**2. Mobile apps for wound management**

To date, many eHealth technologies have been and are being developed; however, they are not well‐catalogued. Relative to wound care, MediSense, WoundRounds, and How2Trak offer web‐based and/or mobile interfaces for wound management. In 2013, WoundMAP Pump, Ulcercare, and Wound Mender entered the stage of wound care apps in various stages of development [20].

#### **2.1. SmartWoundCare system design**

condition monitoring (e.g. diabetes [1]; arthritis [2]), and using mobile devices to replace paper

This chapter overviews the development of a mHealth app called SmartWoundCare, designed to document and assess chronic wounds on Android and iOS smartphones and tablets. The chapter reviews the design of SmartWoundCare, the results of a user trial in a long‐term care facility in Winnipeg, Canada, and the subsequent development of algorithms to provide

The initial application area is pressure ulcers, which is also known as bedsores. However, the app is easily applicable to other wounds as well, such as venous leg ulcers, diabetic foot ulcers,

Decubitus ulcers are more commonly referred to as pressure ulcers or bedsores. They are injuries to the skin, or skin lesions which may extend to underlying tissues. Pressure ulcers typically occur over bony areas of the body as a result of skin pressure and friction when an individual sits or lies in one position for a long time. As such, pressure ulcers often occur in the elderly population and people who may be relatively immobile due to other illness or injury. Bedsores are preventable, but easily aggravated with heat and humidity at the wound site once they are present. Bedsores are also regrettably common, with the incidence of pressure ulcers reported to be as high has 30% in non‐acute care settings, with an average incidence rate

Pressure ulcers have numerous negative impacts on patients, both in immediate comfort and well‐being and in long‐term quality of life. When they develop after a patient is admitted to hospital for other conditions, they can lengthen the patient's overall stay and complicate their overall healing. There are also numerous quality of life impacts reported including the psycho‐ emotional impacts of chronic pain and the negative impacts of social isolation when patients' movements are significantly impaired. A pressure ulcer starts as a seemingly minor skin wound and obscures its significant risk. Pressure ulcers are noted to be the second leading iatrogenic cause of death. From an institutional perspective, pressure ulcers treatment is also

There are many standard patient treatments used to prevent pressure ulcers in patients who are known to be at risk. These include regularly turning patients, optimizing diet and nutrition, caring for skin before pressure ulcers occur, and using pressure mattresses, pillows, and other supports to relieve pressure [12]. However, studies have also identified that due to the chronic and often long‐term duration of pressure ulcers, significant information about the wound over time can become obscured when documentation is not standardized, when risk assessments are not integral to the regular wound assessment protocol, or when assessments are incomplete or lack detail. In part, standardized forms – designed to capture all possible types of pressure ulcers – often become too unwieldy for healthcare workers with heavy patient loads to use

records and share information between multiple healthcare providers [3].

automated analysis of wound images for wound size and colour.

and surgical wounds.

**1.1. Pressure ulcers as the application area**

116 Mobile Health Technologies - Theories and Applications

of 25% over all types of healthcare facilities [4, 5].

costly to the healthcare system [6–11].

effectively [13–15].

SmartWoundCare is similarly a mobile app for Android and iOS devices, developed in a computer engineering research lab at the University of Manitoba, Canada. SmartWoundCare was designed to replace the paper chart used in the Winnipeg Regional Health Authority (WRHA) for pressure ulcer management. The WRHA is a publicly funded system which includes both services and facilities. It serves over 700,000 people and supports referral services to another 500,000 people outside of its boundaries in hospitals, personal care homes, as well as a home care program. Over 28,000 people are employed by the WRHA in over 200 facilities.

As its core functionality, SmartWoundCare allows nurses and other healthcare providers to replicate the information that would be entered on a paper chart. A user can create a new patient record, view an existing patient's record, enter new wounds, and assess existing wounds using the Pressure Ulcer Scale for Healing (PUSH tool) [21], Braden Scale [22], and the Bates‐Jensen tool [23]. Several configurations were considered, in that one device could be associated with a given patient, and each nurse or other healthcare provider who cares for that patient would enter information on that patient's unique device. However, the model chosen was to associate the device with an individual nurse or other healthcare provider, who would use the device with all of their patients on that shift, and then transfer the device to the healthcare provider on the next shift.

