Patient HubmdashA Mobile Based Solution For Elderly ACSRecovery Patients

Hoang Trung Hieu NgoDepartment of Electrical and

Computer EngineeringThe University of Aucklandhngo423aucklanduniacnz

ABSTRACTCardiovascular disease is the primary cause of death in theUnited State with over 34 of all death Cardiac rehabilita-tion (CR) program is proven to improve the patientrsquos lifespanand lifestyle However the traditional CR program has pooruptake due to various of reasons including inconvenience andaccessibility

Patient Hub is the mobile solution for elderly patients whoare recovering from an ACS events after discharged from thehospital The main target demographic is elderly patients whoare over 60 year old Patient Hub allows patients to track theirmedication intakes Patient Hub also increases the interactiv-ity between the doctor and patient Furthermore Patient Hubevaluates patientrsquos mental health by a quiz framework that pa-tients answer daily In addition patients have the control ofchoosing their own exercise We have also developed a webapplication which acts as a black box for the existing systemthat are currently used in the hospital The web application isonly used by doctor At the end of each week an email sum-marises the patientrsquos progress is sent out to the doctor whichdecreases the workload of the doctor

Author KeywordsAndroid Patient Hub HCI elderly patient mobile basedweb-application ACS cardiac rehabilitation mental healthtracking patient health record

INTRODUCTIONAccording to [2] 826 million Americans are affected by car-diovascular disease It is still the primary cause of death inthe United States (34 of all deaths) despite the death rateof cardiovascular disease has dropped [3 2] Good recover-ing plans after an acute coronary syndrome (ACS) event candetermine the lifespan of the patient as well as reduce thehospital readmission rate [1] There are many cardiac reha-bilitation (CR) program clinics around the world that supportthe patients with the recovery plans

However such traditional clinics are having poor uptake dueto various of reasons One of the key factor is the inconve-nience of such clinics to the elderly patient Another majorfactor contributes to the poor uptake is accessibility Gener-ally elderly patients who suffer from an ACS incident do not(or could not) have access to transportation such as car pub-

lic transport etc Hence it would be a difficult task for thepatient to participate to CR clinic

This paper proposes a mobile solution to assist elderly pa-tients who are recovering from an ACS event Our goals are toimprove patient adherence to their recovery plan and enablemore frequent communication between patient and doctor re-gard the patientrsquos recovery process During the developmentof this project we analysed the problem and came up withthree questions that we needed to answer

bull The first question is rdquoIs it possible to develop a mobileapplication to assist patientsrsquo adherence to recovery plansfollowing an ACS eventrdquo

bull Secondly the next question is rdquoHow can we effectivelymonitor patientsrsquo physical and mental health and commu-nication this with their healthcare professionalrdquo

bull Finally our HCI research question rdquoCan the user interfaceof the mobile application be used effectively by the elderlyand people of all levels of educationrdquo

The aim of our project is to answer the question mentionedabove Thus reaching our goals in the process

SURROUNDING LITERATURE

Acute Coronary Syndrome OverviewCoronary artery disease is when atherosclerotic plaque addsup inside the coronary arteries and limits the blood flow(and hence the delivery of oxygen) to the heart [3] Coro-nary artery disease can lead to acute coronary syndrome[3] Acute coronary syndrome (ACS) contains a various ofthe atherosclerotic process such as unstable angina non-ST-segment elevation myocardial infarction (MI) (NSTEMI)and ST-segment elevation MI (STEMI) [2]

Patient PortalPatient health records are health records that can be accessedvia a website It is created to make patientrsquos health informa-tion available to the patients in a safe and secure way Patient-doctor interactivity is also the main target of the patient por-tal However patients must go through a lot of problems toobtain the access Furthermore they are currently focusingmainly on sharing information rather than tracking the phys-ical and mental health of the patients In addition currentlyweb-based applications do not have the ability to create noti-fication to remind the users

Web And Application UsabilityFor this project the demographic we focused on was the ageof the patient rather than the culture and education We re-duced the scope of our project due to the time constraint andlack of man power The layout techniques we used were fo-cusing on element sizing element location and informationlayout For element sizing larger elements such as iconsimages text are recommended when dealing with older peo-ple In addition different elements should be clearly sepa-rated When designing an application the flow of the screencan be confusing to elder users Hence it is best practice tokeep the sequence of screens to the minimal Information lay-out is also crucial for elderly consumers If two or more com-ponents are closer together they tend to be seen as togetherThus it can be confusing when two different components arenot related but are close to each other

RELATED WORKDuring our research we have come across the Care Assess-ment Platform (CAP) The CAP was developed to addressthe problem of not having enough patients participate in CRprograms CAP is an integrated home-based CR model thatfeaturing information and communication technology (ICT)which includes internet and a mobile phone All the essentialcomponents of traditional CR such as education exercisetraining behaviour modification strategies physical activityand psychological counseling are provided through CAP [5]

IMPLEMENTATION PROCESS

ScopeThe scope of our project is aiming for elderly patients whoare over 60 year old and recently discharge from the hospitalafter an ACS incident and are in recovery

PersonasWe generated two personas to be the main users of our prod-ucts

PatientLisa Johnson is a 70 year old woman who is currently enjoy-ing retirement life She lives alone as her husband has passedaway however her two sons visit her regularly to check upon her health They do this because Lisa has recently been avictim of an ACS incident She was treated in hospital andwas eventually able to leave along with a long detailed listof medication and recovery advice Lisa also suffers fromAlzheimerrsquos disease which causes her to often forget certainevents She is the main target user for our mobile application

DoctorOur second persona is Jacob William Jacob is a 53 year oldgeneral practitioner He works on average 60 hours everyweek He has two children who have recently moved outgiving him more time to spend with his wife and with hishobbies Jacob enjoys playing golf and reading fiction nov-els and due to his long weekly hours does not enjoy havingthese interrupted by work requirements He has a fairly goodgrasp on working with technology as his work requires himto use computers and email for communication As Jacobdoes not have a lot of time on his hands and deals with up

to 100 patients every week he expects the tools he uses to bestraightforward and fast to use He cares a lot about his workand forms personal bonds with his patients to ensure that hecan provide them with the best care possible He is our maintarget consumer for the web application

