Data collection with iPhone Web apps efficiently collecting patient data using mobile devices

Abstract

The use of mobile and ubiquitous computing devices is advantageous for collecting and sharing patient data at the bedside or in hospital waiting areas. iPhone web applications - or web apps - combine the power of Internet based solutions with the simplicity of multi-touch and gesture technology, all one portable device. Since many data collection platforms have moved to an online paradigm (or are in the process of doing so), a web app is an ideal solution. In this work, we show the advantages of using a web app for patient data collection, as an imaging engine, and for patient feedback and survey systems. This can be achieved by taking advantage of simple functions available on the iPhone OS when using an online collection platform.

Full text

Data Collection with iPhone Web Apps
Efficiently Collecting Patient Data Using Mobile Devices
Ali Hamou, Stacey Guy, Benoit Lewden,
Adam Bilyea, Femida Gwadry-Sridhar
I-THINK Research, Lawson Health Research Institute
London, ON Canada
{ali.hamou, stacey.guy}@sjhc.london.on.ca
{benoit.lewden, adam.bilyea}@lawsonresearch.com
femida.gwadrysridhar@lhsc.on.ca
Michael Bauer
Department of Computer Science
The University of Western Ontario
London, ON Canada
bauer@csd.uwo.ca
Abstract—The use of mobile and ubiquitous computing devices is
advantageous for collecting and sharing patient data at the
bedside or in hospital waiting areas. iPhone web applications —
or web apps — combine the power of Internet based solutions
with the simplicity of multi-touch and gesture technology, all one
portable device. Since many data collection platforms have
moved to an online paradigm (or are in the process of doing so), a
web app is an ideal solution. In this work, we show the
advantages of using a web app for patient data collection, as an
imaging engine, and for patient feedback and survey systems.
This can be achieved by taking advantage of simple functions
available on the iPhone OS when using an online collection
platform.
Keywords-iPhone; patient data collection; imaging engine;
electronic health record; patient feedback systems
I. INTRODUCTION
Traditional portable systems (tablets or laptop systems)
have been cumbersome and difficult for patients to use due to
their large size, clumsy interfaces and limited battery life.
Device costs were also quite expensive and difficult to replace
and maintain. The use of ubiquitous computing devices
(especially smart mobile phone technology) for collecting data
is better suited in a high tech hospital environment.
Only a handful of hospitals have migrated or adopted the
use of mobile systems (and applications). Such systems would
increase efficiency and reduce errors for a multitude of
applications. One popular system – which was only introduced
in 2007 – is Apple Inc’s iPhone (and iPod touch). This smart
phone has garnered great public consumer support, making it
an extremely widespread mainstream device. (1) Taking
advantage of this popularity and user understanding, helps to
create more streamlined workflows that can incorporate the
patient directly within a hospital or clinical setting. Some of
these will be outlined below.
A. Medical Applications for the iPhone
There are a growing number of medical applications
tailored for the iPhone with Apple Inc suggesting over 700 as
of January 2010. (5;10;11) Some of the available applications
border on data collection tools with features such as self-report
and sharing information with a consulting physician. Various
medical professionals are now using the iPhone to access
patient electronic records, laboratory test result values,
medication information and reference systems (such as contra-
indications), charge capture decision-support tools and medical
calculators. (7) Below we describe some applications.
FitnessBuilder, pioneered by PumpOne, is a physical
therapy tool that allows a physical therapist and the client to
communicate during therapy. This application allows the
therapist to assign exercises, and patients to report how much
of the exercise routine they have completed. The physical
therapist is then able to monitor the progress of the patient. (12)
AsthmaMD is a self-management application with features
such as a diary, graphing ability, and medication logs. This
application encourages the interaction of physician and patient
by sharing charts and information as well as sharing the user’s
information for research purposes. (15)
Hopkins Antibiotic Guide is an application for the
management and diagnosis of syndromes and pathogens with a
reference guide on antibiotics, as well as a section for
comments by the author. (5)
There are also a growing number of reference apps for the
iPhone. Epocrates is an extensive drug database for information
on dosage, interactions, laboratory tests, adverse reactions,
pharmacological information, profiles on clinical news and
conference highlights. (5;13) Attesting to the popularity of this
application is the claim that 100,000 physicians use this
application via their iPhone.(14) Similar applications are
Medilyzer, (a drug reference application with information
about side effects and dosage) and Procedures Consult (a
medical reference application, providing educational material
to students and professionals). The reference applications
generally include animation, illustrations, and video. (15)
Programs that assist decision making have become quite
prolific. KidneyCalc is an application that guides decisions
about dosage for patients with renal dysfunction. (15)
Handbook of Signs and Symptoms is a decision-tool
application whereby medical staff can identify signs and
symptoms and discover the most probable cause. (15)
Differential Diagnosis i-pocket is a similar product with over