As with all software, some general design objectives were established. These included keeping the user interface as simple as possible, using colours and other cues to focus the user's attention on important information, minimizing the steps needed to complete tasks, aligning the flow of information with emerging standard expectations from users ("look and feel"), and using the user's input to guide them to the applicable areas (and conversely, using the user's input to skip over areas not relevant for the particular patient or the particular wound). In light of the small screen size of a smartphone or tablet device, free‐form comments in data entry are discouraged by design. Entering data from pre‐set menu options is designed to reduce errors and to enable better comparisons between assessments, even when completed by different people. In a large‐scale rollout within a facility or a healthcare region, attention would also need to be given to battery life of the device, protocols for infection control, and the EMR as part of the legal medical record.

Beyond the duplication of paper‐based charting, SmartWoundCare was designed for several intended benefits:

	- **•** Alerts: When logging into SmartWoundCare, the user will see a list of alerts, including wounds that are due for re‐assessment and wounds that are deteriorating. The specific

parameters for the alerts (days between assessments, criteria used to determine deterioration) can be set by the user.

**•** Because users have individual preferences on how they best understand data, Smart‐ WoundCare presents wound histories in three formats: text, graph, and photographs. Text histories allow a user to scroll through a summary of the main wound parameters from one assessment to the next. Graph histories plot an overall wound score (e.g. generated from the PUSH tool) against time. Using the smartphone or tablet devices' built‐in cameras, users can also add wound photographs to the record, and scroll through the images in a chronological gallery for each individual wound.

By design, the benefit of SmartWoundCare is its potential as an EMR, either on a stand‐alone basis or integrated into a wider EMR system within a facility or region. As such, privacy of data is a non‐negotiable concern. In its current form, SmartWoundCare requires each user to set up a unique user ID and password to facilitate a secure login and the login is restricted to that device. When envisioning a fully networked application within a facility or wider region, SmartWoundCare access rights would be confirmed by a secure connection to a server storing all information. Connections would be via cellular or Wi‐Fi, relying on all standard Internet security protocols. In that case, all login IDs and passwords would be managed centrally by a server‐side application rather than a device‐based login. An additional benefit of a central server, which could be facility‐specific or shared between several facilities, is the potential for additional data analysis in a Big Data framework. For example, when large datasets are available centrally in standard formats, they can be examined for anomalies, trends, and correlations that ultimately feed into the body of knowledge for pressure ulcer treatment.

Selected screenshots of SmartWoundCare (iOS version) are shown in **Figures 1**–**5**.


**Figure 1.** Patient list upon login (iOS).

(WRHA) for pressure ulcer management. The WRHA is a publicly funded system which includes both services and facilities. It serves over 700,000 people and supports referral services to another 500,000 people outside of its boundaries in hospitals, personal care homes, as well as a home care program. Over 28,000 people are employed by the WRHA in over 200 facilities. As its core functionality, SmartWoundCare allows nurses and other healthcare providers to replicate the information that would be entered on a paper chart. A user can create a new patient record, view an existing patient's record, enter new wounds, and assess existing wounds using the Pressure Ulcer Scale for Healing (PUSH tool) [21], Braden Scale [22], and the Bates‐Jensen tool [23]. Several configurations were considered, in that one device could be associated with a given patient, and each nurse or other healthcare provider who cares for that patient would enter information on that patient's unique device. However, the model chosen was to associate the device with an individual nurse or other healthcare provider, who would use the device with all of their patients on that shift, and then transfer the device to the

