A Mobile Health Application to Assist Health Professionals: A Case

Study in a Portuguese Nursing Home

Márcia Esteves

1 a

, Marisa Esteves

2 b

, António Abelha

2 c

and José Machado

2 d

Universidade of Minho, Campus Gualtar, 4470 Braga, Portugal

Algoritmi Research Center, University of Minho, Campus Gualtar, 4470 Braga, Portugal

Keywords: Health Information and Communication Technology, Mobile Health, Health Professionals, Elders, Nursing

Home, Ethical Issues in Medicine.

Abstract: The rapidly aging population has been a matter of concern over years since this problematic has been posing

several challenges to healthcare systems worldwide. In Portugal, which is one of the countries with the largest

aging population, nursing homes have been getting a higher demand, and health professionals are overloaded

with work. Furthermore, the fact that few nursing homes use health information and communication

technology (ICT) resorting to paper to record information and clinically manage their residents is a

tremendous problem, since this method is more prone to errors and time-consuming. Thus, this paper proposes

the design and development of a mobile application for health professionals working in a Portuguese nursing

home with the intention of assisting them at the point-of-care, by recording and providing all the necessary

information, and helping them to schedule, perform, and digitally record their tasks. This solution will help

health professionals to provide better care, by reducing time-waste and errors, and, consequently, to improve

elders’ quality of life. A mobile solution was chosen since a hand-held device, which can be used anywhere

and anytime, is able to give access and store all the needed information at the point-of-care.

1 INTRODUCTION

Over the last few years, the rapidly aging population

has been a matter of concern, namely because of the

challenges this situation is posing to healthcare

systems in many countries all over the world (Kuo et

al. 2016, Mostaghel 2016). In fact, the statistics

regarding the aging population are alarming:

comparatively to the growth of the whole population,

it is estimated the elderly population is growing twice

as fast (Mostaghel 2016). Consequently, this

demographic change leads to several problems,

namely to the increase in the costs of elderly care

(Mostaghel 2016) and of the number of elders in

nursing homes.

In Portugal, which is one of the countries with the

largest aging population in the world (UN DESA

2015), the increasing number of elders in nursing

homes has been one of the major challenges caused

by the aging population (Pereira 2018, RTP 2019). In

https://orcid.org/0000-0003-4770-5502

https://orcid.org/0000-0001-9710-847X

https://orcid.org/0000-0001-6457-0756

https://orcid.org/0000-0003-4121-6169

fact, finding a place in a nursing home in Portugal has

been a tremendous challenge for several elders since

the demand is higher, and the vacancies are filling up

quickly (Pereira 2018, RTP 2019). On the order hand,

health professionals are overloaded with work since

the number of elderly people is high compared to the

number of health professionals (Borja-Santos 2015,

DN/Lusa 2018), which can lead to the decrease of the

quality of the nursing care delivered, and, more than

not, nursing homes use rudimentary methods, i.e.

paper, to record information and clinically manage

residents, which can be time-consuming (Alexander

and Wakefield 2009, Broughton et al. 2013).

Therefore, there is an urgent need to face these

challenges and improve elders’ quality of life and the

care delivered in nursing homes. Thus, with these

problems in mind, this project emerged and consists

in designing and developing a mobile application for

health professionals, i.e. nurses and doctors, working

in a Portuguese nursing home that can assist them at

338

Esteves, M., Esteves, M., Abelha, A. and Machado, J.

A Mobile Health Application to Assist Health Professionals: A Case Study in a Portuguese Nursing Home.

DOI: 10.5220/0007809203380345

In Proceedings of the 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2019), pages 338-345

ISBN: 978-989-758-368-1

the point-of-care and help them to schedule, perform,

and digitally record their tasks.