800 sings, symptoms and abnormal findings. (15) MedMath
and MedCalc are both medical calculator applications that
include commonly used medical equations. (5)
One of the primary functions of an iPhone was the ability to
Podcast presentations, hence broadcasts of medical
presentations or conference content can also be uploaded to any
iPhone device. (5)
B. Health Projects using iPhone Technology
The Doylestown Hospital project wanted to improve clinic
workflow. In turn they gave physicians access to the hospital
electronic medical records database using the iPhone to
facilitate this. (8) A primary reason the project called for
iPhone usage is that after initial installation, the device
automatically wirelessly synchs with the hospital server. (7)
iPhones allowed physicians to access information necessary for
patient care such as laboratory results and vital signs while
enabling them to explain surgical procedures through imaging
capabilities. (8)
George Washington University Hospital developed a
project aimed at improving cardiology patient care which
enabled physicians to access EKG images from their iPhone.
This simplified the physician’s on-call routine decreasing the
burden on emergency room staff. This rapid access to patient
data led to improving turn-around times for patients. (7)
Utilising the iPhone as a platform for anatomical education
was found to be successful in multiple educational centres
since sources (such as imaging data and educational videos)
were effortlessly transferred to and easily accessible by the
iPhone. (1)
Memorial Hermann Healthcare System is currently drafting
systems that envision physicians using their iPhone as a
medical reference tool and to view patient information in a
secure manner – with remote wipe facilities and passcode
protection. (9) This particular hospital currently makes use of
the AirStrip OB application in order to monitor labour with
delivery room data such as contraction patterns. (9)
II. METHODOLOGY
We conducted this research with an aim to propose the use
of an iPhone application within the healthcare sector. Several
applications for the iPhone have been created in order to test
such mechanisms on real world systems for various clinics.
The application specified in this work, was designed for use in
an atheroscerlotic patient clinic (SPARC) that relies on a
MySQL backend database and a PHP front end web platform.
Each specific section of the iPhone application will be
described here.
A. Patient Demographics Acquisition
One of the foundations of any health record is patient
demographics. It represents the core data for any medical
institution. Accurate demographics equates to eventual accurate
statistical analysis. In traditional systems, a triage nurse (or
assistant) collects baseline foundation data manually. In other
words, either the patient or the nurse fills out forms by hand –
which are eventually transcribed or coded to an electronic
database housing all patient records. These traditional systems
introduce a redundancy to the entry mechanism which leads to
various quality control issues. These include: errors in filling
out initial handwritten forms, errors unintentionally transcribed
to the database during coding, etc. Furthermore this process
requires two separate steps, manual collection and electronic
transcription, in order to populate the database; hence twice the
amount of time and resources are used by the clinic.
In order to alleviate such issues, a mobile web application
(web app) was designed for use with the clinic’s database. This
web app was designed for the iPhone to take advantage of the
interface features offered – such as gesture support. The
acquisition tool allows for demographic data to be directly
imported into the database, which could be done by either
patient or nurse onsite. Furthermore, validation (which was
implemented using JavaScript) was applied to each field
ensuring that data was not missed or incorrectly filled. Such
techniques allowed for further increases in quality control
ensuring accurate patient record entry.
Figure 1(a) depicts a screenshot of the patient
demographics acquisition system. For this web app, detailed
history was required by the client. The web app takes
advantage of all the user interface enhancements of the iPhone
along with soft keyboard features for data input.
B. Imaging Platform
An imaging platform was created in this web app since the
use of imaging data (whether CT, Ultrasound, MRI, etc)
associated with a patient’s record was required. This is used in
two ways:
1. The first allows the clinician to analyze a complete patient
record, including all associated test results in order to
verify findings. Gesture-supported tools such as magnify
and reorient allows the clinician to highlight and focus on
various aspects of the patient images.
2. The second allows the clinician to illustrate a patient’s
condition and would help them cope with their illness.
Ultrasounds were imaged in the proposed iPhone
application such that multiple views (for instance
bifurcation, internal carotid, four-chamber, apex, etc) were
available for the user to select and magnify.
Figure 1(b) depicts an example of a four-chamber view
echocardiogram. This image can be selected and manipulated
by the user using simple hand gestures (tapping, pinching, etc)
as defined by the iPhone’s interface.
This platform is easily extended to include multimodal
datasets and simple registration and segmentation algorithms.
These are only limited by the processing power of the iPhone –
as such algorithm efficiency is critical to ensuring these tools
would be used.
C. Patient Surveys and Learning Tools
Feedback mechanisms from patients provide valuable
information that can be stored and queried on the database.
Once collected, this section of the web app can also be used to
train and teach patients about various issues regarding the