As with all software, some general design objectives were established. These included keeping the user interface as simple as possible, using colours and other cues to focus the user's attention on important information, minimizing the steps needed to complete tasks, aligning the flow of information with emerging standard expectations from users ("look and feel"), and using the user's input to guide them to the applicable areas (and conversely, using the user's input to skip over areas not relevant for the particular patient or the particular wound). In light of the small screen size of a smartphone or tablet device, free‐form comments in data entry are discouraged by design. Entering data from pre‐set menu options is designed to reduce errors and to enable better comparisons between assessments, even when completed by different people. In a large‐scale rollout within a facility or a healthcare region, attention would also need to be given to battery life of the device, protocols for infection control, and the EMR as

Beyond the duplication of paper‐based charting, SmartWoundCare was designed for several

**1.** *Data sharing between multiple healthcare providers:*the potential to seek consultation between multiple healthcare providers, including wound clinicians, physicians, allied health professionals (e.g. occupational therapy), and other specialists as needed. This potential reduces the need to transport the patient between facilities, saving the patient considerable discomfort and stress, and saving cost in the overall wound treatment. Just as significantly, the timeliness of interventions and changes in the direction of care can be improved. Information sharing (i.e. a telehealth framework) can occur within a given facility, within the same community, or between major centres and remote communities where remote communities do not have specialized health services. In Canada, with a small population

**•** Alerts: When logging into SmartWoundCare, the user will see a list of alerts, including wounds that are due for re‐assessment and wounds that are deteriorating. The specific

living in a large geographical area, this is of particular relevance.

healthcare provider on the next shift.

118 Mobile Health Technologies - Theories and Applications

part of the legal medical record.

**2.** *Data organization and interpretation:*

intended benefits:

**Figure 2.** Wound locations and status (iOS).



**Figure 3.** Assessment data entry screen (iOS).


**Figure 4.** Single wound summary in list and graph format.

**Figure 2.** Wound locations and status (iOS).

120 Mobile Health Technologies - Theories and Applications

**Figure 3.** Assessment data entry screen (iOS).

**Figure 5.** Chronological wound image gallery (iOS).

#### **2.2. User trial – SmartWoundCare on Android**

SmartWoundCare in a prototype Android version was subject to a small‐scale user trial. Voluntary participants were nurses in a personal care home in Winnipeg, Canada, and they used the mobile app with their patients. The objective was to obtain nurses' impressions on the app's design, its functionality, and how it performed as a part of their daily clinical experiences in treating patients' wounds. Investigating patients' experiences and patients' health outcomes with the app was beyond the scope of the user trial.

The user trial took place in Riverview Health Centre (RHC) in Winnipeg, Canada. Riverview Health Centre provides rehabilitation, palliative, and long‐term care. The facilities consist of hospital and personal care home units with almost 400 beds overall, as well as community programs and outpatient services. Riverview specializes in geriatric rehabilitation, brain injury, and stroke rehabilitation, palliative care, and complex long‐term care.

All nurses at RHC were invited to participate in the user trial. Approximately 12 nurses expressed interest, and after timelines and the scope of the nurses' participation were estab‐ lished, eight nurses (three men and five women) remained willing to participate. Their participation was entirely voluntary and was not financially compensated. The nurses all had regular duties caring for patients with pressure ulcers or other wounds, and they were full‐ time employees of RHC. The participants had a range of experience, ranging from less than 10 years nursing experience to over 20 years in a personal care home settings specifically, and ranged from 30 to 60 years in age.

Participants were also asked to judge themselves on their comfort with technology. Four participants judged themselves to be "very tech‐savvy" while the other four judged themselves to be "comfortable with common features of phones and tablets". Participants' confidence with smartphone/tablet interfaces and with touch screens was self‐assessed at 4.57/5.00 (range=4.0– 5.0; SD=0.53) and 4.71/5.00 (range=4.0–5.0; SD=0.49), respectively.

To preserve anonymity, the characteristics of participants were intentionally not cross‐ referenced with one another.

The nurses received a new Nexus 4 smartphone (four nurses) or a new Nexus 7 tablet (four nurses) with SmartWoundCare loaded and a training manual for the wound care app. They were given a 90‐minute training and demonstration of the app. After this training session, the nurses took the mobile devices home and familiarized themselves with SmartWoundCare further before beginning the user trial.

