SUPPORTING NURSING CARE ASSESSMENT PROTOCOLS

WITH SMARTPHONES

Ilídio C. Oliveira

1,2

, Nelson Silva

, Ivo da Veiga

and João P. S. Cunha

1,2

IEETA - Institute of Electronics and Telematics Engineering of Aveiro, Aveiro, Portugal

Dep. of Electronics, Telecommunications and Informatics, University of Aveiro, Aveiro, Portugal

Hospital Infante Dom Pedro, Aveiro, Portugal

Keywords: Nursing informatics, Mobile devices, Skin integrity.

Abstract: Technological advances in mobile phones make them appealing to support nursing care at the point of

treatment, especially by combining the easy-of-use, mobility and wireless communications. Novel

capabilities, such as picture capturing, enlarge the applications scope. In this work, we present the HOPE

system to facilitate nursing care documentation, by leveraging on standard off-the-shelf mobile phones. The

proposed system moves a substantial part of the work usually deferred and performed at desktop computers

to the moment and place of care. In addition, health professionals can document the clinical cases with

photos, using the mobile phone built-in camera, which is being applied in diabetic foot consultation. Basic

support for wound measurement is available. The information acquired is integrated in the patient’s

Electronic Health Record and can be shared using the mobile devices or the workstations. The proposed

system is in pilot use at two Portuguese hospitals targeting inpatient care and diabetic foot consulting.

1 INTRODUCTION

Care provision includes a significant amount of

effort on effective documentation of patient

conditions and performed actions. In nursing care,

documentation time is estimated to surpass half of

the nurse’s activities (Kossman and Scheidenhelm,

2008). The introduction of Electronic Health

Records (EHR) (Häyrinen et al., 2008) including the

nursing domain, led professionals, in many cases, to

defer the documentation activities, since the

available information systems are not well adjusted

to be used at the bed side (Stevenson et al., 2010);

(Andersen et al., 2009).

An emergent paradigm is the use of handheld

computers to support nursing care planning and

recording (Garrett and Klein, 2008); (Lu et al.,

2005). These devices meet the mobility requirements

of the practice and their integration with

organization wide information systems can raise the

efficiency of nursing care documentation (Lu et al.,

2005).

The convergence of handheld computers (or

Personal Digital Assistants) and mobile phone

features in the same devices originated the nowadays

popular smartphone concept. As a consequence,

there’s a mass expansion of the familiarity with

smartphones operation and significant decrease on

devices cost. This trend extends the opportunities to

use modern smartphones in nursing care and

telemedicine (Istepanian et al., 2006); (Ebner et al.,

2008). The combination of intrinsic support for

mobility, rich and intuitive user interfaces, and

wireless communications provide sound arguments

for their introduction in care settings, if articulated

with the existent “ecosystem” of health information

systems.

Mobile devices are being used to take pictures of

wounds and skin lesion to document clinical cases.

Such approaches can be found in teledermatology

projects (Ebner et al., 2008); (Pirris et al., 2010).

Nurses are also aware of its potential (Berglund et

al., 2007) but implementations are still lacking.

In this work, we present the HOPE system,

which uses smartphones to help nursing care

recording at the point of care. The smartphones are

not expected to replace the existing desktop-based

solutions, but act as a practical first line or recording

that can be performed at patient side. In addition, the

smartphone’s built-in camera is also used to capture

images of lesions, allowing for skin integrity

monitoring of inpatients and to monitor diabetic foot

C. Oliveira I., Silva N., da Veiga I. and P. S. Cunha J..

SUPPORTING NURSING CARE ASSESSMENT PROTOCOLS WITH SMARTPHONES.

DOI: 10.5220/0003783100810086

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2012), pages 81-86

ISBN: 978-989-8425-88-1

 2012 SCITEPRESS (Science and Technology Publications, Lda.)

lesions.

The motivating context for this work arose from

the nursing practice at Hospital São Sebastião

(HSS), located in Feira, Portugal. Presently, the

system has been also in pilot used at a second

Hospital (Hospital Infante Dom Pedro, Aveiro,

Portugal).

2 METHODS

2.1 Workflow 1: Patient Assessment

Protocol

The HSS hospital uses a comprehensive EHR, which

includes the nursing record too. The system provides

support for hundreds of data fields to follow

inpatient nursing care. The patient assessment

protocol, in particular, includes over 120 data fields,

from more subjective information, like social

context and habits, to more objective details, such as

biosignals, pain scales and wounds characteristics.

The assessment stage is performed each day (not

necessarily altogether) in the presence of the patient,

but the nursing staff opts to defer recording activities

to a later stage, and use paper notes as a memory

helper. This is justified by the absence of mobile

interfaces and the complexity of the desktop system.

In this context, the Health-On-Palm Environment

(HOPE) system has been proposed to facilitate

patients’ assessment routines by nurses. The

objective of HOPE is not to replace the existing and

comprehensive desktop system, but to move a subset

of those recording needs to the nurses’ smartphone.