In order to have a better understanding of the

relevance of this project, it is essential to present the

main challenges faced by the nursing home for which

this project is being developed. Firstly, there is no

electronic health records to clinically manage the

residents, whereby all the information is gathered in

papers which make the record and the access to this

information a lot more time-consuming, especially at

the point-of-care, since the professionals constantly

need to go back to the nursing station in order to

retrieve or record information. This situation makes

the risk of misplacing, losing, or forgetting

information much higher.

Moreover, there are few health professionals

comparatively to the high amount of elderly people.

Lastly, due to the lack of time and the overload of

work experienced by the health professionals, some

clinical information is not properly or not at all

recorded. Thus, in order to solve these problems,

there is a need to design and develop a solution that

can help these health professionals at the point-of-

care and, subsequently, enhance the care delivered

and the elders’ quality of life.

Therefore, the proposed solution consists of a

mobile application that would allow health

professionals to:

 Have access and manage the personal and

clinical information of the residents at the

point-of-care as well as add and disable

residents when necessary;

 Create clinical and nursing notes, and consult

the clinical and nursing notes’ history of each

resident;

 Schedule nursing interventions, e.g. wound

care, nasogastric tube and urinary catheters

replacement, periodic evaluations, and

tracheostomy care, among others, and confirm

their execution;

 Record the evaluations made by them, and

consult the history of these evaluations for each

resident;

 Record new wounds and their treatment and

evolution via images and observations, and

consult the wound history of each resident;

 Consult the history of the medical records of

each resident, and add new medical records;

 Have a simplified plan of the nursing home to

identify which resident is in each room and bed.

The novelty of this project lies in the fact that few

nursing homes use health ICT, which consists in any

form of electronic solution that allows to retrieve,

store, manage, manipulate, and transmit digital

information in a healthcare setting, despite their great

potential and well-known advantages (Alexander and

Wakefield 2009, Broughton et al. 2013, Ko et al.

2018, Wei and Courtney 2018). In fact, they can

enhance the quality of care, reduce time-waste, e.g.

by accessing and recording the information at the

point-of-care, and improve the sharing of

information, e.g. by making the information more

accessible and legible (Alexander and Wakefield

2009, Rouleau et al. 2015). Moreover, the lack of

literature and of an integrated body of knowledge on

the use of ICT in nursing homes show that there is

still much work that needs to be done in this area.

Concerning the structure of this paper, the state of

the art related to this project is presented in Section 2.

Subsequently, Section 3 discusses the research

strategies selected to design and develop this project.

Thereafter, in Section 4, a brief description of the case

study, i.e. of the Portuguese nursing home for which

the proposed solution is being developed, is presented

with the intention of having a better understanding of

the main challenges encountered in the institution

and, thus, affirm and validate the relevance of this

project. Then, in Section 5, the results achieved are

presented. Finally, to conclude this paper, a

discussion of the results attained is presented in

Section 6, and, lastly, in Section 7, the main

conclusions of the project are explained, and future

work is suggested.

2 STATE OF THE ART

2.1 Mobile Health

Over the last few years, the implementation and rapid

expansion of mobile technology, which refers to all

the technology that can be used “on-the-move”, have

been impacting several industries, and the healthcare

industry is not an exception (Aungst 2013, Ventola

2014). In fact, the use of mobile health (mHealth), i.e.

of mobile devices and applications in a health and

clinical context (Nouri et al. 2018), to help health

professionals to execute their daily tasks, namely to

manage and monitor patients, to access and manage

health records and other types of data, and to enhance

the decision-making process, among others, has been

transforming several aspects of the health industry

(Prgomet et al. 2009, Ventola 2014, O’ Connor and

O’ Reilly 2018).

In this context, the use of mobile devices in

healthcare settings has been rapidly growing and,

consequently, the development of mobile

applications for these devices, thus leading to the

A Mobile Health Application to Assist Health Professionals: A Case Study in a Portuguese Nursing Home

339

rapid integration of mobile devices in healthcare

settings (Ventola 2014, O’ Connor and O’ Reilly

2018). Furthermore, the adoption of mobile

technology by health professionals can be explained

by the need to have a better and easier communication

and access to the information at the point-of-care

since a single device, which is portable, light, and

small, can gather and give access to all the needed

information anywhere and anytime (Prgomet et al.

