, non-clinical staff, patients, caregivers, and IT/management personnel, whose perspectives were integrated to ensure a comprehensive and user-centered system design.

Motamed Cancer Institute (MCI) has been recognized for its significant contributions to cancer research and clinical practice. An independent assessment by the Iranian Ministry of Health ranked MCI first among all cancer research centers—clinical and biomedical—in the country in 2024. Additionally, MCI secured second place among clinical research centers with independent funding and over a decade of experience. Among 833 evaluated centers, MCI’s Breast Cancer Research Center ranked within the top 10, highlighting its leadership in interdisciplinary research, patents, and high-impact publications.

Research questions

• What are the organizational requirements?

• What are the functional and non-functional (system) requirements of the telemedicine system for breast cancer patients?

• What are primary needs for stakeholders?

Methodology

This study was conducted at the Motamed Cancer Institute. An exploratory sequential mixed-methods approach, incorporating both quantitative and qualitative methods, was employed across five stages, following the requirements engineering framework outlined by Ian Somerville in Software Engineering [17]. Qualitative data were first collected through semi-structured interviews and focus group discussions to explore stakeholder needs. Quantitative data were subsequently derived from participants’ responses to the checklist to prioritize and categorize the identified requirements [18–21].

Requirements elicitation

A narrative literature review was conducted across databases including Scopus, Google Scholar, PubMed, and ScienceDirect, covering publications from 2012 to 2024. Boolean operators (AND/OR) were used to combine key terms, including “Need assessment”, “Iran,” “Breast Cancer,” “Tele oncology,” and “Telemedicine” guided the search. Insights from the literature facilitated the development of a comprehensive checklist for requirement gathering. Findings from the qualitative phase, together with evidence from the literature and Sommerville’s Requirements Engineering framework, were used to develop a structured checklist. (Supplementary File 1).

The detailed search strategy, databases, and key findings of the narrative literature review are presented in Table 1.

Table 1.

Search strategy details

Search Component	Description
Strategy	Combination of controlled vocabulary and free-text terms related to breast cancer and telemedicine, including: (“breast cancer” OR “breast neoplasm” OR “breast carcinoma”) AND (“telemedicine” OR “telehealth” OR “tele-oncology”) AND (“needs assessment” OR “requirements engineering”). Boolean operators (AND/OR) were applied; MeSH terms were used in PubMed where applicable. Limits: English language, publications from 2012 to 2024. Eample: (((((((“breast cancer”) OR (“breast neoplasm”)) OR (“breast carcinoma”)) AND (“telemedicine”)) OR (“telehealth”)) OR (“tele-oncology”)) AND (“needs assessment”)) OR (“requirements engineering”). Boolean operators (AND/OR) were used; MeSH terms applied in PubMed. Limits: 2012–2024, English language. (pubmed)
Databases/Sources	PubMed, Scopus, Google Scholar, ScienceDirect
Results Retrieved	Initial hits (approximate): PubMed: 148; Scopus: ≈100; ScienceDirect: ≈60; Google Scholar: additional relevant records identified. After removal of duplicates and screening of titles and abstracts, 22 studies were included for narrative synthesis and requirements extraction.
Analysis Method	Narrative synthesis mapped to Sommerville’s Requirements Engineering framework ​
Key Findings	Identification of organizational, system-level, and stakeholder-related requirement categories

Data collection

Qualitative data were collected through semi-structured interviews and focus group discussions with 41 stakeholders, including clinical staff (n = 12), non-clinical administrative staff (n = 17), patients with breast cancer (n = 4), and patient companions (n = 8).

Each session lasted approximately 40 min and was conducted between November and December 2024. Participants were recruited using purposive and convenience sampling until data saturation was achieved. Data saturation was determined according to Braun and Clarke’s thematic analysis framework [22]. There were four steps in developing the checklist: (1) extracting requirements from the literature (2), categorizing organizational, system, and stakeholder needs (3), expert review for thematic relevance, and (4) pre-collection refinement.

A checklist was developed specifically for this study, based on findings from the narrative literature review and Sommerville’s Requirements Engineering framework. Before and during the interviews and focus group discussions, participants were explained the rationale for inclusion, importance and feasibility of each checklist item and were asked to comment. Expert review sessions were held for validation using consensus-based techniques in line with the Somerville Validation Methods, including structured review and consensus scoring.

