Ravina Kaniyawala: Mobile Health Solution for Surgery Outcome Project

This project, by Ravina Paresh Kaniyawala from Auckland University of Technology, under the supervision of Dr. Roopak Sinha, explores the development of a mobile health (mHealth) solution to enhance surgery outcomes. The research addresses the growing role of information technology in healthcare, particularly the use of mobile applications and smart gadgets to improve patient care, communication, and monitoring. The project aims to propose, create, and implement technological facilities that facilitate communication between doctors and patients, ultimately improving patient health outcomes. The research is guided by three key questions: identifying requirements from medical standards, architecting an mHealth platform, and building a prototype mobile app for patients and a web interface for clinicians. The project includes a comprehensive literature review, examining the impact of mHealth on surgical care, patient satisfaction, and post-operative recovery. The review highlights the benefits of mHealth in reducing hospital stays, improving patient self-care, and facilitating remote monitoring. The research also addresses challenges such as the need for timely responses from healthcare providers and the importance of user-friendly applications. The project’s findings are expected to contribute to the advancement of mHealth solutions in surgical care.

A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
Ravina Paresh Kaniyawala
Auckland University of Technology
Supervisor: Dr. Roopak Sinha

A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
1. Introduction:
The modern world has witnessed an enormous growth in technology and scientific advancement
through the implementation of several mobile applications and smart gadgets that made life
easier and more convenient. Information technology plays a significant role in improving patient
care and with its advancements, it is widely used in all sectors including health care
organizations to provide an accurate and right care to the patients, access patient’s necessary
information, keep record, make communication between physician and patient more convenient,
ensure transparency in medical charge, provide the patient information and enable them to keep
tract on themselves with the help of mobile application, thereby increasing the overall outcome
of the patient’ health and ensuring patient’s satisfaction (Bowles, Dykes & Demiris, 2015). It
falls under the responsibility of the healthcare providers to assist patients with quality care during
pre-surgery, in the course of surgery and also post-surgery and therefore, a detail survey needs to
be brought into effect that aims at improving patient’s life by giving them facilities to track their
activities after surgery and enable them to directly report to the doctor so that they can be
monitored very closely (Lu et al., 2018). The m-health solution should be designed in such a
way so as to incorporate the surgical methods and manual things involved in the surgery to get a
clear information of the surgical treatment. It should contain the devices used in the surgery like
heart measuring device, body sensor and other smart gadgets so that patient’s activity can be
monitored after the surgery (Semple & Armstrong, 2016). The aim and purpose of this research
paper is to propose, create and implement certain technological facilities that can help doctors
and patient ease their communication which will ultimately result in an improved health outcome
of the patients.
The three research questions for this project are provided below:
1. What are the primary requirements from relevant industry and medical standards involved in
effecting and monitoring surgery- related health plans?
2. How can a mHealth platform be architected to meet the primary requirements identified in
RQ1?
3. How can a prototype of the mHealth platform identified in RQ2, consisting of a mobile app
for patients and a web interface for clinicians, be built?

A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
2. Background:
Smart devices has been established that has changed people’s lives and made everything more
convenient. Recent studies have shown the implementation of Information Technology in
healthcare sectors and their association with improving patient’s life and therefore increases the
patient’s overall satisfaction. Patient’s experience and satisfaction is considered to be an
important outcome in medical health care and it makes the central pillars of health care quality
(Lu et al., 2018). The satisfaction is associated with the treatment and care they receive from the
medical practitioners that influence their perception about quality care. Therefore, the usage of
mobile health applications has helped to improve the quality of healthcare and it has been proven
that through the installation of several facilities like reminders and diagnostic information into
the mobile application can promote the patient’s experience, satisfaction and health (Lu et al.,
2018). In surgical care, there is a growing drift towards reducing the amount of days staying in
the hospital and indulging patients into self-care. However, expedited discharge can lead to poor
outcome of the patients thereby increasing the health complications. Therefore, to address this
challenge, mobile applications has been discovered and developed to facilitate monitoring and
support discharge of the patients ensuring quality care (Semple & Armstrong, 2016).