2009, Ventola 2014, O’ Connor and O’ Reilly 2018).

In fact, mHealth has been proving to be quite

promising and to offer several benefits, such as

(Prgomet et al. 2009, West 2012, Ventola 2014):

 Faster accessibility and better management of

the data since all the data is gathered in a single

source, which can be used anywhere and at the

time of need, making the access to information

much more convenient;

 Faster and better decision-making process,

since it provides access to information at the

point-of-care where the decisions are being

made, thus leading to a lower error rate;

 And, consequently, an enhancement of the

quality of the care delivered and of the elders’

life, among other advantages.

In some cases mobile applications are developed

without truly understanding, assessing, and meeting

the needs of health professionals, thus resulting in

their under-utilization (Nouri et al. 2018, O’ Connor

and O’ Reilly 2018). Therefore, a better evaluation of

the needs of health professionals should be done

before developing these applications. Nevertheless,

the benefits of mHealth are undeniable and a higher

investment should be done in this area since it can

improve the quality of the care delivered and of the

patients’ quality of life.

2.2 Ethical Issues in Medicine

Without a doubt, the use of health ICT and mHealth

in healthcare settings provides many benefits to the

clinical practice having the potential to enhance the

care delivered, as mentioned previously. However,

despite the advantages offered by these technologies,

challenges and issues may arise from the use of

solutions based on them. In fact, one of the main

challenges associated with the introduction of any

form of technology in healthcare settings are ethical

issues.

In this context, one of the problems that can be

pointed is the fear and distrust that the confidentiality

and privacy of the electronic health records and data

of the patients are compromised and not guaranteed,

since, comparatively to the traditional paper-based

method, technological advancements made access to

data and the break of the privacy of health

information easier (Wallace 2015, Nouri et al. 2018).

Additionally, despite the many advantages and

benefits provided by mHealth, some health

professionals still remain hesitant regarding its use,

since mHealth applications are currently being used

without having a complete understanding about their

effectiveness, accuracy, quality, and associated risks

(Ventola 2014, Nouri et al. 2018).

Therefore, during the design, development, and

implementation of mHealth applications, a set of

best-practice standards should be thoughtfully

followed in order to ensure their quality, accuracy,

and safety (Misra et al. 2013, Ventola 2014, Nouri et

al. 2018). Moreover, after their development, these

applications should be subjected to a proper and

rigorous set of validation and evaluation methods as

a way to guarantee their quality, accuracy, correct

use, safety, and importance in a healthcare setting

(Misra et al. 2013, Ventola 2014, Nouri et al. 2018).

3 RESEARCH STRATEGIES

In order to have well-defined standards and an

organized path to follow, this project is being

sustained by a set of methods with the intention of

ensuring its success. Firstly, extensive research was

made with the aim of identifying a broad range of

options. Then, after analysing the available options, a

choice was made based on the method that was the

most effective to meet the established objectives and

adequate according to the scope of this project.

Therefore, the main research strategy that is being

followed during the course of this project is design

science research (DSR). DSR was chosen since it is

suitable for ICT research projects, which is the case

of this study (Hevner et al. 2004, Peffers et al. 2007).

The main purpose of the DSR strategy is to create and

evaluate objects know as artefacts, i.e. solutions, in

order to solve organizational problems (Hevner et al.

2004). Thus, in a simplified way, DSR corresponds to

a rigorous science research method that offers a set of

techniques, principles, and procedures that must be

followed in order to design and develop successful

solutions (Peffers et al. 2007).

The DSR methodology can be divided into the

steps shown in Figure 1.