The item was designed to explore three major domains of needs:

1. Organizational Needs

2. System (Functional and Non-Functional) Needs

3. Stakeholder (User and Patient) Need

Quantitative data were extracted from participants’ responses in structured tables.

The origin and development sources of the checklist items are summarized in Table 2.

Table 2.

Checklist origin

Checklist Item	Origin	Description/Example
Organizational Needs	Literature review + Observations + Sommerville framework	“Therapeutic position” (100%), “Management support” (100%), “Financial sustainability” (72.4%)
System Needs	Literature review + Observations + Sommerville framework	Functional: Web-based (100%), Clinical integration (100%), 3G (75.6%) Non-Functional: Security (100%), Usability (100%), Scalability (90.2%)
Stakeholder Needs	Interviews / Focus Group + Discussions + Observations	Privacy (100%), Digital literacy (95.1%), Equitable needs (92.7%)
Secure communication needs	Literature review + Observations	Oncology literature + “physical/digital security” (100%)
Stakeholder elicitation methods	Sommerville framework + Interviews / Focus Group Discussions	Interviews/FGDs (41 stakeholders)
Prioritization & negotiation	Data analysis (SPSS + Thematic)	SPSS + thematic analysis
Verifiability checks	Validation (Expert panel)	75% consensus (5 criteria)
Traceability policy	Requirements management (Sommerville)	Documentation + change tracking

For patients with breast cancer, inclusion criteria included a pathology-confirmed diagnosis according to national or international oncology guidelines (e.g., TNM classification), the ability to operate telemedicine equipment following training, sufficient communication skills, and cognitive as well as psychological stability. Patients were additionally required to demonstrate basic digital literacy, consistent access to the internet, and availability of appropriate telecommunication devices. Companions were subject to the same inclusion criteria, with the exception of the breast cancer diagnosis.

Exclusion criteria included severe cognitive impairment, active psychiatric disorders affecting communication, and inability to participate in interviews. Requirements related to digital literacy, internet access, and communication devices were part of the patient inclusion criteria and were assessed prior to participation.

For organizational stakeholders, inclusion criteria included a minimum of three years of relevant professional experience and possession of at least a master’s degree. Patients were additionally required to demonstrate basic digital literacy, consistent access to the internet, and availability of appropriate telecommunication devices.

Data analysis

The qualitative themes were analyzed using thematic analysis, following the six-phase framework proposed by Braun and Clarke [22]. This involved familiarization with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. Quantitative frequencies were analyzed using descriptive statistics via SPSS version 22 to aid in prioritizing the identified needs.

Through triangulation (using multiple data sources, methods, or perspectives simultaneously to increase the accuracy and validity of findings), quantitative and qualitative findings were integrated. Convergences divergences and complementary insights are expressed according to the mixed method by Creswell and Fetters et al. [18, 20]. Joint integration was carried out in the development and interpretation of the instrument, allowing qualitative findings to shape the construction of checklists and subsequently transformed into quantitative summaries.

Requirements validation

A validation meeting was convened with experts, including specialists in health information management, medical informatics, IT, senior management, physicians, and nurses. The documented requirements were reviewed against initial findings, and any omitted items were reinstated upon achieving at least 75% consensus among participants. A multidisciplinary panel confirmed the content validity of the checklist, and reliability was supported through repeated revisions and consistency checks during validation sessions, with items retained after achieving ≥ 75% expert agreement. It was explained to the participants that in the next stages, their opinions will be used in the design and development of the system, and they will be provided with the necessary training to use the system. The validation process considered five key criteria: validity, consistency, completeness, realism, and verifiability, as outlined by Sommerville.

Requirements management and use case development

To maintain effective control and traceability throughout the project lifecycle, a structured requirements management process was implemented, encompassing systematic documentation, prioritization based on defined criteria, change tracking mechanisms, and regular stakeholder communication regarding requirement statuses and modifications. Additionally, scenarios and use cases were developed to enhance understanding of user interactions and refine system requirements.

Use case scenario: remote breast cancer Follow-up consultation

Actor

Patient and Physician (oncologist or oncology nurse).

Supporting actors

Administrative staff, IT support, Telemedicine platform.