Low Fi Prototype

Figure 1 Final iteration low fi prototype

Lo-fi prototype of the mobile application was developed inthe early stage of this project After a few iterations and re-finements with the help of the personas mentioned above thefinal lo-fi prototypes were produced as show in Figure 1 Asshown lo-fi prototype is sketches of how the screens shouldlook like and their interaction However it does not necessarylook or interact like the end product [4]

On the other hand lo-fi prototype has a couple disadvan-tages Firstly it does not represent font text or the color ofthe screen Secondly lo-fi prototype does not show the sizeof the image or button However it is important to the de-velopment as it outlines the layout of the application whichhelps the developers organise their ideas and thoughts

Web-applicationWe developed a web application to be used by doctors to storepatientrsquos recovery information It acts as a black box thatmdashin

(a) Login screen (b) Patient information screen

(c) Add dosage screen (d) Treatment screen

Figure 2 Web application prototype

real worldmdashwould be an existing system that is already be-ing used by the doctors The web-application allows doctorto be able to sign up login createview patients createadddosages for patients and treatments and download QR codeof the patient QR code is one of our solutions to solve theresearch question It is a way for the patient to login without auser-name and password which overcome the problem of el-derly patients tend to forget login information Each QR codeis the encoded token authentication which stores on the serverside Due to the web-application acts as a black box we haveomitted the security issues (eg store the token authenticationas plain text and the token does not have an expire time)

Furthermore to answer the second question proposed abovewe have developed a framework to gather patientrsquos mentalstate each day The questionnaire is used to collect the quanti-tative data from the patients Each answer has different scoreassigned When the user answers a question the answer willbe submit to the web-application At the end of the weekan email will be sent to the doctor It comprehensively sum-marises the progress of the patient and their mental stage to-ward the treatment The doctor will be able to see how manymedications they misses the reason why they did not takethe medications total exercise in the week and their averagescore of their mental health from the questionnaire If theaverage score of a patient below a certain point a recommen-dation is sent out to the doctor depending on the score range

As mentioned above this web application acts as a black boxfor an existing system Hence we did not go to a great dealto refine the HCI element of the website

Mobile ApplicationFor mobile application a much larger HCI consideration hadbeen accounted for during the development of the applicationThe login screen (Figure 3a) prompts the users to select startto begin Pressing start button will lead the patients to QRcode scanning application which the patients can then scantheir QR code to login The main screen (Figure 3b) showstodayrsquos tasks Tasks include exercise take medication and dothe quiz Medication tasks are separated into morning af-

(a) Login screen (b) Dosage screen

(c) Medication check screen (d) Medication feedbackscreen

Figure 3 Mobile application prototype

ternoon and evening panel and depending on the time of thepatientrsquos dosage the panel will appear accordingly When pa-tient click on the medication panel a list of prescribed med-ications appears to remind the patient which medication totake as shown in Figure 3c Patients can go through and man-ually click the medication to taken as they are taking the med-ication or click rdquoCheck Allrdquo to check all the medication astaken If the patient misses one or more medications a feed-back screen (Figure 3d) appears to prompt the user to answerwhy they did not take the medication(s)

When the patient clicks the exercise panel the exercise screenwill appear as shown in Figure 4a It prompts the user to enterthe exercise they did and the duration of the exercise Whenthe patient selects the quiz panel quiz screen is shown (Figure4b and 4c) This is the mental health framework that allows

(a) Exercise screen (b) Mental feedback screen 1

(c) Mental feedback screen 2 (d) All done screen

Figure 4 Mobile application prototype cont

the doctor to know the mental state of the patient with thecurrent treatment On top of the screen is a green bar whichindicates the progress of the quiz as the patients go throughAfter finishing all the tasks Figure 4d shows the finish screenwhere all panels are checked off as done This indicates tothe patients that they have done all the tasks for the day Ifthe users are unsure they can re-open the application on thesame day The done screen will stay there until the next daywhen they have more tasks It will be the All the informationentered by the patients are stored in the server

To accommodate with elderly people navigation difficulty weforced the mobile application to only have one level naviga-tion whenever we can (except for quiz screen) After done atask or series of tasks (eg answering questionnaire) the useris returned into the main screen (Figure 3b) Furthermore

Patient Hub1 addresses the HCI challenge by using big iconsimages and buttons for elderly patients With larger size oficons images and buttons elder patients make less mistakeswhen clicking Larger text is also part of our design to helpthe older patients easily read

Moreover elements such as panels radio buttons are locatedfar apart which indicate that they are not grouped togetherThis helps elderly patients to lessen error prone when select-ing a panel Additionally Patient Hub provides feedbacks tothe user whenever necessary For instance when the patientselect other on the questionnaire the answer box will thenhave hint for the user to answer Another example is the fin-ish screen that have the green tick over the panel the titlechange color to grey and the panelrsquos functionality is disablewhen the patient finishes a respective task

Last but not least related information is grouped togetherwith a line that acts as separator (shown in Figure 3c) Inthis example rdquo1 tablet(s)rdquo is for rdquoAcebutololrdquo Therefore itis arranged closer together with a line separator to ensure thatthe elder patients do not misunderstand or mislead about theinformation

Architecture View

Figure 5 Patient Hubrsquos architecture view

Patient Hub uses the classic client-server architecture An-droid mobile application acts as the client which sends andreceives HTTP REST requests and responses in JSON respec-tively The server is deployed in Heroku which was developedin Ruby on Rails Ruby on Rails uses the classic Model-View-Controller (MVC) architecture to separate the applica-tion into three different components Model is the centralcomponent which manages the data rules and logic of webapplication View populates the forms tables and text to theuser Controller accepts inputs and translates into commandswhich control models and views

For the user interface we used HAML SASS JQueryJavascript to create forms and tables We also used externallibraries such as DataTables2 (tables) SimpleForm3 (forms)Devise4 (authentication and authorisation) etc to design de-velop and manage the web application We also implementeda few APIs for the client to receive and send the necessary1httpspatienthubherokuappcom2httpswwwdatatablesnet3httpsgithubcomplataformatecsimple form4httpsgithubcomplataformatec

information which are stored on the server For databasewe used PostgreSQL with ActiveRecord wrapper to eliminateimplementing SQL queries