In order to perform the first three steps – “Problem

Identification and Motivation”, “Definition of the

Solution’s Objectives”, and “Design and

Development of the Solution” – focus groups, semi-

structured interviews, and questionnaires were made

ICT4AWE 2019 - 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health

340

Figure 1: Schematic representation of the steps composing

the design science research strategy.

with the health professionals working in the nursing

home for which this project is being developed. The

information given by these professionals was

fundamental and valuable since it allowed to identify

and understand the main challenges encountered by

them. Thus, it was then possible to identify and

motivate the problems that needed to be solved, to

define the objectives and benefits of the proposed

solution, and, finally, to design the architecture of the

solution, which is currently being developed.

Additionally, observation of the case study was also

necessary since it allowed to have a better

understanding of the conditions of the nursing home.

The fourth and fifth steps – “Demonstration” and

“Evaluation”, respectively – are currently being

executed: the design of the proposed solution was

demonstrated to the target audience, i.e. the health

professionals, and as the solution is being developed,

the professionals are being consulted to assess if the

established objectives are being met and if changes

need to be done. It must be mentioned that in order to

evaluate the usefulness and accuracy of the proposed

solution, a proof of concept (PoC) was made.

Finally, the last step of the DSR methodology –

“Communication” – is currently being performed.

This step consists of diffusing the importance of the

problem and the novelty of the proposed solution,

which is the aim of this paper.

It must be mentioned that during all stages of the

design and development of this project, ethical issues

are being taken into account and safeguarded to

guarantee the quality, accuracy, and safety of the

solution and that confidentiality issues do not arise.

4 CASE STUDY

The case study for which the proposed solution is

being developed corresponds to a Portuguese nursing

home, which is being managed by a Portuguese

hospital. Thus, in this section, a brief description of

the case study will be presented in order to identify

the main issues of the nursing home and the

challenges faced by the health professionals.

As mentioned before, focus groups, semi-

structured interviews, and questionnaires were

performed with the health professionals in order to

identify their needs and the main challenges faced by

them. Additionally, the case study was subjected to

observation to assess the conditions of the nursing

home. Thus, it is possible to identify a set of

challenges and issues that need to be solved:

 The nursing home does not use health ICT or

any other form of technological progress. There

is only one computer in the nursing station, and

it is not being used to record or document

clinical information. Additionally, there are not

electronic health records or any other form of

digital information to clinically manage the

residents. Therefore, the professionals use

handwritten charts and medical records, and all

the information is stored and recorded in

papers. This situation makes the access and

record of information a lot more time-

consuming, especially at the point-the-care,

since the professionals constantly need to go

back to the nursing station in order to retrieve

or document information. On the other hand,

this situation makes the risk of losing,

misplacing, forgetting, and documenting the

information in the wrong place higher;

 All the tasks performed by the health

professionals are scheduled and documented in

handwritten charts or boards, which can lead to

errors since its more confusing and less

organized than to digitally schedule and

document tasks;

 There is no wireless internet connection in the

nursing home. The only internet connection

available is in the nursing station where the

computer is located. This situation makes it a

lot more difficult to implement any kind of

mHealth solution since the nursing home does

not have the necessary needs;

A Mobile Health Application to Assist Health Professionals: A Case Study in a Portuguese Nursing Home

341

 There are few health professionals

comparatively to the high amount of elderly

people. Thus, at times, the health professionals

are overloaded with work. This situation

combined with the fact that all the information

is documented through papers poses the risk of

some clinical information not being properly or

at all recorded.

During the realization of these interviews and

focus groups, it was also mentioned that the nursing

home tried to implement a web application but

without success. This web application had the intent

of converting all the information recorded in papers

to the digital form, allowing the health professionals

to schedule tasks, document them, and record clinical

information. However, this application was

abandoned because it was time-consuming and not

user-friendly: the health professionals constantly

needed to return to the nursing station, where the

computer was, to use the application, thus spending

too much time with it, e.g. scheduling tasks and

documenting information.