Scenario

A breast cancer patient requests a follow-up consultation and receives an appointment via the telemedicine platform or in-person visit for follow-up appointments or an initial visit. Training on how to use the system is provided. At the scheduled time, the doctor and patient log into the platform and begin a secure, encrypted, two-way video consultation with the patient. During the session, the doctor reviews the patient’s medical history, answers questions, and updates the care plan. Consultation notes are securely stored in the system and accessible to authorized staff. In the event of technical issues, such as internet connectivity issues, the system can switch to an audio-only session or allow for a change in session time. Administrative and IT staff provide support as needed to ensure smooth operation.

Key points

• Two-way communication between patient and doctor.

• Appointment scheduling via the platform.

• Secure and encrypted data management.

• System operation supported by administrative and IT staff.

Scenario development was conducted prior to and during the qualitative data collection phase as an analytical tool by the research team, informed by the narrative literature review and direct observation of clinical workflows at the Motamed Cancer Centre. Key user groups and operational processes were identified through field observations and preliminary interactions with the clinical setting, and initial use-case scenarios were drafted accordingly to model typical telemedicine-based breast cancer follow-up workflows.

The developed scenarios were not directly evaluated by study participants; instead, they were reviewed, refined, and confirmed during expert panel sessions to ensure clinical relevance, feasibility, and alignment with institutional practices. The scenarios served as a foundation for the structured identification of functional and non-functional system requirements.

Based on the scenarios and supporting literature, a structured requirements checklist was developed. During interviews and focus group discussions, participants reviewed and provided feedback on the checklist items derived from the scenarios and literature, focusing on the relevance, importance, and feasibility of each requirement. The final checklist items were subsequently validated through expert consensus, ensuring consistency between scenario-based workflow analysis, stakeholder input, and the finalized system requirements.

A representative use case scenario for remote breast cancer follow-up consultations is presented in Table 3.

Table 3.

Use case: remote Follow-Up consultation

Step	Actor	Action	System Feature
1	Patient	Requests follow-up	Appointment scheduling
2	System	Confirms & instructs	User guidance
3	Patient & Physician	Video consultation	Encrypted, two-way communication
4	Physician	Reviews history & updates plan	EMR integration
5	System	Stores consultation notes	Secure storage
6	System	Handles technical issues	Audio-only fallback / rescheduling
7	Admin / IT	Provides support	Technical & administrative assistance

Result

The following tables present the composition of participants involved in completing the needs assessment checklist. Table 4 outlines the distribution of clinical and non-clinical staff by department and job role, encompassing a total of 36 individuals. Table 5 details the demographic breakdown of patients and their companions by age group, comprising 21 participants. These compositions provide a comprehensive overview of the diverse stakeholders contributing to the assessment process.

Table 4.

Composition of clinical and Non-Clinical staff by department and job role

Staff Group	Department	Job Role	Number of Participants	Work experience (years)
Non-Clinical	Administrative	Secretary	2	< 10 years
Non-Clinical	Administrative	IT Staff	2	8–15
Non-Clinical	Administrative	Cashier	2	< 10 years
Non-Clinical	Administrative	Accountant	1	6
Non-Clinical	Administrative	Health Informatics	2	< 10 years
Non-Clinical	Administrative	Receptionist	3	5–10
Clinical	Clinical	Laboratory Staff	2	3–5
Clinical	Clinical	Oncology Nurse	3	15–20
Clinical	Clinical	Surgeon	3	< 25 years
Clinical	Clinical	Oncologist	2	< 20 years
Clinical	Clinical	Radiologist	2	8–10
Clinical	Clinical	Oncology Counselor	3	< 20 years
Clinical	Clinical	General Practitioner	2	< 25 years
		Total	29

Table 5.

Composition of patients and companions by age group

Role	Age Group	Gender	Number Of participants
Patient	40–50	F	2
Patient	50–60	F	1
Patient	60–70	F	1
Patient Companion	20–30	F	3
Patient Companion	30–40	F	3
Patient Companion	40–50	F	2
Total			12

participants were categorized into two primary groups: clinical and non-clinical staff, and patients along with their companions.

The first group comprised 29 staff members from various departments within the clinical center. This included 17 non-clinical personnel occupying roles such as secretaries, IT staff, cashiers, accountants, health informatics specialists, and receptionists. The remaining 12 participants were clinical professionals, including laboratory staff, oncology nurses, surgeons, oncologists, radiologists, oncology counselors, and general practitioners.