effects of their medications and counter indications if stopped.
Furthermore, it can be used to collect and track patient
knowledge, their medication compliance, satisfaction and
health related quality of life.
The gesture supported interface allows for ease of data
entry of these surveys, which can be filled out while the patient
is waiting for the clinician. Several devices can be reserved for
patient waiting rooms which can collect feedback and educate
the patient about their illness simultaneously. They can also be
used to inform the patient that the clinician is ready to see
them. Furthermore, patients can provide their email address,
which would allow the system to send educational material to
the patient following their visit.
Figure 1(c) depicts an example of a patient survey and
feedback form. Patient lifestyle habits allowed the clinic to
make more accurate decisions on diagnosis and future
outcomes. These feedback systems provided a means for the
clinic to improve their workflow and operations center.
III. ADVANTAGES OF THE PLATFORM
Many advantages have already been mentioned as to using
smart mobile systems (direct entry, portable, relatively
inexpensive, remote wipe features, etc), however many specific
reasons exist for utilizing Apple Inc’s iPhone platform:
 The iPhone allows for adaptation and flexibility at each
level of its operating system. (2)
 The iPhone can be easily sterilised for use with patients by
means of a standard alcohol wipes. (3) This can prevent
the possible spread of microbes or other germs present
within the hospital environment.
 With specific functions such as an accelerometer and
microphone, multimodal data can be collected or captured.
(4)
o Given the motion sensors embedded in the iPhone, it
could allow for the possibility of monitoring a person’s
agility and movement (possibly monitoring various
movement based disorders).
o Accelerometers may aid in mental health i.e. many
disorders are accompanied by physical signs and
symptoms (physical movement as well as activity levels)
such as frenetic motions which aid in diagnosis of a
mental condition. (4)
 Data that can be potentially mined from the iPhone could
provide rich, dynamic information in a second-by-second
account of the patient’s experience. (4) Although this is an
intervention, the patient may consider this as part of their
daily routine as the device is not overly intrusive and is
enjoyable to use.
 The iPhone as a data collection tool could help monitor the
patient’s response to a given treatment (be it medication
compliance or based on behaviour change). (4)
 The touch-screen and gesture support allows for easy and
familiar user interaction, as well as panning images with a
finger tip - essentially interacting with the phone. (1;5)
This is particularly relevant where older patients are
concerned. The touch facility requires less agility then
using a point and click device.
 The built in GPS could provide, with patient consent,
tracking of patient location and geographical patterns that
could be useful in diet and nutrition initiatives. (4)
 The wireless and 3G capabilities allow for easy and
seamless access to the internet. (1;6)
A. User Interface and Mainstream Proliferation
Touch screen interfaces have traditionally suffered from
cramped layouts and poor displays. This has led them to rely on
soft pens for navigation. The iPhone user interface relies
primarily on finger based navigation, and a minimalist layout
paradigm. In other words, screens must be kept simple and
focused, relating only to the operations desired.
Application features are structured at a very high level. This
ensures that application abide by the standards outlined by the
provided libraries. These standards provide, hierarchical levels
that are easily retractable, which allow for switching between
main functionality without losing your position, editing of
information while maintaining context, etc. The simple and
intuitive layout of the interface allows for natural
understanding of programs running on the iPhone, which
allows users to take full advantage of the application without a
learning curve.
The rapid adoption rate and popularity of the iPhone (and
iPhone OS devices) have made the use of such systems
advantageous, as most clinicians and patients have access to
them and are familiar to use such systems. This makes them
ideal for small clinic use that sees a high throughput of patients.
For instance a clinic could purchase several iPod Touch
devices (instead of iPhones) for a relatively inexpensive
amount – and they would not require mobile phone plans.
These devices can communicate with the database via a
wireless network or Bluetooth connection rather than a mobile
data plan.
B. Rapid Development Model
Apple Inc. has provided several tutorials and an extremely
comprehensive literature set on its iPhone development
platform. Furthermore, examples and drag-and-drop interfaces
for creating web apps (or fully flanked iPhone applications)
facilitate rapid development times. Each section of the iPhone
application designed took minimal development time since
current PHP pages were simply adapted to the mobile screen
size and various gesture features were added.
Since iPhone development is carried out using xCode
(Apple Inc’s integrated development environment) and
involves similar methods and library calls as writing standard
Mac OS X applications, there was virtually no learning curve
for our current developers. Those that had no prior experience
with Objective-C (the language used for Mac OS X
development), followed Apple Inc’s online tutorials and were
creating example programs extremely quickly. The relatively
low learning curve for development created great excitement
and drove rapid development times.