A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
3. Literature Review
3.1 Method of Literature Review
The purpose of this literature review is to discuss every aspects of this Mobile Health
Information Management system through conducting a systematic review of various secondary
data resources such as Books, Articles, Published Reports and others. Most of the resources
reviewed for this research are collected from online databases such as NCBI dataase, Google
Scholars, Biomedcentral and others. Several keywords have been used to collect the relevant
literatures on this topic such as biomedical mobile application, medical informatics application,
surgery applications for mobile devices and mobile health application.
Database of Secondary
resources
Key words used for research Boolean functions for
research
 NCBI dataase
 Google Scholars
 Biomedcentral
 Researchgate
biomedical mobile
application
medical informatics
application
surgery applications for
mobile devices and mobile
health application
 -
 “”
 NOT
 AND
 OR
 Capital letters
3.2 Systematic Research
Also referred to as mHealth, mobile health is an umbrella term that refers to the use of mobile
devices in the practice of public health and medicine. The term is generally used for referring to
mobile phones, computers, tablets, and smart watches, and has emerged in recent years as a
major segment of electronic health. Mobile health has been found imperative in breaking down
the obstructions of distance for countryside New Zealanders, for more than 16 years and efforts
are currently being taken by the government to ensure that health professionals and patients
obtain fairness of ‘face-to-face’ communication and access to necessary healthcare services
(Mhurchu et al., 2014). This was in accordance to Perera (2018) who stated that notwithstanding
the obtainability numerous actuator and sensor devices intended to co-perform, few of them can
be integrated in smart homes. Their findings suggested that Internet of Things and ICT are
associated with a range of benefits, including low-cost and low-power devices that can be used
for developing a network that comprises of interconnected smart objects. It has also been stated
by Dowdeswell, Sinha and Haemmerle (2016) that cyber-physical systems are able to exert a
control over multifaceted physical components and processes, at the time of cooperating in the
form of distributed network agents. Furthermore, owing to the complexity and scale of
interactions that are associated with cyber-physical systems, it is difficult to maintain and
implement traceability policies that are precise and easy to accomplish.

A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
According to Grissinger (2016) automatic alerts can deliver an actual means of disseminating
indispensable information about a patient and the intervention to clinicians who are entitled with
the responsibility of prescribing, dispensing, and administering the intended treatment regimen.
These alerts are envisioned to upkeep medical decisions about the efficacy and safety of
pharmaceutical therapies. In addition, the alerts are characteristically communicated through
different cautionary posts that arrive on the screen of mobile health devices. Furthermore, no or
minimal acknowledgment or action, in relation to the alert on mobile device is generally
obligatory on the part of the users to continue. It has been affirmed by Sanger et al. (2014) that
surgical site infections (SSI) that occur after discharge of patients from hospitals have been
identified as a major reason behind morbidity, expenditure and concern for the patients.
Nonetheless, perceptions amid patients about the barriers that they encounter, at the time of
seeking care, in relation to post-discharge SSI have not been measured adequately. The
researchers conducted surveys and semi-structured interviews and found that some of the major
challenges that act as impediment in management of post-discharge surgical wound
complications encompass lack of adequate knowledge for wound nursing, absence of self-
efficacy for wound management at home, and lack of available communication with healthcare
providers. The researchers further elaborated on the fact that mHealth wound monitoring
application was considered extremely acceptable by the patients, and pronounced its potential to
deliver more recurrent, thorough, and expedient follow-up for wound monitoring. In addition, the
mHealth wound monitoring application was also found to lower post-discharge anxiety, when
compared to the existing practice. However, some of the major concerns related to mHealth
wound monitoring were inaccessibility of device and absence of timely response from the
healthcare providers.
In the words of Gunter et al. (2016) surgical patients are progressively spending their time in the
usage of mHealth platforms, with the aim of monitoring wound recovery, while communicating
with the healthcare providers during post-discharge period. Notwithstanding the extensive
eagerness for mHealth, lack of studies on user experience made the researchers explore the
patient usability of an image-based mHealth software for post-operative wound monitoring. The
researchers found that mean time spent by patients in training session and application completion
was 4.7 (2.1-12.8) minutes and 5.0 (1.4-16.6) minutes, respectively. Besides high user
satisfaction of 83.3 out of 100, 55.5% patients independently completed the application, with
maximum difficulty encountered at the time of taking digital imageries of surgical wounds. The
findings therefore, suggested that using a smartphone application increased satisfaction among
patients, in relation to their wound monitoring.
It has been established by Armstrong, Coyte, Brown, Beber and Semple (2017) that patients who
are subjected to ambulatory surgery can often follow-up their care through the use of mobile
health application, in comparison to conventional and in-person visits after their surgeries. They
conducted a randomised trial among 65 patients and found that patients who used the mobile