The second group consisted of 12 individuals, encompassing patients aged between 40 and 70 years, and their companions aged between 20 and 50 years. This diverse demographic provided valuable insights into the patient experience and support systems within the clinical environment.

Organizational needs

Table 6 summarizes the organizational needs of the telemedicine system as reported by 29 participants, all of whom were personnel (administrative, managerial, and clinical staff) of Motamed Cancer Centre. Patients and caregivers were not included in this part of the study, as organizational needs are primarily assessed from the perspective of institutional stakeholders.

Table 6.

Organizational needs (Motamed cancer Centre) according to participants (clinical and non-clinical)

No.	Organizational Needs	Positive Responses (%)	Negative Responses (%)
1	A system that supports the enhancement of the center’s therapeutic position.	29 (100%)	0
2	A system where online and in-person consultation tariffs are appropriately applied.	29 (100%)	0
3	A system supported by the center’s senior management team.	29 (100%)	0
4	Provision of sustainable financial resources for system development and maintenance.	29 (100%)	0
5	Training and cultural promotion among staff and patients for effective system use.	29 (100%)	0
6	A system integrated with current clinical workflows.	27 (93.10%)	2(6.89%)
7	A system compatible with resources in urban, rural, and remote areas.	26 (89.65%)	3(10.34%)
8	A system facilitating communication between doctors and health caregivers in remote and urban areas.	26 (89.65%)	3(10.34%)
9	A system that supports the center’s financial standing.	21 (72.41%)	8(27.58%)
10	A system that supports the center’s status among other cancer research centers in Iran.	19 (65.51%)	10(34.48%)

Note: Counts are integers derived by proportionally scaling original percentages to the actual sample size (N = 29). Percentages are recomputed from counts and shown to one decimal place; rows may not sum to exactly 100% due to rounding

All respondents (100%) agreed on the necessity of a system that:

• supports the enhancement of the center’s therapeutic position,

• ensures the appropriate application of online and in-person consultation tariffs,

• is backed by the center’s senior management,

• secures sustainable financial resources for development and maintenance, and.

• provides continuous training and cultural promotion among staff and patients to ensure effective use.

The lowest agreement observed was for enhancing the center’s reputation among other cancer research centers in Iran (65.5%).

While fundamental structural and managerial supports are considered universally essential, financial sustainability and institutional positioning are also recognized as critical—albeit to a comparatively lesser extent.

System needs

Table 7 outlines the system needs identified by participants. Functional requirements were assessed by all 41 respondents, including staff, patients, and patient companions, whereas non-functional requirements were evaluated solely by the 29 staff members.

Table 7.

System needs (Telemedicine System) according to participants

No.	System Needs (Functional)	Positive Responses (%)	Negative Responses (%)	Total Participants
1	A system that can be utilized in the treatment center in the shortest possible time.	41 (100%)	0	41
2	A web-based system design	41 (100%)	0	41
3	A system capable of integrating with other clinical and administrative information systems.	41 (100%)	0	41
4	A system designed and implemented with stakeholder participation (user-centered).	38 (92.68%)	3 (7.31%)	41
5	System scalability to accommodate increasing users and services.	37(90.24%)	4(9.75%)	41
6	Capability to provide services during emergencies and crises (e.g., pandemics).	37(90.24%)	4(9.75%)	41
7	A system that can offer services at a minimum on 3G mobile networks.	31 (75.60%)	10(24.39%)	41
8	Support for multiple languages to enhance accessibility for patients with diverse linguistic backgrounds.	30 (73.17%)	11(26.82%)	41
Non-Functional Requirements				staff members
No.	System Needs (Non-Functional)	Positive Responses (%)	Negative Responses (%)	(Clinical non clinical)
9	A system ensuring physical and digital security.	29 (100%)	0	29
10	A user-friendly system.	29 (100%)	0	29
11	Capability for continuous performance evaluation and monitoring to improve service quality.	27(93.10%)	2 (6.89%)	29

Among the functional requirements, all respondents (100%) agreed on the necessity of a system that can be rapidly deployed in the treatment center, is web-based, and is capable of integrating with other clinical and administrative information systems. The lowest agreement observed was for multilingual options to enhance accessibility for diverse patient populations (73.2%).

