Evaluation of the Cross-Platform Framework Flutter Using the

Example of a Cancer Counselling App

Leon Lovrić

, Mahsa Fischer

, Natalie Röderer

and Alexander Wünsch

Faculty of Business and Transport Management (WV), Heilbronn University of Applied Sciences, Heilbronn, Germany

University Medical Center Freiburg, Department of Psychosomatic Medicine and Psychotherapy, Faculty of Medicine,

Albert Ludwigs University, Freiburg, Germany

Keywords: Cross-Platform Frameworks, Flutter, Health Applications, Cancer Counselling.

Abstract: The advance of digitalization is constantly bringing new solutions to various areas of life in our society. The

COVID-19 pandemic, among other things, brought increased attention to the application and support of

treatments through digital solutions in the healthcare sector due to contact restrictions. However, the

development of digital solutions comes at a high cost in terms of time and expenses. Mobile app development

requires the development of two separate apps for the two respective market-leading mobile operating systems,

iOS and Android. Cross-platform frameworks make it possible to develop apps for both operating systems on

a single code base, thus saving the development and maintenance of two separate codes. Flutter is currently

the most popular cross-platform framework for the development of mobile apps. This paper has evaluated

Flutter based on an existing criteria catalogue. As a usage context for the evaluation, a prototype for Cancer

Counselling App of the University Medical Center Freiburg was implemented. According to the gained own

prototyping experience with Flutter and a thorough literature analysis in this area, the criteria catalogue was

filled out and the result was compared with other mobile App development paradigms.

1 INTRODUCTION

Digitalisation has long since arrived in the healthcare

sector and is increasingly changing processes and

procedures. The COVID 19 pandemic has made

many people aware of the advantages that

digitalisation of the health system can bring. This has

resulted in a new openness to the possibilities of

digitalisation. In recent years, there has also been a

significant push towards digital healthcare in health

legislation (Weber and Heitmann 2021).

Digital solutions are fundamentally suitable in

healthcare to ensure quality for treatments. This is due

to two characteristics of digital solutions, the

possibility of a complete collection of data and the

ability to provide data independent of time and date

(Brönneke and Debatin 2022).

Together with the Heilbronn University of

Applied Science and Fraunhofer Institute for Systems

and innovation Research ISI, among others, the

University Medical Center Freiburg launched the

Cancer Counselling App project (Krebsberatungs-

App) in 2020 supported by the Federal Ministry of

Education and Research in Germany. The Cancer

Counselling App is intended to provide psycho-

oncological counselling for cancer patients and their

relatives.

Every second person develops cancer during his

or her life (Centre for Cancer Registry Data at the

Robert Koch Centre 2016). The incidence of cancer

has been increasing for decades, whereas mortality

has been decreasing on an age standardised basis

(Centre for Cancer Registry Data at the Robert Koch

Centre 2016). As a result, the number of cancer

patients and long-term survivors is increasing (Centre

for Cancer Registry Data at the Robert Koch Centre

2016). Since cancer patients are often under

considerable psychological distress (Mehnert et al.

2014), it is important that they have access to low-

threshold psycho-oncological support when needed

(Federal Ministry of Health 2008). Cancer patients

and their relatives can receive psycho-oncological

support at the Psychosocial Cancer Counselling

Centre in Freiburg. Internal statistics show that

demand has increased in recent years. To be able to

meet the increasing demand, a Cancer Counselling

App is to be developed as a supplement to the services

offered.

In recent years, several app- and web-based

support options have already been developed in the

Lovri

c, L., Fischer, M., Röderer, N. and Wünsch, A.

Evaluation of the Cross-Platform Framework Flutter Using the Example of a Cancer Counselling App.

DOI: 10.5220/0011824500003476

In Proceedings of the 9th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2023), pages 135-142

ISBN: 978-989-758-645-3; ISSN: 2184-4984

 2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)

135

field of psycho-oncology. These include, for

example, psycho-oncological web-based

programmes for relaxation (Urech et al., 2018), a

web-based support programme for relatives

(Bodschwinna et al., 2022) or an app for psycho-

oncological support (Fosanis GmbH n.d.). All apps

can be used largely independently of third parties, i.e.,

there is little or no interaction with professionals (e.g.,

psycho-oncologists). However, the relationship

aspect has been proven to be particularly important in

counselling and psychotherapy (Priebe & McCabe

2008) and should therefore be taken up as an

innovative aspect in the Cancer Counselling App.