Database Schema

Figure 6 Patient Hubrsquos database schema view

We designed and implemented to store the data that are sentfrom the clients (feedbacks) as well as from the web applica-tion (dosages patients) These data are utilised through theweb application as well as the mobile application As shownin Figure 6 we implemented six tables Each doctor managestheir patients Each patient has many dosages which can ei-ther be exercise or medication treatment Dosages can be indifferent day by specify the frequency field Each dosage canhave multiple feedbacks on different day if the patient did nottake a medication To track the mental state of the patientQuizFeedback stores all the information that patientsrsquo answerto a particular question of their mental health

EVALUATIONDue to time constraint ethic approval and the nature ofour software we cannot do a proper usability study for ourapplication However we worked closely with CatherineCallaghermdasha head nurse in Waikato Hospitalmdashand MarkBurrowsmdashEchocardiographer at Waikato Hospitalmdashduringthe project We gave them the video of the mobile applica-tion and asked for their feedbacks

Mark Burrowsrsquos feedbacks

bull The questionnaire is a good non-confrontational way ofgetting feedbacks from the patients Symptomatic feed-back is the priority and this could be developed nicely by anurse specialist

bull Compliance is always a problem with or without an appli-cation so it cannot really be addressed

bull Patient Hub is an excellent tool for the heart failure ACSnurse and rehab nurse as they can engage with the patient

post event Therefore he suggests that nurses should beaimed as a stakeholder of the application

bull The QR code idea is brilliant in keeping the medical doctorin control and responsible for hisher patient

Unfortunately we have not heard back from CatherineCallagher

FUTURE WORKOne of our key future work is to implement a push notificationservice to enable medication notification on mobile phonePush notification acts as a reminder to the patients wheneverthey forget to do a task Moreover to develop a valid feelingquestionnaire framework the next possible future work is towork with researchers in relevant fields Furthermore addingscheduling appointment feature is also one of the possible fu-ture work

Additionally Patient Hub can also integrate built-in phonesensors as well as bluetooth scales for activity tracking andweight entering Lat but not least Patient Hub can shiftthe focus of only Android mobile application to provide toa range of mobile platform such as Iphone Windows Phoneetc to attract a larger range of patients

CONCLUSIONHeart attack is the leading cause of death world wide CRprogram is proven to extend patientrsquos lifespans and lifestyleHowever due to inconveniences and accessibility of the CRprogram it has poor uptake Patient Hub is a mobile appli-cation that is designed for elderly ACS recovery patients Itincreases the interactivity between patients and doctors Themobile application also assists the users to take correct medi-cation at the right time to do exercise and to track their mentalhealth toward the treatment

The web application was created to be the black box of theexiting system that currently uses in the hospital It has pa-tientrsquos information treatments dosages and patientrsquos feed-backs about the treatments and their mental health Weeklyemail is sent to the doctor summarising the patientrsquos recoveryprogress as well as the state of their mental health so that thedoctor can act accordingly

ACKNOWLEDGMENTSWe would like to thank Catherine Callagher Adrian JamesAmandus and Mark Burrows for the guidance and feedbacksthey gave us throughout the project We also would like tothank Dr Jim Warren for his inputs and guidance during thedevelopment of the application

REFERENCES1 Lan C Lai J-S and Chen S-Y Exercise training for

patients after coronary artery bypass grafting surgeryhttpcdnintechweborgpdfs29327pdf

2 Leeper B Cyr A M Lambert C and Martin KAcute coronary syndrome Critical care nursing clinics ofNorth America 23 4 (2011) 547ndash557httpwww-ncbi-nlm-nih-govezproxyaucklandacnzpubmed22118113

Web And Application UsabilityFor this project the demographic we focused on was the ageof the patient rather than the culture and education We re-duced the scope of our project due to the time constraint andlack of man power The layout techniques we used were fo-cusing on element sizing element location and informationlayout For element sizing larger elements such as iconsimages text are recommended when dealing with older peo-ple In addition different elements should be clearly sepa-rated When designing an application the flow of the screencan be confusing to elder users Hence it is best practice tokeep the sequence of screens to the minimal Information lay-out is also crucial for elderly consumers If two or more com-ponents are closer together they tend to be seen as togetherThus it can be confusing when two different components arenot related but are close to each other

RELATED WORKDuring our research we have come across the Care Assess-ment Platform (CAP) The CAP was developed to addressthe problem of not having enough patients participate in CRprograms CAP is an integrated home-based CR model thatfeaturing information and communication technology (ICT)which includes internet and a mobile phone All the essentialcomponents of traditional CR such as education exercisetraining behaviour modification strategies physical activityand psychological counseling are provided through CAP [5]

IMPLEMENTATION PROCESS

ScopeThe scope of our project is aiming for elderly patients whoare over 60 year old and recently discharge from the hospitalafter an ACS incident and are in recovery

PersonasWe generated two personas to be the main users of our prod-ucts

PatientLisa Johnson is a 70 year old woman who is currently enjoy-ing retirement life She lives alone as her husband has passedaway however her two sons visit her regularly to check upon her health They do this because Lisa has recently been avictim of an ACS incident She was treated in hospital andwas eventually able to leave along with a long detailed listof medication and recovery advice Lisa also suffers fromAlzheimerrsquos disease which causes her to often forget certainevents She is the main target user for our mobile application

DoctorOur second persona is Jacob William Jacob is a 53 year oldgeneral practitioner He works on average 60 hours everyweek He has two children who have recently moved outgiving him more time to spend with his wife and with hishobbies Jacob enjoys playing golf and reading fiction nov-els and due to his long weekly hours does not enjoy havingthese interrupted by work requirements He has a fairly goodgrasp on working with technology as his work requires himto use computers and email for communication As Jacobdoes not have a lot of time on his hands and deals with up

to 100 patients every week he expects the tools he uses to bestraightforward and fast to use He cares a lot about his workand forms personal bonds with his patients to ensure that hecan provide them with the best care possible He is our maintarget consumer for the web application