The nurses used SmartWoundCare (Android version) during their nursing shifts. Smart‐ WoundCare was only used for patients who had pressure ulcers and who had consented to participate in the user trial. Given the patient population, patient consent was provided either directly or through a designate such as a family member. Participants used SmartWoundCare for at least seven shifts. At times, vacation schedules interrupted data collection over consec‐ utive shifts. In most cases, participants were able to use SmartWoundCare for a longer period (more than seven shifts), enhancing the depth and scope of their feedback. All data collection was completed within two‐and‐a‐half months of the start of the user trial.

Using SmartWoundCare in nursing practice was an additional workload over the participants' regular nursing duties, because it did not replace but rather it duplicated the paper chart that forms the patient's official medical record.

Once the nurses had been using SmartWoundCare for approximately 3 weeks, the nurses completed an anonymous on‐line survey. This data collection instrument was timed to gain participants' immediate opinions and experiences of SmartWoundCare's functionality and design. The survey was administered via Surveymonkey and included open‐ and closed‐ ended questions on SmartWoundCare features, content, look and feel, usability, navigation between screens, assessment of its intended advantages over paper‐based charting, as well as overall qualitative impressions of how well SmartWoundCare fits into nursing practice. An important part of the survey was for participants to assess the commensurability of the wound data entered into SmartWoundCare relative to data entered on paper‐based forms (scope and format), as this forms the basis of the integrity of the app.

Six weeks later and after an initial analysis of the survey results, a focus group session was held with the participants and the researchers. The focus group was used to probe into the survey results. In that way, the findings of the user trial include both the immediate and the long‐term impressions of the app's features and intended benefits, both of which are valuable to assess functionality. The research design complied with qualitative research norms, in which data and interpretations of data are validated by using triangulation and member checks.

The findings were then used to identify the key design issues for ongoing development of both the Android and a subsequent iOS version of SmartWoundCare.

#### *2.2.1. Findings*

used the mobile app with their patients. The objective was to obtain nurses' impressions on the app's design, its functionality, and how it performed as a part of their daily clinical experiences in treating patients' wounds. Investigating patients' experiences and patients'

The user trial took place in Riverview Health Centre (RHC) in Winnipeg, Canada. Riverview Health Centre provides rehabilitation, palliative, and long‐term care. The facilities consist of hospital and personal care home units with almost 400 beds overall, as well as community programs and outpatient services. Riverview specializes in geriatric rehabilitation, brain

All nurses at RHC were invited to participate in the user trial. Approximately 12 nurses expressed interest, and after timelines and the scope of the nurses' participation were estab‐ lished, eight nurses (three men and five women) remained willing to participate. Their participation was entirely voluntary and was not financially compensated. The nurses all had regular duties caring for patients with pressure ulcers or other wounds, and they were full‐ time employees of RHC. The participants had a range of experience, ranging from less than 10 years nursing experience to over 20 years in a personal care home settings specifically, and

Participants were also asked to judge themselves on their comfort with technology. Four participants judged themselves to be "very tech‐savvy" while the other four judged themselves to be "comfortable with common features of phones and tablets". Participants' confidence with smartphone/tablet interfaces and with touch screens was self‐assessed at 4.57/5.00 (range=4.0–

To preserve anonymity, the characteristics of participants were intentionally not cross‐

The nurses received a new Nexus 4 smartphone (four nurses) or a new Nexus 7 tablet (four nurses) with SmartWoundCare loaded and a training manual for the wound care app. They were given a 90‐minute training and demonstration of the app. After this training session, the nurses took the mobile devices home and familiarized themselves with SmartWoundCare

The nurses used SmartWoundCare (Android version) during their nursing shifts. Smart‐ WoundCare was only used for patients who had pressure ulcers and who had consented to participate in the user trial. Given the patient population, patient consent was provided either directly or through a designate such as a family member. Participants used SmartWoundCare for at least seven shifts. At times, vacation schedules interrupted data collection over consec‐ utive shifts. In most cases, participants were able to use SmartWoundCare for a longer period (more than seven shifts), enhancing the depth and scope of their feedback. All data collection

Using SmartWoundCare in nursing practice was an additional workload over the participants' regular nursing duties, because it did not replace but rather it duplicated the paper chart that

was completed within two‐and‐a‐half months of the start of the user trial.

health outcomes with the app was beyond the scope of the user trial.