According to own research cancer patients face

the following problems: Being overwhelmed, lack of

knowledge about the existence of cancer counselling

centres, living in a rural area, physical impairments or

language barriers. Yet every second person develops

cancer during his or her life; the proportion of those

affected (patients and relatives) is therefore very high.

The Cancer Counselling App is intended to create a

solution to overcome these problems and improve the

low-threshold nature of psychosocial care, initially in

Freiburg and later, ideally, throughout Germany.

Within this work an initial implementation of the

Cancer Counselling App is made in the form of a

prototype and then the cross-platform framework -

Flutter - used for this is evaluated.

The development of digital solutions in the form

of mobile applications is associated with high costs

and time expenditures. A systematic, structured, and

engineered development of apps on mobile devices

entails various challenges, functions and limitations

that need to be considered. High hardware and

software fragmentation is one of the biggest

challenges in designing, developing, and testing

mobile apps. Due to the number of different mobile

devices and operating system versions, there are

different development paradigms for mobile

applications. In addition to the native paradigm, there

are other paradigms whose goal is a development that

is more independent of the operating system (Vollmer

2017).

One of these paradigms is the development

through cross-platform frameworks. By evaluating

different paradigms, Shah et al. (2019) were able to

identify the cross-compiled development paradigm as

the best alternative to native development. It has

several advantages and is therefore very interesting

for the development of the Cancer Counselling App.

Among the advantages are (El-Kassas et al. 2017):

• The App is developed once and is available to

more users who use different platforms

• Ease of development as the App is written

once and deployed many times on different

platforms

• Reduction of the development time and

efforts.

As part of a case study, a first prototype of the

Cancer Counselling App is created using the cross-

platform framework Flutter. Subsequently, Flutter is

evaluated through a criteria catalogue. The results

enable a comparison among native paradigm, Flutter

and other cross-platform frameworks.

2 RELATED WORK

Flutter has steadily grown in popularity since its

release in late 2017 (Zammetti 2019). However, there

are hardly any works that evaluate Flutter on a

broader set of criteria like with a criteria catalogue.

Only partial aspects such as performance or

scalability of Flutter are examined. Mobile app

development is time consuming and expensive

(Vollmer 2017). The resulting work should therefore

support the decision of Flutter being used for the

development of digital health applications as well as

other types of mobile applications.

The original aim of the literature review of this

work was to identify criteria suitable for evaluating

and assessing Flutter in terms of the suitability of this

technology for mobile app development. While

conducting the literature review, a catalogue of

criteria of Rieger and Majchrzak (2019) was found.

The catalogue of criteria emerged from a literature

review to identify criteria regarding the evaluation of

cross-platform frameworks and a subsequent

evaluation by experts. The literature analysis includes

some works that were already found in the process of

the originally planned literature analysis of this

bachelor thesis. Therefore, the criteria catalogue was

very well suited to be used for the evaluation of

Flutter.

In the paper by Rieger and Majchrzak (2019),

however, only Cordova and React Native as well as

native development have been evaluated to date. This

means that an evaluation of Flutter is still pending. An

evaluation of Flutter to the extent of the criteria

catalogue could not be identified in the literature

review. The discovered works that deal with the

evaluation of Flutter mostly only examine the

technology regarding individual aspects, such as the

performance or scalability of Flutter apps.

The second phase of the literature analysis was

about evaluating criteria from the criteria catalogue

that could not be evaluated through the

ICT4AWE 2023 - 9th International Conference on Information and Communication Technologies for Ageing Well and e-Health

136

implementation of the prototype nor through the

literature analysis. These are five criteria: Durability,

scalability, security, robustness, and performance. A

total of 16 sources were identified that deal with the

evaluation of at least one of the unevaluatable criteria.

3 METHODOLOGY

For the methodological procedure of this work, the

approach for case studies according to Lindner (2020)

is applied. After formulating a research question the

work is divided into three components. These are

Determination of Evaluation Criteria, Case Study:

Development of the Prototype and an Evaluation

based on the identified Criteria.

3.1 Determination of Evaluation

Criteria

For the evaluation of Flutter, the criteria catalogue for

cross-platform frameworks by Rieger and Majchrzak

(2019) is used.

Rieger and Majchrzak (2019) deliberately try not

to provide any precise guidelines or checklists for

evaluating the individual criteria to do justice to the

rapid development and change in the field of mobile

application development. The description of the

individual criteria as well as exemplary evaluation

profiles should be used to assign a score from 0

(unsatisfactory) to 5 (complete satisfactory).

Nevertheless, the result of the individual evaluation

should be as objective as possible at the end, which is

why all criteria are weighted according to their

relevance.