C. Security
In general, when dealing with any patient record or
information, all data must be secured and housed behind a
hospital firewall system. One of the main objectives in using a
web app was to build a system without breaking this
imperative. The use of web apps provided this functionality,
since any data would be accessed through the secure site
already established by the current database.
Current PHP pages that were retooled for the iPhone
leveraged the same security protocols on the original website
accessing patient data. Furthermore, all of the actions taken by
any user of the web app was logged and stored on the database.
Hence any malicious attempts to circumvent security or corrupt
data are quickly detected and access is revoked (reinstating the
original data if changes that did occur become trivial).
IV. CONCLUSIONS
In order to improve efficiency in collecting patient data,
tablet systems or lightweight client computers have been
adopted by various clinics for use in patient waiting rooms.
These systems have been found to improve workflow, increase
the accuracy of data acquisition systems, and streamline patient
feedback mechanisms. The use of ubiquitous mobile devices
(such as iPhone OS technology, which further supports future
platforms – such as the iPad) allows to further improve such
practices. The proliferation of these mainstream devices has
encouraged a strong paradigm shift in the consumer space
which encourages their adoption in an ever growing e-health
world.
We have shown that it is possible to use of iPhones for
collecting patient data, displaying various imaging modalities,
and collecting feedback is advantageous when used in a clinical
setting. Our future research will involve pilot work with
patients evaluating the applications in order to improve
adherence to lifestyle, diet and medication use changes. We
aim to do this through a cross-over trial where patients are
initially given traditional care interventions followed by the use
of our iPhone application. We will also conduct focus groups
with our patients to ensure that we are responsive to their needs
and preferences in future development.
The web app created for this project will be extended to be
used in other clinical centres which would aim to improve their
respective workflows and data collection systems. There are
implications to both individual health (where the application
can be personalized based on patient preferences and needs) as
well as at the population level (where these devices can be used
to reach different age cohorts). Although cardiovascular disease
is very prevalent, the emerging diseases such as childhood
obesity and type 2 diabetes in these patients is equally
(a)
(b)
(c)
Figure 1. iPhone web app screenshots. (a) Detailed patient demographics acquisition platform, (b) Imaging platform, (c) Patient
survey and feedback platform.

compelling and requires new media to engage patients. We
believe the iPhone provides a unique opportunity achieve this.
ACKNOWLEDGMENT
No financial support was received for this work. This work
was made possible by Dr. David Spence and his clinic that
provided the platform to create our applications from. This
work was partially supported by Apple Canada Inc and Philip
Hume (higher education representative) by providing the
necessary equipment and tools.
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