5.0; SD=0.53) and 4.71/5.00 (range=4.0–5.0; SD=0.49), respectively.

ranged from 30 to 60 years in age.

122 Mobile Health Technologies - Theories and Applications

referenced with one another.

further before beginning the user trial.

forms the patient's official medical record.

injury, and stroke rehabilitation, palliative care, and complex long‐term care.

The objectives of the survey and the focus group were to obtain feedback on the design and functionality of the app and to investigate the nurses' experiences in using the app. The main numerical findings discussed in this section are summarized in **Table 1**.



**Table 1.** Numerical findings of a user trial on the android version of SmartWoundCare.

In general, findings over the user trial indicated that SmartWoundCare was easily learned and used in the participants' nursing duties, and that it was well‐matched to the PUSH and Braden Scale tools. The benefit of the smartphone was that it was easily carried in the pocket of a uniform; however, a drawback was that the text size was difficult to read. On the other hand, tablet devices were more difficult to carry and store but had the advantage of readability.

The user trial used an Android version of the SmartWoundCare prototype, and as a custom‐ built software application, it did not always conform to users' expectations of the look and feel of software and how one navigates through software. Areas that caused some initial confusion included cross‐navigation between different parts of the app, and confirming saves and deletions of data. Subsequent development on the Android version and later the iOS version of SmartWoundCare was a marked shift to the expected "look and feel" of mobile apps, as opposed to a custom interface.

As an important part of validating the robustness of SmartWoundCare for its intended application, nurses confirmed a strong commensurability in content and data entry between SmartWoundCare and paper versions of the PUSH and Braden Scale tools. Participants reported that the intuitive guidance accurately reflected the fields necessary for a given patient and their wound condition.

However, SmartWoundCare was developed to do more than duplicate a paper chart, and the user trial also investigated the nurses' perceptions of the added intelligence in the app. Although the user trial took place over a relatively short period of time, the nurses indicated that they appreciated and recognized the potential of the wound histories. The text histories were met with slightly better perception than the graph histories (**Table 1**), although not to an extent of statistical significance (*p* = 0.05).

A suggestion for additional features in SmartWoundCare is centred on developing a glossary of specialized terms. This was identified as a useful feature even for experienced wound care nurses.

Another feature of SmartWoundCare over and above paper charts are the alerts that display to the user upon login. These alerts received mixed reviews by the users, with the primary complaint being that the alerts needed a more prominent place within the app rather than their location within a menu with five other menu options. In the subsequent iOS version, alerts follow a more standard format for iOS mobile apps.

#### *2.2.2. Wound images as the key benefit*

**Survey parameter** *All parameters are ranked on a Likert‐type scale*

Text history: this presentation is helpful in understanding

124 Mobile Health Technologies - Theories and Applications

Text history: this presentation adds to my understanding of

Graph history: this presentation is helpful in understanding wound

Graph history: this presentation adds to my understanding of the

history of the patient's/resident's wounds and wound care, compared to not

**Table 1.** Numerical findings of a user trial on the android version of SmartWoundCare.

the history of the patient's/resident's wounds and wound care, compared to not

Text history: this presentation is easy to understand 4.50 4.0–5.0 0.55

Graph history: this presentation is easy to understand 3.67 2.0–5.0 1.03

In general, findings over the user trial indicated that SmartWoundCare was easily learned and used in the participants' nursing duties, and that it was well‐matched to the PUSH and Braden Scale tools. The benefit of the smartphone was that it was easily carried in the pocket of a uniform; however, a drawback was that the text size was difficult to read. On the other hand, tablet devices were more difficult to carry and store but had the advantage of readability.