3.2 Case Study

Within the case study a prototype of the Cancer

Counselling App was developed with Flutter. To

understand the requirements and the different target

groups for the app, a requirements workshop was

conducted together with the University Medical

Center Freiburg. An appointment scheduling, chat,

information overview and intervention functionalities

were identified as the main functions of the app. The

users of the app can be assigned to the roles: Patients,

relatives of patients, psych-oncologists and social

workers.

Within the prototype a registration and login as

well as a chat function are developed. By

implementing these functions, sufficient experience

in development with Flutter can be gained to be able

to evaluate Flutter regarding the aspects of data

management, data processing or the UI.

For the development of the login and registration

function, the authentication system of Firebase was

used. Firebase has libraries and services through

which the creation and management of users can be

implemented. A complete authentication back-end is

provided for login with passwords, federated identity

providers, email links and text messages. Up to

10,000 free authentications are available per month,

which is fully sufficient for the volume of

authentications provided by the prototype.

Figure 1: Sequence Diagram Chat Function.

Figure 2: Chat Function Screenshots.

The chat section concept is similar to common

messenger apps such as Whatsapp or Facebook

Messenger. The aim of the chat functionality is to

enable communication between the patients and the

followings: cancer counselling centre, other

counselling services (e.g. nutrition counselling, social

services), self-help groups, other patients with similar

Evaluation of the Cross-Platform Framework Flutter Using the Example of a Cancer Counselling App

137

disease and emergency center. However, the design

of this function is still open and yet to be fully

discussed, whether patients are free to exchange

information with each other in chats, there is a fear of

negative conversations that would be

counterproductive for the psychological well-being

of the patients. Suitable ways for patients to exchange

information with each other are yet to be discussed.

Nevertheless, the development of the chat

function offers a good possibility to also test the

integration of external libraries, among other things.

The chat function was implemented using the UI

library "Flyer Chat" (Flyer Chat 2022). With almost

500 likes, the "Flyer Chat" package is currently the

most popular chat UI library in the official package

repository for Dart and Flutter. In addition to UI

widgets, the library also offers functions for

integrating Firebase as a backend. This means that it

can be integrated into backends that already exist for

App UI and the backend function together.

3.3 Evaluation Based on Identified

Criteria

With the nature of this work being about mobile apps

other weights from Rieger and Majchrzak's (2019)

catalogue except the weight for smartphone app

development have been removed. To have a

comparison to other cross-platform frameworks, as

well as to native development, the ratings of these

from Rieger and Majchrzak (2019) have been

retained. Criteria that cannot be assessed through the

prototype development process are assessed through

a literature review (Fettke 2006; Webster and Watson

2002; Brocke et al. 2009) or through Flutters official

documentation (Flutter 2022).

4 EVALUATION

The criteria of the criteria catalogue in table 1 can be

categorized in infrastructure, development, app and

usability criterions.

Table 1: Criteria Catalogue.

Criteria

Weight (%)

Flutter

Phone Gap

(Cordova)

React Native

Native Apps

I1 License 5 5 5 5 5

I2 Target

Platforms

6 5 5 4 1

I3 Development

Platfroms

2 5 5 4 2

I4 Distribution

Channels

2 5 3 3 4

I5 Monetisation 1 5 3 3 5

I6 Internationalisat

ion

1 5 3 3 5

I7 Long-Term

Feasibilit

5 3 5 3 4

D1 Development

Environment

7 4 5 4 5

D2 Preparation

Time

7 4 4 4 3

D3 Scalability 2 4 3 4 3

D4 Development

Process Fit

2 4 3 3 2

D5 UI Design 4 4 3 2 4

D6 Testing 3 3 4 3 5

D7 Continous

Deliver

3 3 5 3 3

D8 Configuration

Mana

ement

1 0 0 0 3

D9 Maintainability 2 4 4 4 2

D10 Extensibility 2 3 5 2 5

D11 Custom Code

Integration

2 5 3 3 5

D12 Pace of

Development

4 4 4 3 0

A1 Hardware

Access

4 5 4 3 5

A2 Platform

Functionalit

5 5 4 3 5

A3 Connected

Devices

3 5 2 2 5

A4 Input

Hetero

eneit

1 4 4 4 5

A5 Output

Hetero

eneit

1 4 4 4 5

A6 App Life Cycle 2 4 4 4 5

A7 System

Integration

3 5 3 3 5

A8 Security 3 2 0 0 3

A9 Robustness 2 3 4 2 3

A10 Degree of

Mobilit

1 3 1 3 5

U1 Look and Feel 5 4 3 4 5

U2 Performance 4 4 2 3 5

U3 Usage Patterns 2 2 2 2 2

U4 User

Authentication

3 1 0 0 1

Weighted Score

ICT4AWE 2023 - 9th International Conference on Information and Communication Technologies for Ageing Well and e-Health