With regard to non-functional requirements, all staff participants (100%) emphasized the need for a secure system that ensures both physical and digital safety, as well as a user-friendly interface. The lowest agreement was for continuous performance evaluation and monitoring to support ongoing service quality improvement (93.1%).

Stakeholder (User) needs

Table 8 presents the stakeholder needs identified by participants (n = 41, including staff, patients, and caregivers). All respondents (100%) emphasized the importance of ensuring the privacy and security of personal information for both patients and staff. The lowest agreement observed was for establishing effective communication channels among stakeholders to facilitate feedback exchange and continuous system improvement (85.4%).

Table 8.

Stakeholder needs (System Users) according to participants

No.	Stakeholder Needs	Positive Responses (%)	Negative Responses (%)
1	Ensuring the privacy and security of personal information for patients and staff.	41 (100%)	0 (0%)
2	A system accessible to users with minimal digital literacy and skills.	39 (95.12%)	2 (4.87%)
3	A system that equally addresses the needs of all stakeholders.	38 (92.68%)	3 (7.31%)
4	Establishing effective communication channels among stakeholders for feedback exchange and continuous system improvement.	35 (85.36%)	6 (14.63%)

Discussion

This study offers a replicable framework that can inform the development of digital health solutions in similar contexts. This study presents an innovative approach by integrating requirements engineering principles, particularly Ian Sommerville’s model, to identify and define stakeholder needs for the design and implementation of a telemedicine system for breast cancer care. Employing a mixed-methods strategy, including extensive stakeholder engagement, scenario development, and user-centered design, ensured that the system aligns with the diverse and context-specific needs of patients and healthcare providers at the Motamed Cancer Institute.

Key findings include:

• Organizational Readiness and Strategic Alignment: Consensus among participants highlights the necessity of senior management support, sustainable financial resources, and comprehensive training initiatives. These elements align with existing literature emphasizing that leadership commitment and resource allocation are fundamental for the adoption and sustainability of telemedicine services.

• Technical Specifications and System Design: Identification of functional requirements such as rapid deploy ability, scalability, interoperability, and web-based accessibility, alongside non-functional requirements like security and user-friendliness, ensures the system’s adaptability to diverse technological infrastructures. Although universal agreement exists on core fundamental system features—such as deployment speed, web-based design, integration, security, and usability—participants emphasized the need for broader adaptability and inclusivity to ensure crisis resilience and to effectively address patient diversity.

• Stakeholder Engagement and User-Centered Design: Emphasis on privacy, security, and inclusivity in design addresses the needs of users with varying digital literacy levels, fostering trust and promoting adoption. A broad consensus among system users indicates that privacy, inclusivity, and equitable design are foundational to the successful adoption of telemedicine platforms. They also underline the significance of ongoing communication and participatory mechanisms to ensure that the system evolves in alignment with stakeholder need.

Comparison with other studies

Our findings align with recent studies emphasizing the importance of user-centered design, stakeholder engagement, and digital readiness in developing telemedicine systems, particularly in oncology settings [23].

Similarly, Park et al. (2024) developed a breast cancer follow-up program using a mixed-methods requirements gathering approach [24]. While their study offers valuable insights, our research provides a broader perspective by incorporating organizational, clinical, and technical viewpoints, potentially enhancing the system’s long-term sustainability.

Lee et al. (2023) examined digital health interventions for cancer survivors and found that personalization, provider involvement, and integration into clinical workflows are crucial for successful implementation [25]. These elements were strongly supported by stakeholders in our study, underscoring their importance in telemedicine systems.

Furthermore, Zanaboni and Wootton (2012) argued that many telemedicine projects fail due to inadequate needs assessments during the design phase. They stressed the importance of aligning system requirements with local clinical workflows—a key recommendation that also arose [26] in our study, where 85.96% of respondents emphasized the need for workflow integration.

Keesara et al. (2020) highlighted that many telemedicine systems failed to scale due to misalignment with health system infrastructure, privacy concerns, and lack of policy support [27]. These barriers were also reflected in our digital maturity assessment, where interoperability and leadership support scored among the lowest domains.