Moreover, the health professionals manifested

their wish of needing a mobile application that would

allow them to be anywhere in the nursing and still

have access to information and schedule and

document their daily tasks. Therefore, there is a need

to design and develop a mobile solution, i.e. a

mHealth application, that would help these health

professionals at the point-of-care by allowing them to

have access, document, consult, and manipulate

information anywhere in the nursing home and,

subsequently, enhance the care delivered and the

elders’ quality of life.

5 RESULTS

As mentioned previously, the nursing home for which

this project is being developed does not have any

form of technological progress and, naturally, any

database implemented. Therefore, before designing

the architecture of the mHealth application, a

database had to be defined to support it and to allow

the storage of the necessary data.

Thus, a MySQL database, which is a highly

secure, reliable, and scalable relational database, was

designed and created. Thereafter, once the database

created, it had to be deployed and implemented in the

server of the Portuguese hospital that is managing the

nursing home. A MySQL database was chosen

because the server was already configured for this

type of database. Additionally, it must be mentioned

that although the database has been successfully

implemented in the server, it remains to be populated

with real data, i.e. residents’ and health professionals’

information.

On the other hand, the proposed solution is being

developed using React Native, which is a JavaScript

framework that allows the development of native

mobile applications (Facebook Inc. 2019). React

Native was chosen since the same code can deploy on

both iOS and Android, thus saving a lot of time in the

development process. Moreover, React Native has an

optimal performance for mobile environments.

Additionally, a REST API written in PHP with

SQL queries is being developed in order to allow the

sharing of data between the frontend, i.e. the mobile

application, and the backend, i.e. the database. PHP

was chosen since the server in which the database was

implemented is only configured for this programming

language.

In Figure 2, a schematic representation of the

interactions between the different elements of the

proposed solution is presented.

Figure 2: Schematic representation of the interactions

between the different elements of the proposed solution.

Firstly, the user, i.e. the health professional, needs

to sign up for an account in the mobile application.

Then, all the data provided by the user, i.e. his login

credentials and his personal data, is stored into the

ICT4AWE 2019 - 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health

342

database. Alternatively, if the user already has an

account, he needs to sign in into the mobile

application with his login credentials.

Once the user is successfully registered into the

application, the following features are provided to

him:

 Profile: the user can have access and edit his

personal data;

 Management of the residents: the user can view

and edit the personal data of each resident.

Additionally, the user can add new residents

when needed or disactivate a given resident.

Moreover, it is also possible to view and edit

the contacts of each resident as well as add and

remove contacts;

 Clinical notes: if the user is a doctor, he can

create new clinical notes and consult the

clinical notes’ history of each resident.

However, if he is a nurse, the user is only able

to consult the clinical notes’ history;

 Nursing notes: if the user is a nurse, he can

create new nursing notes and consult the

nursing notes’ history of each resident.

However, if he is a doctor, the user is only able

to consult the nursing notes’ history;

 Management of the clinical information of the

residents: the user can consult and edit the

clinical information of each resident;

 Management of wounds: the user can record

new wounds as well as consult and document

their evolution for each resident. Additionally,

the user can consult the wounds’ history of

each resident;

 Periodic evaluations: the user can add a new

periodic evaluation and consult the periodic

evaluations’ history of each resident;

 Periodic evaluations of the capillary blood

glucose: the user can add new periodic

evaluations of the capillary blood glucose for

residents with diabetes. Moreover, it is also

possible to consult the history of the periodic

evaluations of the capillary blood glucose of

each resident with diabetes;

 Medical records: the user can add new medical

records or consult the medical records’ history

of each resident;

 Planning: the user can schedule nursing

interventions for each resident;

 Plan of the nursing home: the user can consult

which resident is in each room and bed;

 Calendar: the user has a calendar in which he

can consult the nursing interventions scheduled

as well as cancel a nursing intervention or

confirm its execution;

 Sign out: the user can sign out of his account.

6 DISCUSSION

In order to demonstrate the potential, quality, utility,

and practicality of the proposed solution, a PoC was

made. Therefore, in this section, a SWOT analysis is

performed to identify the main strengths and

weaknesses, which are internal factors, and

opportunities and threats, which are external factors,

of the proposed solution.