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4.1 Infrastructure

Flutter is open source and licensed under BSD

(GitHub 2022) (I1 Licence). Flutter supports the

following target platforms: both Android and iOS

apps, interactive apps that can be run via web hosting

or on the desktop under Windows and, since the latest

release of Flutter version 3, also under macOs or

Linux (Flutter 2022) (I2 Target Platform). Flutter

apps can also be developed under all these operating

systems (Flutter 2022) (I3 Development Platform). In

addition to the Apple App Store and the Google Play

Store, the developed app packages can also be

published in the Microsoft Store and Snap Store

(Linux) (Flutter 2022) (I4 Distribution Channels).

Flutter offers various monetisation options through

the integration of advertising, in-app purchases, and

the connection to Apple Pay and Google Pay (Flutter

2022) (I5 Monetisation). Regarding

internationalisation, there is the possibility of

identifying the language setting of the users’ end

device and providing corresponding language

packages (a total of 78 languages are supported)

(Flutter 2022) (I6 Internationalisation). Masaad

Alsaid et al. (2021) estimate the longevity of Flutter

to be quite good, since Google, one of the biggest tech

giants, is behind the technology. The degree of use by

the community is also quite high (JetBrains 2022) and

even makes Flutter the current most popular cross-

platform framework, which is very promising for the

longevity of the technology. However, the technology

is still relatively young (I7 Long-Term Feasibility).

4.2 Development

The choice of an IDE is not limited under Flutter, but

not all development environments have Flutter

support. With Andorid Studio, IntelliJ IDEA and

Visual Studio Code, Flutter is supported by popular

development environments (Flutter 2022). Visual

Studio was able to support the process of prototype

development with helpful tools, like an auto

complementation for the code and emulator support

(D1 Development Environment). Dart can be

classified as a developer-friendly programming

language. Since Dart is an object-oriented

programming language, development is relatively

close to the native development paradigm of Android.

However, due to fewer required lines of code and

many prefabricated functions, development in Flutter

is even easier and faster compared to native

development (D2 Preparation Time). By using state

management approaches, Flutter projects can be

made very scalable. Among other things, the "BLoC"

approach enables the modularisation of the

architecture of a Flutter app, making it scalable and

maintainable with only a few adjustments (Bardram

2020; Payne 2020; Szczepanik and Kędziora 2020)

(D3 Scalability, D4 Development Process Fit, D9

Maintainability). Flutter has many pre-built UI

widgets through which a UI can be quickly built.

Optionally, by using MaterialApp or Cupertiono

libraries, these widgets can be rendered on the

respective operating system with the appropriate

design language. In this case, however, two versions

of the app would still have to be developed with the

respective design language (D5 UI Design). Flutter

offers various functions for the execution of

automated tests. These can be divided into the

following categories: Unit Tests, Widget Tests and

Integration Tests. Testing iOS through Xcode

(development environment for macOS) is not

possible under Windows or Linux. There are a

handful of CD tools including Codemagic, Bitrise,

Appcircle and fastlane that support automated flutter

testing (Flutter 2022) (D6 Testing, D7 Continous

Delivery). Due to the modularisation using a state

management approach, third-party extensions can be

offered well. However, with around 24,000 (Dart

packages 2022a), there are currently still few third-

party libraries and usually there is not much further

help for integrating and adapting the library functions

beyond the documentation provided by the library

publishers (D10 Extensibility). Flutter also offers the

possibility of platform-specific implementations

through native code. Alternatively, third-party

packages can also be integrated with native code

(Flutter 2022) (D11 Custom Code Integration). Due

to many prefabricated widgets, the development

speed is relatively fast, which is also reflected in the

lines of code required (D12 Pace of Development).