Low Fi Prototype

Figure 1 Final iteration low fi prototype

Lo-fi prototype of the mobile application was developed inthe early stage of this project After a few iterations and re-finements with the help of the personas mentioned above thefinal lo-fi prototypes were produced as show in Figure 1 Asshown lo-fi prototype is sketches of how the screens shouldlook like and their interaction However it does not necessarylook or interact like the end product [4]

On the other hand lo-fi prototype has a couple disadvan-tages Firstly it does not represent font text or the color ofthe screen Secondly lo-fi prototype does not show the sizeof the image or button However it is important to the de-velopment as it outlines the layout of the application whichhelps the developers organise their ideas and thoughts

Web-applicationWe developed a web application to be used by doctors to storepatientrsquos recovery information It acts as a black box thatmdashin

(a) Login screen (b) Patient information screen

(c) Add dosage screen (d) Treatment screen

Figure 2 Web application prototype

real worldmdashwould be an existing system that is already be-ing used by the doctors The web-application allows doctorto be able to sign up login createview patients createadddosages for patients and treatments and download QR codeof the patient QR code is one of our solutions to solve theresearch question It is a way for the patient to login without auser-name and password which overcome the problem of el-derly patients tend to forget login information Each QR codeis the encoded token authentication which stores on the serverside Due to the web-application acts as a black box we haveomitted the security issues (eg store the token authenticationas plain text and the token does not have an expire time)

Furthermore to answer the second question proposed abovewe have developed a framework to gather patientrsquos mentalstate each day The questionnaire is used to collect the quanti-tative data from the patients Each answer has different scoreassigned When the user answers a question the answer willbe submit to the web-application At the end of the weekan email will be sent to the doctor It comprehensively sum-marises the progress of the patient and their mental stage to-ward the treatment The doctor will be able to see how manymedications they misses the reason why they did not takethe medications total exercise in the week and their averagescore of their mental health from the questionnaire If theaverage score of a patient below a certain point a recommen-dation is sent out to the doctor depending on the score range

As mentioned above this web application acts as a black boxfor an existing system Hence we did not go to a great dealto refine the HCI element of the website

Mobile ApplicationFor mobile application a much larger HCI consideration hadbeen accounted for during the development of the applicationThe login screen (Figure 3a) prompts the users to select startto begin Pressing start button will lead the patients to QRcode scanning application which the patients can then scantheir QR code to login The main screen (Figure 3b) showstodayrsquos tasks Tasks include exercise take medication and dothe quiz Medication tasks are separated into morning af-

(a) Login screen (b) Dosage screen

(c) Medication check screen (d) Medication feedbackscreen

Figure 3 Mobile application prototype

ternoon and evening panel and depending on the time of thepatientrsquos dosage the panel will appear accordingly When pa-tient click on the medication panel a list of prescribed med-ications appears to remind the patient which medication totake as shown in Figure 3c Patients can go through and man-ually click the medication to taken as they are taking the med-ication or click rdquoCheck Allrdquo to check all the medication astaken If the patient misses one or more medications a feed-back screen (Figure 3d) appears to prompt the user to answerwhy they did not take the medication(s)

When the patient clicks the exercise panel the exercise screenwill appear as shown in Figure 4a It prompts the user to enterthe exercise they did and the duration of the exercise Whenthe patient selects the quiz panel quiz screen is shown (Figure4b and 4c) This is the mental health framework that allows

(a) Exercise screen (b) Mental feedback screen 1

(c) Mental feedback screen 2 (d) All done screen

Figure 4 Mobile application prototype cont

the doctor to know the mental state of the patient with thecurrent treatment On top of the screen is a green bar whichindicates the progress of the quiz as the patients go throughAfter finishing all the tasks Figure 4d shows the finish screenwhere all panels are checked off as done This indicates tothe patients that they have done all the tasks for the day Ifthe users are unsure they can re-open the application on thesame day The done screen will stay there until the next daywhen they have more tasks It will be the All the informationentered by the patients are stored in the server

To accommodate with elderly people navigation difficulty weforced the mobile application to only have one level naviga-tion whenever we can (except for quiz screen) After done atask or series of tasks (eg answering questionnaire) the useris returned into the main screen (Figure 3b) Furthermore

Patient Hub1 addresses the HCI challenge by using big iconsimages and buttons for elderly patients With larger size oficons images and buttons elder patients make less mistakeswhen clicking Larger text is also part of our design to helpthe older patients easily read

Moreover elements such as panels radio buttons are locatedfar apart which indicate that they are not grouped togetherThis helps elderly patients to lessen error prone when select-ing a panel Additionally Patient Hub provides feedbacks tothe user whenever necessary For instance when the patientselect other on the questionnaire the answer box will thenhave hint for the user to answer Another example is the fin-ish screen that have the green tick over the panel the titlechange color to grey and the panelrsquos functionality is disablewhen the patient finishes a respective task

Last but not least related information is grouped togetherwith a line that acts as separator (shown in Figure 3c) Inthis example rdquo1 tablet(s)rdquo is for rdquoAcebutololrdquo Therefore itis arranged closer together with a line separator to ensure thatthe elder patients do not misunderstand or mislead about theinformation

Architecture View

Figure 5 Patient Hubrsquos architecture view

Patient Hub uses the classic client-server architecture An-droid mobile application acts as the client which sends andreceives HTTP REST requests and responses in JSON respec-tively The server is deployed in Heroku which was developedin Ruby on Rails Ruby on Rails uses the classic Model-View-Controller (MVC) architecture to separate the applica-tion into three different components Model is the centralcomponent which manages the data rules and logic of webapplication View populates the forms tables and text to theuser Controller accepts inputs and translates into commandswhich control models and views