The main strengths of the proposed solution are

as follow:

 Reduces time-waste since health professionals

can have access and record information at the

point-of-care;

 Reduces errors since it decreases the risk of

misplacing, losing, or forgetting information;

 Enhances the nursing care delivered and the

elders’ quality of life since less errors are being

made and health professionals have more time

to perform their tasks;

 Makes the scheduling of tasks less confusing

and more organized;

 Reduces the amount of paper that is being

generated with hand-written charts;

 Has high usability due to its user-friendly

design with well-defined paths and decision

points and organized information;

 Has high adaptability since the proposed

solution was designed to allow its easy

implementation in other nursing homes;

 Has high scalability since new features can be

easily added.

However, some weaknesses can be pointed to the

proposed solution:

 Need of a wireless internet connection, which

is not currently available in the nursing home;

 Need of mobile devices such as mobile phones

and tablets to use the solution;

 Need to populate the database with real data,

i.e. residents’ and health professionals’

information, which will require time resources;

 Need to train the health professionals to use the

solution.

On the other hand, the opportunities of the

proposed solution are as follow:

 Technological improvement of the nursing

home, which can lead to the demand for

improving other processes;

 Elimination of the paper-based method used by

the nursing home, which is rudimentary and

more prone to errors, having clinical data

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343

stored in databases. This data could be used to

complement the mobile application with

business intelligence (BI) clinical indicators,

which can enhance the decision-making

process and the care delivered;

 Implementation of the mobile application in

other nursing homes.

Lastly, the following threats can be highlighted

for the proposed solution:

 Potential issues may arise if the necessary

needs are not provided to the nursing home,

namely if the wireless internet connectivity is

not reliable and if there are not any mobile

device. In these cases, the health professionals

would not be able to use mobile application.

7 CONCLUSION AND FUTURE

WORK

In conclusion, this paper shows that, in Portugal,

nursing homes need several improvements, more

specifically, technological improvements, in order to

solve some of the problems faced by them, e.g. the

overload of work faced by health professionals. Thus,

in this context, this project emerged and consists in

designing and developing a mobile solution that

would help and assist the health professionals of a

Portuguese nursing home at the point-of-care.

As mentioned throughout this paper, with this

solution, it is intended to allow these professionals to

have access, document, consult, and manipulate

information anywhere in the nursing home.

Therefore, this solution will help to reduce time-

waste and errors made by health professionals and,

subsequently, enhance the nursing care delivered and

the elders’ quality of life.

In this paper, the architecture and the features of

the proposed solution were presented. However, as

future work, it is intended to continue the

development of the mobile application since,

currently, certain features remain to be implemented.

Thereafter, it is envisioned to populate the database

with real data, i.e. residents’ and health professionals’

information.

On the other hand, it is also planned to provide the

nursing home with the necessary needs, namely a

reliable wireless internet connection and mobile

devices such as tablets or mobile phones, for health

professionals to be able to use the mobile application.

Moreover, it is foreseen to test the application with

the health professionals to assess if the objectives are

being met and if changes need to be done.

Finally, in the future, when enough data will be

gathered throughout the use of this application, it is

hoped to complement it with BI clinical indicators

related to both the residents and the health

professionals. These indicators would help to obtain

useful knowledge to support the decision-making

process improving its outcomes, which can be proven

by previous and current work by the research team

(Esteves, Miranda, and Abelha 2018, Esteves,

Miranda, Machado, et al. 2018, Neves et al. 2018,

Esteves et al. 2019). Additionally, if the mobile

solution proves to be of quality, it is envisioned to

implement it in more nursing homes. This will be

possible since the mobile application was designed to

allow its adaptability according to the needs of similar

institutions.

ACKNOWLEDGEMENTS

This work has been supported by FCT – Fundação

para a Ciência e Tecnologia within the Project Scope:

UID/CEC/00319/2019.

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