A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
application were able to attend 0.66 in-person visits, in comparison 1.64 in-person visits that
were found among patients who attended in-person follow-up care regimen. In addition, patients
who used the mHealth application were found to send more emails to health care professionals
during the first 30 days following the surgery (mean, 0.65 vs 0.15; incidence rate ratio, 4.13;
95% CI, 1.55-10.99; P = .005), when compared in-person patient follow-up group. The benefits
of mHealth outcomes were also demonstrated by Symer, Abelson, Milsom, McClure and Yeo
(2017) who conducted a pilot study of a novel mHealth application among patients who were
subjected to major abdominal surgery. The researchers conducted the study amid 31 patients and
found that an estimated 83.9% patients were able to complete an application-associated task, for
minimum 70% of the time. Furthermore, 89% patients suggested that the mHealth application
was considerably easy to monitor health outcomes. Besides, 1.1 alerts were generated on an
average by the patients, and most often the patients were able to complete the single-item
photoaffective meter. This findings also suggested that use of mHealth application demonstrated
the potential to improve health outcomes among patients who underwent abdominal surgery.
It has also been suggested by Jaensson, Dahlberg and Nilsson (2018) females often display an
increased likelihood of manifesting poor recovery after anaesthesia, when compared to males.
The findings suggested that females aged less than 45 years reported suggestively high global
scores, in relation to SwQoR questionnaire, concomitant with poor recovery during 1-10 post-
operative days, when compared to females aged more than 45 years or older (P=.001 to P=.008).
In contrast, males aged less than 45 years demonstrated high scores during 2-6 postoperative
days, in comparison to those aged more (P=.001 to P=.006). Thus, the research findings
provided evidence for sex resemblances in postoperative recovery amid male and female patients
who were subjected to mHealth follow-up.
Wang et al. (2018) also confirmed the above findings by conducting a randomised controlled
trial to determine the impacts of a mobile healthcare application on the health outcomes of
patients who had been discharged after a stoma. The researchers found that stoma self‐efficacy
score and psychosocial adjustment amid patients who were subjected to home care through a
mobile application were meaningfully greater than the control group during follow‐up
(p < 0.05). Furthermore, the results also indicated that stoma complications reduced amid
patients who used the mobile application. This in turn provided evidence for the fact that home
care mobile application acts in the form of an effective intervention, for supporting the self-
efficacy and emotional adjustment of stoma patients, following their discharge. In other words,
mHealth applications help in ensuring continuity of care, in addition to delivering guidance to
the patients in a timely manner. DeAntonio et al. (2019) also presented findings that are in
accordance to those presented above. The researchers tried to explore the application of a
handheld telemedicine (TM) device amid pediatric surgical patients and found that there were no
differences to the TM care plan, after missed diagnoses, “in person” evaluations, additional
clinic visits, or visits to the emergency department among those who had been subjected to only