For the user interface we used HAML SASS JQueryJavascript to create forms and tables We also used externallibraries such as DataTables2 (tables) SimpleForm3 (forms)Devise4 (authentication and authorisation) etc to design de-velop and manage the web application We also implementeda few APIs for the client to receive and send the necessary1httpspatienthubherokuappcom2httpswwwdatatablesnet3httpsgithubcomplataformatecsimple form4httpsgithubcomplataformatec

information which are stored on the server For databasewe used PostgreSQL with ActiveRecord wrapper to eliminateimplementing SQL queries

Database Schema

Figure 6 Patient Hubrsquos database schema view

We designed and implemented to store the data that are sentfrom the clients (feedbacks) as well as from the web applica-tion (dosages patients) These data are utilised through theweb application as well as the mobile application As shownin Figure 6 we implemented six tables Each doctor managestheir patients Each patient has many dosages which can ei-ther be exercise or medication treatment Dosages can be indifferent day by specify the frequency field Each dosage canhave multiple feedbacks on different day if the patient did nottake a medication To track the mental state of the patientQuizFeedback stores all the information that patientsrsquo answerto a particular question of their mental health

EVALUATIONDue to time constraint ethic approval and the nature ofour software we cannot do a proper usability study for ourapplication However we worked closely with CatherineCallaghermdasha head nurse in Waikato Hospitalmdashand MarkBurrowsmdashEchocardiographer at Waikato Hospitalmdashduringthe project We gave them the video of the mobile applica-tion and asked for their feedbacks

Mark Burrowsrsquos feedbacks

bull The questionnaire is a good non-confrontational way ofgetting feedbacks from the patients Symptomatic feed-back is the priority and this could be developed nicely by anurse specialist

bull Compliance is always a problem with or without an appli-cation so it cannot really be addressed

bull Patient Hub is an excellent tool for the heart failure ACSnurse and rehab nurse as they can engage with the patient

post event Therefore he suggests that nurses should beaimed as a stakeholder of the application

bull The QR code idea is brilliant in keeping the medical doctorin control and responsible for hisher patient

Unfortunately we have not heard back from CatherineCallagher

FUTURE WORKOne of our key future work is to implement a push notificationservice to enable medication notification on mobile phonePush notification acts as a reminder to the patients wheneverthey forget to do a task Moreover to develop a valid feelingquestionnaire framework the next possible future work is towork with researchers in relevant fields Furthermore addingscheduling appointment feature is also one of the possible fu-ture work

Additionally Patient Hub can also integrate built-in phonesensors as well as bluetooth scales for activity tracking andweight entering Lat but not least Patient Hub can shiftthe focus of only Android mobile application to provide toa range of mobile platform such as Iphone Windows Phoneetc to attract a larger range of patients

CONCLUSIONHeart attack is the leading cause of death world wide CRprogram is proven to extend patientrsquos lifespans and lifestyleHowever due to inconveniences and accessibility of the CRprogram it has poor uptake Patient Hub is a mobile appli-cation that is designed for elderly ACS recovery patients Itincreases the interactivity between patients and doctors Themobile application also assists the users to take correct medi-cation at the right time to do exercise and to track their mentalhealth toward the treatment

The web application was created to be the black box of theexiting system that currently uses in the hospital It has pa-tientrsquos information treatments dosages and patientrsquos feed-backs about the treatments and their mental health Weeklyemail is sent to the doctor summarising the patientrsquos recoveryprogress as well as the state of their mental health so that thedoctor can act accordingly

ACKNOWLEDGMENTSWe would like to thank Catherine Callagher Adrian JamesAmandus and Mark Burrows for the guidance and feedbacksthey gave us throughout the project We also would like tothank Dr Jim Warren for his inputs and guidance during thedevelopment of the application

REFERENCES1 Lan C Lai J-S and Chen S-Y Exercise training for

patients after coronary artery bypass grafting surgeryhttpcdnintechweborgpdfs29327pdf

2 Leeper B Cyr A M Lambert C and Martin KAcute coronary syndrome Critical care nursing clinics ofNorth America 23 4 (2011) 547ndash557httpwww-ncbi-nlm-nih-govezproxyaucklandacnzpubmed22118113

(a) Login screen (b) Patient information screen

(c) Add dosage screen (d) Treatment screen

Figure 2 Web application prototype

real worldmdashwould be an existing system that is already be-ing used by the doctors The web-application allows doctorto be able to sign up login createview patients createadddosages for patients and treatments and download QR codeof the patient QR code is one of our solutions to solve theresearch question It is a way for the patient to login without auser-name and password which overcome the problem of el-derly patients tend to forget login information Each QR codeis the encoded token authentication which stores on the serverside Due to the web-application acts as a black box we haveomitted the security issues (eg store the token authenticationas plain text and the token does not have an expire time)

Furthermore to answer the second question proposed abovewe have developed a framework to gather patientrsquos mentalstate each day The questionnaire is used to collect the quanti-tative data from the patients Each answer has different scoreassigned When the user answers a question the answer willbe submit to the web-application At the end of the weekan email will be sent to the doctor It comprehensively sum-marises the progress of the patient and their mental stage to-ward the treatment The doctor will be able to see how manymedications they misses the reason why they did not takethe medications total exercise in the week and their averagescore of their mental health from the questionnaire If theaverage score of a patient below a certain point a recommen-dation is sent out to the doctor depending on the score range

As mentioned above this web application acts as a black boxfor an existing system Hence we did not go to a great dealto refine the HCI element of the website

Mobile ApplicationFor mobile application a much larger HCI consideration hadbeen accounted for during the development of the applicationThe login screen (Figure 3a) prompts the users to select startto begin Pressing start button will lead the patients to QRcode scanning application which the patients can then scantheir QR code to login The main screen (Figure 3b) showstodayrsquos tasks Tasks include exercise take medication and dothe quiz Medication tasks are separated into morning af-

(a) Login screen (b) Dosage screen

(c) Medication check screen (d) Medication feedbackscreen

Figure 3 Mobile application prototype

ternoon and evening panel and depending on the time of thepatientrsquos dosage the panel will appear accordingly When pa-tient click on the medication panel a list of prescribed med-ications appears to remind the patient which medication totake as shown in Figure 3c Patients can go through and man-ually click the medication to taken as they are taking the med-ication or click rdquoCheck Allrdquo to check all the medication astaken If the patient misses one or more medications a feed-back screen (Figure 3d) appears to prompt the user to answerwhy they did not take the medication(s)