In a study conducted by Hosseini et al. (2024) in Iran, the importance of stakeholder-centered design and system scalability—especially in resource-constrained settings—was emphasized. Their findings showed that neglecting user needs was a primary factor in telehealth programs failing to scale beyond pilot phases [28]. These results are consistent with earlier research highlighting the vital role of stakeholder engagement, system usability, and organizational readiness in the successful deployment of telemedicine systems.

Unlike many previous studies, our research used Sommerville’s requirements engineering framework to systematically capture, validate, and prioritize functional and non-functional requirements. This structured approach offered a clearer path for translating stakeholder needs into system design elements, providing a more methodologically grounded foundation than many traditional needs assessments.

By incorporating both functional and non-functional system requirements, and aligning them with stakeholder and organizational perspectives, our study provides a more holistic view than many previous telemedicine assessments, which tend to focus on a single user group (e.g., patients or physicians) or limited technological aspects.

Conclusion

A comprehensive stakeholder needs assessment encompassing organizational, technical, and patient-centered dimensions is imperative prior to the design and implementation of a telemedicine system for breast cancer care at the Motamed Cancer Institute.

This study demonstrates that a structured needs assessment, grounded in requirements engineering principles, effectively identifies these multifaceted needs, ensuring alignment with real-world clinical workflows and user expectations.

Organizational support, characterized by leadership commitment, sustainable financing, and training, forms the foundation for effective adoption. Technically, the system must be secure, scalable, interoperable, and user-friendly to meet the diverse demands of patients and healthcare providers. Crucially, continuous stakeholder engagement throughout development fosters trust, usability, and responsiveness.

This research contributes a novel, replicable framework for telemedicine system design in oncology, particularly relevant to middle-income countries like Iran. Future efforts should focus on expanding system deployment across multiple centers, conducting pilot studies to assess usability and effectiveness, and exploring long-term impacts on patient outcomes and healthcare delivery.

By addressing these dimensions, telemedicine platforms can fulfill their promise of equitable, high-quality cancer care, ultimately improving health outcomes and patient quality of life.

Strengths of the study

This study demonstrates a novel and rigorous approach by integrating well-established requirements engineering principles—base on Ian Sommerville’s models—to assessment stakeholder needs for the telemedicine system’s design and implementation. By employing a mixed-methods framework—including in-depth stakeholder engagement, scenario development, and user-centered design—we ensured alignment with the diverse and context-specific needs of both patients and healthcare providers at the Motamed Cancer Institute.

Limitations

Conducted at a single, highly specialized cancer center in Iran, the findings may not fully generalize to other institutions or cultural contexts. Additionally, the sample size, although diverse, is limited to stakeholders affiliated with the Motamed Cancer Institute.

Recommendations

Future research should explore the scalability of the system across diverse healthcare settings and patient populations. Additionally, longitudinal studies assessing the impact of the telemedicine system on clinical outcomes, patient satisfaction, and cost-effectiveness would provide a more comprehensive evaluation of its efficacy.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

A: Hamideh asad allah khan valiC: Ehsan NabovatiD: Asiyeh Olfatbakhsh B *:Fatemeh Rangraz Jeddi A. and B were responsible for drafting and writing the manuscript.C. provided methodological consultation, specifically recommending the use of the Sommerville approach and overseeing the execution of its phases.D. contributed clinical expertise, advising on requirements relevant to clinical practice as well as contextual considerations of the research setting.

Funding

This study is part of Hamideh Asadollah Khan Vali’s doctoral dissertation titled ‘Design and Evaluation of a Telemedicine System for Providing Counseling and Treatment Follow-up Services to Breast Cancer Patients’ (approval code: 40244). It was conducted within the framework of the dissertation to address one of its major research questions. Additionally, this research received no financial support.

Data availability

The datasets generated and analyzed during this study are not publicly available due to ethical and privacy considerations. However, they are available from the corresponding author upon reasonable request.

Declarations

Ethical approval

IR.KAUMS.NUHEPM.REC.1402.014(Kashan University of Medical Sciences and Health Services). This study was approved by the Ethics Committee of Kashan University of Medical Sciences (IR.KAUMS.NUHEPM.REC.1402.014). The research complied with the ethical principles of the Declaration of Helsinki. Participation in the study was voluntary, and completion of the questionnaire was considered as implied informed consent. The participants’ information was kept anonymous and.

Consent to participate

Not applicable.

Competing interests

The authors declare no competing interests.