The user trial used an Android version of the SmartWoundCare prototype, and as a custom‐ built software application, it did not always conform to users' expectations of the look and feel of software and how one navigates through software. Areas that caused some initial confusion included cross‐navigation between different parts of the app, and confirming saves and deletions of data. Subsequent development on the Android version and later the iOS version of SmartWoundCare was a marked shift to the expected "look and feel" of mobile apps, as

As an important part of validating the robustness of SmartWoundCare for its intended application, nurses confirmed a strong commensurability in content and data entry between SmartWoundCare and paper versions of the PUSH and Braden Scale tools. Participants reported that the intuitive guidance accurately reflected the fields necessary for a given patient

However, SmartWoundCare was developed to do more than duplicate a paper chart, and the user trial also investigated the nurses' perceptions of the added intelligence in the app. Although the user trial took place over a relatively short period of time, the nurses indicated that they appreciated and recognized the potential of the wound histories. The text histories were met with slightly better perception than the graph histories (**Table 1**), although not to an

**Mean score**  **Range Standard**

4.50 4.0–5.0 0.55

4.50 4.0–5.0 0.55

3.83 3.0–5.0 0.75

3.67 2.0–5.0 1.03

**deviation**

*from 1.0 (low) to 5.0 (high)*

having this text‐based history available

having this graph‐based history available

opposed to a custom interface.

and their wound condition.

extent of statistical significance (*p* = 0.05).

wound progression

progression

The strongest finding of the user trial was the value and benefit of wound images (photo‐ graphs) in SmartWoundCare. Through both the survey and the focus group, nurses identified numerous benefits for the nurse at the bedside, for the patient and their family, and for the physician and allied health professionals. Nurses appreciated the ability to photograph the wound and the associated ability to show the wounds to the patient on the device.

There are several benefits of wound images. At times, wounds are located on body parts that a patient cannot directly observe, such as buttocks, heels, or the soles of feet. The wound photo allowed them to see the wound and get a sense of its size and severity. Often, this led to a better understanding for patients and their families regarding the importance of wound hygiene and treatments.

Another reported benefit is the time saved with each wound assessment, which could add up to significant time during a shift. It can take up to 20 minutes to undress, treat, and re‐dress a wound. If another healthcare provider (e.g. physician, physical therapist, wound clinician) asks to see the wound, the dressings need to be removed and the wound redressed after consultation. As a first option, the nurses could show the wound photograph to others in the healthcare team, and then a judgement was made as to whether the wound needed to be undressed or whether the photograph met the needed information within the healthcare team. A further advantage is when the healthcare team is consulting on a wound, the additional information that the wound photograph provided in comparison to solely having a verbal or written description of the wound.

Overall, the ability to add a wound history from photographs to the patient record was recognized for its potential to reduce the number of dressing changes and thus promote healing. The finding also supported SmartWoundCare's potential impact in telehealth.

The findings of the user trial also corresponded to other research findings related to the value of wound photograph, which is contingent on the quality of camera equipment, photomi‐ crography (the art of photographing small objects in large scale), the orientation of the camera lens relative to the wound, flash settings relative to consistent lighting, and duplicate photo‐ graphs [17]. Two separate studies examined measurements of wounds taken in traditional ways compared to measurements taken from photographs. In those studies, the wounds were venous leg ulcers and diabetic foot ulcers, respectively [24, 25]. The conventional technique to measure wounds is to lay a transparent film over the wound, to trace the wound margin on the film, and then to lay the film over graph paper and count the number of squares. When comparing this technique to measurements derived from digital images, the latter method resulted in improved accuracy, lower inter‐observer variations, and improved ease of use. Because the film physically touches the patient's wound and can cause irritation, the digital photograph also had the advantage of being a non‐contact method. Another study explored the potential of telehealth, specifically videoconferencing, compared to in‐person assessment for pressure ulcer assessment. Both procedures led to very similar assessment of the stage of the wound. However, the telehealth approach led to an overestimate of wound size and volume when compared to in‐person assessment [26].