When the patient clicks the exercise panel the exercise screenwill appear as shown in Figure 4a It prompts the user to enterthe exercise they did and the duration of the exercise Whenthe patient selects the quiz panel quiz screen is shown (Figure4b and 4c) This is the mental health framework that allows

(a) Exercise screen (b) Mental feedback screen 1

(c) Mental feedback screen 2 (d) All done screen

Figure 4 Mobile application prototype cont

the doctor to know the mental state of the patient with thecurrent treatment On top of the screen is a green bar whichindicates the progress of the quiz as the patients go throughAfter finishing all the tasks Figure 4d shows the finish screenwhere all panels are checked off as done This indicates tothe patients that they have done all the tasks for the day Ifthe users are unsure they can re-open the application on thesame day The done screen will stay there until the next daywhen they have more tasks It will be the All the informationentered by the patients are stored in the server

To accommodate with elderly people navigation difficulty weforced the mobile application to only have one level naviga-tion whenever we can (except for quiz screen) After done atask or series of tasks (eg answering questionnaire) the useris returned into the main screen (Figure 3b) Furthermore

Patient Hub1 addresses the HCI challenge by using big iconsimages and buttons for elderly patients With larger size oficons images and buttons elder patients make less mistakeswhen clicking Larger text is also part of our design to helpthe older patients easily read

Moreover elements such as panels radio buttons are locatedfar apart which indicate that they are not grouped togetherThis helps elderly patients to lessen error prone when select-ing a panel Additionally Patient Hub provides feedbacks tothe user whenever necessary For instance when the patientselect other on the questionnaire the answer box will thenhave hint for the user to answer Another example is the fin-ish screen that have the green tick over the panel the titlechange color to grey and the panelrsquos functionality is disablewhen the patient finishes a respective task

Last but not least related information is grouped togetherwith a line that acts as separator (shown in Figure 3c) Inthis example rdquo1 tablet(s)rdquo is for rdquoAcebutololrdquo Therefore itis arranged closer together with a line separator to ensure thatthe elder patients do not misunderstand or mislead about theinformation

Architecture View

Figure 5 Patient Hubrsquos architecture view

Patient Hub uses the classic client-server architecture An-droid mobile application acts as the client which sends andreceives HTTP REST requests and responses in JSON respec-tively The server is deployed in Heroku which was developedin Ruby on Rails Ruby on Rails uses the classic Model-View-Controller (MVC) architecture to separate the applica-tion into three different components Model is the centralcomponent which manages the data rules and logic of webapplication View populates the forms tables and text to theuser Controller accepts inputs and translates into commandswhich control models and views

For the user interface we used HAML SASS JQueryJavascript to create forms and tables We also used externallibraries such as DataTables2 (tables) SimpleForm3 (forms)Devise4 (authentication and authorisation) etc to design de-velop and manage the web application We also implementeda few APIs for the client to receive and send the necessary1httpspatienthubherokuappcom2httpswwwdatatablesnet3httpsgithubcomplataformatecsimple form4httpsgithubcomplataformatec

information which are stored on the server For databasewe used PostgreSQL with ActiveRecord wrapper to eliminateimplementing SQL queries

Database Schema

Figure 6 Patient Hubrsquos database schema view

We designed and implemented to store the data that are sentfrom the clients (feedbacks) as well as from the web applica-tion (dosages patients) These data are utilised through theweb application as well as the mobile application As shownin Figure 6 we implemented six tables Each doctor managestheir patients Each patient has many dosages which can ei-ther be exercise or medication treatment Dosages can be indifferent day by specify the frequency field Each dosage canhave multiple feedbacks on different day if the patient did nottake a medication To track the mental state of the patientQuizFeedback stores all the information that patientsrsquo answerto a particular question of their mental health

EVALUATIONDue to time constraint ethic approval and the nature ofour software we cannot do a proper usability study for ourapplication However we worked closely with CatherineCallaghermdasha head nurse in Waikato Hospitalmdashand MarkBurrowsmdashEchocardiographer at Waikato Hospitalmdashduringthe project We gave them the video of the mobile applica-tion and asked for their feedbacks

Mark Burrowsrsquos feedbacks

bull The questionnaire is a good non-confrontational way ofgetting feedbacks from the patients Symptomatic feed-back is the priority and this could be developed nicely by anurse specialist

bull Compliance is always a problem with or without an appli-cation so it cannot really be addressed

bull Patient Hub is an excellent tool for the heart failure ACSnurse and rehab nurse as they can engage with the patient

post event Therefore he suggests that nurses should beaimed as a stakeholder of the application

bull The QR code idea is brilliant in keeping the medical doctorin control and responsible for hisher patient

Unfortunately we have not heard back from CatherineCallagher

FUTURE WORKOne of our key future work is to implement a push notificationservice to enable medication notification on mobile phonePush notification acts as a reminder to the patients wheneverthey forget to do a task Moreover to develop a valid feelingquestionnaire framework the next possible future work is towork with researchers in relevant fields Furthermore addingscheduling appointment feature is also one of the possible fu-ture work

Additionally Patient Hub can also integrate built-in phonesensors as well as bluetooth scales for activity tracking andweight entering Lat but not least Patient Hub can shiftthe focus of only Android mobile application to provide toa range of mobile platform such as Iphone Windows Phoneetc to attract a larger range of patients

CONCLUSIONHeart attack is the leading cause of death world wide CRprogram is proven to extend patientrsquos lifespans and lifestyleHowever due to inconveniences and accessibility of the CRprogram it has poor uptake Patient Hub is a mobile appli-cation that is designed for elderly ACS recovery patients Itincreases the interactivity between patients and doctors Themobile application also assists the users to take correct medi-cation at the right time to do exercise and to track their mentalhealth toward the treatment

The web application was created to be the black box of theexiting system that currently uses in the hospital It has pa-tientrsquos information treatments dosages and patientrsquos feed-backs about the treatments and their mental health Weeklyemail is sent to the doctor summarising the patientrsquos recoveryprogress as well as the state of their mental health so that thedoctor can act accordingly