4.3 App

The enabled integration of native code also enables

access to the hardware, as well as to various

functionalities and the connection of external devices

such as to smartwatches of the target platform. For

this purpose, many packages are already provided in

the form of third-party libraries (Flutter 2022) (A1

Hardware Access, A2 Platform Functionality, A3

Connected Devices). Flutter supports various gesture

inputs with tapping, double tapping, vertical or

horizontal dragging and "drag and drop" (Flutter

2022) (A4 Input Heterogeneity). Also, various

functions are provided to enable screen customisation

for specific devices or to allow users to customise the

screen. Through the possibility of accessing the

Evaluation of the Cross-Platform Framework Flutter Using the Example of a Cancer Counselling App

139

hardware of the target platform, sounds can also be

played (Flutter 2022) (A5 Output Heterogeneity). The

app lifecycle can be observed through the function

"AppLifecycleState" and the states can be described

accordingly (Flutter - Dart API docs 2022) (A6 App

Life Cycle). Flutter offers functions that enable

interface communication via http, for example. In

addition, functions for JSON data processing and

serialisation are also provided (Flutter 2022) (A7

System Integration). Data can be processed through

Flutter in a secure manner, but not as secure as in

native solutions (Shah et al. 2019; Bagul et al. 2022).

There are few features that facilitate secure data

processing (A8 Security). Flutter apps can be

classified as comparatively robust. In interaction with

Firebase, various offline functionalities can be

provided (HOD. Dr R Juliana et al. 2021; Bardram

2020; Payne 2020; Bhole and Kumar 2022) (A9

Robustness). With the ability to develop applications

beyond mobile operating systems, there are now also

new levels of mobility. However, development for

WatchOS, for example, is not yet possible (A10

Degree of Mobility).

4.4 Usability

By enabling the use of design languages of the target

platforms, customised representations can be

developed. The prototype of the Cancer Counselling

App felt like an app and not like a website (U1 Look

and Feel). The performance of Flutter apps can be

classified as very good. It is better than competing

cross-platform frameworks, but in most cases, it does

not quite match the performance of native apps

(Bagul et al. 2022; Carius et al. 2022; IŞITAN and

KOKLU 2020; Mahendra and Anggorojati 2020;

Nawrocki et al. 2021; Rudenko et al. 2021; Biørn-

Hansen et al. 2020) (U2 Performance). As already

described for criterion A9 Robustness, according to

HOD. Dr R Juliana et al. (2021), offline support can

also be ensured in Flutter apps. Support for wallets

can be achieved by integrating libraries such as the

"pass-flutter" (Dart packages 2022b) (U3 Usage

Patterns). Flutter does not offer any further functions

described in the criterion user authentication (U4)

beyond the packages provided for biometric

verification or voice recognition.

5 DISCUSSION & FUTURE

WORK

General deductions of a single case study are not

always possible or only possible to a limited extent.

Therefore, multi-case studies could lead to more

expressive results.

By using multi-studies, scenarios of different

development projects could be evaluated again by

Flutter to crystallise special features. This could have

led to different results according to changed

requirements. Regarding the selection of a

development paradigm for the Cancer Counselling

App project, the prototype could have been created by

using different development paradigms and the

results could have been compared with each other.

Evaluating the results by oneself, leads to the risk

of a subjective evaluation. The additional evaluation

of experts could have counteracted this.

This evaluation of Flutter can be used to support

future decisions regarding the selection of a

development paradigm for mobile app development.

Currently, few evaluations of the scope of this paper

for development through Flutter can be found in

academic databases. With the release of Flutter 3.0,

Flutter apps can now be used on the desktop of

various operating systems. Up to now, the option of

web-hosting Flutter apps already existed. Therefore,

it makes sense to evaluate Flutter on the other

available target platforms as well.

6 CONCLUSIONS

Digitalisation has already brought about many

improvements in information and communication

technology that have already significantly changed

our lives in many aspects. Today, it is not yet

complete and is an ongoing process that also brings

changes to other areas of our everyday lives.

In Germany's healthcare system, the COVID 19

pandemic provided another boost to digitalisation.

Mobile applications can increase the quality of

treatments. Local treatments can also be

supplemented or partially replaced.

Cross-platform frameworks enable easy

development because apps can be written once and

deployed multiple times on different platforms

through these technologies. This can reduce

development time and effort. The most popular cross-

platform frameworks are Cordova, Ionic, React

Native and Flutter. Flutter is steadily gaining

ICT4AWE 2023 - 9th International Conference on Information and Communication Technologies for Ageing Well and e-Health

140

relevance and is currently the most popular cross-

platform framework.

For the evaluation, a catalogue of criteria for

cross-platform frameworks was identified. Based on

the criteria, Flutter was evaluated in terms of

infrastructure, development, the developed app and

its usability. A prototype of the Cancer Counselling

App was created to be able to evaluate Flutter through

the criteria catalogue based on the resulting

experiences, complemented by a literature analysis

and the official documentation of Flutter. The results

show that Flutter with the highest overall score in the

criteria catalogue is a considerable alternative to

native app development.

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