**1. Introduction and background**

Increasingly, mobile consumer electronic devices are able to make meaningful applications in mobile health or mHealth, defined as the delivery of healthcare and healthcare support through mobile devices. For example, there are apps that allow users to track diet and fitness, health

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condition monitoring (e.g. diabetes [1]; arthritis [2]), and using mobile devices to replace paper records and share information between multiple healthcare providers [3].

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 automated analysis of wound images for wound size and colour.

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, and surgical wounds.

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

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

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 costly to the healthcare system [6–11].

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 effectively [13–15].

In many other areas of healthcare delivery, electronic health (eHealth) is being examined for its promise to increase the overall efficiency of a healthcare system and to improve patient outcomes. As eHealth grows in scope and maturity, its potential includes improvements and enhancements to patient safety, health outcomes, financial efficiencies, and communication between multiple healthcare providers.

When considering the health burden of pressure ulcers, the area of electronic medical records (EMR) within eHealth is of particular interest. In the research literature, EMRs are reported to have positive impacts on the quality of care and to reduce the reliance or use of care [16].

Several studies examined the impact of EMRs relative to chronic wounds specifically. In one, an EMR system simplified wound evaluation and treatment. In this case, the impact is highly dependent on a standardized protocol for taking pictures of the wound [17]. In another study, the financial benefits of home telehealth in treating bedsores were examined. The findings indicated low‐cost technologies did lead to cost savings, whereas high‐cost technologies did not have that benefit. The study also determined that home telehealth could decrease the prevalence of advanced stage pressure ulcers [18]. However, not all EMR systems for wound care are effective. Other research identified that common problems with wound EMRs included redundancy or the opposite situation where the platform was not flexible or detailed enough to consider all potential types of wounds. Other issues included the lack of standard vocabulary, and custom‐built EMRs which were not transferable to include or integrate with other medical records or across facilities [19].

While EMRs and other forms of electronic documentation are not a panacea, there is emerging evidence that when properly designed, they can potentially lead to better communication, better patient information and wound charting, and ultimately improved patient care and health outcomes. The work outlined in this chapter follows this anticipation that better compliance in documenting wound care, higher consistency in how a wound is documented, and the added intelligence provided by the app relative to alerts and information presentation can influence health outcomes.