A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
TM postoperative evaluations. However, most of the patients reported extreme satisfaction and
92% caregivers stated that they felt contented with TM-only post-operative assessment. These
data also indicated that use of TM among post-operative patients was effective and safe.
It has also been postulated by Slade Shantz and Veillette (2014) that mass production and
miniaturization of countless sensors have made conceivable the incorporation of output and
sensor applications in wearable platforms. Notwithstanding the customer emphasis of wearable
insurgency, particular surgical applications are being established in recent years that are
categorised as namely, assistive, augmentative, and assessment functions. Furthermore, the
researchers also state that use of augmentative and assistive mHealth technology will facilitate
enhanced communication between healthcare providers and patients, in addition to improving
clinical decision making related done by surgeons.
3.2.1 Literature review on previously made mHealth solution
a) monitoring the symptoms and sending alerts
There are certain ways in which the post-surgery patients’ symptoms are being monitored. SMS
and using the mHealth application were the most common ways for doing this. As suggested in
study by (Cleeland et al., 2011; Carrier et al., 2016; Debono et al., 2019; DeVito Dabbs et al.,
2016; Semple et al., 2015) the most monitored symptoms are temperature and pain. But even the
other symptoms monitored in these studies were nausea, dizziness, any shortness of breath,
constipation, weight, blood pressure output.
Four after surgery patient care monitoring system (Cleeland et al., 2011; Carrier et al., 2016;
DeVito Dabbs et al., 2016; Semple et al., 2015) sends some alerts to the clinic depending on the
patient response to application. If in any case some symptoms are not normal the medical teams
or the doctors will immediately response to such things.
In paper, (Semple et al., 2015) patient has been monitored and survey is being done in which
patient were asked to send some daily images of their recovery or wound after surgery so that
medical team can track the patient’s progress. The pictures send by patients seems to be normal
to the surgeon and then they cancel their follow up visit with the doctor.
One of the application had been developed by (Debono et al. -23) which could help in generating
the response from the doctors. The patients were supposed to push alarm of either green, orange
or red alarm depending on their emergency level of symptom (which can be pain, fever etc. )
During the survey it had been found that total of 31.7% of patient pressed either orange or red
alarm which require response and out of which 18 to some 19 patient who generated the alarm
for orange or red code, their response had been solved over just a call and not needed any
consultation.
Similarly, one another application by (Cleeland et al. -10) in which the alerts had been sent to
respected clinics in some of event like pain, breathing problem, less heart rating etc using some
pre-determined evaluation criteria.

A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
One of the study which is being done by (Martinez-Ramos et al. -17) reports that there were total
96 patient out of which 30 patient generated alerts for surgical wounds. 29 out of these 30 patient
complication had been solved and they need not have to readmit their self to hospital.
b) Patient Age Literature Review for using mHealth solution
Four research shows study on the pediatric patients among which two studies says that parent or
the patient caretakers were the one who responses to the messages, on the other hand other two
studies says that patients themselves needs to respond to the messages (Suchy et al., 2009; Lin et
al., 2012; Chen et al., 2012; Sachse et al., 2016). Some other study focuses on the using mHealth
solution by adult aged and the average age should be between 25.3 to 62 (DeVito Dabbs et al).
c) Application vs SMS based solution
While talking about the application based patient monitoring system and SMS based system,
both have their own aspects that had been found during the study of literature while keeping in
account of primary outcome of medications or their protocols. The given table1 shows the study
done of literature and the result of them.
Table 1: Alert (either using SMS or application) sent to the Patient and their conclusion for
using
Literature Type Findings
Debono et al. – 23 Application There were 31.7% of patient who had triggered
the alert using the application and among which
62.1% of patient’s alert were generated on very
first day, some 10.3% of patient triggered it on
next day and majority of 74.4% patient generated
alert after 3 days coz of their pain. Healthcare
provider had concluded that this resulted in
decreased number of personal visit with the
doctor. This result in saving the time and making
process more faster giving relaxation to patient.
Jiang et al. – 26 Application Out of 55% pf patient use alert feature of the
application for reporting their increased
temperature, blood pressure or some pulse rate
problem.
Semple et al. – 29 Application While using the application, there were two
surgical complication that had been identified for
breast reconstruction and one of them was
orthopaedic patient who had been identified to
increase of erythema.
Cleeland et al. – 10 Automatic Phone
calls
The automatic phone calls to the clinic had been
made the medical group experience felt that there
was greater number of reduction in some symptom
which was earlier 19 and reduced to only 8%.