The careful selection of which segments of the

nursing evaluation protocol were to be supported in

the mobile device became a critical success factor.

This definition has been achieved over multiple

interactions with domain experts, to avoid system

rejection due to insufficient involvement of domain

users (Stevenson et al., 2010).

Using the HOPE system, the nurse starts by

authenticate himself on the mobile device (Fig. 1).

Patient details can then be easily retrieved from

the Hospital-wide EHR by entering the record

number on the device or by reading it from a bar

code (often available in stickers and bracelets) using

the built-in camera. The previous assessment context

is retrieved and can be accessed in the smartphone.

The nurse will then complete the assessment

protocol, going through a wizard-like interaction

(Fig. 2). Errors in data entry (e.g.: inconsistent

values) are immediately revealed by changing field

colours. At any point, the data collected can be

uploaded to the central servers using the device

wireless networking capabilities.

Figure 1: Views on the step-by-step assessment protocol.

Left: steps to be completed. Right: signaling error with

color feedback.

Figure 2: Nursing assessment protocol executed in the

HOPE mobile system.

2.2 Workflow 2: Diabetic Foot Protocol

The HOPE application enables the use of the built-in

camera in the diabetic foot consultation. The patient

will initially receive treatment at a primary care

facility but, if suffering from severe conditions, s/he

will be referred to secondary care provider

(Hospital). After the patient acute conditions have

been stabilized, s/he will be followed at the primary

care again (Fig. 3).

Wounds related to the diabetic foot condition

take a long time to heal, usually spanning for several

months. During this time, the wound evolution can

be hard to monitor without a visual record, due to

the time span and the number of care professionals

involved (different teams and service points). Note

that wound assessment is being conducted at each

care organization, but little information is usually

shared, especially with respect to multimedia types.

HEALTHINF 2012 - International Conference on Health Informatics

Figure 3: Diabetic foot distributed care workflow.

This clinical case brings a complying need for

visual evidence that can be supported by

smartphones. In addition, it requires a distributed,

collaborative workflow, which gave us the

opportunity to integrate the mobile application in the

more comprehensive Regional Health Network

(Oliveira et al, 2011).

2.3 Mobile Usability Requirements

The acceptance of mobile devices in care practice is

heavily connected to the practicability and user-

friendliness of the solutions (Stevenson et al., 2010);

(Andersen et al., 2009). Factors such as the small

screens size, tolerance to wireless network

availability and energy-aware applications become

essential requirements in software conception. In

this sense, the following design options have show

to play a significant role on HOPE acceptance:

 Elimination of free text fields. Data entry is

based on values selected from close lists (Fig. 2).

When and if a note taking approach is necessary

then the nurse has the ability to record an audio note

(and later transcribe it to the desktop system).

 Prompt visual field validation. Extensible field

validation is implemented to ensure robust data

entry. Inconsistencies in fields (e.g.: values out of

range) are visual marked by changed the field

background colour, a much less intrusive alarm than

popping message boxes (Fig. 2).

 Automatic persistence and recovery. The nurse’s

work is being continuously persisted and can be

recalled at any point, especially in case of battery

failure.

 Full support for on-line and off-line operation.

Although some features can only be completed in

the presence of network connectivity (e.g.: submit

the patient assessment), the overall operation is

available in off-line mode. Besides being battery-

savvy, this approach is required to tolerate the

intermittence of wireless coverage along the

Hospital.

 Touch-based interactions. User interfaces were

optimized for stylus-less operations, allowing the

use of a finger as the main pointing and data entry

“device”.

 Non-blocking operations. Potential lengthy

operations, such as data synchronization with the

central node, use non-blocking calls (multi-threaded)

avoiding the nurse to wait for the device to continue

the work.

2.4 System Architecture

The HOPE mobile application is implemented in

Windows Mobile and Android smartphones for data

recording and image acquisition. These are native

applications, programmed from the scratch for each

target platform with the standard SDK. The mobile

device is also used for local visualization (to access

previously entered information).

Besides the mobile application module, the

HOPE system relies on a Central node for collecting

the uploaded information and acting as a proxy to

the several Hospital Information systems. The

Central node includes the following modules: the

HOPE repository, Integration Services and the Web

application.

Figure 4: Modular system architecture.

The Repository holds the database specific to

support the HOPE workflows, like persisting the

wounds images. The Integration Services dialog

with the surrounding enterprise systems, namely to

authenticate nurses against the organization

reference Directory system and to retrieval patient

demographics. Integration services also handle the

interaction with the Regional Health Information

Network for the diabetic foot distributed workflow,

acting as a provider for the wounds information, and

SUPPORTING NURSING CARE ASSESSMENT PROTOCOLS WITH SMARTPHONES

a consumer, for patient and professionals

identification.

The Web Application module extends the mobile

device capabilities, providing helper tools to analyze

the captured images and a friendly environment to

explore wounds information in the diabetic

consulting (Fig. 4).