ACKNOWLEDGMENTSWe would like to thank Catherine Callagher Adrian JamesAmandus and Mark Burrows for the guidance and feedbacksthey gave us throughout the project We also would like tothank Dr Jim Warren for his inputs and guidance during thedevelopment of the application

REFERENCES1 Lan C Lai J-S and Chen S-Y Exercise training for

patients after coronary artery bypass grafting surgeryhttpcdnintechweborgpdfs29327pdf

2 Leeper B Cyr A M Lambert C and Martin KAcute coronary syndrome Critical care nursing clinics ofNorth America 23 4 (2011) 547ndash557httpwww-ncbi-nlm-nih-govezproxyaucklandacnzpubmed22118113

(a) Exercise screen (b) Mental feedback screen 1

(c) Mental feedback screen 2 (d) All done screen

Figure 4 Mobile application prototype cont

the doctor to know the mental state of the patient with thecurrent treatment On top of the screen is a green bar whichindicates the progress of the quiz as the patients go throughAfter finishing all the tasks Figure 4d shows the finish screenwhere all panels are checked off as done This indicates tothe patients that they have done all the tasks for the day Ifthe users are unsure they can re-open the application on thesame day The done screen will stay there until the next daywhen they have more tasks It will be the All the informationentered by the patients are stored in the server

To accommodate with elderly people navigation difficulty weforced the mobile application to only have one level naviga-tion whenever we can (except for quiz screen) After done atask or series of tasks (eg answering questionnaire) the useris returned into the main screen (Figure 3b) Furthermore

Patient Hub1 addresses the HCI challenge by using big iconsimages and buttons for elderly patients With larger size oficons images and buttons elder patients make less mistakeswhen clicking Larger text is also part of our design to helpthe older patients easily read

Moreover elements such as panels radio buttons are locatedfar apart which indicate that they are not grouped togetherThis helps elderly patients to lessen error prone when select-ing a panel Additionally Patient Hub provides feedbacks tothe user whenever necessary For instance when the patientselect other on the questionnaire the answer box will thenhave hint for the user to answer Another example is the fin-ish screen that have the green tick over the panel the titlechange color to grey and the panelrsquos functionality is disablewhen the patient finishes a respective task

Last but not least related information is grouped togetherwith a line that acts as separator (shown in Figure 3c) Inthis example rdquo1 tablet(s)rdquo is for rdquoAcebutololrdquo Therefore itis arranged closer together with a line separator to ensure thatthe elder patients do not misunderstand or mislead about theinformation

Architecture View

Figure 5 Patient Hubrsquos architecture view

Patient Hub uses the classic client-server architecture An-droid mobile application acts as the client which sends andreceives HTTP REST requests and responses in JSON respec-tively The server is deployed in Heroku which was developedin Ruby on Rails Ruby on Rails uses the classic Model-View-Controller (MVC) architecture to separate the applica-tion into three different components Model is the centralcomponent which manages the data rules and logic of webapplication View populates the forms tables and text to theuser Controller accepts inputs and translates into commandswhich control models and views

For the user interface we used HAML SASS JQueryJavascript to create forms and tables We also used externallibraries such as DataTables2 (tables) SimpleForm3 (forms)Devise4 (authentication and authorisation) etc to design de-velop and manage the web application We also implementeda few APIs for the client to receive and send the necessary1httpspatienthubherokuappcom2httpswwwdatatablesnet3httpsgithubcomplataformatecsimple form4httpsgithubcomplataformatec

information which are stored on the server For databasewe used PostgreSQL with ActiveRecord wrapper to eliminateimplementing SQL queries

Database Schema

Figure 6 Patient Hubrsquos database schema view

We designed and implemented to store the data that are sentfrom the clients (feedbacks) as well as from the web applica-tion (dosages patients) These data are utilised through theweb application as well as the mobile application As shownin Figure 6 we implemented six tables Each doctor managestheir patients Each patient has many dosages which can ei-ther be exercise or medication treatment Dosages can be indifferent day by specify the frequency field Each dosage canhave multiple feedbacks on different day if the patient did nottake a medication To track the mental state of the patientQuizFeedback stores all the information that patientsrsquo answerto a particular question of their mental health

EVALUATIONDue to time constraint ethic approval and the nature ofour software we cannot do a proper usability study for ourapplication However we worked closely with CatherineCallaghermdasha head nurse in Waikato Hospitalmdashand MarkBurrowsmdashEchocardiographer at Waikato Hospitalmdashduringthe project We gave them the video of the mobile applica-tion and asked for their feedbacks

Mark Burrowsrsquos feedbacks

bull The questionnaire is a good non-confrontational way ofgetting feedbacks from the patients Symptomatic feed-back is the priority and this could be developed nicely by anurse specialist

bull Compliance is always a problem with or without an appli-cation so it cannot really be addressed

bull Patient Hub is an excellent tool for the heart failure ACSnurse and rehab nurse as they can engage with the patient

post event Therefore he suggests that nurses should beaimed as a stakeholder of the application

bull The QR code idea is brilliant in keeping the medical doctorin control and responsible for hisher patient

Unfortunately we have not heard back from CatherineCallagher

FUTURE WORKOne of our key future work is to implement a push notificationservice to enable medication notification on mobile phonePush notification acts as a reminder to the patients wheneverthey forget to do a task Moreover to develop a valid feelingquestionnaire framework the next possible future work is towork with researchers in relevant fields Furthermore addingscheduling appointment feature is also one of the possible fu-ture work

Additionally Patient Hub can also integrate built-in phonesensors as well as bluetooth scales for activity tracking andweight entering Lat but not least Patient Hub can shiftthe focus of only Android mobile application to provide toa range of mobile platform such as Iphone Windows Phoneetc to attract a larger range of patients

CONCLUSIONHeart attack is the leading cause of death world wide CRprogram is proven to extend patientrsquos lifespans and lifestyleHowever due to inconveniences and accessibility of the CRprogram it has poor uptake Patient Hub is a mobile appli-cation that is designed for elderly ACS recovery patients Itincreases the interactivity between patients and doctors Themobile application also assists the users to take correct medi-cation at the right time to do exercise and to track their mentalhealth toward the treatment