A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
Majority of clinic respond to the phone call alerts
within 24hrs.
Mundi et al. – 13 SMS +
Application
The study evaluates that patient average BMI rate
had been decreased to 45.1 from 46.3.
Martinez-Ramos et
al. – 17
Photos sent to
clinic using email,
phone
communication
While conducting the study, total 31.3% of patient
had suffered from surgical wound problems after
surgery. Using this feature, some patients concern
had been tracked using the photo sent using email
daily and the problem had been resolved. 16
patients had been return to hospital without any
photo prompting or any intervention of healthcare
team.
Carrier et al. SMS In this study, patient seems to be very active using
SMS as 90% of patient had answered all SMS that
had been sent to them. From the SMS sent and
replied from patient total of 48 alerts were
generated. The 56% of alert was due to pain and
other 40% was due to not responding to any SMS.
These alert leads 4% of patient to visit doctor for
their problems, among which 3 patient needs to
hospitalise again and two had to do operation
again for some complication. But overall, the
study suggests that because of earlier detection of
symptoms patients had been saved from
complications.
Chen et al. -21 SMS Total of 88% of the patient had responded to all
the messages. Among which not even a single
patient reported of having any high pain. This
study conclude that SMS has been very helpful for
them for following up on the condition of child
patient post tonsillectomy.
Sachse et al. -28 SMS In this study, total of 95% of patient found SMS
really helpful service and helped them in very
positive ways. 42% of patient reported that most
important message sent to them was to apply the
plenty of sunscreen which keeps them safe and
alerted continuously.
3.3 Primary requirements
This project had focus on conducting a thorough and comprehensive investigation that will
facilitate identification of the requirements and demands of diverse stakeholders who play a key
role in surgeries that are conducted amid patients. The major stakeholders of a particular
healthcare system are namely, the surgeons, physicians, patients, healthcare staff, pharmaceutical
firms, government and insurance companies.

A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
Hence, determining the role requirements of the stakeholders will provide an insight about
their expectations, in relation to surgical health outcomes of patients. In addition, the review will
also try to determine the manual and traditional approaches that are currently associated while
delivering optimal care services to patients undergoing surgeries. The prospect of mHealth
market is anticipated to grow in the coming decade, in addition to the fact that several
applications have already gained attention that focus on remote health monitoring of patients.
The review will also place due emphasis on analysing the strategies that can be adopted for
enhancing life of the patients, by providing them the opportunity to access technological
facilities, with the aim of helping them track their health status, following a surgery.
The project will also encompass presentation of a system architecture for demonstrating the
required needs of the stakeholder. This will be accomplished by development of a prototype of
mHealth system that will comprise of devices commonly used in surgery such as, heart
measuring device and body sensor. Implementation of this system architecture will ease
communication of patients with healthcare professionals, and demonstrate the efficacy of
mHealth platform for enhancing surgical outcomes.
From the detailed literature review in the previous section, we can identify our primary
requirements to make some prototype of system which will give additional facility and one roof
to make bridge for making communication possible between doctor and patient. To Conduct this
project of developing a mobile application for integrated surgical care the primary requirements
are:
 Identifying the complicacies among patient of surgical department
 Understanding the process of surgical treatments and interventions
 Understanding the types of communication required among caregivers, doctors and
facilitators in surgical treatments
 Conceptual operation of the application and their communication networks
 Findings of equipment purchasing and software subscription
 Final application coding, debugging and testing platform
Primary requirements for Application:
 SMS alert for reporting to patient about their conditions
 Emergency click notification system for both patient and doctor
 Patient regular reports uploading using application to replace sending emails to doctor
 Before surgery tips by doctor to follow for patient integrated in the application so patient
can keep themselves updated.
 Checklist of activity done so, both patient and doctor can track them and do the analysis.
 Monitoring patient’s heartrate and reporting after surgery to check the conditions.