The interaction between the smartphone and the

central module is based in standard Web Services

which allows several smartphone operating systems

to be used. The interaction between the Central node

and the Hospital Information Systems and the

Regional Information Network is also based on the

Web Services stack.

Figure 5: Diabetic foot wounds images captured with the

smartphone (for the same patient) in two different

consultations.

2.5 Pictures Use in Skin Integrity

Monitoring

HOPE support to carry skin integrity and wounds

monitoring is included in two stages:

1) At the point of care, the nurse can take several

pictures of the region of interest which will be

associated with a particular patient and assessment

event. The nurse can do a basic review, for example,

to reject unsatisfactory photos. The body area being

considered is marked on the full body map,

facilitating an overview of the existence of photos, if

any (Fig. 6). Pictures from several assessment

moments (e.g.: several days) will be available for

visualization in the smartphone as in the desktop

(web module).

2) Additional features are available outside the

smartphone, once the data has been synchronized

with the Central node. A web-based application

(HOPEweb) will allow the nurse to do basic

measurements and picture annotation (Fig. 7).

The measuring method in use does not require any

special hardware nor imposes picture acquisition

constraints. In fact, it is meant to work with of the

shelf mobile phones and tolerate variability in

picture quality standards. The nurse will place a

reference object in the same plan of the wound and

take a picture of these two elements with the smart

phone camera orthogonally aligned. Afterwards, in

the web module, the nurse or other professional will

identify the reference object and the system will

calculate measurements and areas of wounds based

on its size. The goal is not to supply a full wound

measurement solution, like in (Bowling et al., 2009),

but basic support for nursing care, in which the user

has to delimitate the areas of interest interactively.

2.6 Security Issues

The storage of EHR in mobile devices raises

concerns on patient data security and privacy (Lu et

al., 2005). In this context, the HOPE system is not

used for storing clinical data, except for the period

while the data has been recorded but not yet

uploaded.

Figure 6: Overview of the body locations documented

with photos (text labels indicate the type of wound being

signaled). Similar maps are used in the mobile device and

web application (the later being dislayed).

Figure 7: Wound measurement support using a reference

object and interactive user delimitation of areas. Pictures

can be organized in series for easy comparison.

HOPE uses the device memory card as the

HEALTHINF 2012 - International Conference on Health Informatics

primary storage device (although it can operate

without it). This may support scenarios towards the

individual assignment of storage tokens (memory

cards) to staff members. The physical association

between professionals and storage tokens may help

on raising users’ confidence, especially for settings

in which the smart phone itself can be shared among

professionals. Note, however, that separation of user

contexts is already implemented by Access Control

Lists associated to nurses’ logins.

3 RESULTS

The HOPE system has been deployed in two

Hospitals, in Portugal. In each Hospital, a pilot users

group was formed, with volunteer nurses. Although

at an early stage of introduction, it was possible to

validate the entire workflow, including the

integration with the external Hospital-wide

information systems (different at each organization).

For this validation, a group of twelve nurses from

medical awards is being involved in pilot used. The

nurses are asked to use the mobile application to

search for a patient, collect the answers to a short

clinical interview and document skin lesions with

photos. In the present stage, nurses’ feedback is

being collected by a key domain user, which is a

nurse which received extensive train on the

application; he supports his peers and informally

collects usage feedback. A more formal and

extensive assessment is required, and structured

questionnaires will follow.

Preliminary observation of execution times

doesn’t reveal relevant speed-ups in care

documentation activities using HOPE. Other

benefits, however, have been perceived and reported

by the pilot users. The ability to browse previous

information and to record the nursing protocols at

the point of care (by the patient) is referred as the

main benefit of the system. The HOPE solution was

found to provide a more practical user interaction

and bears the potential to reduce documentation

omissions induced by deferring data entry.

The pilot use of the skin integrity monitoring in

HOPE has raised the awareness of this kind of tool

for clinical applications in both Hospitals. The

specific case of diabetic foot monitoring with a

regional scope is being piloted. (Fig. 5).

Work in progress includes collecting further

evidence that HOPE can provide a safer and more

productive environment for nursing care, besides the

existing pilot users group.

4 CONCLUSIONS

The HOPE system has successfully introduced off-

the shelf smartphones in nursing practice. A key

issue towards system acceptance was the careful

selection of the subset of the information to be

supported in the device, along the synchronization

with Hospital central systems, including the patient

EHR. The novel use of the built-in camera allows

for skin integrity monitoring along several days for

inpatients, establishing basic tools for wounds

evolution assessment.

Besides the use of the HOPE system for inpatient

nursing care, the system is being used also in multi-

institution nursing protocols, such as the diabetic

foot, for longitudinal documentation of wounds

assessment.

ACKNOWLEDGEMENTS

The authors would like to acknowledge the fruitful

collaboration of the Hospitals’ staff, both and HSS

(Feira) and HIP (Aveiro) and the technical

contributions from J. Ribeiro and J. C. Santos.

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