The web application was created to be the black box of theexiting system that currently uses in the hospital It has pa-tientrsquos information treatments dosages and patientrsquos feed-backs about the treatments and their mental health Weeklyemail is sent to the doctor summarising the patientrsquos recoveryprogress as well as the state of their mental health so that thedoctor can act accordingly

ACKNOWLEDGMENTSWe would like to thank Catherine Callagher Adrian JamesAmandus and Mark Burrows for the guidance and feedbacksthey gave us throughout the project We also would like tothank Dr Jim Warren for his inputs and guidance during thedevelopment of the application

REFERENCES1 Lan C Lai J-S and Chen S-Y Exercise training for

patients after coronary artery bypass grafting surgeryhttpcdnintechweborgpdfs29327pdf

2 Leeper B Cyr A M Lambert C and Martin KAcute coronary syndrome Critical care nursing clinics ofNorth America 23 4 (2011) 547ndash557httpwww-ncbi-nlm-nih-govezproxyaucklandacnzpubmed22118113

information which are stored on the server For databasewe used PostgreSQL with ActiveRecord wrapper to eliminateimplementing SQL queries

Database Schema

Figure 6 Patient Hubrsquos database schema view

We designed and implemented to store the data that are sentfrom the clients (feedbacks) as well as from the web applica-tion (dosages patients) These data are utilised through theweb application as well as the mobile application As shownin Figure 6 we implemented six tables Each doctor managestheir patients Each patient has many dosages which can ei-ther be exercise or medication treatment Dosages can be indifferent day by specify the frequency field Each dosage canhave multiple feedbacks on different day if the patient did nottake a medication To track the mental state of the patientQuizFeedback stores all the information that patientsrsquo answerto a particular question of their mental health

EVALUATIONDue to time constraint ethic approval and the nature ofour software we cannot do a proper usability study for ourapplication However we worked closely with CatherineCallaghermdasha head nurse in Waikato Hospitalmdashand MarkBurrowsmdashEchocardiographer at Waikato Hospitalmdashduringthe project We gave them the video of the mobile applica-tion and asked for their feedbacks

Mark Burrowsrsquos feedbacks

bull The questionnaire is a good non-confrontational way ofgetting feedbacks from the patients Symptomatic feed-back is the priority and this could be developed nicely by anurse specialist

bull Compliance is always a problem with or without an appli-cation so it cannot really be addressed

bull Patient Hub is an excellent tool for the heart failure ACSnurse and rehab nurse as they can engage with the patient

post event Therefore he suggests that nurses should beaimed as a stakeholder of the application

bull The QR code idea is brilliant in keeping the medical doctorin control and responsible for hisher patient

Unfortunately we have not heard back from CatherineCallagher

FUTURE WORKOne of our key future work is to implement a push notificationservice to enable medication notification on mobile phonePush notification acts as a reminder to the patients wheneverthey forget to do a task Moreover to develop a valid feelingquestionnaire framework the next possible future work is towork with researchers in relevant fields Furthermore addingscheduling appointment feature is also one of the possible fu-ture work

Additionally Patient Hub can also integrate built-in phonesensors as well as bluetooth scales for activity tracking andweight entering Lat but not least Patient Hub can shiftthe focus of only Android mobile application to provide toa range of mobile platform such as Iphone Windows Phoneetc to attract a larger range of patients

CONCLUSIONHeart attack is the leading cause of death world wide CRprogram is proven to extend patientrsquos lifespans and lifestyleHowever due to inconveniences and accessibility of the CRprogram it has poor uptake Patient Hub is a mobile appli-cation that is designed for elderly ACS recovery patients Itincreases the interactivity between patients and doctors Themobile application also assists the users to take correct medi-cation at the right time to do exercise and to track their mentalhealth toward the treatment

The web application was created to be the black box of theexiting system that currently uses in the hospital It has pa-tientrsquos information treatments dosages and patientrsquos feed-backs about the treatments and their mental health Weeklyemail is sent to the doctor summarising the patientrsquos recoveryprogress as well as the state of their mental health so that thedoctor can act accordingly

ACKNOWLEDGMENTSWe would like to thank Catherine Callagher Adrian JamesAmandus and Mark Burrows for the guidance and feedbacksthey gave us throughout the project We also would like tothank Dr Jim Warren for his inputs and guidance during thedevelopment of the application

REFERENCES1 Lan C Lai J-S and Chen S-Y Exercise training for

patients after coronary artery bypass grafting surgeryhttpcdnintechweborgpdfs29327pdf

2 Leeper B Cyr A M Lambert C and Martin KAcute coronary syndrome Critical care nursing clinics ofNorth America 23 4 (2011) 547ndash557httpwww-ncbi-nlm-nih-govezproxyaucklandacnzpubmed22118113

3 Overbaugh K J Acute coronary syndrome AJN TheAmerican Journal of Nursing 109 5 (2009) 42ndash52 httpovidsptxovidcomsp-3160bovidwebcgiQS2=434f4e1a73d37e8c78e6973bbb18ee807d6d3d24cfa942a91c16e96b19

4 Rudd J Ken S and Isensee S Low vs high-fidelityprototyping debate Magazine Interactions 3 (1993)76ndash85 httpdeliveryacmorgezproxyaucklandacnz101145230000223514p76-ruddpdfip=13021615878ampid=223514ampacc=ACTIVE20SERVICEampkey=65D80644F295BC0D1A1C2C69CF2E7D6D4D4702B0C3E38B354D4702B0C3E38B35ampCFID=554346427ampCFTOKEN=31323752amp__acm__=1445373309_a9a6a1ab4ca499c7ff40f93932ba1252

5 Varnfield M Karunanithi M K Sarela A Garcia EFairfull A Oldenburg B F and Walters D L Uptakeof a technology-assisted home-care cardiac rehabilitationprogram Medical Journal of Australia 194 4 (2011)S15 httpsmjainsightcomausystemfilesissues194_04_210211var10260_fmpdf