A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
4. Methodology
4.1 Selection of Methodology
Design science approach focuses on the expansion and presentation of artifacts, in addition to the
obvious purpose of refining the practical application of the artifact. mHealth technology
comprises of adaptable and mutable software, hardware, and human interfaces. In other words,
use of mHealth application provides several exclusive and thought-provoking design difficulties
that call for novel and original ideas. Furthermore, use of design science approach has been
found extremely pertinent to mHealth investigation, owing to the fact that it is based on the
development of innovative artifacts for solving real-world problems (Cronholm & Göbel, 2016).
This project was guided by the Information System Research (ISR) Framework that is based on
design science approach for informing growth and expansion of information system.
Incorporation of this system involved iteratively repeating the design and development cycle, till
an anticipated final artefact had been achieved.
4.1.1 First Cycle
Through the usage of the ISR Framework, three research cycles had been employed. The first
cycle referred to as the relevance cycle encompassed conducting an investigation to comprehend
the situation of the patients (end-users) by exploring their necessities through a sequence of
interactions such as, focus groups (Schnall, Rojas, Travers, Brown III & Bakken, 2014). For this
stage, literature review of the paper in which the feedback of users had been taken for healthcare
application features will be done for identifying the anticipated features, content, and function of
mHealth application.
On conducting a thematic analysis of the literature review of what user seeks in the application
and their responses, four major functional requirements were identified namely, (i) managing
medications, (ii) monitoring wound, (iii) easy communication with providers, and (iv) faster
recovery. The providers and patients also suggested that some of the functionalities and tools that
must be included in the mHealth application are notes, reminders/alerts, testimonials of lived
experiences, chat boxes/forums, games/virtual rewards, and personal outreach.
4.1.2 Second Cycle
The second phase involved the rigour cycle where a comprehensive assessment of artefacts and
theories underwrote design science and presentation realm knowledge base. This encompassed
conducting a systematic review of already existing studies (SLR), published in English, on or
after 2010 that were based on the implementation of mobile health applications for follow-up
care after surgical treatment.

A MOBILE HEALTH SOLUTION TO IMPROVE SURGERY OUTCOME
4.1.3 Third Cycle – Design Cycle
The design cycle was the third phase, which was conducted with the primary objective of
enhancing the design and increased probability of technology acceptance. With the aim of
accomplishing objectives of this particular cycle, findings obtained from the previous parts of the
research were incorporated (Gorini et al., 2018). These comprised of a list of features, content,
and functions as deciphered from the focus groups, together with findings obtained from the
literature review.
An user-centered dispersed information design approach and participating action investigation
method for formulating the user-centered session activities. Two design sessions were
conducted, with each consecutive design sitting being established based on the evidence
collected from the preceding design session. The objective of the first session was to recognise
optimal features for enhancing surgical outcome needs of patients (Schnall, Rojas, Travers,
Brown III & Bakken, 2014). The patients discussed several topics and did not seek help from
existing mHealth prototypes or applications. The patients were asked to envisage the broad
categories, in the form of a distinct screen on mobile application. The themes obtained from
focus group were presented, followed by asking the participants the aspects that were related to
functionality of mHealth application. The second design session involved helping the
stakeholders sketch an interface for the anticipated mHealth application, This helped in
determining the preferences of the participants about mHealth application that can help improve
their surgical health outcomes.
5. System Architecture
This chapter shows the detail of system architecture for mHealth application. The first part of
this section will explain about the details of requirements, constraints, quality attributes, drivers
etc. For the use of system architecture the ADD process is being followed for which the template
suggested by (Clements et al., 2002) will be used. The usage of ADD template demonstrate
identifying the drivers for architecture, definition and proper documentation for the different
views for mHealth solution. Different views given in this chapter will demonstrate how it had
helped in the initial stages of creation of system architecture. ADD (Attribute Driven Design)
method make sure that the drivers and attribute define for the system will be matched at the end.
This process is followed to rectify that specification of prototype meets the project requirements.
5.1 Attribute Driven Design Methodology (ADD)
Write about the ADD process by giving some paper reference (one paragraph)